Federal Register, Volume 70 Issue 155 (Friday, August 12, 2005)

[Federal Register Volume 70, Number 155 (Friday, August 12, 2005)]
[Rules and Regulations]
[Pages 47278-47707]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 05-15406]

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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, 413, 415, et al.

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

Federal Register / Vol. 70, No. 155 / Friday, August 12, 2005 / Rules
and Regulations

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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-F]
RIN 0938-AN57

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

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

ACTION: Final rule.

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SUMMARY: We are revising the Medicare hospital inpatient prospective
payment systems (IPPS) for operating and capital-related costs to
implement changes arising from our continuing experience with these
systems. In addition, in the Addendum to this final rule, we describe
the 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 rate-of-increase limits as
well as 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 changes are applicable to discharges
occurring on or after October 1, 2005, with one exception: The changes
relating to submittal of hospital wage data by a campus or campuses of
a multicampus hospital system (that is, the changes to Sec.
412.230(d)(2) of the regulations) are effective on August 12, 2005.
Among the policy changes that we are making 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: Effective Dates: The provisions of this final rule, except the
provisions of Sec. 412.230(d)(2), are effective on October 1, 2005.
The provisions of Sec. 412.230(d)(2) are effective on August 12, 2005.
This rule is a major rule as defined in 5 U.S.C. 804(2). Pursuant to 5
U.S.C. 801(a)(1)(A), we are submitting a report to Congress on this
rule on August 1, 2005.

FOR FURTHER INFORMATION CONTACT:
Marc Hartstein, (410) 786-4548, 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.
Debbra Hattery, (410) 786-1855, Quality Data for Annual Payment
Update Issues.
Martha Kuespert, (410) 786-4605, Specialty Hospitals Definition
Issues.

SUPPLEMENTARY INFORMATION:

Electronic Access

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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 implantable 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
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

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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)
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. Summary of Provisions of the FY 2006 IPPS Proposed Rule
1. Changes to the DRG Reclassifications and Recalibrations of
Relative Weights
2. Changes to the Hospital Wage Index
3. Revision and Rebasing of the Hospital Market Basket
4. Other Decisions and Changes to the PPS for Inpatient
Operating and GME Costs
5. PPS for Capital-Related Costs
6. Changes for Hospitals and Hospital Units Excluded From the
IPPS
7. Payment for Blood Clotting Factors for Inpatients With
Hemophilia
8. Determining 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
C. Public Comments Received in Response to the FY 2006 IPPS
Proposed Rule
II. Changes to DRG Classifications and Relative Weights
A. Background
B. DRG Reclassifications
1. General
2. Yearly Review for Making DRG Changes; Request for Public
Comment
3. Pre-MDC: Intestinal Transplantation
4. MDC 1 (Diseases and Disorders of the Nervous System)
a. Strokes
b. Unruptured Cerebral Aneurysms
5. MDC 5 (Diseases and Disorders of the Circulatory System)
a. Severity Adjusted Cardiovascular Procedures
b. Automatic Implantable Cardioverter/Defibrillator
c. Coronary Artery Stents
d. Insertion of Left Atrial Appendage Device
e. External Heart Assist System Implant
f. Carotid Artery Stent
g. Extracorporeal Membrane Oxygenation (ECMO)
6. MDC 6 (Diseases and Disorders of the Digestive System):
Artificial Anal Sphincter
7. MDC 8 (Diseases and Disorders of the Musculoskeletal System
and Connective Tissue)
a. Hip and Knee Replacements
b. Kyphoplasty
c. Multiple Level Spinal Fusion
d. Charite(tm) Spinal Disc Replacement Device
8. MDC 18 (Infectious and Parasitic Diseases (Systemic or
Unspecified Sites)): Severe Sepsis
9. MDC 20 (Alcohol/Drug Use and Alcohol/Drug Induced Organic
Mental Disorders): Drug-Induced Dementia
10. 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
11. Surgical Hierarchies
12. Refinement of Complications and Comorbidities (CC) List
a. Background
b. Comprehensive Review of the CC List
c. CC Exclusion List for FY 2006
13. 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
14. Changes to the ICD-9-CM Coding System
15. Other Issues
a. Acute Intermittent Porphyria
b. Prosthetic Cardiac Support Device (Code 37.41)
c. Coronary Intravascular Ultrasound (IVUS) (Procedure Code
00.24)
d. Islet Cell Transplantation
C. Recalibration of DRG Weights
D. LTC-DRG Reclassifications and Relative Weights for LTCHs for
FY 2006
1. Background
2. 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. Low-Volume LTC-DRGs
4. Steps for Determining the FY 2006 LTC-DRG Relative Weights
5. Other Public Comments Relating to the LTCH PPS Payment
Policies
E. 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. Changes to the Hospital Wage Index
A. Background
B. Core-Based Statistical Areas for the Hospital Wage Index
C. Occupational Mix Adjustment to FY 2006 Index
1. Development of Data for the Occupational Mix Adjustment
2. Calculation of the Occupational Mix Adjustment Factor and the
Occupational Mix Adjusted Wage Index
D. Worksheet S-3 Wage Data for the FY 2006 Wage Index Update
E. Verification of Worksheet S-3 Wage Data
F. Computation of the FY 2006 Unadjusted Wage Index
G. Computation of the FY 2006 Blended Wage Index
H. Revisions to the Wage Index Based on Hospital Redesignation

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1. General
2. Effects of Reclassification
3. Application of Hold Harmless Protection for Certain Urban
Hospitals Redesignated as Rural
4. FY 2006 MGCRB Reclassifications
5. FY 2006 Redesignations under Section 1886(d)(8)(B) of the Act
6. Reclassifications under Section 508 of Pub. L. 108-173
I. FY 2006 Wage Index Adjustment Based on Commuting Patterns of
Hospital Employees
J. Requests for Wage Index Data Corrections
IV. 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 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 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 IPPS-Excluded 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
3. Calculation of the Medicare Fraction
4. Calculation of the Medicaid Fraction
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. 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
6. Report of Adjustment (Exception) Payments
B. Critical Access Hospitals (CAHs)
1. Background
2. Policy Change Relating to Continued Participation by CAHs in
Lugar Counties
3. 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
VIII. Payment for Blood Clotting Factor Administered to Hemophilia
Inpatients
IX. MedPAC Recommendations
A. Medicare Payment Policy
1. Update Factor
2. Quality Incentive Payment Policy
3. Refinement of DRGs Based on Severity of Illness
4. APR-DRGs
5. DRG Relative Weights
6. High-Cost Outliers
B. Other MedPAC Recommendations
X. Other Required Information
A. Requests for Data From the Public
B. Collection of Information Requirements

Regulation Text

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

I. Summary and Background
II. 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. 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 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 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. Changes to Payment Rates for Acute Care Hospital Inpatient
Capital-Related Costs for FY 2006
A. Determination of Federal Hospital Inpatient Capital-Related
Prospective Payment Rate Update
1. Capital Standard Federal Rate Update
a. Description of the Update Framework
b. Comparison of CMS and MedPAC Update Recommendation
2. Outlier Payment Adjustment Factor
3. Budget Neutrality Adjustment Factor for Changes in DRG
Classifications and Weights and the Geographic Adjustment Factor
4. Exceptions Payment Adjustment Factor
5. Capital Standard Federal Rate for FY 2006
6. Special Capital Rate for Puerto Rico Hospitals
B. Calculation of Inpatient Capital-Related Prospective Payments
for FY 2006
C. Capital Input Price Index
1. Background

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2. Forecast of the CIPI for FY 2006
IV. 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 Wage Indexes for Federal Fiscal
Year 2006; 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 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 Wage 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 March 2005 GROUPER V22.0]
Table 7B--Medicare Prospective Payment System Selected Percentile
Lengths of Stay: [FY 2004 MedPAR Update March 2005 GROUPER V23.0]
Table 8A--Statewide Average Operating Cost-to-Charge Ratios-July
2005
Table 8B--Statewide Average Capital Cost-to-Charge Ratios-July 2005
Table 9A--Hospital Reclassifications and Redesignations by
Individual Hospital and CBSA--FY 2006
Table 9B--Hospital Reclassifications and Redesignation by Individual
Hospital Under Section 508 of Pub. L. 108-173--FY 2006
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)--July
2005
Table 11--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 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 patient. 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

[[Page 47282]]

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
on or after 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; 68 FR 45674, August 1, 2003, and 69 FR 45721,
July 30, 2004). 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 (LTCH PPS final rule (70 FR
24168)). LTCHs not meeting the definition in Sec. 412.23(e)(4) of the
regulations 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. LTCHs meeting the definition in Sec. 412.23(e)(4)
will be paid based on 100 percent of the standard Federal rate. 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 January 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 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 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.

B. Summary of the Provisions of the FY 2006 IPPS Proposed Rule

In the FY 2006 IPPS proposed rule (70 FR 23306), we set forth
proposed changes to the Medicare IPPS for operating costs and for
capital-related costs in FY 2006. We also set 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 were proposed to 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 proposed
and the issues we addressed in the FY 2006 IPPS proposed rule.
1. Changes to the DRG Reclassifications and Recalibrations of Relative
Weights
As required by section 1886(d)(4)(C) of the Act, we proposed annual
adjustments to the DRG classifications and relative weights. Based on
analyses of Medicare claims data, we proposed to establish a number of
new DRGs and make changes to the designation of diagnosis and procedure
codes under other existing DRGs.
We also presented analysis of FY 2006 applicants for add-on
payments for high-cost new medical services and technologies (including
public input, as directed by Pub. L. 108-173, obtained in a town hall
meeting).
We proposed 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. Changes to the Hospital Wage Index
We proposed revisions to the wage index and the annual update of
the wage data. Specific issues addressed included the following:

[[Page 47283]]

The FY 2006 wage index update, using wage data from cost
reporting periods that began during FY 2002.
The occupational mix adjustment to the wage index that we
began to apply effective October 1, 2004.
The revisions to the wage index based on hospital
redesignations and reclassifications.
The 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 were in effect for the FY 2006 wage index.
3. Revision and Rebasing of the Hospital Market Baskets
We proposed 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 also set
forth the data sources used to determine the proposed revised market
basket relative weights and choice of price proxies.
4. Other Decisions and Changes to the PPS for Inpatient Operating and
GME Costs
In the proposed rule, we discussed 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.
Changes in the application of the budget neutrality
adjustment to MDHs and SCHs for computing the hospital-specific rate.
Updated national and regional case-mix values and
discharges for purposes of determining rural referral center status.
The payment adjustment for low-volume hospitals.
The IME adjustment for TEFRA hospitals that are converting
to IPPS hospitals, and IME FTE resident caps for urban hospitals that
are granted rural reclassification and then withdraw that rural
classification.
Changes to implement section 951 of Pub. L. 108-173
relating to the provision of patient stay days/SSI data maintained by
CMS to hospitals for the purpose of determining their DSH percentage.
Changes relating to hospitals' geographic classifications,
including multicampus hospitals and urban group hospital
reclassifications.
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 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 the proposed rule, we did not propose any policy changes to the
capital-related prospective payment system. For the readers' benefit,
we discussed the payment policy requirements for capital-related costs
and capital payments to hospitals.
6. Changes for Hospitals and Hospital Units Excluded from the IPPS
In the proposed rule, we discussed 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. Changes in Payment for Blood Clotting Factor
In the proposed rule, we discussed 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 the 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
established the proposed threshold amounts for outlier cases. In
addition, we addressed 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 the 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 the proposed rule, as required by sections
1886(e)(4) and (e)(5) of the Act, we provided our recommendations of
the appropriate percentage changes for FY 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 the 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 were addressed in section IX. of the preamble of the
proposed rule. 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.

[[Page 47284]]

C. Public Comments Received in Response to the FY 2006 IPPS Proposed
Rule

We received over 2,000 timely items of correspondence containing
multiple comments on the FY 2006 IPPS proposed rule. Summaries of the
public comments and our responses to those comments are set forth below
under the appropriate heading.

II. Changes to DRG Classifications and Relative Weights

A. Background

Section 1886(d) of the Act specifies that the Secretary shall
establish a classification system (referred to as DRGs) for inpatient
discharges and adjust payments under the IPPS based on appropriate
weighting factors assigned to each DRG. Therefore, under the IPPS, we
pay for inpatient hospital services on a rate per discharge basis that
varies according to the DRG to which a beneficiary's stay is assigned.
The formula used to calculate payment for a specific case multiplies an
individual hospital's payment rate per case by the weight of the DRG to
which the case is assigned. Each DRG weight represents the average
resources required to care for cases in that particular DRG, relative
to the average 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 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.
1. General
Cases are classified into DRGs for payment under the IPPS based on
the principal diagnosis, up to eight additional diagnoses, and up to
six procedures performed during the stay. In a small number of DRGs,
classification is also based on the age, sex, and discharge status of
the patient. The diagnosis and procedure information is reported by the
hospital using codes from the International Classification of Diseases,
Ninth Revision, Clinical Modification (ICD-9-CM).
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 520 DRGs in 25 MDCs. (We note that, in the FY 2006
proposed rule (70 FR 23313), we inadvertently stated that there were
519 DRGs.) The table below lists the 25 MDCs.

Major Diagnostic Categories (MDCs)
------------------------------------------------------------------------

-------------------------------------------------------------------------
1 Diseases and Disorders of the Nervous System.
2 Diseases and Disorders of the Eye.
3 Diseases and Disorders of the Ear, Nose, Mouth, and Throat.
4 Diseases and Disorders of the Respiratory System.
5 Diseases and Disorders of the Circulatory System.
6 Diseases and Disorders of the Digestive System.
7 Diseases and Disorders of the Hepatobiliary System and Pancreas.
8 Diseases and Disorders of the Musculoskeletal System and Connective
Tissue.
9 Diseases and Disorders of the Skin, Subcutaneous Tissue, and Breast.
10 Endocrine, Nutritional and Metabolic Diseases and Disorders.
11 Diseases and Disorders of the Kidney and Urinary Tract.
12 Diseases and Disorders of the Male Reproductive System.
13 Diseases and Disorders of the Female Reproductive System.
14 Pregnancy, Childbirth, and the Puerperium.
15 Newborns and Other Neonates with Conditions Originating in the
Perinatal Period.
16 Diseases and Disorders of the Blood and Blood Forming Organs and
Immunological Disorders.
17 Myeloproliferative Diseases and Disorders and Poorly Differentiated
Neoplasms.
18 Infectious and Parasitic Diseases (Systemic or Unspecified Sites).
19 Mental Diseases and Disorders.
20 Alcohol/Drug Use and Alcohol/Drug Induced Organic Mental Disorders.
21 Injuries, Poisonings, and Toxic Effects of Drugs.
22 Burns.
23 Factors Influencing Health Status and Other Contacts with Health
Services.
24 Multiple Significant Trauma.
25 Human Immunodeficiency Virus Infections.
------------------------------------------------------------------------

In general, cases are assigned to an MDC based on the patient's
principal diagnosis before assignment to a DRG. However, for FY 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 47285]]

Pre-Major Diagnostic Categories (Pre-MDCs)
------------------------------------------------------------------------

------------------------------------------------------------------------
DRG 103.............................. Heart Transplant or Implant of
Heart Assist System
DRG 480.............................. Liver Transplant and/or
Intestinal Transplant
DRG 481.............................. Bone Marrow Transplant
DRG 482.............................. Tracheostomy for Face, Mouth, and
Neck Diagnoses
DRG 495.............................. Lung Transplant
DRG 512.............................. Simultaneous Pancreas/Kidney
Transplant
DRG 513.............................. Pancreas Transplant
DRG 541.............................. Tracheostomy with Mechanical
Ventilation 96+ Hours or
Principal Diagnosis Except for
Face, Mouth, and Neck Diagnosis
with Major Operating Room
Procedures
DRG 542.............................. Tracheostomy with Mechanical
Ventilation 96+ Hours or
Principal Diagnosis Except for
Face, Mouth, and Neck Diagnosis
Without Major Operating Room
Procedures
------------------------------------------------------------------------

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.
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 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.
In the FY 2006 IPPS proposed rule (70 FR 23312), we proposed
numerous changes to the DRG classification system for FY 2006 and to
the methodology used to recalibrate the DRG weights. The changes we
proposed to the DRG classification system, the public comments we
received concerning the proposed changes, the final DRG changes, and
the methodology used to recalibrate the DRG weights are set forth
below. The changes we are implementing in this final rule will be
reflected in the FY 2006 GROUPER, version 23.0, and are effective for
discharges occurring on or after October 1, 2005. Unless otherwise
noted in this final rule, our DRG analysis is based on data from the
September 2004 update of the FY 2004 MedPAR file, which contains
hospital bills received through September 30, 2004 for discharges in FY
2004.
2. Yearly Review for Making DRG Changes; Request for Public Comment
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

[[Page 47286]]

December in order to be considered and possibly included in the next
annual proposed rule updating the IPPS.
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 lengths 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.
To date, we have not used specific statistical standards as part of
our guidelines for determining when DRG changes are warranted. However,
we could potentially establish objective guidelines that are used in
the DRG development process. For instance, such standards could include
a minimum percentage or absolute difference in average charges or
length of stay and number of cases in order for us to create a DRG or
change the DRG assignment of a particular code or service. As part of
our review and analysis of MedPAC's recommendations, we will consider
whether to establish such guidelines for making DRG reclassification
decisions. We welcome public comments on this issue.
3. 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 did not propose any DRG modification for intestinal
transplantation cases for FY 2006.
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.
Comment: Several commenters, including an institute that performs
intestinal transplantation, supported our decision to reassign
intestinal transplantation cases to DRG 480. One commenter commended
CMS for its progress, but urged us to continue to evaluate a separate
DRG for intestinal transplantation. While payment has improved, the
commenter stated that it is still inadequate, and insufficient
reimbursement could ultimately hinder beneficiary access to care.
Response: As indicated in the FY 2006 IPPS proposed rule (70 FR
23315), we found only three cases in the Medicare data that included an
intestinal transplant. We found that the average charges were less for
intestinal transplant cases ($138,922) than liver transplant cases
($165,314). Thus, even though we have a very low number of cases to
make these comparisons, the data do not suggest that intestinal
transplants are underpaid in DRG 480. We remain committed to assigning
procedures to the most appropriate DRG based on clinical coherence and
utilization of resources using the most recently available data. As we
stated in the FY 2005 IPPS final rule (69 FR 48977), when we receive
sufficient additional Medicare data on intestinal transplantation
cases, we will again consider the DRG assignment for intestinal
transplants.
Comment: One commenter concurred with the decision to assign
intestinal transplant cases to DRG 480 but recommended that CMS create
separate DRGs for liver-intestinal and liver-kidney transplants. The
commenter requested that CMS report average charges for these cases in
the final rule. The commenter noted that DRGs have been created for
double organ transplants such as DRG 512 (Simultaneous Pancreas/Kidney
Transplant).
Response: While the focus of our review in the proposed rule was
limited to whether we should reassign intestinal transplants to DRG
480, we reviewed all cases in this DRG. Based on our review of the FY
2004 MedPAR data, the following table illustrates our findings:

----------------------------------------------------------------------------------------------------------------
Number of Average length Average
DRG cases of stay charges
----------------------------------------------------------------------------------------------------------------
DRG 480......................................................... 959 16.65 $165,622
Liver Transplantation........................................... 876 16.5 165,314
Intestinal Transplantation...................................... 3 26.0 138,922
Liver-Intestinal Transplantation................................ 1 72.0 539,841
Liver-Kidney Transplantation.................................... 79 21.3 237,759
----------------------------------------------------------------------------------------------------------------

As we stated in the proposed rule (70 FR 23315), while the average
charges and length of stay were much higher for the one liver-
intestinal transplantation case, for which we had data, than the other
cases in DRG 480, the case would likely be paid as an outlier. One case
is insufficient to create a new DRG. Similarly, we are reluctant to
create a

[[Page 47287]]

new DRG for such a small number of liver-kidney transplant cases, even
though average charges and length of stay are higher for liver-kidney
transplants than other cases in DRG 480. As discussed, in section IX.A.
of this final rule, we plan in the next year to undertake a
comprehensive review of the existing Medicare DRG system and expect to
make changes to the DRGs to better reflect the severity of illness. As
we study this issue, we will further analyze hospital costs for
patients needing multiple organ transplants. At this time, we are not
making any further modifications to the DRGs for multiple transplants
in FY 2006.
4. 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. 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, CMS has been monitoring the DRGs and cases in which
this code can be found, particularly with respect to cardiac and stroke
DRGs.
Last year, CMS 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 would
help to identify patients who have strokes that are more severely and
costly and would recognize the higher charges that these cases generate
because of their higher hospital resource utilization. At that time,
the presenters provided evidence that strokes where tPA was used were
both more severe and more resource intensive. Specifically, they showed
that patients who were given tPA for strokes had higher stroke severity
scores at presentation, and that they were more expensive to care for
because of increased intensive care unit monitoring requirements,
increased diagnostic imaging costs, and increased laboratory and
pharmacy costs. They also demonstrated that these patients had markedly
better clinical outcomes. The stroke representatives made two
suggestions concerning the stroke DRGs.
The first proposal suggested 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, 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 include
only cases where patients with strokes caused by arterial occlusion (or
clot(s)) are also treated with tPA thrombolytic therapy.
We have examined the MedPAR data for the cases in DRGs 14 and 15.
We 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:

----------------------------------------------------------------------------------------------------------------
Average length Average
DRG Count of stay charges
----------------------------------------------------------------------------------------------------------------
14--All Cases................................................... 221,879 5.67 $18,997
14--Cases with intracranial hemorrhage.......................... 41,506 5.40 19,193
14--Cases with intracranial hemorrhage with code 99.10.......... 61 7.4 37,045
14--Cases with intracranial hemorrhage without code 99.10....... 41,445 5.3 19,167
14--Cases without intracranial hemorrhage....................... 180,373 5.74 18,952
14--Cases without intracranial hemorrhage with code 99.10....... 2,085 7.20 35,128
14--Cases without intracranial hemorrhage without code 99.10.... 178,288 5.72 18,763
15--All cases................................................... 71,335 4.53 14,382
15--Cases with intracranial hemorrhage.......................... 0 0 0
15--Cases without intracranial hemorrhage....................... 71,335 4.53 14,382
15--Cases without intracranial hemorrhage with code 99.10....... 302 5.10 24,876
15--Cases without intracranial hemorrhage without code 99.10.... 71,033 4.53 14,337
----------------------------------------------------------------------------------------------------------------

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. In the FY 2006 IPPS proposed rule, we
did not propose a change to the stroke DRGs because of the small number
of reperfusion cases reported. However, we stated that 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.
In the FY 2006 IPPS proposed rule, we invited public comment on the
changes to DRGs 14 and 15 suggested by the hospital representatives. In
addition, we solicited 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.
Comment: Forty commenters supported the creation of a new DRG to
recognize the group of patients who presented with stroke and who also
received thrombolytic therapy. The commenters cited the following
reasons for supporting this proposal: Increased costs of caring for
these patients, specifically in intensive care unit, more

[[Page 47288]]

diagnostic imaging studies, and laboratory and pharmacy resources. In
addition, the commenters noted that the proposal is also supported by
evidence that patients receiving thrombolytic therapy have strokes of
increased severity. The commenters also stated that the proposal
demonstrates the need for hospitals to have an incentive to establish
the infrastructure necessary to provide stroke patients with aggressive
evaluation and management services, such as thrombolytic therapy, which
have become the standard of care.
Response: We appreciate the commenters' responses in reply to our
solicitation for public comment on the changes to DRGs 14 and 15 as
suggested in the proposed rule. The level of detail provide in the
responses helped us to formulate a change to the medical stroke DRGs.
We agree with the commenters that there is an increased cost in caring
for these patients including increased use of the intensive care unit,
more diagnostic imaging studies, and laboratory and pharmacy resources.
We also agree that--(1) the data indicate that patients receiving
thrombolytic therapy have increased severity; and (2) reperfusion
therapy is a good means to segregate these patients into a separate
DRG.
Comment: One commenter encouraged CMS to modify DRGs 14 and 15
using one of two options. The first option would be to create DRG ``A''
where hemorrhagic and ischemic strokes were combined, but only
supportive care was given, while DRG ``B'' would contain those
hemorrhagic and ischemic stroke cases in which reperfusion or
hemostatic agents were administered.
Alternatively, the commenter suggested that DRGs 14 and 15 could be
modified by creating four new DRGs. DRG ``A'' would contain cases of
hemorrhagic stroke and supportive care, DRG ``B'' would contain cases
of hemorrhagic stroke treated with hemostatic agents, DRG ``C'' would
contain cases of ischemic stroke and supportive care, and DRG ``D''
would contain cases of ischemic stroke treated with reperfusion agents.
Response: This commenter is suggesting that the DRG system
recognize treatment of hemorrhage strokes with hemostatic agents as
well as ischemic strokes with reperfusion agents. While we anticipate
great industry strides in the treatment of stroke, currently no
approved hemostatic agent is on the market. According to the
manufacturer(s) of hemostatic agents, it is unlikely that these agents
will be available for use during FY 2006. Therefore, we do not have any
Medicare charge information that supports creating separate DRGs for
hemorrhagic stroke patients treated with hemostatic agents as we do for
ischemic stroke patients treated with thrombolytic therapy. When
hemostatic agents are available on the market, we will reevaluate this
issue.
Comment: One commenter believed that the two potential changes to
the stroke DRGs as set forth in the proposed rule are too limited as
written. The commenter believed that the descriptor, ``reperfusion
agent'', is not broad enough to encompass other promising
pharmacotherapies for stroke that are in late stages of clinical
development. The commenter pointed out that these therapies include
treatment for both ischemic stroke and hemorrhagic stroke. The
commenter further noted that it is unlikely that any of the potential
therapies will be approved for use during FY 2006. The commenter
recommended that CMS broaden the title for the proposed new DRG to
include a wider range of any newly approved therapies.
Response: While we look forward to improved therapies for treating
patients with strokes, we are unable to create DRGs that recognize as
yet unapproved treatment modalities. When the FDA has approved
additional pharmaceuticals for the treatment of either ischemic or
hemorrhagic stroke, we will evaluate the data and make DRG changes as
appropriate. We point out that the DRG titles cannot possibly
acknowledge all the codes located therein. The important part of the
DRG is the structure of the logic; that is, what codes are assigned to
the DRG.
Comment: One commenter recommended that CMS commit to creating a
surgical DRG for ischemic stroke patients who are treated with surgical
interventions. The commenter included several scenarios of possible
diagnosis and procedure coding combinations that CMS could use to
identify stroke cases and increase the scope of our analysis.
Response: Our goal was not to review all stroke cases within the
MedPAR database, but to identify those cases in medical DRG 14, and
possibly DRG 15, that might have included the administration of tPA as
identified by procedure code 99.10. DRGs that identify a precise
surgical procedure already exist; all of the combinations of procedure
codes suggested by the commenter already appropriately group to DRGs
within MDC 1.
Comment: One commenter stated that because code 99.10 was not
reimbursable [did not have an impact on DRG assignment], hospital
coders often did not use it. Some hospitals in which reperfusion
therapy was commonplace never used this code.
Response: We would like to take this opportunity to reiterate that
all cases should be accurately and completely coded, irrespective of
the DRG implications of a specific code or codes. By coding accurately
and completely, we will have more information on patient care costs for
different services and treatments that better enable us to research
further changes to the DRG system.
Comment: One commenter noted that, because only a single type of
reperfusion agent is presently approved for stroke treatment, the
proposed change would create a DRG that is, de facto, product specific.
In addition, the commenter stated that the DRG change on which CMS
requested comment would improve access to therapy for only a small
fraction of all stroke patients. The commenter added that
implementation of a narrowly-defined change [by creating a specific
stroke-plus-tPA DRG] may necessitate further changes to the stroke DRGs
in the near future to ensure patient access to emerging drug therapies
once approved.
Response: While we did not propose a specific change to the stroke
DRGs in the proposed notice, we have decided to modify the DRGs to
distinguish those cases in which tPA is used as a treatment modality
based on the strong support for this change voiced by commenters. When
we reviewed the data represented in the above table, we noted that the
average standardized charges for all cases in DRG 14 were $18,997, but
that the subset of 2,085 cases in which tPA was used had average
standardized charges of $35,128. We noted that the cases in DRG 14
without hemorrhage that did not report the use of tPA had average
standardized charges of $18,763, which was comparable with the figures
for all cases in the DRG. Given that these cases are easily
identifiable through the use of procedure code 99.10, and that the
average standardized charges are $16,131 higher for the cases using
tPA, we decided to carve these cases out of the existing DRGs 14 and
15, and represent them in a new DRG. We are changing the structure of
stroke DRGs not to award higher payment for a specific drug but to
recognize the need for better overall care for this group of patients.
Even though a tPA is indicated only for a small proportion of stroke
patients (only those experiencing ischemic strokes treated within 3
hours of the onset of symptoms), our data suggest that there are enough
patients to support the DRG change. While our goal

[[Page 47289]]

is to make payment relate more closely to resource use, we also note
that use of a tPA in a carefully selected patient population will lead
to better outcomes and overall care and may lessen the need for
postacute care. With regard to the potential need to modify stroke DRGs
in the future, we note that we perform an update to the DRGs and modify
DRGs every year. We reiterate that should additional types of therapy
be approved, we will evaluate them, and after judicious study, will
make appropriate DRG title and/or logic changes as required.
In this final rule, after consideration of public comments received
and based on our analysis of MedPAR data that supports the creation of
a DRG that identifies embolic stroke combined with tPA treatment, we
are creating new DRG 559 (Acute Ischemic Stroke with Use of
Thrombolytic Agent). From a data consistency standpoint, we believe
that adding a new DRG identifying these cases will be less disruptive
to our stakeholders than creating three new DRGs, two of which would
mimic existing DRGs 14 and 15. The GROUPER logic for DRGs 14 and 15
will not be affected by this change; that is, the GROUPER content of
DRGs 14 and 15 will be the same in FY 2006 as it was in FY 2005. The
structure of the new DRG 559 includes the following codes:

Principal Diagnosis

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
arteries, with cerebral infarction
433.81, Occlusion and stenosis of other specified
precerebral artery, with cerebral infarction
433.91, Occlusion and stenosis of unspecified precerebral
artery, with cerebral infarction
434.01, Cerebral thrombosis, with cerebral infarction
434.11, Cerebral embolism, with cerebral infarction
434.91, Cerebral artery occlusion, unspecified, with
cerebral infarction

and

Nonoperating Room Procedure

99.10, Injection or infusion of thrombolytic agent
We will continue to monitor stroke DRGs in the future. As noted
above, should treatment modalities change, we will be open to making
changes to the DRG structure that will recognize improvements in
treatment and technology.
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 data for unruptured cerebral aneurysms cases in
DRGs 1 and 2. In our analysis of these 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 did not propose a change in
the structure of these DRGs relating to unruptured cerebral aneurysm
cases for FY 2006.
Comment: Several commenters agreed that the minimal differences in
charges for unruptured cerebral aneurysms cases compared to all cases
assigned to DRGs 1 and 2 do not justify a change in the DRG assignment
for these cases. One commenter stated that unruptured cerebral aneurysm
cases should be reclassified into a new DRG. The commenter stated that
a new DRG is warranted to understand the true weight of these
procedures and to establish reimbursement that recognizes the cost of
medical devices used to treat unruptured cerebral aneurysms.
Response: Our analysis is based on the most recent charge
information available reflecting the overall resources used to treat
unruptured cerebral aneurysms in Medicare patients. We concur with the
commenters that there are minimal differences in the charges for the
unruptured cerebral aneurysm cases compared to all cases assigned to
DRGs 1 and 2 and that the results of the data do not justify creation
of a new DRG. We believe that unruptured cerebral aneurysms are
appropriately assigned to DRGs 1 and 2. Therefore, we are not making
any modifications to the DRG assignment for unruptured cerebral
aneurysms.
5. MDC 5 (Diseases and Disorders of the Circulatory System)
a. Severity Adjusted Cardiovascular Procedures
In response to the FY 2006 IPPS proposed rule, one commenter noted
that section 507(c) of Pub. L. 108-173 required MedPAC to conduct a
study to determine how the DRG system should be updated to better
reflect the cost of delivering care in a hospital setting. The
commenter noted that MedPAC reported that the ``cardiac surgery DRGs
had high relative profitability ratios.'' While the commenter noted
that it may take time to conduct and complete a thorough evaluation of
the MedPAC payment recommendations for all DRGs, the commenter strongly
encouraged CMS to revise the cardiac DRGs through patient severity
refinements as part of the final rule to be effective for FY 2006. In
section IX.A. of the preamble to this final rule, we are responding in
detail to this comment by making significant revisions to a number of
cardiovascular DRGs that currently contain patients with a wide range
of severity and resource consumption in order to reflect more
accurately the resources required to care for different kinds of
cardiovascular patients. Accordingly, in response to the issues raised
by the commenter and as an interim step until we can complete a
comprehensive review of MedPAC's recommendations, we are deleting
current DRGs 107, 109, 111, 116, 478, 516, 517, 526, and 527, and
creating new DRGs 547 through 558 in their place.
We received several comments on the FY 2006 IPPS proposed rule that
recommended that we split additional cardiovascular DRGs based on the
presence or absence of heart failure, acute myocardial infarction, and
shock. As indicated in section IX.A. of this final rule, we conducted a
focused review of a number of different cardiovascular DRGs and are
making revisions to them based on a newly designated list of ``major
cardiovascular conditions.''
We believe these new DRGs will help to address a number of the
concerns raised by these commenters. We intend to monitor these DRGs
carefully in upcoming years and welcome input regarding the success of
these DRGs in

[[Page 47290]]

reflecting patient severity and resource use.
b. 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 to 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 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:

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 that would 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:

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 the
acknowledged coding problems in the use of code 37.26, we believe it is
inappropriate to base a defibrillator DRG assignment on the EPS code.
Cases identified with this code capture patients who require less
resource use than patients who have a cardiac catheterization.
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 proposed 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 defibrillator is
reasonable and necessary and for quality improvement. These

[[Page 47291]]

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.
Comment: One commenter stated that there has been considerable
confusion surrounding the use of code 37.26. The commenter indicated
that coders are unclear whether code 37.26 should be reported when an
electrophysiologic study (EPS) is performed as part of a defibrillator
implantation or only when defibrillator device checks are performed.
The commenter pointed out that the continuing efforts of the Editorial
Advisory Board for Coding Clinic to clarify the use of this code have
led to changes in coding advice published in Coding Clinic for ICD-9-CM
by the American Hospital Association. However, the commenter stated,
while the change in coding advice was intended to clarify use of code
37.26, coders continue to have questions about it. The commenter
supported our proposal to remove code 37.26 from the list of cardiac
catheterizations for DRGs 535 and 536 and agreed with CMS' plans to
continue working to clarify use of this code or modify the code through
the ICD-9-CM Coordination and Maintenance Committee. The commenter
suggested that, once the coding issues are resolved and consistent data
are collected, CMS should reexamine the DRG assignment(s) for code
37.26.
Other commenters opposed our proposal to remove code 37.26 from
DRGs 535 and 536. These commenters stated that code 37.26 is used to
capture a variety of disparate procedures with varying purposes, sites
of service, and intensity, and that the resultant data are not
representative of any one of these. Other commenters stated that the
code contains three separate procedures of varying intensity:
Electrophysiology study, intraoperative device interrogation, and
noninvasive programmed stimulation. Several commenters believed that
the payment change would have a severe financial impact on their
hospitals. They believed it is inappropriate to make the change without
the data to justify the change. Several commenters stated that the
change would have a significant impact on the use of CRT-D implants
because the devices are more costly. The commenters suggested that,
before considering a revision to DRGs 535 and 536 for code 37.26, CMS
should resolve the coding confusion. The commenters asked that the code
be discussed at the September 29, 2005 ICD-9-CM Coordination and
Maintenance Committee meeting and suggested that separate codes be
created for the different procedures currently captured by code 37.26.
According to the commenters, the new codes that are created could go
into effect on October 1, 2006. The commenters suggested that, once
data are available, CMS should consider a revision to DRGs 535 and 536
for EPS procedures.
Response: We agree with the commenter that there is considerable
confusion regarding the use of code 37.26. It is possible that code
37.26 is being used for a variety of electrophysiologic procedures such
as EPS, noninvasive programmed electrical stimulation, and programmed
electrical stimulation. However, as indicated in the proposed rule and
above in this final rule, our data show that the cases coded with 37.26
that were not separately coded with a cardiac catheterization had
average charges of $98,900.13 in DRG 535 and $85,390.88 in DRG 536
compared to $127,130.79 and $110,493.86, respectively, for all other
cases in these DRGs. For this reason, we believe it is appropriate to
include code 37.26 in DRG 515 and no longer assign it to DRGs 535 and
536 that are for patients who receive a cardiac catheterization.
As we discussed earlier in this section of the preamble, Medicare
significantly expanded coverage of implantable defibrillators on
January 27, 2005 (Pub. No. 100-3, section 20.4) to patients who have a
prior history of heart disease but are not in acute heart failure.
These prophylactic defibrillator implants are expected to significantly
increase the number of patients in DRGs 515, 535, and 536. It is our
experience that most of these patients will not be receiving a cardiac
catheterization and will be less resource-intensive than the acute
heart failure patients receiving an implantable defibrillator. We note
that the Bernstein Research Call publication of April 27, 2005 stated
that this DRG change could ``dampen the elective implantation of de-
novo CRT-D or dual chamber devices into relatively stable patients.''
The article further states that CMS ``realizes that the new
prophylactic ICD [implantable cardioverter defibrillators] eligibility
requirements do not require an EP test, and that EP tests per se do not
consume sufficient resources to justify the reimbursement differentials
seen between DRGs 515 versus 535 and 536.'' We believe it is
particularly important to make the change to DRGs 515, 535, and 536 at
this time, given the expansion of Medicare coverage of implantable
defibrillators and the evidence that suggests that patients who receive
an EP test, but not a cardiac catheterization, are less expensive than
other patients receiving these devices.
We will address code 37.26 at our September 29-30, 2005 meeting of
the ICD-9-CM Coordination and Maintenance Committee meeting. The public
is encouraged to participate in this meeting and offer suggestions for
code modifications. Information on this meeting can be found at: http://www.cms.hhs.gov/paymentsystems/icd9.
Comment: Five commenters stated that CMS' data show that the
average charges for cases with code 37.26 are significantly higher than
those in DRG 515. The commenters suggested that the volume of cases is
significant enough to create a new DRG for cases with cardiac
defibrillator implant without cardiac catheterization, but with code
37.26.
Response: Given the extensive comments concerning coding problems
with code 37.26, we do not believe it is appropriate to create a new
DRG that would specifically capture defibrillator implants with this
code. Therefore, we are not creating the suggested new DRG at this
time. As stated earlier, we will continue to work with the coding and
health care community to modify code 37.26 so that it will lead to more
consistent reporting. Once we have better data, we will evaluate
additional DRG modifications.
After consideration of the public comments received on the proposed
rule, in this final rule, we are implementing the modification of DRGs
535 and 536 as proposed for FY 2006. We are removing code 37.26 from
the list of cardiac catheterizations for DRGs

[[Page 47292]]

535 and 536 and adding the code in DRG 515.
c. 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. In the FY 2006
proposed rule (70 FR 23318 through 23319), we included the following
discussion regarding the commenter's concerns:

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
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.''

In response to those comments, we analyzed the MedPAR data to
determine the impact of certain secondary diagnoses or complicating
conditions on the four stent DRGs. 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

[[Page 47293]]

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
(Subarachnoid hemorrhage), 431 (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 (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 (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. Because 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. The 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.
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.)
Thus, we proposed to restructure the coronary stent DRGs on the
basis of the standard CC list to differentiate cases that require
greater resources. We believed this list to be more inclusive of true
comorbid or complicating conditions than selection of specific
secondary diagnosis codes. Therefore, we anticipated that restructuring
these DRGs on this basis would result in a logical arrangement of cases
with regard to both clinical coherence and resource consumption. We
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 encompassed most of the cases on the
recommended list, as well as other cases with additional CCs requiring
additional resources. We 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:

----------------------------------------------------------------------------------------------------------------
Number of Average length- Average
DRG cases of-stay charges
----------------------------------------------------------------------------------------------------------------
DRG 516--All Cases.............................................. 37,325 4.79 $40,278
DRG 516 Cases With CC........................................... 25,806 5.5 43,691
DRG 516 Cases Without CC........................................ 11,519 3.0 32,631
DRG 517--All Cases.............................................. 64,022 2.58 32,145
DRG 517 Cases With CC........................................... 50,960 2.8 33,178
DRG 517 Cases Without CC........................................ 13,062 1.5 28,113
DRG 526--All Cases.............................................. 51,431 4.36 45,924
DRG 526 Cases With CC........................................... 32,904 5.2 49,751
DRG 526 Cases Without CC........................................ 18,527 2.8 39,126
DRG 527--All Cases.............................................. 176,956 2.23 36,087
DRG 527 Cases With CC........................................... 137,641 2.4 37,142
DRG 527 Cases Without CC........................................ 39,315 1.3 32,392
----------------------------------------------------------------------------------------------------------------

[[Page 47294]]

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 suggested that a ``with and without CC'' split in
DRG 516 and 526 was warranted. At the same time, the data did not show
such a clear differentiation, in either average charges or lengths of
stay, among the cases in DRGs 517 and 527.
As a result of this analysis, in the proposed rule, we had
originally proposed to delete DRGs 516 and 526, and to substitute four
new DRGs in their place. These new DRGs were to have been 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 intended 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 did not
support restructuring DRGs 517 and 527 based on the presence or absence
of a CC. Therefore, we proposed to retain these two DRGs in their
current forms. We believed this revised structure would result in a
more inclusive and comprehensive array of cases within MDC 5 without
selectively recognizing certain secondary diagnoses as ``complex.''
We received a number of comments on the proposed restructuring of
DRGs 516, 517, 526, and 527 in the FY 2006 IPPS proposed rule.
Comment: All of the commenters approved of the proposed
restructuring of these DRGs, especially with regard to dividing DRGs
516 and 526 on the basis of the presence or absence of complicating
secondary diagnoses.
Response: We appreciate the comments submitted in support of this
proposal.
Comment: One commenter noted that the average patient receives 1.5
stents, and expressed the desire for CMS to begin ``appropriate
reimbursement'' in FY 2006, consistent with the additional expense
involved when multiple stents are inserted. One commenter remained
concerned that the DRG weights significantly underestimate the true
costs of performing drug-eluting stent procedures, especially for
multiple vessel, multiple stent procedures, and expressed concern that
the proposed relative weights could result in financial losses for
hospitals, with the result that access to stent procedures is
discouraged.
Response: We created new ICD-9-CM procedure codes effective for
discharges on or after October 1, 2005, to capture both the number of
stents inserted and the number of vessels treated. Absent accurate
charge data, we cannot predict the correct relative weight for a DRG
containing more than one stent. We reiterate that we will continue to
monitor the MedPAR data, and will make future evidence-based changes to
the DRG structure and logic as warranted.
Comment: Several commenters supported the maintenance of separate
reimbursement structures for drug-eluting stents and recommended that
we continue to separate drug-eluting and bare metal stents in different
DRGs until such time as the bare metal stents represent an
insignificant proportion of the total coronary stent discharges.
Response: We recognize that the resources surrounding bare metal
stents and drug-eluting stents differ appreciably and will continue to
keep these cases separate from each other until such time as it is
appropriate, according to the evidence provided in our MedPAR data,
that these cases can be combined.
Comment: Several commenters supported CMS' proposal to create eight
new procedure codes; four codes describing the number of vessels
treated and four codes describing the number of stents inserted. In
addition, two commenters suggested that CMS should issue a separate
communication reiterating the correct use of these codes.
Response: We take this opportunity to clear up a misconception. The
codes published in Tables 6A through 6F are not proposed codes. They
are final codes, and as such, are not subject to comment. Absent any
typographical errors or late changes to the codes, they may be
considered available for use on October 1 of the following fiscal year.
This year, because of the changes made by the March 31, 2005 and April
1, 2005 ICD-9-CM Coordination and Maintenance Committee, the codes in
the proposed rule were not as complete as those codes published in this
final rule. The codes contained in Tables 6A through 6F of this final
rule include all new codes for FY 2006, which will go into effect on
October 1, 2005.
CMS partners with the American Hospital Association with regard to
correct coding advice published in the Coding Clinic for ICD-9-CM.
AHA's fourth edition of the year always includes the new codes for the
upcoming year and includes examples on their proper use. In addition,
CMS' MedLearn site at http://www.cms.hhs.gov/medlearn/icd9code.asp#top
contains coding information.
Comment: One commenter recommended that the use of the eight new
codes describing number of vessels and number of stents be used on both
coronary and peripheral vessels.
Response: The note that will appear at the top of the 00.4 (Adjunct
Vascular System Procedures) section of Tabular section of the ICD-9-CM
Procedure Coding Book will read as follows: ``These codes can apply to
both coronary and peripheral vessels. These codes are to be used in
conjunction with other therapeutic procedure codes to provide
additional information on the number of vessels upon which a procedure
was performed or the number of stents inserted, or both. As
appropriate, hospitals should code both the number of vessels operated
on (00.40 through 00.43) and the number of stents inserted (00.45
through 00.48).
Comment: One commenter stated that by the time CMS gets data on the
eight new codes, it will be FY 2008, and hospitals will have had
inadequate reimbursement for multiple stents until then. The commenter
suggested that CMS incorporated additional payment for multiple stents
and multiple vessels treated into the FY 2007 weights.
Response: We will follow the use of these codes, but may not be
prepared to make any DRG changes based on their use with only one
year's worth of data.
Comment: One commenter stated that DRGs should not be restructured
for multiple stent insertion without adequate data to support our
decisionmaking process.
Response: We agree and intend to closely follow the use of these
eight new codes in the MedPAR data.
Comment: One commenter was not convinced that the proposed new
structure of DRGs 516 and 526, with and without comorbidities and
complications should be the permanent solution for all coronary stent
DRGs. This commenter agreed that the new structure of these DRGs should
not preclude subsequent restructuring of the stent DRGs.
Response: We agree that restructuring DRGs 516 and 526 in the
proposed manner might not be a permanent solution for classifying all
stent DRGs. However, we have now decided not to adopt the proposed
restructuring of DRGs 516 and 526 that was described in the proposed
rule. We have now determined that it is appropriate to restructure nine
DRGs in MDC 5, including DRGs 516, 517, 526, and 527,

[[Page 47295]]

on the basis of the presence or absence of a major cardiovascular
condition. We are making this change in the DRG structure in response
to public comments concerning our response to MedPAC's recommendations
to better recognize severity in the DRG system. The full text of the
changes we are making to the cardiovascular DRG, including the coronary
artery stent DRGs, can be found in section IX.A. of this final rule.
Comment: One commenter requested that CMS adopt an ICD-9-CM code
that was discussed at the October 7, 2004 ICD-9-CM Coordination and
Maintenance Committee. That code, had it been adopted, would have been
00.44 (Procedure on bifurcated vessels) in the new series of codes
describing the number of vessels treated. The commenter stated that the
creation of this code is critical to understanding the contemporary
approaches to treatment of coronary artery disease. The commenter
further stated that treatment of stenosis [of a blood vessel] at a
bifurcation represents 25 to 30 percent of percutaneous coronary
interventions and recommended that coders use one code for number of
vessels, one code for number of stents, and an additional code to note
that a bifurcated vessel was treated. According to the commenter, a new
code for the treatment of a bifurcated vessel is necessary because the
existing codes that describe the number of vessels treated (codes 00.40
through 00.43) will only be used by coders for the counting of
uninterrupted, straight vessels.
Response: We did not choose to create a new code for procedure on a
bifurcated vessel for two reasons. First, we do not believe that level
of granularity is needed in order to accurately code stent insertion
for bifurcated vessels. We believe that the codes for multiple stents
and vessels will provide the necessary information about resource use
for the procedure. Second, we are concerned that coders will not have
sufficient information documented in the medical record to identify
procedures on bifurcated vessels as opposed to a specific number of
procedures on a specific number of vessels. Because procedures on
bifurcated vessels are so prevalent (25 to 30 percent, according to the
commenter), they should be considered technical variants rather than
distinct entities to be coded separately. We solicited input from the
industry when creating the new coronary stent codes, and we believe
that the new codes as they exist adequately capture resource
utilization. We also note that this level of detail is not present in
the Current Procedural Terminology (CPT) coding structure, which is the
basis upon which physicians are paid.
Accordingly, in this final rule, for FY 2006, we are deleting DRGs
516, 517, 526, and 527 for percutaneous placement of both drug-eluting
and nondrug-eluting stents. We are creating four new DRGs in their
places. Rather than divide these DRG pairs based on whether the patient
had an acute myocardial (AMI), we are splitting each pair of DRGs based
on the presence or absence of a major cardiovascular condition.
Although, as discussed in the proposed rule, in the past we have
expressed concerns regarding selectively recognizing secondary
diagnoses or complicating conditions, particularly conditions from
other MDCs, in making DRG assignments, we believe these concerns are
not relevant to the new cardiovascular DRGs. While we are adopting an
approach for distinguishing patients with complex conditions, with a
few exceptions, our approach uses complex cardiovascular conditions (or
diagnoses within the MDC) to decide whether a patient should be
assigned to the higher weighted DRG. In those cases where we have used
a diagnosis from another MDC in assigning a patient to the MCV DRG, the
condition is generally a closely related vascular condition that is
linked to the patient's cardiovascular illness. We believe that this
revised structure identifies subgroups of significantly more severe
patients who use greater hospital resources more accurately than was
possible under the previous DRGs. The new DRG titles are:
DRG 555 (Percutaneous Cardiovascular Procedure With Major
Cardiovascular Diagnosis (formerly DRG 516)
DRG 556 (Percutaneous Cardiovascular Procedure With Non-
Drug-Eluting Stent Without Major Cardiovascular Diagnosis (formerly DRG
517)
DRG 557 (Percutaneous Cardiovascular Procedure With Drug-
Eluting Stent With Major Cardiovascular Diagnosis (formerly DRG 526)
DRG 558 (Percutaneous Cardiovascular Procedure With Drug-
Eluting Stent Without Major Cardiovascular Diagnosis (formerly DRG 527)
We refer the reader to section IX.A. of the preamble to this final
rule for a full presentation of the changes to the DRGs for coronary
artery stents for FY 2006.
Although we are adopting some restructuring of the coronary stent
DRGs for FY 2006, it is important to note that this change does not
preclude proposals in subsequent years to further restructure the
coronary stent DRGs based on the number of vessels treated. 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.
After we have pertinent data in our historical MedPAR database, we will
analyze those data in order to determine whether a restructuring of the
DRGs based on multiple vessel treatment or insertion of multiple
stents, or both, is warranted.
We refer the reader to Table 6B of this final rule for the
descriptions of 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). Coders are encouraged to use as many codes as necessary to
describe each case, using new code 00.66 (Percutaneous transluminal
coronary angioplasty [PTCA] or coronary atherectomy) and one code each
for the number of vessels treated and the number of stents inserted.
Coders are encouraged to record codes accurately, irrespective of
whether the code has an impact on the DRG assignment, as these data
will potentially be the basis for future DRG restructuring.
d. Insertion of Left Atrial Appendage Device
Atrial fibrillation is a common heart rhythm disorder that can lead
to a cardiovascular blood clot formation

[[Page 47296]]

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:

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 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:

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 this
analysis, we proposed to move procedure code 35.52 out of DRG 108 and
place it in DRG 518.
Comment: One commenter agreed that the left atrial appendage device
procedure code should be moved out of DRG 108 and into DRG 518 based on
significantly lower average charges and length of stay as compared to
the majority of cases within the current classification.
Response: Even though this comment did not exactly reflect our
proposal regarding the left atrial appendage device, we are
interpreting the commenter's statement to mean that it agreed that code
35.52 should be removed from DRG 108.
Comment: One commenter addressed the proposed removal of code 35.52
from DRG 108. The commenter acknowledged that the resource intensity
for patients undergoing percutaneous atrial septal defect repair is
less than that of open repair, but did not believe that the costs are
akin to procedures presently assigned to DRG 518 because of the cost of
the closure device and additional testing, such as electrocardiography.
The commenter recommended that CMS not move code 35.52 out of DRG 108
until better data can be gathered and a more appropriate reimbursement
calculation can be developed.
Response: This year, CMS undertook an extensive review of MDC 5
after issuance of the FY 2006 IPPS proposed rule in response to
MedPAC's recommendations regarding restructuring the Medicare DRG
system to improve payment accuracy under the IPPS. A discussion of the
results of that review and our subsequent decision in response to a
comment on the proposed rule to make changes to nine cardiovascular
DRGs, can be found in section IX.A. of this preamble. During that
review, we evaluated each surgical DRG within MDC 5. In addition,
within each DRG, we evaluated each procedure code to determine the
number of cases,

[[Page 47297]]

the average length of stay, and the average standardized charges. In
DRG 108, the results were the same as in the table shown above in this
section, and published in the FY 2006 IPPS proposed rule. Code 35.52
had an average length of stay of approximately one fourth of the rest
of the cases in that DRG, and had average charges that were greater
than $51,700 less than the remainder of the cases in DRG 108. In
addition, code 35.52 represents a closed technique approach, unlike the
other cases in DRG 108. We believe this is compelling evidence that
this procedure is not most appropriately assigned to DRG 108.
Therefore, we are finalizing our proposal to move code 35.52 out of DRG
108 and into DRG 518 with cases that resemble it in average length of
stay, average charges, and clinical coherence. We believe that this
move will result in a more coherent group of cases in DRG 518 that
reflect all percutaneous procedures.
Comment: Three commenters did not believe that the left atrial
appendage device, represented by new code 37.90, should be placed in
DRG 518. They believed that DRG 518 does not cover the costs for the
procedure and device, and suggested placement in another DRG that would
include similar procedures and a better reimbursement. Two commenters
suggested that a more appropriate DRG would be either DRG 108 or DRG
111 (Major Cardiovascular Procedures Without CC).
Response: Based on our data review and discussion above, we do not
believe that placement of code 37.90 is appropriate in DRG 108. Code
37.90 is a percutaneously placed device utilizing local anesthesia, and
with an expected length of stay of one day.
We reviewed cases in the MedPAR file assigned to both DRG 110
(Major Cardiovascular Procedures With CC) and DRG 111. The results of
the review show that both open and percutaneous procedures are grouped
in these paired DRGs. A comparison of the MedPAR data in DRGs 110, 111,
and 518 is shown in the following table:

----------------------------------------------------------------------------------------------------------------
Average
DRG Number of Average length standardized
cases of stay charges
----------------------------------------------------------------------------------------------------------------
DRG 110......................................................... 53,527 \1\ 8.4 $66,475
DRG 111......................................................... 9,438 \1\ 3.43 26,941
DRG 518--All cases.............................................. 38,624 3.49 27,591
DRG 518 with code 37.90......................................... 0 0 0
----------------------------------------------------------------------------------------------------------------
\1\ Days.

As shown in the table, code 37.90 in DRG 518 has not been reported
in the database yet. It is a new code; therefore, it has no payment
history. We note that the cases in DRG 518 closely match those in DRG
111 in terms of both average length of stay and average charges.
However, we also note that DRGs 110 and 111 are paired DRGs with
significantly different average charges and lengths of stay. Even with
a CC, we believe it is unlikely that an endovascular placement of a
left atrial appendage device will approximate the costs of cases to be
assigned to DRG 110. Therefore, in our view, there is the potential for
significant overpayment if we were to assign the left atrial appendage
device to DRG pairs 110 and 111. We continue to believe that placement
of the left atrial appendage device in DRG 518 is appropriate absent
any evidence that would convince us otherwise. Therefore, we are not
making any changes in our proposal in this final rule. We will continue
to monitor its data in our annual review of DRGs and the IPPS.
As we proposed, in this final rule we are moving procedure code
35.52 out of DRG 108 and placing it in DRG 518. We believe that this
move will result in a more coherent group of cases in DRG 518 that
reflect all percutaneous procedures.
e. 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 subsequent 2 years, we decided
to realign the 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
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 the patients 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).

[[Page 47298]]

Further, the Medicare charge data show that patients in DRG 525
receiving the external heart assist system had an average length of
stay that was more than 28 days less than all patients in DRG 103.
The manufacturer suggested that the payment differential between
DRGs 103 and 525 provides 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 (code
37.66). 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:

----------------------------------------------------------------------------------------------------------------
Number of Average length Average
DRG cases of stay charges
----------------------------------------------------------------------------------------------------------------
DRG 103--All cases.............................................. 633 37.5 $313,583
DRG 103 with code 37.65 reported................................ 9 81.3 625,065
DRG 525--All cases.............................................. 291 13.66 173,854
DRG 525 with code 37.65 reported................................ 110 9.26 206,497
DRG 525 without code 37.65 reported............................. 181 16.34 154,015
----------------------------------------------------------------------------------------------------------------
Note: This table does not contain the same data that appear in the table in the proposed rule (70 FR 23322). The
row containing ``DRG 103 without code 37.65'' had values of ``0'' in all fields. These entries were confusing
and therefore deleted.

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 all 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 overpaid, which would be inconsistent with our
goal of coherent reimbursement structure within the DRGs. In addition,
the relative weight of DRG 103 would ultimately 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 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 did not propose to make any changes to the structure of
either DRG 103 or DRG 525.
Comment: Six commenters mentioned the high cost of the external
heart assist device and for treatment for implantation of the device,
and requested that CMS increase payment to cover the cost of caring for
the patients that can benefit from this technology.
Two commenters agreed with CMS' assessment that the cost associated
with implantation of an external heart assist system are considerably
less than a heart transplant or insertion of an implantable heart
assist system. One commenter echoed CMS' concerns that movement of code
37.65 to DRG 103 would result in overpayment for that service and would
result in a decrease of the relative weight of the heart transplant
DRG, ultimately resulting in underpayment of heart transplant cases.
Both commenters agreed with CMS' decision not to include the
implantation of external heart assist systems in DRG 103.
Several commenters noted that significant achievements in the areas
of patient selection, implantation technique, and post-implant
management have been made surrounding this technology. They added that
improvements in the external heart assist device itself have been
reported to make the newer devices safer and more durable. One
commenter noted that observations from personal experience and research
demonstrate that recent improvements to the device have resulted in
increased survival rates from 35 percent (the national average) to
nearly 50 percent. Several commenters mentioned that, with experience,
they have discovered that a longer period of support is required than
was originally anticipated for the patient's native heart to recover.
The commenters stated that, originally, patients were supported an
average of 5 to 7 days, but it has been found that patient outcomes
were better with a longer support period, perhaps as long as 30 to 60
days. These commenters cited the increased expenses related to
supporting the patient and the major financial commitment on the part
of the hospitals choosing to treat this severely ill group of patients
as reasons for requesting increased payment for this population of
cases.
One commenter offered the following four proposals to address the
payment differences between the external heart assist device and an
implantable device:
Create a new DRG for patients requiring heart assist
devices who also sustained an Acute Myocardial Infarction (AMI) because
these patients have higher resource consumption than patients with
other diagnoses in MDC 5.
Assign all cases with AMI and a procedure code of 37.65 to
DRG 103.
Increase the overall weight of DRG 525 to better align it
with ``true hospital charges.''
Allow a second DRG payment or an add-on payment for heart
transplantations if recovery of the patient's native heart is first
attempted.
Response: We appreciate the commenters' thorough understanding of
the IPPS DRG grouping and payment process. We are aware that the
external heart assist device cases represent a very resource-intensive
group of patients. For this reason, we carefully reviewed the
suggestions from the commenter about potential DRG payment policy
changes that we could make to address the issue. We reviewed the MedPAR
data in DRG 525, using ICD-9-CM codes 410.01 through 410.91 to identify
AMIs. In

[[Page 47299]]

addition, we reviewed all cases of patients who received the external
heart assist device procedure represented by ICD-9-CM code 37.65. The
results are summarized in the following table:

----------------------------------------------------------------------------------------------------------------
Average length
Number of of stay Average
cases (days) charges
----------------------------------------------------------------------------------------------------------------
DRG 525--Cases with Any Diagnosis of AMI........................ 46 8.5 $195,758
DRG 525--Cases of Principal Diagnosis of AMI.................... 31 8.9 210,369
DRG 525--Cases with Secondary Diagnosis of AMI.................. 15 7.7 165,562
DRG 525--Cases with No Diagnosis of AMI......................... 71 9.2 204,472
DRG 525--All Cases.............................................. 291 13.66 206,497
----------------------------------------------------------------------------------------------------------------

We do not believe that these data demonstrate that the presence of
an AMI has significant impact on either the length of stay or the
average standardized charges. All cases with AMI have lower lengths of
stay than both the average of all cases in DRG 525 (13.66 days) and the
71 cases in which no AMI was documented (9.2 days). Likewise, only
those cases with a principal diagnosis of AMI have slightly higher
charges than either the group without AMI, or the total of all cases.
Because the data do not justify it, we are rejecting the suggestion of
creating a new DRG for patients receiving an external heart assist
device, as identified by procedure code 37.65, with any diagnosis of
AMI.
With respect to the commenter's second suggestion, our data clearly
demonstrate in the above table that patients with an AMI and procedure
code 37.65 have average standardized charges of $210,369. The first
table in this section that was included in the proposed rule shows that
cases in DRG 103 have average standardized charges of $313,583. We
believe that the relative weight of DRG 103 would eventually decrease
by moving all of the less resource-intensive external heart procedures
into the same DRG with the more expensive heart transplant cases. For
these reasons, we are rejecting the commenter's proposal to assign
cases with AMI and code 37.65 to DRG 103.
With regard to the suggestion (received many times) to selectively
increase the relative weight of specific DRGs, the DRG relative weights
are annually recalibrated based on Medicare hospital discharges using
the most current charge information available (FY 2004 MedPAR file for
the FY 2006 relative weights). We use a complex mathematical algorithm
to determine the relative weights that is fully explained in section
II. of this preamble. The DRG relative weights are neither arbitrarily
nor capriciously assigned. However, if we adopted the suggestion to
select a relative weight for a specific DRG outside of this process, we
are concerned that the relative weight determination would be viewed as
arbitrary and capricious, and we would lose the advantage of having an
objective methodology that bases the relative weight on average
hospital charges. For this reason, we are not adopting the commenter's
suggestion to select a relative weight for external heart assist device
cases outside of our traditional process.
The commenter's fourth suggestion was to make two payments for a
single inpatient stay when the patient receives the external heart
assist system, recovery of the patient's native heart is attempted and
fails, and the patient receives a heart transplant. In cases where the
patient received the external heart assist system and later receives a
heart transplant, the case is already paid using DRG 103. In this
situation, the relative weight for DRG 103 will reflect the average
charges for all patients in the DRG, including those described in the
scenario presented by the commenter. Thus, to the extent that hospital
charges for these patients are already reflected in the relative weight
for the DRG, we do not believe that it is necessary for Medicare to
make a second payment. To arbitrarily select one DRG, or a group of
DRGs, and add an additional DRG payment to those cases is contrary to
our stated goal of having a system in which all cases are fairly
considered by the same recalibration formula. Therefore, we do not
intend to either determine an additional DRG payment or an add-on
payment for this category of patients.
We reiterate that our data do not support the argument that
patients receiving the external heart assist device have longer lengths
of stay than other patients in DRG 525, even though the data show that
their average charges are higher, as noted in the above table. In
determining the possible reasons for higher average charges and lower
lengths of stay, we further examined the Medicare billing data. We
found that almost 76 percent of the Medicare beneficiaries receiving
the external heart device expired during the hospital stay. Thus, the
shorter length of stay and the higher average charges for these
patients compared to other patients in DRG 525 are likely explained by
the high cost of the device and the fact that these patients are
severely ill and frequently expire.
Upon further analysis of the data, we did find that there was a
single subgroup of patients who are comparable in resource usage and
length of stay to those included in DRG 103. These patients received
both the external heart assist device and later had it removed after a
lengthy period of rest and recovery. We note that commenters provided
information indicating that survival rates are improving for patients
receiving more advanced versions of these devices. In addition,
commenters provided information indicating that longer periods of
support with the external heart assist device are improving patients'
survival chances and opportunity to be discharged with their native
heart. According to information included with the comments, the data
show a 50-percent survival rate with an average total length of stay of
43 days for all AMI heart recovery patients. On average, a surviving
patient will receive 31 days of average support time followed by an
additional 38 days in the hospital after the device is removed. Based
on the commenter's information from a later year than our MedPAR data,
it is clear that patients weaned from the external heart assist system
have longer lengths of stay and are very different from the average
patients having this procedure that are in our FY 2004 data. Given the
newness of this procedure, the Medicare charge data included a limited
number of patients having the device implanted and removed. However,
the Medicare charge data did support that patients receiving both an
implant and removal of an external heart assist system in a single
hospital stay had an average length of stay exceeding 50 days and
average charges of $378,000 that are more comparable to

[[Page 47300]]

patients in DRG 103 than DRG 525. While we did not suggest a change to
DRG 103 in the proposed rule, we believe that consideration of the
comments is best served by recognizing this unique subset of patients
and making a DRG change which acknowledges the increased resources
required for improvements in their care.
The commenter has provided us with data showing that with superior
patient selection, and increased duration of treatment with an improved
device, the patients are more likely to be discharged from the hospital
with the native heart intact. While we have limited Medicare data and
the data are from a different year than the commenter's data, our data
do support that patients having an external heart assist device
implanted and removed during the same admission are comparable to in
costs and average length of stay to heart transplant and implantable
heart assist system patients in DRG 103. While we did not suggest a
change to DRG 103 in the proposed rule, we believe that consideration
of the comments is best served by recognizing this unique subset of
patients, and making a DRG change that acknowledges the increased
resources required for improvement in their care. Because we believe
that this therapy offers a treatment option to patients who have
limited alternatives, we are making a change to the DRG using the
limited Medicare data we have available rather than waiting a year to
receive more supporting data.
For the reasons stated above, for FY 2006, we are reconfiguring DRG
103 in the following manner: Those patients who have both the
implantation of the external VAD (code 37.65) and the explantation of
that VAD (code 37.64) prior to the hospital discharge will be assigned
to DRG 103. The revised DRG 103 contains the following codes:
33.6, Combined heart-lung transplantation
37.51, Heart transplantation
37.66, Insertion of implantable heart assist system

Or
37.65, Implant of external heart assist system

And

37.64, Removal of heart assist system.
By making this change, Medicare will be making higher payments for
patients who receive both an implant and an explant of an external
heart assist system during a single hospital stay. Our intent in
establishing this policy is to recognize the higher costs of patients
who have a longer length of stay and are discharged alive with their
native heart. Cases in which a heart transplant also occurs during the
same hospitalization episode would continue to be assigned to DRG 103.
In order to accurately monitor these patients and obtain more
information on patients with these conditions, we intend to have the
Quality Improvement Organizations (QIOs, formerly the PROs) review all
cases in DRG 103 under the auspices of their eighth scope of work to
determine whether implantation and care during the admission were
reasonable and necessary to promote the recovery of the injured
myocardium and lead to improvement of the patient's condition. For
medical review under this contract, the QIOs determine whether items
and services are reasonable and medically necessary and whether the
quality of such services meets professionally recognized standards of
health care. In addition, in hospitals subject to the IPPS, the QIOs
review the validity of diagnostic information, the completeness,
adequacy, and quality of care provided, and the appropriateness of
admissions and discharges. We will continue to examine the claims data
in upcoming years to determine if CMS' consideration surrounding the
unique circumstances of these patients and this treatment modality were
in the best interest of both the patients and the Medicare program.
f. 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 its
April 1, 2004 meeting, the ICD-9-CM Coordination and Maintenance
Committee 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). We established
codes for carotid artery stenting procedures for use with discharges
occurring on or after October 1, 2004 inpatients who are enrolled in an
FDA-approved clinical trial and are using on-label FDA-approved stents
and embolic protection devices. These codes are as follows:

00.61 (Percutaneous angioplasty or atherectomy of
precerebral (extracranial vessel(s)); and
00.63 (Percutaneous insertion of carotid artery stent(s)).
We assigned procedure code 00.61 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). Other DRG assignments can be found in Table 6B of the
Addendum to the FY 2005 IPPS final rule (69 FR 49624).
In the FY 2005 IPPS 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 the FY
2006 IPPS proposed rule and this final rule, we used 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 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 carotid artery stenting. For this
evaluation, we used principal diagnosis code 433.10 (Occlusion and
stenosis of carotid artery, without mention of cerebral

[[Page 47301]]

infarction) to reflect the clinical trial criteria.
The following chart shows our findings:

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, 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.
We received 11 comments on our presentation of the carotid stent
device issue in the FY 2006 IPPS proposed rule.
Comment: One commenter recommended that CMS include carotid
stenting in the DRG for carotid endarterectomy in FY 2006 and ensure
that the data it is collecting for setting payment rates in FY 2007
appropriately accounts for the cost of the device.
Response: Code 38.12 (Endarterectomy, other vessels of head and
neck) describes the open endarterectomy procedure, and is assigned to
DRGs 533 and 534 which is the same DRG assignment as the endovascular
endarterectomy. Therefore, both the open endarterectomy and the
placement of carotid stent result in assignment to the same DRG, which
reflects CMS' policy of placing new codes in predecessor DRGs. We point
out that codes 00.61 and 00.63 must be used together to allow payment
for carotid stenting. Code 00.63 is not recognized by the GROUPER
program as a stand-alone O.R. procedure and, as such, has no impact on
DRG assignment. Therefore, we anticipate that the cost of the device
will be reflected in the hospital charges.
Comment: One commenter agreed with our presentation in the proposed
rule and suggested that we should make no change to the DRG assignment
for carotid artery stenting.
Response: We agree and will not be making a change to the DRG
assignment for carotid artery stenting.
Comment: Nine commenters encouraged CMS to create two new DRGs for
carotid stent procedures and split these new DRGs on the basis of the
presence or absence of comorbidities or complications. They believed
that, even though the current volume of carotid artery stenting cases
appears small, the recent availability of FDA-approved devices, new and
ongoing clinical trials, multiple post-market registries, as well as
expanded Medicare coverage, will result in a large increase in the
number of cases. They also expressed concern that the potential
increase in patient volume and their perceived inadequate payment for
carotid artery stent cases will create a financial hardship on
facilities providing this technology, potentially resulting in
decreased Medicare beneficiary access to this beneficial therapy.
Response: We continue to believe that the most appropriate changes
to the IPPS and the structure of the DRGs are based on evidence of a
significant difference in average costs between technology itself and
the DRG where its code is assigned. Because the ICD-9-CM procedure
codes are new, we do not have data showing that carotid artery stents
are more costly than other cases in DRGs 533 and 534. Further, using
codes 39.50 and 39.90 as proxies for carotid artery stenting, we did
not observe a substantial difference in average charges between cases
using these codes and other cases in the DRGs. For this reason, we do
not have sufficient evidence to warrant a DRG change at this time.
In this final rule, we are retaining code 00.61 in DRGs 533 and 534
for FY 2006. We will continue to monitor the Medicare charge data in
our annual review of DRGs and the IPPS.
g. 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.
Prior to the proposed rule, 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.

[[Page 47302]]

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:

----------------------------------------------------------------------------------------------------------------
Average
Number of Average length Average charges for
DRG with code 39.65 reported cases of stay charges for all cases in
ECMO cases the DRG
----------------------------------------------------------------------------------------------------------------
4.............................................. 23 9 $147,766 $120,496
105............................................ 21 8 131,700 89,831
541............................................ 14 62.9 561,210 273,656
All Other DRGs................................. 20 18.1 308,341 NA
----------------------------------------------------------------------------------------------------------------

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 proposed to reassign ECMO cases reporting code 39.65
to DRG 541. We also proposed 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.
Procedure''.
Comment: Several commenters supported the proposed modification to
ECMO cases reporting code 39.65 to DRG 541.
Response: We appreciate the commenters' support.
Accordingly, in this final rule, we are adopting as final the
proposed change to ECMO cases reporting code 39.65 to DRG 541 with
minor modification. To further clarify the change, we are changing the
title of DRG 541 to ``ECMO or Tracheostomy With Mechanical Ventilation
96+ Hours or Principal Diagnosis Except Face, Mouth, and Neck With
Major O.R.'' This title has been modified since the proposed rule (70
FR 23324) to delete the term ``Diagnoses'' from the title. For
consistency purposes, we are also changing the DRG title for DRG 542
from ``Tracheostomy With Mechanical Ventilation 96+ Hours or Principal
Diagnosis Except Face, Mouth, and Neck Diagnoses Without Major O.R.
Procedure'' to ``Tracheostomy With Mechanical Ventilation 96+ Hours or
Principal Diagnosis Except Face, Mouth, and Neck Without Major O.R.''
6. 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 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 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 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 the 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,

[[Page 47303]]

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 did not propose any further changes to the DRGs for these
procedures at this time. Neither did we propose to change the structure
of DRGs 146 or 147 at this time.
Comment: One commenter agreed that we should maintain the current
DRG assignment for codes 49.75 and 49.76. The commenter recommended
that CMS continue to monitor the use of these codes and their DRG
assignment.
Response: We acknowledge the support of the commenter and will
continue to monitor utilization of the services with codes 49.75 and
49.76.
For FY 2006, we are retaining codes 49.75 and 49.76 within DRGs 146
and 147, as proposed.
7. 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/ icd9/. We also received written comments on this
request prior to the issuance of the FY 2006 IPPS proposed rule.
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- 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 as 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
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

[[Page 47304]]

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 final 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 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 the FY 2006 IPPS 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

[[Page 47305]]

$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.

----------------------------------------------------------------------------------------------------------------
Average length
DRG Number of of stay Average
cases (days) charges
----------------------------------------------------------------------------------------------------------------
209--All cases.................................................. 430,776 4.57 $30,695.41
209 With hip replacement codes 81.51 and 81.52 reported......... 181,460 5.21 31,795.84
209 With hip revision code 81.53 reported....................... 20,894 5.57 38,432.04
209 With knee replacement code 81.54 reported................... 209,338 3.92 28,525.66
209 With knee revision code 81.55 reported...................... 18,590 4.64 35,671.66
----------------------------------------------------------------------------------------------------------------

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
proposed 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 proposed to assign the following codes to the new proposed DRG
544: 81.51, 81.52, 81.54, 81.56, 84.26, 84.27, and 84.28.
We proposed to assign the following codes to the proposed new DRG
545: 00.70, 00.71, 00.72, 00.73, 00.80, 00.81, 00.82, 00.83, 00.84,
81.53, and 81.55.
In response to the FY 2006 IPPS proposed rule, we received the
following public comments:
Comment. Four commenters supported our proposal to delete DRG 209
and to create proposed new DRGs 544 and DRG 545. One commenter stated
that the proposed rule reveals that the average joint revision charges
are $7,000 higher than original joint replacements, which supports the
point that joint revision procedures are more resource-intensive than
initial replacements.
Another commenter commended CMS for its efforts to provide
appropriate payment for revision hip and knee arthroplasty by proposing
to split DRG 209 into DRG 544 and 545, and to expand the scope of the
relevant ICD-9-CM procedure codes included in these DRGs. The commenter
stated that the new codes, in particular, are an important component in
aligning hospital reimbursement with hospital costs and patient
benefits of total joint arthroplasty. The commenter encouraged CMS to
continue its dialogue with industry and providers regarding further DRG
changes to primary joint arthroplasty procedures, which represent
approximately 90 percent of total hip and knee arthroplasty procedures.
One commenter recommended that CMS consider the number of
individual components used in the joint replacement when future DRG
revisions are made. The commenter stated the hospital's costs will vary
based on the number of parts replaced during the procedure. According
to the commenter, we may be overpaying simple head and/or liner
exchanges in hips, and patellar/insert exchanges in knees relative to
primary hip and knee procedures. The commenter indicated that, with the
more specific ICD-9-CM codes, CMS will be able to evaluate further
changes in the joint replacement and revision DRGs.
We did not receive any comments that opposed the proposed DRG
revisions for hip and knee replacements.
Response: We appreciate the support of the commenters. We will use
the data obtained from use of the new codes to consider future DRG
revisions for joint replacement and revision procedures.
In this final rule, for FY 2006, we are adopting the DRG revisions
relating to hip and knee replacements as proposed. We are deleting DRG
209 and creating new DRG 544 (Major Joint Replacement or Reattachment
of Lower Extremity) and new DRG 545 (Revision of Hip or Knee
Replacement). The new DRG 544 includes the following code assignments:
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
The new DRG 545 includes the following code assignments:
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 believe that the creation of the new DRGs 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

[[Page 47306]]

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 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 the FY 2006 IPPS 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:

----------------------------------------------------------------------------------------------------------------
Number of Average length Average
DRG cases of stay (days) charges
----------------------------------------------------------------------------------------------------------------
233--All cases.................................................. 14,066 6.66 $28,967.78
233 With code 78.49 reported.................................... 8,702 5.91 25,402.71
233 Without code 78.49 reported................................. 5,364 7.88 34,571.39
234--All cases.................................................. 7,106 2.79 18,954.80
234 With code 78.49 reported.................................... 4,437 2.61 18,426.11
234 Without code 78.94 reported................................. 2,669 3.09 19,833.71
----------------------------------------------------------------------------------------------------------------

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, in the FY 2006 IPPS
proposed rule, we did not propose to change the DRG assignment of code
81.66 to DRGs 233 and 234.
Comment: Two commenters supported our proposal not to change the
DRG assignment of code 81.66 (Kyphoplasty). Both commenters agreed with
our proposal to keep code 81.66 in DRGs 233 and 234. They also agreed
that we should wait for bill data using the new kyphoplasty code prior
to considering any DRG modification.
Response: We appreciate the commenters' support for our proposal.
In this final rule, for FY 2006, we are retaining the assignment of
code 81.66 in DRGs 233 and 234. As we proposed, we will consider
whether further changes are warranted once additional hospital charge
data are available using the new code.
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 IPPS 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)

[[Page 47307]]

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 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
remain 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.

----------------------------------------------------------------------------------------------------------------
Average length
DRG Number of of stay Average
cases (days) charges
----------------------------------------------------------------------------------------------------------------
497............................................................. 27,346 6.08 $64,471.82
498............................................................. 17,943 3.80 48,440.80
497 and 498 With spinal fusions of 4 or more vertebrae reported. 7,881 6.3 77,352.00
497 and 498 With principal diagnosis of curvature of the spine 2,006 8.91 95,315.00
or bone malignancy.............................................
----------------------------------------------------------------------------------------------------------------

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 proposed to create a new DRG 546 for
noncervical spinal fusions with a principal diagnosis of curvature of
the spine and malignancies: proposed new DRG 546 (Spinal Fusions Except
Cervical With Principal Diagnosis of Curvature of the Spine or
Malignancy). We proposed to include in the proposed new DRG cases all
noncervical spinal fusions cases previously assigned to DRGs 497 and
498 that have a principal diagnosis of curvature of the spine or
malignancy and with 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. We proposed
that 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 and that 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). Therefore,
we limited our proposed changes to the spinal fusion DRGs for FY 2006
to the creation of the proposed DRG 546 discussed above. However, we
indicated that 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 also solicited
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.
Comment: A number of commenters supported our proposal to create
new DRG 546 (Spinal Fusions Except Cervical With Principal Diagnosis of
Curvature of the Spine or Malignancy) to include all noncervical spinal
fusions previously assigned to DRGs 497 and 498 that have a principal
diagnosis of curvature of the spine or malignancy. One commenter stated
that the addition of new DRG 546, with its higher weight, would help
reimburse hospitals more adequately for the resources used in treating
patients with significant spinal deformities and other problems. One
commenter stated that the cost associated with a multilevel spine
fusion when the patient has a diagnosis of curvature of the spine or
malignancy exceeds the current Medicare reimbursement.
Several commenters noted that the following four ICD-9-CM diagnosis

[[Page 47308]]

codes are manifestation codes that cannot be reported as a principal
diagnosis:
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
The commenter pointed out that these codes can only be reported as
a secondary diagnosis. Therefore, the commenters stated that our
proposed DRG logic for DRG 546 would not work with these four codes.
Response: We appreciate the support of the commenters for the
creation of the new DRG 546. We agree that this new DRG would better
align Medicare payment with hospital costs for treating these more
severe orthopedic cases. We also agree that codes 737.40, 737.41,
737.42, and 737.43 are not to be reported as a principal diagnosis
because they are manifestation codes. We inadvertently included them
among the list of principal diagnoses that would be assigned to DRG
546. In this final rule, we are removing codes 737.40, 737.41, 737.42,
and 737.43 from the list of principal diagnosis codes that would lead
to an assignment of DRG 546. However, we will retain these codes as a
secondary diagnosis that will result in an assignment to DRG 546
because they describe curvature of the spine. Therefore, patients
admitted with an orthopedic diagnosis who receive a spinal fusion will
be assigned to DRG 546 if codes 737.40, 737.41, 737.42, and 737.43 are
present as a secondary diagnosis. Consistent with this change in the
GROUPER logic, we will also remove the term ``principal diagnosis''
from the proposed title so that DRG 546 will be titled ``Spinal Fusions
Except Cervical With Curvature of the Spine or Malignancy.''
Comment: One commenter suggested that CMS consider adding the
following diagnoses to the list of codes that would be assigned to the
new DRG 546:
213.2, Benign neoplasm of bone and articular cartilage;
vertebral column, excluding sacrum and coccyx
238.0, Neoplasm of uncertain behavior of other and
unspecified sites and tissues; Bone and articular cartilage
239.2, Neoplasms of unspecified nature; Bone, soft tissue,
and skin
721.7, Spondylosis and allied disorders; Traumatic
spondylopathy
724.3, Other and unspecified disorders of back; Sciatica
732.8, Other specified forms of osteochondropathy
756.19, Anomalies of spine; Other
Response: We discussed these additional diagnosis codes recommended
by the commenter with our medical advisors and they agree that the
first three listed codes (213.2, 238.0, and 239.2) should be added
because they are neoplasm codes. Therefore, they are clinically similar
to the other neoplasm codes on our proposed list. Our medical advisors
did not support the addition on the latter four codes because they are
vague codes that do not necessarily represent significant conditions.
Therefore, in this final rule, we are adding codes 213.2, 238.0, 239.2
to our list of conditions in DRG 546. We are not adding codes 721.7,
724.3, 732.8, or 756.19.
After careful consideration of the public comments received, in
this final rule, we are establishing a new DRG 546 (Spinal Fusions
Except Cervical with Curvature of the Spine or Malignancy). New DRG 546
will be composed of all noncervical spinal fusions previously assigned
to DRGs 497 and 498 that have a principal or secondary diagnosis of
curvature of the spine or a principal diagnosis of a malignancy. The
principal diagnosis codes that will lead to this DRG assignment are the
following:
170.2, Malignant neoplasm of vertebral column, excluding
sacrum and coccyx
198.5, Secondary malignant neoplasm of bone and bone
marrow
213.2, Benign neoplasm of bone and articular cartilage;
vertebral column, excluding sacrum and coccyx
238.0, Neoplasm of uncertain behavior of other and
unspecified sites and tissues; Bone and articular cartilage
239.2, Neoplasms of unspecified nature; bone, soft tissue,
and skin
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
737.8, Other curvatures of spine
737.9, Unspecified curvature of spine
754.2, Congenital scoliosis
756.51, Osteogenesis imperfecta
The secondary diagnoses that will lead to the new DRG 546
assignment are:
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
d. CHARITE\TM\ Spinal Disc Replacement Device
As we noted in our discussion of applications for new technology
add-on payments for FY 2006 in section II.E. of the IPPS proposed rule
(70 FR 23362), the applicant for new technology for CHARITE\TM\
requested a DRG reassignment for cases involving implantation of the
CHARITE\TM\ Artificial Disc. CHARITE\TM\ is a prosthetic intervertebral
disc. On October 26, 2004, the FDA approved the CHARITE\TM\ Artificial
Disc for single level spinal arthroplasty in skeletally mature patients
with degenerative disc disease between L4 and S1. The applicant
requested a DRG assignment for these cases from DRG 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 of an inpatient stay to
implant an artificial disc prosthesis are similar to spinal fusion and
inclusion in DRGs 497 and 498 should be made consistent with section
1886(d)(5)(K) of the Act that indicates a clear preference for
assigning a new technology to a DRG based on similar clinical or
anatomical characteristics and costs. As indicated in section II.E. of
this final rule, we did not find that CHARITE\TM\ meets the substantial
clinical improvement criterion and are not considering a DRG
reassignment under the new technology provisions. However, we did
evaluate whether to reassign CHARITE\TM\ to a different DRG using the
Secretary's authority under section 1886(d)(4) of the Act.

[[Page 47309]]

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 and final rules, we described the new DRG assignments for
these new codes in Table 6B of the Addendum to those rules. We received
a number of comments on the FY 2005 IPPS proposed rule recommending
that we change the assignments for these codes from DRG DRGs 499 and
500 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 stated that we would continue to
analyze this issue and solicited further public comments on the DRG
assignment for spinal disc prostheses.
We received a number of public comments in response to the FY 2006
proposed rule. A summary of the comments and our responses follow.
Comment: One commenter supported our recommendation to keep the
CHARITE\TM\ spinal disc procedure code in DRGs 499 and 500. The
commenter took no position on CMS' decision on whether to grant add-on
payment for new technology for the CHARITE\TM\ spinal disc procedure.
However, the commenter stated that until further data becomes publicly
available, it would be premature to reassign spinal disc prostheses to
DRGs 497 and 498. The commenter stated that waiting for Medicare data
would be consistent with the approach CMS used in considering changes
to DRGs 497 and 498 for account for multilevel spinal fusion. (We did
not propose a change for FY 2006 to account for multilevel spinal
fusions because sufficient data were not available in MedPAR under the
new multilevel spine fusion procedure codes.) The commenter also stated
that the spinal fusion DRGs were well-established based on several
years of utilization and accrual of cost experience. Without a fuller
understanding of the expected resource use of cases with spinal disc
prostheses, the commenter was concerned that reassignment of these
procedures to DRGs 497 and 498 may have the potential to cause an
inappropriate reduction in future weights for spinal fusion. Therefore,
the commenter recommended that spinal disc replacements be kept in DRGs
499 and 500 until data are available to evaluate this change.
Response: We agree with the commenter that our policy is to assign
a new procedure code to a DRG based on the assignment of its
predecessor code until we have Medicare charge data to evaluate a DRG
modification. We also agree that the spinal fusion cases are well-
established based on several years of utilization and cost experience.
Without Medicare data that shows Medicare charges for CHARITE\TM\
artificial discs in DRGs 499 and 500 and until we receive Medicare
charge data using the new procedure codes, it is difficult to evaluate
a request for a DRG modification.
Comment: Eight commenters opposed our proposal of keeping
CHARITE\TM\ artificial discs in DRGs 499 and 500 until we received
Medicare charge data. These commenters recommended that the CHARITE\TM\
spinal disc procedure (code 84.65) be moved out of DRGs 499 and 500 and
into the spinal fusion DRGs (DRG 497 and 498). According to the
commenters, the current DRG assignment to DRGs 499 and 500 provides a
very significant economic disincentive for hospitals to use CHARITE\TM\
in the Medicare population. Based on information submitted with its new
technology application, these commenters argued that hospital resources
for patients receiving CHARITE\TM\ artificial discs are most closely
comparable to patients in DRGs 497 and 498 (the data provided to
support the new technology application are discussed in detail in
section II.E. of this final rule). The commenters also stated that the
Health Service Cost Review Commission (HSCRC) of Maryland developed new
artificial disc DRGs for its DRG system.
Response: With respect to the commenter's point regarding the
HSCRC, we acknowledge that they recently decided to create new DRGs for
artificial disc patients. We understand that the HSCRC established
these new DRGs with relative weights that are higher than DRGs 499 and
500 and less than the spinal fusion DRGs (DRGs 497 and 498). We are
unaware of the criteria that the HSCRC uses for creating separate DRGs.
Currently, we do not have a basis for creating a separate DRG for
spinal disc protheses because we have no FY 2004 Medicare charge data
that could be used to set the FY 2006 relative weight. Therefore, we
are unable to adopt an option similar to that of the HSCRC at this
time.
For its new technology application, we note that the applicant
supplied cost data for 376 total cases where CHARITE\TM\ was actually
used, including 12 cases involving Medicare patients. The data for the
12 Medicare patients did not come from the MedPAR data systems because
that information is not yet available due to the fact that give that
FDA approval and the code used to identify these patients was not
effective until October 2004. Thus, as with all new technology
applications, the data supporting whether the technology meets the cost
criterion came directly from the applicant and not from Medicare's data
systems. While the applicant also supplied data from the FY 2003 MedPAR
file, we note that these cases did not actually involve the CHARITE\TM\
artificial disc. Rather the applicant modified the claims data for
spinal fusion cases by removing the medical and surgical costs
associated with the spinal fusions. The applicant then replaced these
costs with costs represented to be those of a typical CHARITE\TM\
artificial disc. These data are acceptable to evaluate whether a new
technology meets the cost criterion in a new technology application
because, by definition, there is limited or no Medicare data upon which
to evaluate a new technology's costs. However, these data do not meet
the standards that we apply for making a change to a DRG. That is, we
use the predecessor code for a new technology until we have evidence
from Medicare's data systems that suggest a change to the DRG
assignment is warranted.
As stated previously, we do not have Medicare charge information to
evaluate a DRG change at this time. For this reason, we are not making
a change to the DRG assignment for CHARIT[Eacute]^TM.
However, we will consider whether a DRG reassignment for
CHARIT[Eacute]^TM is warranted for FY 2007, once we have
information from Medicare's data system that will assist us in
evaluating the cost of these patients.
8. 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 as a principal diagnosis
currently are assigned to DRG 416 (Septicemia Age >17) and DRG 417
(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 again addressed
this issue in the FY 2006 IPPS proposed rule

[[Page 47310]]

(70 FR 23329) as we had in the FY 2005 IPPS final rule (69 FR 48975).
In both instances, we did not believe 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. For this reason, we did not propose a new DRG for severe
sepsis for FY 2006.
Comment: Two commenters expressed concerns about the sequencing
instructions for severe sepsis. They pointed out that current ICD-9-CM
coding guidelines mandate that a code from category 038.x be sequenced
as the principal diagnosis followed by code 995.92 for patients
admitted in respiratory failure who also have severe sepsis. The
commenters expressed concerns that this sequencing instruction results
in lower hospital reimbursement for patients with severe sepsis placed
on mechanical ventilation. These commenters did not recommend that CMS
create a new DRG for patients with severe sepsis. Instead, they
suggested that the codes or guidelines, or both, be modified so that
other conditions can be sequenced as the principal diagnosis.
Response: We share the concern of the commenters about sequencing
guidelines for patients with severe sepsis and respiratory failure. The
current ICD-9-CM codes for systemic inflammatory response syndrome
(SIRS), codes 995.91 through 995.94, that include severe sepsis mandate
these sequencing guidelines. However, the National Center for Health
Statistics (NCHS) discussed modifications to these codes at the April
1, 2005 ICD-9-CM Coordination and Maintenance Committee meeting. NCHS
has scheduled this topic for further discussion at the September 29-30,
2005 Committee meeting. Suggestions for revising these codes and any
resulting guidelines should be sent to Donna Pickett, NCHS, 3311 Toledo
Road, Room 2402, Hyattsville, MD 2082, or to the e-mail address
[email protected].
Comment: One commenter expressed disappointment that CMS did not
create a new DRG for severe sepsis. The commenter disagreed with our
statement that these patients could not be easily identified within our
Medicare data. The commenter stated that severe sepsis is a systemic
inflammatory syndrome in response to infection that is associated with
acute organ dysfunction. The commenter suggested that CMS use the SIRS
ICD-9-CM codes for infection plus organ dysfunction along with an ICD-
9-CM procedure code for organ support such as ventilation management
(code 96.7x), acute renal replacement (codes 39.95 and 54.98), or
vasopressor support (code 00.17), to identify these patients. The
commenter recommended that CMS create two new DRGs, one for medical
severe sepsis patients with organ support and another for surgical
severe sepsis patients with organ support. The commenter recommended
that these two DRGs be assigned as pre-MDCs.
Response: There were extensive discussions about the problems in
using the current SIRS codes at the March 31-April 1, 2005 ICD-9-CM
Coordination and Maintenance Committee meeting. A summary report of
this meeting can be found at the Web site: http://www.cdc.gov/nchs/icd9cm. As stated earlier, NCHS has scheduled further discussions on
this topic for the September 29-30 Committee meeting.
Given the considerable confusion among the coding community
regarding the use of these codes, we believe it would be premature to
consider new DRGs for severe sepsis patients at this time. Therefore,
we are not making revisions to the DRG for severe sepsis patients at
this time. We will continue to work with NCHS to improve the codes so
that our data on these patients improve. We will continue to examine
data on these patients as we consider future modifications.
9. 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

[[Page 47311]]

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. As indicated in the FY 2006 IPPS 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 did not propose
changes to the current structure of DRGs 521 through 523 for FY 2006.
Comment: One commenter expressed concern that CMS did not propose
any DRG change to code 292.82, drug-induced dementia. The commenter
stated that a patient admitted with dementia due to an adverse effect
of a drug would result in code 292.82, followed by the appropriate E
code as a secondary diagnosis, grouping to one of the alcohol and drug
abuse DRGs (521 through 523). The commenter indicated an adverse effect
of a drug should not be confused with alcohol or drug abuse and
recommended that CMS examine the potential impact of not reassigning
code 292.82 into a new DRG from both a quality of care and a financial
perspective.
Response: We appreciate the commenter's recommendation. However, as
we indicated above and in the FY 2006 IPPS proposed rule, drug-induced
dementia develops as a result of use of a drug. Therefore, it is
appropriate to assign the code to DRGs 521, 522, or 523. As we
indicated in the FY 2006 proposed rule (70 FR 23330), we did receive
suggestions that drug-induced dementia due to the adverse effects of a
drug or poisoning be assigned to DRGs 429, 449, 450, or 451. However,
we believe these DRGs should only be assigned when the hospital uses
the appropriate poisoning or other codes sequenced as the principal
diagnosis. In addition, the data analyzed from the FY 2004 MedPAR file
did not support a modification to DRGs 521 through 523. Our data show
that hospital charges for patients assigned to DRGs 521 through 523
with a principal diagnosis of code 292.82 and no drug abuse secondary
diagnosis were similar to other patients in these DRGs. Given that no
other secondary diagnosis codes were used, it is not possible to know
whether these patients were more clinically similar to patients in DRGs
426, 449, 450, 451, or 521 through 523. Absent any other diagnoses
other than code 292.82, we have no evidence that these patients were
clinically different than other patients in DRGs 521 through 523.
After consideration of the comments received, as we proposed, in
this final rule we are not changing the DRG assignment for drug-induced
dementia (code 292.82) for FY 2006.
10. Medicare Code Editor (MCE) Changes
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.
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 DRGs 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

[[Page 47312]]

pediatric arena, as we proposed we are not making the commenter's
suggested changes to the MCE ``newborn age edit'' for FY 2006.
Comment: One commenter requested that CMS reconsider making the
necessary revisions to the ``newborn age edit'' and other pediatric
data. The commenter suggested that if CMS continues its current stance
regarding the internal level of expertise to develop newborn and
pediatric edits, then these edit should be removed from the MCE.
Response: We believe the commenter's recommendation to remove the
newborn and pediatric edits from the MCE has merits and will consider
it for FY 2007. However, we believe it is important that we have an
opportunity to analyze this issue further and consider any comments
from interested parties before eliminating these edits.
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''. In the FY 2006 IPPS proposed
rule, we proposed to remove code 796.6 from these two edits and add it
to the ``Newborn Diagnoses'' edit.
We did not receive any comments on this proposal. Therefore, in
this final rule, we are adopting the proposal as final without
modification.
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, in the FY 2006 IPPS proposed rule, we proposed 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 proposed to remove code 257.2 from the ``Male Only'' gender edit
in the MCE.
We did not receive any comments on these proposals. Therefore, in
this final rule, we are adopting the proposals as final without
modification.
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/). 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 proposed to add code 305.1 to the MCE edit ``Questionable Admission-
Principal Diagnosis Only'' in order to make tobacco use disorder a
noncovered admission.
We did not receive any comments on this proposal. Therefore, in
this final rule, we are adopting the proposal as final without
modification.
e. Noncovered Procedure Edit
Effective October 1, 2004, CMS adopted the use of code 00.61
(Percutaneous angioplasty or atherectomy 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 proposed to remove codes 00.61, 00.63, and V70.7 from
the MCE noncovered procedure edit.
We did not receive any comments on this proposal. Therefore, in
this final rule, we are adopting the proposal as final without
modification.
f. Error in Non-Covered Procedure Edit--code 36.32
It has come to our attention that an entry in the Non-Covered
Procedures section of the MCE was made in error. Procedure code 36.32
(Other transmyocardial revascularization) is covered as a late or last
resort for patients with severe (Canadian Cardiovascular Society
classification Classes III or IV) angina (stable or unstable). The
angina symptoms must be caused by areas of the heart not amenable to
surgical therapies. Therefore, as code 36.32 is erroneously in the Non-
Covered Procedure edit in the MCE, we are removing it from the edits
for FY 2006.
11. Surgical Hierarchies
Some inpatient stays entail multiple surgical procedures, each one
of which, occurring by itself, could result in assignment of the case
to a different DRG within the MDC to which the principal diagnosis is
assigned. Therefore, it is necessary to have a decision rule within the
GROUPER by which these cases are assigned to a single DRG. The surgical
hierarchy, an ordering of surgical classes from most resource-intensive
to least resource-intensive, performs that function. Application of
this hierarchy ensures that cases involving multiple surgical
procedures are assigned to the DRG associated with the most resource-
intensive surgical class.
Because the relative resource intensity of surgical classes can
shift as a function of DRG reclassification and recalibrations, we
reviewed the surgical hierarchy of each MDC, as we have for previous
reclassifications and recalibrations, to determine if the ordering of
classes coincides with the intensity of resource utilization.
A surgical class can be composed of one or more DRGs. For example,
in MDC 11, the surgical class ``kidney transplant'' consists of a
single DRG (DRG 302) and the class ``kidney, ureter and major bladder
procedures'' consists of three DRGs (DRGs 303, 304, and 305).
Consequently, in many cases, the surgical hierarchy has an impact on
more than one DRG. The methodology for determining the most resource-
intensive surgical class involves

[[Page 47313]]

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, in the FY 2006
IPPS proposed rule (70 FR 23332), we proposed 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 proposed reordering--
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).
Comment: Several commenters agreed with the proposed changes in the
surgical hierarchy for MDC 5.
Response: We appreciate the commenters' support. However, because
in this final rule we are deleting 9 DRGS and creating 12 new DRGs in
MDC 5, as discussed under ``MedPAC Recommendations'' in section IX.A of
this preamble, we are reordering the following DRGs in MDC 5:
DRG 106 (Coronary Bypass With PTCA) above DRGs 547 and 548
(Coronary Bypass With Cardiac Catheterization With and Without Major CV
Diagnosis, respectively);
DRGs 547-548 above DRGs 549 and 550 (Coronary Bypass
Without Cardiac Catheterization With and Without Major CV Diagnosis,
respectively);
DRG 113 (Amputation For Circulatory System Disorders
Except Upper Limb or Toe) above DRG 551 (Permanent Cardiac Pacemaker
Implant With Major CV Diagnosis or AICD Lead or Generator);
DRG 551 above DRG 552 (Other Permanent Cardiac Pacemaker
Implant Without Major CV Diagnosis);
DRG 552 above DRG 557 (Percutaneous Cardiovascular
Procedure With Drug Eluting Stent With Major CV Diagnosis);
DRG 557 above DRG 555 (Percutaneous Cardiovascular
Procedure With Major CV Diagnosis);
DRG 555 above DRG 558 (Percutaneous Cardiovascular
Procedure With Drug Eluting Stent Without Major CV Diagnosis);
DRG 558 above DRG 556 (Percutaneous Cardiovascular
Procedure Without Major CV Diagnosis);
DRG 556 above DRG 518 (Percutaneous Cardiovascular
Procedure Without Coronary Artery Stent Or AMI);
DRG 518 above DRG 553 (Other Vascular Procedures With CC
With Major CV Diagnosis);
DRG 553 above DRG 554 (Other Vascular Procedures With CC
Without Major CV Diagnosis);
DRG 554 above DRG 479 (Other Vascular Procedures Without
CC).
In MDC 8, we proposed to reorder--
DRG 496 (Combined Anterior/Posterior Spinal Fusion) above
DRG 546 (Spinal Fusions Except Cervical With Curvature of the Spine or
Malignancy).
DRG 546 above DRGs 497 and 498 (Spinal Fusions 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).
Comment: Several commenters agreed with the proposed changes in the
surgical hierarchy for MDC 8.
Response: We appreciate the commenters' support. Based on a test of
the proposed revisions using the March 2005 update of the FY 2004
MedPAR file and the revised GROUPER software, we found that the
revisions to MDC 8 are still supported by the data.
Accordingly, in this final rule, we are adopting the proposed
change in the surgical hierarchy for MDC 8 as final, without
modification.
12. Refinement of Complications and Comorbidities (CC) List

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

[[Page 47314]]

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 1986 DRG data to the 2004 DRG data that
were included in the DRGs Definitions Manual, GROUPER Version 22.0, we
found the following:
Cases with CC: 79.9 percent
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:

------------------------------------------------------------------------
Code Code description 2004 count
------------------------------------------------------------------------
041.7...................... Pseudomonas Infection in 47,350
Conditions Classified
Elsewhere and/or of
Unspecified Site.
253.6...................... Disorders of 23,613
Neurohypophysis.
414.12..................... Dissection of Coronary 2,377
Artery.
359.4...................... Toxic Myopathy............. 1,875
031.2...................... Disseminated Disease Due to 1,428
Mycobacteria.
451.83..................... Phlebitis and 376
Thrombophlebitis of Deep
Veins of Upper Extremities.
------------------------------------------------------------------------

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

------------------------------------------------------------------------
Code Code description 2004 count
------------------------------------------------------------------------
424.0...................... Mitral Valve Disorder...... 401,359
305.00..................... Alcohol Abuse Unspecified 69,099
Use.
578.1...................... Blood in Stool............. 53,453
723.4...................... Brachial Neuritis/ 5,829
Radiculitis, Not Otherwise
Specified.
684........................ Impetigo................... 1,230
293.84..................... Anxiety Disorder in 1,153
Conditions Classified
Elsewhere.
------------------------------------------------------------------------

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, as indicated in the FY
2006 IPPS proposed rule, 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 indicates
that 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

[[Page 47315]]

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.
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 significant structural 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. In
the FY 2006 IPPS proposed rule, we encouraged comment 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.
Comment: Several commenters agreed with CMS that changes in
resource utilization and in inpatient hospital care, particularly the
focus on decreasing length of stay, may be resulting in the CC
distinction not being able to differentiate resource utilization and
patient severity as well as it has in the past. Several commenters
agreed that it may be valuable to conduct a substantial and
comprehensive review of the CC list for the future. While some
commenters applauded CMS' efforts to keep refining the DRG system, the
commenters believed that review of the CC list can only be taken as an
interim step and a more refined DRG system can only be accomplished
with more specific clinical classification systems capable of providing
more complete information about a patient's condition and the services
provided to treat those conditions--namely, ICD-10-CM and ICD-10-PCS.
Some commenters suggested waiting to adopt the MedPAC recommendations
until these new coding classification systems are implemented.
MedPAC stated that a comprehensive review and revision of the CC
list might lead to a desirable improvement in the extent to which
payment rates reflect patient severity of illness. However, MedPAC does
not expect that even a major revision of the list would greatly improve
the extent to which the IPPS payment rates recognize the effects of
differences in patient severity of illness. MedPAC noted that the CC
distinction is based entirely on the presence or absence of any CC,
implicitly assuming that all CCs have equal effects on severity of
illness and costs. Even if the CC review process were to correctly
identify all secondary diagnoses that significantly affect hospitals'
costs, MedPAC's research and CMS' earlier work have shown that simply
distinguishing between patients with and without CCs fails to capture
large, predictable differences in costs among patients. MedPAC stated
that further differentiation is necessary to make the most effective
use of information about patients' secondary diagnoses and to help
minimize opportunities for hospitals to benefit financially from
patient selection.
Response: There has not been a comprehensive review of the CC list
in over 20 years. Such a review may indicate that a more focused list
will better distinguish the effects of CCs on severity of illness than
earlier analysis. Until this comprehensive review and analysis are
complete, we will not know whether there is merit in adopting a
modification of the CC list or whether it will be necessary to adopt a
more comprehensive change to the DRG system such as APR-DRGs. We
currently plan to continue with our comprehensive review of the CC
list. In addition, we expect shortly to engage a contractor highly
experienced with DRG development to study the APR-DRGs over the next
year. We appreciate the commenters' suggestions about waiting to adopt
MedPAC's recommendations until ICD-10-CM and ICD-10-PCS have been
implemented. While we do not have a proposal in place at this time to
implement ICD-10-CM and ICD-10-PCS, before adopting any major changes
to the DRG system, we will consider the implications of potential
future changes to our coding systems as part of our analysis of
MedPAC's recommendation.
Comment: Commenters gave numerous suggestions for performing the
analysis of the CC list. The suggestions include:
Analyze all diagnosis and procedures codes reported on the
claim, not just nine diagnosis codes and six procedure codes.
Examine the impact of multiple CCs on hospital resource
consumption and length of stay.
Examine further differentiation beyond simply
distinguishing between patients with and without CCs to make the most
effective use of information about patients' secondary diagnoses and
minimize opportunities for hospitals to benefit financially from
patient selection.
Study the need for a general/standard list of CCs that
addresses patient conditions across all body systems and a list of
special severity conditions that are unique to specific population/
diseases.
Consider abandoning length of stay as an indicator for
severity because, in today's clinical environment, length of stay is
determined more by postacute care referral dynamics than patient need.
Consider differentiating comorbidities from complications.
The former are predictable and can be used to easily affect admission
selection.
Compare the existing CC list with those used with other
DRG systems.
Conduct the comprehensive review and analysis cautiously,
systemically, and thoroughly, using external expertise and maintaining
transparency and stakeholder involvement throughout the process, and do
not rush the analysis simply to meet the deadline for the FY 2007 IPPS
rule.
Use open door forums to inform the public of progress.
Consider combining the cases from each DRG pair in one
homogenous DRG. Under such a change, hospitals would still receive the
same total reimbursement for the same patients but would have more
financial incentive to improve the quality and efficiency of care.
Before inclusion as a CC condition, a diagnosis should
meet the following four criteria: (1) The patient group represents a
higher cost in that DRG than those without the comorbid condition; (2)
the condition cannot be prevented, in any possible way, by superior
care in the hospital; (3) the condition is not related to the principal
diagnosis; and (4) there is at least some indication that the patient
would face inadequate options for finding appropriate medical care
without a more appropriate payment.
Response: We appreciate these many suggestions. As we indicated
above, we will continue to conduct a thorough review of the CC list. We
also will be engaging a contractor shortly to assist us with evaluating
APR-DRGs and other mechanisms to better recognize severity in our
payment systems.
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

[[Page 47316]]

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 a 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. We did not receive any comments specific to the diagnosis
codes on the FY 2006 CC list. Therefore, as we proposed in the FY 2006
IPPS proposed rule, we are not deleting 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.
---------------------------------------------------------------------------

As proposed, we are making a limited revision of the CC Exclusions
List to take into account the changes that will be made in the ICD-9-CM
diagnosis coding system effective October 1, 2005. (See section
II.B.14. of this preamble for a discussion of ICD-9-CM changes.) We are
making these changes in accordance with the principles established when
we created the CC Exclusions List in 1987.
We receive one comment that agreed with the revised CC Exclusion
List based on the information provided.
Tables 6G and 6H in the Addendum to this final rule contain the
revisions to the CC Exclusions List that will 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 will not be recognized by the GROUPER as valid
CCs for the asterisked principal diagnosis.
CCs that are deleted from the list are in Table 6H--Deletions from
the CC Exclusions List. Beginning with discharges on or after October
1, 2005, the indented diagnoses will 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 final 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 in hard copy for $250.00. Version 23.0 of the manual is also
available on a CD for $200.00; a combination hard copy and CD is
available for $400.00. 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.
13. Review of Procedure Codes in DRGs 468, 476, and 477
Each year, we review cases assigned to DRG 468 (Extensive O.R.
Procedure Unrelated to Principal Diagnosis), DRG 476 (Prostatic O.R.
Procedure Unrelated to Principal Diagnosis), and DRG 477 (Nonextensive
O.R. Procedure Unrelated to Principal Diagnosis) to determine whether
it would be appropriate to change the procedures assigned among these
DRGs.
DRGs 468, 476, and 477 are reserved for those cases in which none
of the O.R. procedures performed are related to the principal
diagnosis. These DRGs are intended to capture atypical cases, that is,
those cases not occurring with sufficient frequency to represent a
distinct, recognizable clinical group. DRG 476 is assigned to those
discharges in which one or more of the following prostatic procedures
are performed and are unrelated to the principal diagnosis:

[[Page 47317]]

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. We did
not receive any comments on this provision. Therefore, in this final
rule, we are not making 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 proposed to correct this error by moving code 26.12 out of DRG 468
and reassigning it to DRG 477. We received one comment in support of
our proposal to move code 26.12 out of DRG 468 and reassign it to DRG
477. Therefore, we are adopting as final our proposal to move procedure
code 26.12 out of DRG 468 and reassigning it to DRG 477. We received no
comments opposing our plan of not moving any procedure codes from DRG
476 to DRGs 468 or 477 or from DRG 477 to DRG 468. Therefore, as we
proposed, we are not moving 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, as we proposed, we are not adding
any diagnosis codes to MDCs. We did not receive any comments on our
proposal and are therefore not adding any diagnosis codes to any MDCs.
14. 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), the Centers for Disease Control and
Prevention, 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 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

[[Page 47318]]

as the American Health Information Management Association (AHIMA), the
American Hospital Association (AHA), and various physician specialty
groups, as well as individual physicians, 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 final rule. The Committee held its 2005 meeting on March 31-April
l, 2005. New codes for which there was a consensus of public support
and for which complete tabular and indexing changes were made by May
2005 are included in the October 1, 2005 update to ICD-9-CM. Code
revisions that were discussed at the March 31-April 1, 2005 Committee
meeting were not finalized in time to include them in the FY 2006 IPPS
proposed rule. These additional codes are included in Tables 6A through
6F of this final rule and are marked with an asterisk (*).
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
final rule. As we stated above, the code numbers and their titles were
presented for public comment at the ICD-9-CM Coordination and
Maintenance Committee meetings. Both oral and written comments were
considered before the codes were approved. In the FY 2006 IPPS proposed
rule, we only solicited 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 received consensus and that were finalized are included in
Tables 6A through 6F of this 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 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 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.

[[Page 47319]]

A discussion of this timeline and the need for changes are included
in March 31-April 1, 2005 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 Web 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
section 503(a) of Pub. L. 108-173. Any midyear coding updates will be
available through the Web sites 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 Web sites 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.
Comment: Five commenters recommended that CMS modify its DRG
GROUPER and instruct fiscal intermediaries to expand the number of
diagnoses processed from 9 to 25 and the number of procedures processed
from 6 to 25. The commenters were concerned that CMS was not evaluating
all reported diagnoses and procedures that could possibly affect a
patient's severity of illness or the resources used, or both. The
commenters pointed out that the current DRG GROUPER only considers 9
diagnoses and up to 6 procedures; that hospitals submit claims to CMS
in electronic format, and that the HIPAA compliant electronic
transaction standard, HIPAA 837i, allows up to 25 diagnoses and 25
procedures. The commenters stated that fiscal intermediaries are
currently ignoring or omitting the additional codes (beyond 9 diagnoses
and 6 procedures) submitted by hospital providers, since these
additional diagnoses and procedures are not needed by the GROUPER to
assign a DRG. Several commenters stated that, while it is important for
inpatient acute hospitals, it is even more crucial for LTCHs whose
patients are medically complex and have multiple illnesses beyond the
nine diagnoses allowed by CMS. Several commenters further stated that a
list of CCs qualifying for comorbidity adjustments for inpatient
psychiatric facility services was only recently introduced under the
new IRP PPS. Thus, the commenter added, these hospitals have not
historically used the software available to sort and rearrange
secondary diagnosis cods so that all CCs possibly affecting the DRG
grouping are prioritized. One commenter stated that the continued use
of more limited diagnosis and procedure codes acts as a disincentive
for the reporting of additional codes, and will result in less precise
assignment of DRGs.
Response: The commenters are correct that the current Medicare
GROUPER does not process codes submitted electronically on the 837i
electronic format beyond the first 9 diagnoses and the first 6
procedures. This limitation is not being imposed by the GROUPER. CMS
made the decision to process only the first 9 diagnosis codes and first
6 procedure codes. While HIPAA requires CMS to accept up to 25 ICD-9-CM
diagnosis and procedure codes on the HIPAA 837i electronic format, it
does not require that CMS process that many diagnosis and procedure
codes.
As suggested by the commenters, there is value in retaining
additional data on patient conditions that would

[[Page 47320]]

result from expanding Medicare's data system so it can accommodate
additional diagnosis and procedure codes. We will consider this issue
further as we contemplate further refinements to our DRG system to
better recognize patient severity. However, while it would be a simple
matter to modify our GROUPER software to accept and evaluate 25
diagnosis and 25 procedure codes, extensive lead time to allow for
modifications to our internal and contractors' electronic systems would
be necessary before we could process and store this additional
information. We are unable to move forward with this recommendation
without carefully evaluating implementation issues. Nevertheless, we
plan to proceed with this evaluation as we consider further changes to
our DRG systems.
Comment: Many commenters recommended that CMS act immediately to
adopt coordinated implementation of ICD-10-CM and ICD-10-PCS in the
United States. Some of these commenters noted that Pub. L. 108-173
(MMA) included report language urging the Secretary to move forward
with the implementation of ICD-10 as quickly as possible. The
commenters noted that the National Committee on Vital and Health
Statistics (NCVHS) raised concerns about the viability of ICD-9-CM in
2003 and stated it was ``increasingly unable to address the needs for
accurate data for health care billing, quality assurance, public health
reporting, and health services research.'' The commenter further noted
that the NCVHS recommended in 2003 that DHHS act expeditiously to
initiate the regulatory process for adoption of ICD-10-CM and ICD-10-
PCS. The commenter stated that, as of 2005, ``we are still awaiting a
process from HHS to begin this important transition.'' While some of
the commenters acknowledged the complexities involved with the
transition from ICD-9-CM to ICD-10, the commenters still recommended
that we act quickly to begin adoption of ICD-10. Other commenters also
indicated that the 4-digit structure of ICD-9-CM is limiting the
ability of the procedure coding system to identify new procedures and
new technologies and it is becoming increasingly outdated. According to
these commenters, it is becoming more difficult each year to make
changes to the ICD-9-CM coding system because of the availability of
new codes. One commenter noted that several participants at the March
31-April 1, 2005 ICD-9-CM Coordination and Maintenance Committee
``appeared to be advocating a higher threshold for the award of new
codes based on the ever decreasing number of available codes under ICD-
9-CM.'' Many of the commenters indicated that the coding system's
limitations are making it difficult to compare outcomes and efficacy
between older and newer technologies, identify costs associated with
the new technology, or revise reimbursement policies to appropriately
reflect the cost of patient care when new technology is used. One
commenter indicated that failure to recognize the looming problems with
the ICD-9-CM coding system will impede efforts to meet the President's
goal of adopting electronic health records by 2013.
Many of the commenters referred to ICD-10-PCS as the next
generation of coding systems. They stated that ICD-10-PCS would
modernize and expand CMS' capacity to keep pace with changes in medical
practice and technology. In addition, these commenters stated that the
structure of ICD-10-PCS would incorporate all new procedures as unique
codes that would explicitly identify the technology used to perform the
procedure.
Response: We agree that it is becoming increasingly difficult to
update ICD-9-CM. However, we are continuing to make revisions to ICD-9-
CM and create codes that recognize new medical technology. We continue
to update ICD-10-PCS on an annual basis to keep it up to date with
changing technology. We agree that it is important to have an accurate
and precise coding system for this purpose. However, as noted by many
of the commenters, the transition from one coding system to another
raises many complex operational issues. The Department will continue to
study this matter as we consider whether to adopt ICD-10.
15. Other Issues
a. 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 did not believe
that there is a sufficient difference between the average charges and
average length of stay for these cases to justify proposing a change to
the DRG assignment for treating this condition.
Comment: One commenter agreed with our proposal not to modify the
DRG assignment for acute intermittent porphyria, code 277.1, to DRG 229
due to the minor variance in average charges and length of stay between
porphyria cases and other cases in this DRG.
Response: We appreciate the commenter's support of our proposal.
Review of the MedPAR data did not demonstrate a significant disparity
in the average charges compared to average length of stay.
For FY 2006, as we proposed, we are not modifying the DRG
assignment for code 277.1 (Acute intermittent porphyria) to DRG 229.
b. Prosthetic Cardiac Support Device (Code 37.41)
Code 37.41 (Implantation of prosthetic cardiac support device
around the heart) was addressed in the FY 2006 IPPS proposed rule only
as a notification in Table 6B that the new code was being created to
describe a prosthetic cardiac support device (70 FR 23594). Code 37.41
was deemed to be an O.R. procedure and was assigned to MDC 5 (Diseases
and Disorders of the Circulatory System), DRGs 110 and 111 (Major
Cardiovascular Procedures With and Without CC, respectively). This
device is being marketed as the CorCap^TM Cardiac Support
Device and is intended to prevent and reverse heart failure by
improving the heart's structure and function.
This topic was discussed at the ICD-9-CM Coordination and
Maintenance Meeting on October 7, 2004. At that time, there was no
specific ICD-9-CM code that more precisely identified this procedure,
so coders were advised to use code 37.99 (Other operations on

[[Page 47321]]

heart and pericardium) to describe the operation. Code 37.99 is
currently assigned to DRGs 110 and 111.
As is our established pattern, we assign a new code to its
predecessor code's DRG until we obtain a pattern of use of the code in
the MedPAR data file. After we have evidence-based justification for
reassignment of codes within DRGs, we are better able to make decisions
about the most appropriate placement of those new codes.
We received 11 comments on this topic as part of the comments on
the FY 2006 IPPS proposed rule.
Comment: Most of the commenters responding were cardiovascular
surgeons who were principal investigators participating in the United
States' CorCap^TM clinical trials. All of the commenters
requested that we reconsider the assignment of the prosthetic cardiac
support device from DRGs 110 and 111 to DRG 108, where the resources
[in DRG 108] more closely approximate those associated with
implantation of the device. The commenters stated that procedures in
DRG 108 are more clinically similar to the implantation of the
prosthetic cardiac support device, being exclusively performed on the
internal or external structures of the heart and generally requiring
access through a sternotomy.
One commenter likened this procedure to the maze procedure,
described by code 37.33 (Excision or destruction of other lesion or
tissue of heart, open approach). Another commenter compared it to
transmyocardial revascularization, described by code 36.31 (Open chest
transmyocardial revascularization). Both of these procedure codes are
assigned to DRG 108. Commenters also stated that classification of this
procedure to DRGs 110 and 111 would establish a financial disincentive
for hospitals to adopt this potentially life-saving and cost-reducing
treatment for Medicare beneficiaries suffering from a problem that may
otherwise require implantation of a ventricular assist device or heart
transplant.
Response: As noted above, we have classified procedure 37.41 to the
same DRG as its predecessor code, in accordance with our established
policy. Until we have Medicare billing data that will allow us to
assess whether the new procedure code has been correctly assigned, our
default position is to assign a new procedure code to the same DRG as
its predecessor code. Of major concern to CMS is the late June 2005
decision by an FDA advisory panel urging FDA to reject approval of the
CorCap^TM device on the basis that the panel had not seen
sufficient evidence of benefit for patients with heart failure. The
FDA's concerns included the efficacy of the device in achieving a
longer lifespan for patients, and the possibility that the device's
benefits did not outweigh the risks of surgery. In addition, the FDA
advisory panel had other concerns, including whether the application of
this device around the ventricles of the heart might make future heart
surgeries more difficult.
Code 37.41 is too new to be included in the MedPAR data. Therefore,
we will continue to monitor this prosthetic cardiac support device in
future IPPS updates. As noted above, should FDA approve this device and
should there be an evidence-based justification for reassignment of
codes within these DRGs, we will be open to making changes to the DRG
structure.
c. Coronary Intravascular Ultrasound (IVUS) (Procedure Code 00.24)
Procedure code 00.24 (Coronary intravascular ultrasound) was
addressed in the FY 2005 IPPS proposed rule only as a notification in
Table 6B that for FY 2005 a new code had been created to describe this
imaging technique (69 FR 49624). Code 00.24 describes ultrasonic
imaging within the coronary vessels. It was not assigned ``O.R.''
status within the GROUPER program; that is, the presence or absence of
this code does not affect a claim's DRG assignment or payment.
We received one comment on this procedure code as part of the
public comments on the FY 2006 IPPS proposed rule.
Comment: One commenter noted that IVUS is an added cost to
hospitals. The commenter stated that it has conducted an analysis of
coronary IVUS resource use in calendar year 2004 hospital data to
determine possible impact. The commenter reported its findings that, in
DRGs 516, 517, 526, and 527, cases utilizing IVUS had higher total
charges and higher total costs. The commenter requested that CMS
perform an analysis of FY 2005 coronary IVUS cases and consider
reassigning ICD-9-CM procedure code 00.24 to DRGs where the average
resource use most closely approximates the resource use of cases in
which an IVUS technique has been employed.
Response: We will perform the requested data analysis using FY 2005
MedPAR data for the FY 2007 annual IPPS update.
d. Islet Cell Transplantation
Islet cell transplantation was not a topic addressed in the FY 2006
IPPS proposed rule. The issue of payment for pancreatic islet cell
transplantation in clinical trials was addressed in detail in the FY
2005 IPPS final rule (69 FR 48950). At that time, we discussed section
733(b) of Pub. L. 108-173, which provides that Medicare payments,
beginning no earlier than October 1, 2004, for the routine costs as
well as the costs of the transplantation and appropriate related items
and services will be allowed for Medicare beneficiaries who are
participating in clinical trials as if such transplantations were
covered under Medicare Part A or Part B. In addition, the DRG payment
will be supplemented by an add-on payment that includes pre-transplant
tests and services, pancreas procurement, and islet isolation services.
Cases were assigned to DRG 315 (Other Kidney and Urinary Tract
Procedures).
We received one comment on this topic as part of the public
comments on the FY 2006 IPPS proposed rule.
Comment: One commenter was concerned that the proposed relative
weight for DRG 315 published in the FY 2006 IPPS proposed rule
represented a decrease of almost 33 percent. The commenter also
indicated that it continues to believe that this procedure is
inappropriately classified, and suggested that these cases be
reassigned into pre-MDC DRG 513 (Pancreas Transplant). The commenter
believed the suggested DRG change is justified because islet cell and
pancreas transplants involve substantially similar patient populations.
The commenter further pointed out that the transplants both serve the
same clinical function--that of freeing the patient from insulin
dependence. The commenter requested that CMS identify those admissions
in DRG 315 that involve islet cell transplantation and determine the
actual costs involved to decide whether islet cell transplant cases
should be reclassified to DRG 513.
Response: We do not understand why the commenter believes that the
relative weight for DRG 315 decreased by 33 percent. The FY 2006
proposed relative weight (2.0801 (see Table 5 of the FY 2006 proposed
rule, 70 FR 23587)) is approximately 0.3 percent less than the FY 2005
relative weight (2.0861 (see Table 5 of the FY 2005 final rule, 69 FR
49603)). We have reviewed the MedPAR data for the first quarter of FY
2005, and have found no cases of islet cell transplantation in DRG 315.
Therefore, we do not have a basis for comparison of islet cell
transplantation cases to the remainder of the cases in DRG 315. We also
take this opportunity to clarify that the DRGs are groupings of cases
that are similar both from a clinical perspective

[[Page 47322]]

as well as a resource-intensity perspective. While the commenter's
position is that the same clinical endpoint is attempted with both
islet cell transplantation and pancreas transplant, the result or
endpoint of treatment results is not one of the axis upon which the
DRGs are structured. In addtion, the pancreas transplant involves an
open abdominal procedure in which one pancreas is surgically removed
and a cadaveric pancreas is transplanted. Conversely, islet cells are
infused via catheter. Therefore, from the standpoint of clinical
similarity, we do not believe that the cases are comparable enough to
consider putting the islet cell transplantation into DRG 513.
Comment: The same commenter was concerned about payment for islet
cell transplants under a National Institutes of Health (NIH) clinical
trial. The commenter believed that the $18,848 islet cell isolation
add-on amount is insufficient. This commenter also believed that the
data used to calculate the add-on amount were inadequate to form the
basis for establishing payment.
Response: The $18,848 isolation add-on amount was based on the best
data available, and we remain convinced that it is an appropriate
payment for isolating the islet cells from one pancreas. However, we
have learned that it typically requires two isolations to acquire
enough cells for one infusion. Therefore, while we will maintain the
current rate of $18,848 per isolation, we will pay up to two islet
isolations per discharge. If only one islet isolation is necessary,
Medicare will make an add-on payment of $18,848; if two are necessary,
Medicare will make an add-on payment of $37,696. In cases that require
two islet isolations, CMS will pay for two pancreata. Pancreata will
continue to be paid as a cost pass-through.
We will review the MedPAR data as requested using more complete FY
2005 MedPAR data during our next annual IPPS update for FY 2007.

C. Recalibration of DRG Weights

We are using 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 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
March 31, 2005, 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 12,006,022 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 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/or intestinal, 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/or
intestinal, 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 new weights are normalized by an adjustment factor of 1.47462
so that the average case weight after recalibration is equal to the
average case weight before recalibration. This adjustment is intended
to ensure that recalibration by itself neither increases nor decreases
total payments under the IPPS.
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 DRG weights for FY 2006. Using the FY 2004 MedPAR
data set, there are 41 DRGs that contain fewer than 10 cases. We
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 final rule, we are making a
budget neutrality adjustment to ensure that the requirement of section
1886(d)(4)(C)(iii) of the Act is met.
Comment: One commenter noted that there is a reduction in the
proposed weights for DRG 103 (Heart Transplant or Implant of Heart
Assist System) and DRG 512 (Simultaneous Pancreas/Kidney Transplant).
According to the commenter, the proposed weights represent a 6-percent
reduction in DRG 103 and an 11-percent reduction in DRG 512. The
commenter inquired as to whether these reductions may have

[[Page 47323]]

resulted from a methodological change in the way organ acquisition
costs are addressed in the DRG weighting process.
Response: There is no change in the calculation of the DRG relative
weight. 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.
As described above, the relative weight for each DRG is calculated
by comparing the average charge for cases within each DRG (after
removing statistical outliers) with the national average charge per
case. Therefore, there are several factors that can cause a shift in
the relative weight of a DRG from one fiscal year to the next. For
example, even though the average charges of cases within DRG 103
increased from $278,096 in the FY 2005 final rule to $285,317 in the
proposed rule, it did not increase by an equal or greater percentage
than the national average. As a result, the DRG weight for DRG 103
declined. For DRG 512, the average charges decreased from $85,630 in
the FY 2005 final rule to $83,113 in the proposed rule which accounts
for the decline in the weight.
Comment: One commenter pointed out three typographical errors in
DRG titles in Table 5 (List of Diagnosis Related Groups (DRGs),
Relative Weighting Factors, Geometric and Arithmetic Mean Length of
Stay) in the Addendum to the FY 2006 IPPS proposed rule. The commenter
indicated that the title for DRG 14 should read ``Intracranial
Hemorrhage or Cerebral Infarction'' based on the change in FY 2005 IPPS
final rule (69 FR 48927) and the title for DRG 315 should read ``Other
Kidney & Urinary Tract Procedures'' based on the change in the FY 2003
IPPS final rule (67 FR 49993). The commenter also pointed out a
misspelling of the word ``Malignant'' in the title for DRG 276.
Response: The commenter is correct. We have made these corrections
in Table 5 in the Addendum to this final rule.

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

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 Rate Year (RY) 2006 LTCH PPS final rule (70
FR 24173 through 24175), 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. However, this policy change will
have no effect 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.
As we explained in the FY 2006 IPPS proposed rule (70 FR 23338
through 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) and in section II.B. 14. of this final rule.
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 RY 2006 LTCH PPS final
rule (70 FR 24173 through 24175) and the FY 2006 IPPS proposed rule (70
FR 23338 through 23339), 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 both the RY 2006 LTCH PPS final
rule (70 FR 24174) and the FY 2006 IPPS proposed rule (70 FR 23339),
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),
and in section II.B.13. of this preamble, that since we do not publish
a midyear IPPS rule, April 1 code updates discussed above

[[Page 47324]]

will not be published in a midyear IPPS rule. Rather, we will assign
any new diagnosis 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 coding updates will be available through the Web
sites 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, because 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) and in
section II.B.14. of this preamble, 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. We note 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 Coordination and Maintenance Committee since 1995. Requestors
will be given the opportunity to present the merits for a 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.
However, as we explained in the FY 2006 IPPS proposed rule (70 FR
23339), at the October 2004 ICD-9-CM Coordination and Maintenance
Committee meeting, there were no requests for an April 1, 2005
implementation of ICD-9-CM codes, 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 update to the
ICD-9-CM coding system for FY 2006 is discussed above in section
II.B.14. of this preamble.
As we proposed in the FY 2006 IPPS proposed rule (70 FR 23339), in
this final rule we are making revisions to the LTC-DRG classifications
and relative weights, effective October 1, 2005 through September 30,
2006 (FY 2006), using the latest available data. As we proposed in that
same IPPS proposed rule, the final LTC-DRGs and relative weights for FY
2006 in this final rule are based on the final IPPS DRGs (GROUPER
Version 23.0) discussed in section II. of the preamble to this final
rule.
2. Changes in the LTC-DRG Classifications
a. Background
Section 123 of Pub. L. 106-113 specifically requires that the PPS
for LTCHs be a per discharge system with a DRG-based patient
classification system reflecting the differences in patient resources
and costs in LTCHs while maintaining budget neutrality. Section
307(b)(1) of Pub. L. 106-554 modified the requirements of section 123
of Pub. L. 106-113 by specifically requiring that the Secretary examine
``the feasibility and the impact of basing payment under such a system
[the LTCH PPS] on the use of existing (or refined) hospital diagnosis-
related groups (DRGs) that have been modified to account for different
resource use of long-term care hospital patients as well as the use of
the most recently available hospital discharge data.''
In accordance with section 307(b)(1) of Pub. L. 106-554 and Sec.
412.515 of our existing regulations, the LTCH PPS uses information from
LTCH patient records to classify patient cases into distinct LTC-DRGs
based on clinical characteristics and expected resource needs. The LTC-
DRGs used as the patient classification component of the LTCH PPS
correspond to the DRGs under the IPPS for acute care hospitals. Thus,
as we proposed in the FY 2006 IPPS proposed rule (70 FR 23339), in this
final rule, we are establishing the use of the IPPS GROUPER Version
23.0 for FY 2006 to process LTCH PPS claims for LTCH discharges
occurring from October 1, 2005 through September 30, 2006. The final
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 final rule.
Under the LTCH PPS, we determine relative weights for each of the
DRGs to account for the difference in resource use by patients
exhibiting the case complexity and multiple medical problems
characteristics 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 2006 IPPS proposed rule (70
FR 23340), 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.
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. Just as cases
are classified 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
the ICD-9-CM codes.
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

[[Page 47325]]

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 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 time of discharge of the patient. Therefore,
it is mandatory that the coders continue to report the same principal
diagnosis on all claims and include all diagnosis 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 and is 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 and payment rates. 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 LTCH 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 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.
b. Data
In the FY 2006 IPPS proposed rule (70 FR 23341), we proposed to
calculate the proposed LTC-DRG relative weights for FY 2006 using total
Medicare allowable charges from FY 2004 Medicare hospital bill data
from the December 2004 update of the MedPAR file, which were the best
available data at that time, and we proposed to use the proposed
Version 23.0 of the CMS GROUPER used under the IPPS (as discussed in
that same proposed rule) to classify cases. To calculate the LTC-DRG
relative weights for FY 2006 in this final rule, we obtained total
Medicare allowable charges from FY 2004 Medicare hospital bill data
from the March 2005 update of the MedPAR file, which are the most
recent available data, and we used the Version 23.0 of the CMS GROUPER
used under the IPPS (as discussed in section II.B. of this preamble) to
classify cases. In the FY 2006 IPPS proposed rule (70 FR 23341), we
stated that ``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 final rule, we are using the best
available data, that is, the March 2005 update of the MedPAR file.
As we discussed in the FY 2006 IPPS proposed rule (70 FR 23341), 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 final 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 2004 MedPAR file.
In the FY 2005 IPPS final rule (69 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 noted above, in the FY 2006 IPPS proposed rule, we proposed to
calculate the proposed LTC-DRG relative weights for FY 2006 using the
December 2004

[[Page 47326]]

update of the MedPAR file, which were the most recent available data at
that time. As stated above, in this final rule, we are using the March
2005 update of the FY 2004 MedPAR file for the determination of the FY
2006 LTC-DRG relative weights as these are the best available data. As
we discussed in the FY 2006 IPPS proposed rule (70 FR 23341), based on
an analysis of LTCH claims data from 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 FY 2006 LTC-
DRGs and relative weights presented in that proposed rule or in this
final rule.
Comment: Several commenters cited a study that concluded that the
claims data used to develop the proposed LTC-DRG relative weights (that
is, the December 2004 update of the FY 2004 MedPAR file) contain
irregularities or errors. The commenters' concern was based on a
comparison, by a private research group that was commissioned by one of
the commenters, of the LTCH FY 2004 MedPAR data to the internal records
of one LTCH. The commenters were specifically concerned that the MedPAR
data may underrepresent interrupted stay cases and cases during which
the beneficiary exhausted Medicare Part A benefits. In addition to the
possible underrepresentation of interrupted stay and exhausted benefit
cases, these commenters indicated that they had reviewed the FY 2004
MedPAR data used to develop the proposed FY 2006 LTC-DRG relative
weights and asserted that there are some cases in the FY 2004 MedPAR
file that include overstated or understated charges. They also
indicated that there were ``missing'' LTCH cases that they believe
should be included in the MedPAR file. The commenters further believed
that the missing LTCH cases may be the consequence of ``a high level of
suspended claims which were occurring due to the transition [to a
different billing system during FY 2004].'' Specifically, the
commenters stated that because payment for these suspended claims was
received by April 2004, their claims and associated charges for these
cases should have been reflected in the December 2004 update of the FY
2004 MedPAR file that was used to compute the proposed FY 2006 LTC-DRG
relative weights.
The commenters believed that such errors or irregularities may be
the source of the observed decrease in the average charges of many LTC-
DRGs. Therefore, they urged CMS to reexamine the MedPAR data to ensure
that the charges for all cases are fully accounted for in computing the
final FY 2006 LTC-DRG relative weights.
The commenter who commissioned the study gave a number of examples
of the alleged irregularities/errors in LTCH claims in the FY 2004
MedPAR file. The commenter's findings from a comparison of one
provider's internal records and data reported in the December 2004
update of the FY 2004 MedPAR file, which were used in setting the
proposed LTC-DRG relative weights, were extrapolated to all LTCHs and
then the proposed FY 2006 LTC-DRG relative weights were recalculated
``to correct for these errors.'' The commenter challenged the integrity
of the proposed LTC-DRG relative weights, as well as the final relative
weights, which would be based on a more recent update (March 2005) of
the FY 2004 MedPAR file, in keeping with our historical practice that
uses the best available data for computing payment adjustments for all
Medicare PPSs.
Response: After an extensive analysis of the data submitted by one
of the commenters, we do not agree with the commenters' assertion that
the proposed FY 2006 LTC-DRG relative weights are based on faulty
claims data in the FY 2004 MedPAR file. We believe that the use of
highly case-specific and interim data drawn from the claims records of
one LTCH to challenge the integrity of the LTCH claims in the entire FY
2004 MedPAR file is inappropriate. Our analysis did not reveal systemic
problems that would have undermined the data upon which we based the
proposed FY 2006 LTC-DRG relative weights or the data upon which we are
basing our final FY 2006 LTC-DRG relative weights in this final rule
(as discussed above). As indicated by our analysis of the issues
presented by the commenter, detailed below, we continue to believe that
the March 2005 update of the FY 2004 MedPAR file is the best available
data for setting the FY 2006 LTC-DRG relative weights and it accurately
reflects LTCH charges per discharge.
The comments were based on the commenters' analysis of one LTCH's
data and the results of that analysis were extrapolated to the universe
of LTCHs. We reviewed the LTCH data used by the commenter and compared
that data to the data in both the December 2004 update of the FY 2004
MedPAR file that were used to determine the proposed FY 2006 LTC-DRG
relative weights and in the March 2005 update of the FY 2004 MedPAR
file that are being used to determine the final FY 2006 LTC-DRG
relative weights in this final rule. The commenter raised four
categories of alleged problems: missing discharges related to the
exhaustion of Medicare Part A benefits; inaccurate representation of
interrupted stay cases; cases not reported in the MedPAR file due to
``an atypical level of suspension of LTCH claims''; and cases with
incorrectly reported charges (overstated or understated). Our analysis
revealed that rather than being distinct problems, three of the
concerns raised by the commenters--the benefits-exhausted cases, the
interrupted stay cases, and missing hospital claims--are caused by the
same basic problems. That is, the December 2003 update of the FY 2004
MedPAR file did not include some patient claims from the records of the
one LTCH in question. Because the MedPAR file represents a total
beneficiary stay (total single episode of care) in an inpatient
hospital once a beneficiary has been physically discharged from the
inpatient hospital, as described below, we evaluated the reasons why
such a situation could occur under normal claims processing procedures.
The MedPAR file is a discharge file for inpatient claims and,
therefore, during the creation of the MedPAR file, inpatient hospital
data without a discharge date would not be included. When a claim is
processed for payment calculation, the data from the fiscal
intermediary are included in the Medicare Common Working File (CWF), at
which time payment authorization or denial will be made and, if
authorized, a remittance will be generated to the provider. After the
remittance is generated, the National Claims History (NCH) is updated
to reflect all of the claims submitted for an entire stay, which may
include one claim or multiple claims. The NCH inpatient hospital data
are used in the creation of the MedPAR file and all adjustments are
resolved prior to the creation of a stay record in the MedPAR file. The
creation of the MedPAR file takes all claims submitted for a
beneficiary at the same facility and collapses all the data so that one
record is created that represents a single record of the entire stay at
the facility.
A claim that is correctly coded and submitted timely by the
provider will be captured by the specific update of the NCH files, the
data source for the MedPAR file. However, if there are issues with the
claim, the claim may be suspended. Therefore, even though the hospital
will have a record of the stay, until the issue with the claim is
resolved, it will not process into the NCH and, therefore, will not be
recorded in the MedPAR file. Issues leading to claim suspension may

[[Page 47327]]

include submission-systems failures by the provider, including the
absence of crucial information or incorrect coding of patient status by
the provider. Alternatively, issues may arise during the fiscal
intermediary processing of the claim, as a result of data processing
problems or broader standard systems issues. The fiscal intermediary
may also delay processing the claim pending resolution of policy issues
in specific situations. A fiscal intermediary may need to contact a
subject-matter specialist at Medicare, for example, for assistance in
determining whether a particular atypical patient discharge, treatment,
and readmittance scenario would be governed by the payment rules
established under either of the interrupted stay policies at Sec.
412.531.
Therefore, there are several reasons why claims could be held in
suspension and hence not be ``resolved'' either for payment purposes or
for inclusion in the MedPAR file. We understand that, at any one time,
there may be as many as 25 percent of a hospital's claims in suspension
pending resolution of one or more of the above issues. This statistic
is not reflective of any unique problems in the processing procedure
but rather is a standard feature of a dynamic claims payment process.
In recognition of this fact, and in order to enable a cash flow to a
provider where there may be a disproportionate number of unresolved
claims in suspension, our regulations at Sec. 412.541(f) provide for
accelerated payments, which are reconciled with actual remittances at a
future date.
The commenter's first concern was that a substantial number of
benefits-exhaust claims from the one LTCH were not included in the
March 2004 update of the FY 2004 MedPAR file. Our case-level analysis
revealed several reasons for this, which are discussed below.
Primarily, we believe that there has been some degree of confusion on
by that LTCH as to the policy distinction established under the LTCH
PPS between a discharge for payment purposes and a patient's physical
discharge. In the August 30, 2002 final rule for the LTCH PPS, we
established regulations at Sec. 412.503 specifying that a Medicare
patient is considered ``discharged'' for payment purposes when the
patient no longer has any Medicare covered days (that is, when Medicare
Part A benefits are exhausted). At that point, a LTCH may submit a
``discharge'' claim to its fiscal intermediary and Medicare will issue
a payment for covered care (CMS Pub. 100-4 Chapter 1, Section 50.2)
delivered until the benefits were exhausted. The patient may continue
to receive care at the LTCH, but Medicare Part A will no longer be
financially responsible for that treatment. In that same final rule, we
also established that we would include data for all inpatient days that
a Medicare beneficiary was physically in the LTCH for purposes of
meeting the length of stay requirements to qualify as a LTCH as set
forth under Sec. 412.23(e) (67 FR 55974) and for developing LTC-DRG
relative weights (67 FR 55984). Therefore, for purposes of these two
policies, data from the fiscal year during which the patient is
physically discharged from the LTCH will include the total day count
for the patient's entire stay as well as the total charges for the
entire length of stay, including data from noncovered days, even where
the Medicare payment to the LTCH was made in a prior fiscal year, based
on the earlier bill submitted by the LTCH when the patient's benefits
exhausted.
In response to the commenter's allegation that the data from the
December 2004 update of the FY 2004 MedPAR file did not capture 16 of
35 benefits-exhaust claims for one specific LTCH, CMS' analysis
revealed that 5 of these 16 cases noted by the commenter are, in fact,
included in the more recent March 2005 update of the FY 2004 MedPAR
file. This indicates that if the bill did not appear on the earlier
December update due to a processing suspension, these 5 cases appear in
the March 2005 update of the MedPAR file because the issue for which
the bill was suspended has been resolved by that time. Furthermore, an
additional 7 of the 16 claims that the hospital identified as
``discharged'' represented beneficiaries who were still in the hospital
at the end of FY 2004 (September 30, 2004), even though Medicare was no
longer making payments for their care (and they had been ``discharged
for payment purposes'' under Sec. 412.503). As noted above, only at
physical discharge will data be included in the corresponding MedPAR
file. Once those 7 patients are discharged physically from the LTCH in
question, their data will appear in the MedPAR file for the fiscal year
of their discharge. Accordingly, we do not believe that the absence
from the March 2005 update of the FY 2004 MedPAR file of the four
discharges for this one LTCH represents a systematic and serious
underrepresentation of benefits-exhaust cases in the LTCH FY 2004
MedPAR file.
The commenter also claimed that the MedPAR file had inaccurately
reported interrupted stay cases, that is, a LTCH stay that has an
intervening stay at an acute care hospital for 9 days or less, an IRF
for 27 days or less, or a SNF for 45 days or less during the LTCH stay
(Sec. 412.531). The one LTCH upon which the commenter bases his
concerns had records of 102 interrupted stay cases discharged during FY
2004. Of these, it is claimed that 44 were reported correctly in the
December 2004 update of the FY 2004 MedPAR file upon which the proposed
LTC-DRG relative weights were based. If an episode of care is governed
by the greater than 3 days interruption of stay policy, both segments
of the stay at the LTCH are paid as one. The commenter claimed that, in
such cases, only one-half of particular interrupted stay cases in that
LTCH that were reported were included in the December 2004 update of
the FY 2004 MedPAR file. The commenter also claimed that in other
interrupted stay cases, the entire stay was absent from the December
2004 update of the FY 2004 MedPAR file. We reviewed the commenter's
claims and concluded that most of these cases are included in the
recent March 2005 update of the FY 2004 MedPAR file. We believe that
these cases were not included in the December 2004 update of the FY
2004 MedPAR file because the provider's final bill was in suspension.
It is likely that the cases appear in the March 2005 update of the
FY 2004 MedPAR file because the patient was finally physically
discharged or issues relating to the claim were otherwise settled and
the claims were no longer in suspension. Other claims reported by the
LTCH but still not included in the March 2005 update of the FY 2004
MedPAR file are appropriately not in the MedPAR file because they are
still in suspension for various reasons (as noted above and discussed
in greater detail below).
As stated above, there may be one or even several valid and
appropriate reasons why the interrupted stay cases are suspended. We
understand that the initial implementation of certain LTCH PPS system
changes resulted in problems, including the mechanics of claim
submission. Specifically, for many fiscal intermediaries, the
implementation of the 3-day or less interruption of stay policy at
Sec. 412.531(a) (69 FR 25690) initially led to submission of
overlapping claims, inappropriate payments, recoupment of payments, and
subsequent withdrawal and resubmission of claims, and required
considerable provider education and resulted in initial suspension of
the claims during FY 2004. However, this is no longer a significant
problem for fiscal intermediaries. In fact, the fiscal intermediary
that services the LTCH cited by the commenter noted that several of its
providers worked

[[Page 47328]]

aggressively and in a timely manner to ensure that their claims
governed by this policy were being submitted according to CMS
instructions, and paid and reported accurately. However, other LTCHs
were still working to rectify their claims submission procedures under
the new policies or their internal records. Among those LTCHs that
apparently had data submission and payment problems, the fiscal
intermediary identified the LTCH that was the subject of the
commenter's original data collection. Therefore, while we acknowledge
that there were initial claims processing difficulties with interrupted
stay cases, based on our conversations with the fiscal intermediary
that services approximately two-thirds of all LTCHs, as well as with
the fiscal intermediary that services the LTCH in question and 10 other
LTCHs, we do not believe that there continues to be a significant
issue. Furthermore, we believe that, currently, for the vast majority
of LTCHs, internal records are consistent with the actual payment
adjustments made by their fiscal intermediaries that are reported in
the MedPAR file. However, the few LTCHs that experience an
inconsistency between their internal records and the data reported in
the MedPAR file do so as a result of provider specific billing issues
which are in no way indicative of a widespread or even a significant
problem with the integrity of the FY 2003 MedPAR data.
As noted above, the commenter believes that ``an atypical level of
suspension of LTCH claims'' results from dealing with the FY 2004
conversion from the Arkansas Part A Standard System (APASS) billing
system to the Fiscal Intermediary Share System (FISS) billing system.
The commenter believed this transition resulted in inaccurate and
underreported claims in the FY 2004 MedPAR data. While there were some
initial difficulties with the system transition, our analysis of the
MedPAR data again indicates that those difficulties have been addressed
and, in fact, the MedPAR data accurately reflect provider billings and
are reliable.
Based on discussions with the fiscal intermediaries that process
the vast majority of LTCH bills, we conclude that, although initially
there were some problems with the system's processing of a limited
number of claims that were impacted by either the 3-day or less
interrupted stay policy (Sec. 412.531(a)) or cases of exhaustion of
Medicare benefits, the problems were typically resolved in a timely
manner and the claims are reflected in the March 2005 update of the FY
2004 MedPAR file. Furthermore, the fiscal intermediary that serves the
LTCH in question also noted experiencing some difficulties with its
conversion to the FISS billing system originally, but presently, it is
no longer experiencing a significant number of suspended claims as a
result of those issues.
We also analyzed the commenter's assertions that, for a number of
the LTCH bills in question, the LTCH's internal records of charges
included either additional or fewer charges than the amount reported as
the charges in the December 2004 update of the FY 2004 MedPAR file. The
commenter believed that, because the FY 2004 MedPAR file does not
reflect all of the bill's charges for this LTCH, there is a systemic
problem that affects the calculations of the FY 2006 LTC-DRG relative
weights. We believe the FY 2004 MedPAR file is providing cases with
accurate charge data for that fiscal year. Because all Medicare charges
that are reported in the MedPAR file are taken directly from claims
submitted by providers, in order to further evaluate the commenter's
assertion, we requested that the fiscal intermediary serving this LTCH
review claims that the commenter alleged exemplified the
``discrepancy'' between the LTCH charges identified in its records and
those that appear in the FY 2004 MedPAR file. A comparison of the
electronic claims submitted by the LTCH to the fiscal intermediary did
not reveal any inconsistencies. That is, the charges on the electronic
claims for those cases matched those charges that appeared in the most
recent update (March 2005) of the MedPAR file. Therefore, the MedPAR
data are consistent with charge data submitted by the LTCH to CMS.
Furthermore, as we analyzed each of the commenter's specific
allegations of systemic flaws in the FY 2004 MedPAR data, we have
concluded that the only way that the actual charges could be higher or
lower on the hospital's own records than those charges that appear on
the claim in the NCH (upon which the MedPAR file is derived) would be
if the provider did not include those charges on the bill submitted to
the fiscal intermediary for processing. We note that this issue of a
discrepancy between billed charges and the MedPAR data is not an issue
for other providers. Therefore, we believe that any inconsistencies
between charges for a few cases as listed in the internal records of
one LTCH and those reported for those same cases in the FY 2004 MedPAR
file are due to internal data reporting practices of a specific LTCH
and are not indicative of a widespread problem with the reporting of
charges for LTCHs throughout the country in the FY 2004 MedPAR data
that affects the final LTC-DRG relative weights.
Based upon our detailed analysis of the commenter's assertions, we
believe that there are no systematic errors in the LTCH FY 2004 MedPAR
data and we continue to believe it is appropriate to base the FY 2006
LTC-DRG relative weights on the March 2005 update of the FY 2004 MedPAR
file. We believe that the December 2004 update of the FY 2004 MedPAR
file that we used to determine the proposed LTC-DRG relative weights
for FY 2006 in the FY 2006 IPPS proposed rule reflected the best
available data at that time. Moreover, we maintain that calculating the
final LTC-DRG payment weights set forth in this final rule using the
March 2005 update of the FY 2004 MedPAR file eliminates most of the
issues raised by the commenter, even with the specific claims submitted
by the one LTCH cited by the commenter. Furthermore, based on our
analysis, we conclude that many of the issues experienced by that LTCH
were unique to that hospital and were not systemic issues.
In summary, as explained above, we do not believe there is evidence
to support the contention that there is a systemic flaw in the LTCH FY
2004 MedPAR data or the integrity of the FY 2006 final LTC-DRG relative
weights. Rather, we believe that extrapolation to the entire universe
of LTCHs of the issues of one particular LTCH with its own submission
and reporting history as proof of the unreliability of our FY 2004
MedPAR data is both misleading and inaccurate. Therefore, in this final
rule, we are using the LTCH claims data from the March 2005 update of
the FY 2004 MedPAR file to determine the FY 2006 LTC-DRG relative
weights using the methodology described below.
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

[[Page 47329]]

methodology used to determine the DRG relative weights under the IPPS
described 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,
as implemented in the August 30, 2002 LTCH PPS final rule (67 FR 55989
through 55991), we standardize charges for each case by first dividing
the adjusted charge for the case (adjusted for short-stay outliers
under Sec. 412.529 as described in section II.D.4. (step 3) of this
preamble) by the average adjusted charge for all cases at the LTCH in
which the case was treated. Short-stay outliers under Sec. 412.529 are
cases with a length of stay that is less than or equal to five-sixths
the average length of stay of the LTC-DRG. The average adjusted charge
reflects the average intensity of the health care services delivered by
a particular LTCH and the average cost level of that LTCH. The
resulting ratio is multiplied by that LTCH's case-mix index to
determine the standardized charge for the case.
Multiplying by the LTCH's case-mix index accounts for the fact that
the same relative charges are given greater weight in a LTCH with
higher average costs than they would at a LTCH with low average costs
which is needed to adjust each LTCH's relative charge value to reflect
its case-mix relative to the average case-mix for all LTCHs. Because we
standardize charges in this manner, we count charges for a Medicare
patient at a LTCH with high average charges as less resource intensive
than they would be at a LTCH with low average charges. For example, a
$10,000 charge for a case in a LTCH with an average adjusted charge of
$17,500 reflects a higher level of relative resource use than a $10,000
charge for a case in a LTCH with the same case-mix, but an average
adjusted charge of $35,000. We believe that the adjusted charge of an
individual case more accurately reflects actual resource use for an
individual LTCH because the variation in charges due to systematic
differences in the markup of charges among LTCHs is taken into account.
d. Low-Volume LTC-DRGs
In order to account for LTC-DRGs with low-volume (that is, with
fewer than 25 LTCH cases), in accordance with the methodology
established in the August 30, 2002 LTCH PPS final rule (67 FR 55984),
we group those ``low-volume LTC-DRGs'' (that is, DRGs that contained
between 1 and 24 cases annually) into one of five categories
(quintiles) based on average charges, for the purposes of determining
relative weights. In the FY 2006 IPPS proposed rule (70 FR 23341), we
stated that we would continue to employ this treatment of low volume
LTC-DRGs in determining the FY 2006 LTC-DRG relative weights using the
best available LTCH data. In that same 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. For this final
rule, using LTCH cases from the March 2005 update of the FY 2004 MedPAR
file, we identified 171 LTC-DRGs that contained between 1 and 24 cases.
This list of LTC-DRGs was then divided into one of the 5 low-volume
quintiles, each containing a minimum of 34 LTC-DRGs (171/5 = 34 with 1
LTC-DRG as the remainder). In accordance with our established
methodology, we then make an assignment to a specific low-volume
quintile by sorting the low-volume LTC-DRGs in ascending order by
average charge. For this final rule, this results in an assignment to a
specific low volume quintile of the sorted 171 low-volume 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 LTC-DRG was used to determine which low-volume
quintile received the additional LTC-DRG. After sorting the 171 low-
volume LTC-DRGs in ascending order, we group the first fifth of low-
volume LTC-DRGs with the lowest average charge into Quintile 1. The
highest average charge cases are grouped into Quintile 5. Since the
average charge of the 69th LTC-DRG in the sorted list is closer to the
68th LTC-DRG's average charge (assigned to Quintile 2) than to the
average charge of the 70th LTC-DRG in the sorted list (to be assigned
to Quintile 3), we placed it into Quintile 2. This process was repeated
through the remaining low-volume LTC-DRGs so that 1 low-volume quintile
contains 35 LTC-DRGs and 4 low-volume quintiles contain 34 LTC-DRGs.
In order to determine the relative weights for the 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 used the
five low-volume quintiles described above. The composition of each of
the five low-volume quintiles shown in the chart below was used in
determining the LTC-DRG relative weights for FY 2006. We determined a
relative weight and (geometric) average length of stay for each of the
five low-volume quintiles using the formula that we apply to the
regular LTC-DRGs (25 or more cases), as described below in section
II.D.4. of this preamble. We assigned the same relative weight and
average length of stay to each of the LTC-DRGs that make up that low-
volume quintile. We note that, as this system is dynamic, it is
possible that the number and specific type of LTC-DRGs with a low
volume of LTCH cases will vary in the future. We use the best available
claims data in the MedPAR file to identify low-volume LTC-DRGs and to
calculate the relative weights based on our methodology.

Composition of Low-Volume Quintiles for FY 2006
------------------------------------------------------------------------
LTC-DRG Description
------------------------------------------------------------------------
QUINTILE 1
------------------------------------------------------------------------
17................................... NONSPECIFIC CEREBROVASCULAR
DISORDERS W/O CC.
25................................... SEIZURE & HEADACHE AGE >17 W/O
CC.

[[Page 47330]]

65................................... DYSEQUILIBRIUM.
69................................... OTITIS MEDIA & URI AGE >17 W/O
CC.
86................................... PLEURAL EFFUSION W/O CC.
95................................... PNEUMOTHORAX W/O CC.
102.................................. OTHER RESPIRATORY SYSTEM
DIAGNOSES W/O CC.
133.................................. ATHEROSCLEROSIS W/O CC.
140.................................. ANGINA PECTORIS.
142 ***.............................. SYNCOPE & COLLAPSE W/O CC.
143.................................. CHEST PAIN.
171.................................. OTHER DIGESTIVE SYSTEM O.R.
PROCEDURES W/O CC.
175.................................. G.I. HEMORRHAGE W/O CC.
219.................................. LOWER EXTREM & HUMER PROC EXCEPT
HIP, FOOT, FEMUR AGE >17 W/O CC.
237.................................. SPRAINS, STRAINS, & DISLOCATIONS
OF HIP, PELVIS & THIGH.
241.................................. CONNECTIVE TISSUE DISORDERS W/O
CC.
246.................................. NON-SPECIFIC ARTHROPATHIES.
251.................................. FX, SPRN, STRN & DISL OF FOREARM,
HAND, FOOT AGE >17 W/O CC.
262.................................. BREAST BIOPSY & LOCAL EXCISION
FOR NON-MALIGNANCY.
273.................................. MAJOR SKIN DISORDERS W/O CC.
281.................................. TRAUMA TO THE SKIN, SUBCUT TISS &
BREAST AGE >17 W/O CC.
284.................................. MINOR SKIN DISORDERS W/O CC.
301.................................. ENDOCRINE DISORDERS W/O CC.
305.................................. KIDNEY, URETER & MAJOR BLADDER
PROC FOR NON-NEOPL W/O CC.
312.................................. URETHRAL PROCEDURES, AGE >17 W
CC.
319.................................. KIDNEY & URINARY TRACT NEOPLASMS
W/O CC.
328.................................. URETHRAL STRICTURE AGE >17 W CC.
344.................................. OTHER MALE REPRODUCTIVE SYSTEM
O.R. PROCEDURES FOR MALIGNANCY.
428.................................. DISORDERS OF PERSONALITY &
IMPULSE CONTROL.
431.................................. CHILDHOOD MENTAL DISORDERS.
441.................................. HAND PROCEDURES FOR INJURIES.
445.................................. TRAUMATIC INJURY AGE >17 W/O CC.
509.................................. FULL THICKNESS BURN W/O SKIN GRFT
OR INH INJ W/O CC OR SIG TRAUMA.
511.................................. NON-EXTENSIVE BURNS W/O CC OR
SIGNIFICANT TRAUMA .
--------------------------------------
QUINTILE 2
------------------------------------------------------------------------
11................................... NERVOUS SYSTEM NEOPLASMS W/O CC.
29................................... TRAUMATIC STUPOR & COMA, COMA <1
HR AGE >17 W/O CC.
44................................... ACUTE MAJOR EYE INFECTIONS.
46................................... OTHER DISORDERS OF THE EYE AGE
>17 W CC.
83................................... MAJOR CHEST TRAUMA W CC.
93................................... INTERSTITIAL LUNG DISEASE W/O CC.
97................................... BRONCHITIS & ASTHMA AGE >17 W/O
CC.
122.................................. CIRCULATORY DISORDERS W AMI W/O
MAJOR COMP, DISCHARGED ALIVE.
128.................................. DEEP VEIN THROMBOPHLEBITIS.
136.................................. CARDIAC CONGENITAL & VALVULAR
DISORDERS AGE >17 W/O CC.
139.................................. CARDIAC ARRHYTHMIA & CONDUCTION
DISORDERS W/O CC.
151.................................. PERITONEAL ADHESIOLYSIS W/O CC.
173.................................. DIGESTIVE MALIGNANCY W/O CC.
206.................................. DISORDERS OF LIVER EXCEPT MALIG,
CIRR, ALC HEPA W/O CC.
208.................................. DISORDERS OF THE BILIARY TRACT W/
O CC.
250.................................. FX, SPRN, STRN & DISL OF FOREARM,
HAND, FOOT AGE >17 W CC.
254.................................. FX, SPRN, STRN & DISL OF UPARM,
LOWLEG EX FOOT AGE >17 W/O CC.
259.................................. SUBTOTAL MASTECTOMY FOR
MALIGNANCY W CC.
276.................................. NON-MALIGANT BREAST DISORDERS.
293.................................. OTHER ENDOCRINE, NUTRIT & METAB
O.R. PROC W/O CC.
306.................................. PROSTATECTOMY W CC.
325.................................. KIDNEY & URINARY TRACT SIGNS &
SYMPTOMS AGE >17 W CC.
332.................................. OTHER KIDNEY & URINARY TRACT
DIAGNOSES AGE >17 W/O CC.
334.................................. MAJOR MALE PELVIC PROCEDURES W
CC.
336.................................. TRANSURETHRAL PROSTATECTOMY W CC.
347.................................. MALIGNANCY, MALE REPRODUCTIVE
SYSTEM, W/O CC.
348.................................. BENIGN PROSTATIC HYPERTROPHY W
CC.
399.................................. RETICULOENDOTHELIAL & IMMUNITY
DISORDERS W/O CC.
404.................................. LYMPHOMA & NON-ACUTE LEUKEMIA W/O
CC.
425.................................. ACUTE ADJUSTMENT REACTION &
PSYCHOLOGICAL DYSFUNCTION.
432.................................. OTHER MENTAL DISORDER DIAGNOSES.
433.................................. ALCOHOL/DRUG ABUSE OR DEPENDENCE,
LEFT AMA.
447.................................. ALLERGIC REACTIONS AGE >17.
484.................................. CRANIOTOMY FOR MULTIPLE
SIGNIFICANT TRAUMA.
503.................................. KNEE PROCEDURES W/O PDX OF
INFECTION.
--------------------------------------

[[Page 47331]]

QUINTILE 3
------------------------------------------------------------------------
8.................................... PERIPH & CRANIAL NERVE & OTHER
NERV SYST PROC W/O CC.
21................................... VIRAL MENINGITIS.
31................................... CONCUSSION AGE >17 W CC.
61................................... MYRINGOTOMY W TUBE INSERTION AGE
>17.
67................................... EPIGLOTTITIS.
100.................................. RESPIRATORY SIGNS & SYMPTOMS W/O
CC.
110.................................. MAJOR CARDIOVASCULAR PROCEDURES W
CC.
119.................................. VEIN LIGATION & STRIPPING.
125.................................. CIRCULATORY DISORDERS EXCEPT AMI,
W CARD CATH W/O COMPLEX DIAG.
152.................................. MINOR SMALL & LARGE BOWEL
PROCEDURES W CC.
177.................................. UNCOMPLICATED PEPTIC ULCER W CC.
178.................................. UNCOMPLICATED PEPTIC ULCER W/O
CC.
181.................................. G.I. OBSTRUCTION W/O CC.
185.................................. DENTAL & ORAL DIS EXCEPT
EXTRACTIONS & RESTORATIONS, AGE
>17.
193.................................. BILIARY TRACT PROC EXCEPT ONLY
CHOLECYST W OR W/O C.D.E. W CC.
195.................................. CHOLECYSTECTOMY W C.D.E. W CC.
197.................................. CHOLECYSTECTOMY EXCEPT BY
LAPAROSCOPE W/O C.D.E. W CC.
223.................................. MAJOR SHOULDER/ELBOW PROC, OR
OTHER UPPER EXTREMITY PROC W CC.
227.................................. SOFT TISSUE PROCEDURES W/O CC.
235.................................. FRACTURES OF FEMUR.
266.................................. SKIN GRAFT &/OR DEBRID EXCEPT FOR
SKIN ULCER OR CELLULITIS W/O CC.
270.................................. OTHER SKIN, SUBCUT TISS & BREAST
PROC W/O CC.
274.................................. MALIGNANT BREAST DISORDERS W CC.
295.................................. DIABETES AGE 0-35.
308.................................. MINOR BLADDER PROCEDURES W CC.
369.................................. MENSTRUAL & OTHER FEMALE
REPRODUCTIVE SYSTEM DISORDERS.
424.................................. O.R. PROCEDURE W PRINCIPAL
DIAGNOSES OF MENTAL ILLNESS.
443.................................. OTHER O.R. PROCEDURES FOR
INJURIES W/O CC.
449.................................. POISONING & TOXIC EFFECTS OF
DRUGS AGE >17 W CC.
454.................................. OTHER INJURY, POISONING & TOXIC
EFFECT DIAG W CC.
467.................................. OTHER FACTORS INFLUENCING HEALTH
STATUS.
507.................................. FULL THICKNESS BURN W SKIN GRFT
OR INHAL INJ W/O CC OR SIG
TRAUMA.
531.................................. SPINAL PROCEDURES WITH CC.
532.................................. SPINAL PROCEDURES WITHOUT CC.
--------------------------------------
QUINTILE 4
------------------------------------------------------------------------
22................................... HYPERTENSIVE ENCEPHALOPATHY.
40................................... EXTRAOCULAR PROCEDURES EXCEPT
ORBIT AGE >17.
63................................... OTHER EAR, NOSE, MOUTH & THROAT
O.R. PROCEDURES.
117.................................. CARDIAC PACEMAKER REVISION EXCEPT
DEVICE REPLACEMENT.
118.................................. CARDIAC PACEMAKER DEVICE
REPLACEMENT.
124.................................. CIRCULATORY DISORDERS EXCEPT AMI,
W CARD CATH & COMPLEX DIAG.
150.................................. PERITONEAL ADHESIOLYSIS W CC.
157.................................. ANAL & STOMAL PROCEDURES W CC.
168.................................. MOUTH PROCEDURES W CC.
191.................................. PANCREAS, LIVER & SHUNT
PROCEDURES W CC.
211.................................. HIP & FEMUR PROCEDURES EXCEPT
MAJOR JOINT AGE >17 W/O CC.
216.................................. BIOPSIES OF MUSCULOSKELETAL
SYSTEM & CONNECTIVE TISSUE.
228.................................. MAJOR THUMB OR JOINT PROC, OR OTH
HAND OR WRIST PROC W CC.
288.................................. O.R. PROCEDURES FOR OBESITY.
299.................................. INBORN ERRORS OF METABOLISM.
303.................................. KIDNEY, URETER & MAJOR BLADDER
PROCEDURES FOR NEOPLASM.
310.................................. TRANSURETHRAL PROCEDURES W CC.
323.................................. URINARY STONES W CC, &/OR ESW
LITHOTRIPSY.
339.................................. TESTES PROCEDURES, NON-MALIGNANCY
AGE >17.
341.................................. PENIS PROCEDURES.
360.................................. VAGINA, CERVIX & VULVA
PROCEDURES.
406.................................. MYELOPROLIF DISORD OR POORLY DIFF
NEOPL W MAJ O.R. PROC W CC.
408.................................. MYELOPROLIF DISORD OR POORLY DIFF
NEOPL W OTHER O.R. PROC.
419.................................. FEVER OF UNKNOWN ORIGIN AGE >17 W
CC.
476.................................. PROSTATIC O.R. PROCEDURE
UNRELATED TO PRINCIPAL
DIAGNOSIS.
497.................................. SPINAL FUSION W CC.
500.................................. BACK & NECK PROCEDURES EXCEPT
SPINAL FUSION W/O CC.
502.................................. KNEE PROCEDURES W PDX OF
INFECTION W/O CC.
505.................................. EXTENSIVE BURN OR FULL THICKNESS
BURNS WITH MECH VENT 96+ HOURS
WITHOUT SKIN GRAFT.
506.................................. FULL THICKNESS BURN W SKIN GRAFT
OR INHAL INJ W CC OR SIG TRAUMA.
539.................................. LYMPHOMA AND LEUKEMIA WITH MAJOR
O.R. PROCEDURE WITH CC.
551.................................. PERMANENT CARDIAC PACEMAKER
IMPLANT WITH MAJOR CV DIAGNOSIS
OR AICD LEAD OR GNRTR.
552.................................. OTHER PERMANENT CARDIAC PACEMAKER
IMPLANT WITHOUT MAJOR CV
DIAGNOSIS.

[[Page 47332]]

555.................................. PERCUTANEOUS CARDIOVASCULAR PROC
WITH MAJOR CV DIAGNOSIS.
556*................................. PERCUTANEOUS CARDIOVASCULAR PROC
WITH NON-DRUG-ELUTING STENT
WITHOUT MAJOR CV DIAGNOSIS.
557*................................. PERCUTANEOUS CARDIOVASCULAR PROC
WITH DRUG-ELUTING STENT WITH
MAJOR CV DIAGNOSIS.
--------------------------------------
QUINTILE 5
------------------------------------------------------------------------
1.................................... CRANIOTOMY AGE >17 W CC.
75................................... MAJOR CHEST PROCEDURES.
77................................... OTHER RESP SYSTEM O.R. PROCEDURES
W/O CC.
154.................................. STOMACH, ESOPHAGEAL & DUODENAL
PROCEDURES AGE >17 W CC.
161.................................. INGUINAL & FEMORAL HERNIA
PROCEDURES AGE >17 W CC.
200.................................. HEPATOBILIARY DIAGNOSTIC
PROCEDURE FOR NON-MALIGNANCY.
210.................................. HIP & FEMUR PROCEDURES EXCEPT
MAJOR JOINT AGE >17 W CC.
218.................................. LOWER EXTREM & HUMER PROC EXCEPT
HIP, FOOT, FEMUR AGE >17 W CC.
230.................................. LOCAL EXCISION & REMOVAL OF INT
FIX DEVICES OF HIP & FEMUR.
268.................................. SKIN, SUBCUTANEOUS TISSUE &
BREAST PLASTIC PROCEDURES.
290.................................. THYROID PROCEDURES.
304.................................. KIDNEY, URETER & MAJOR BLADDER
PROC FOR NON-NEOPL W CC.
345.................................. OTHER MALE REPRODUCTIVE SYSTEM
O.R. PROC EXCEPT FOR MALIGNANCY.
364.................................. D&C, CONIZATION EXCEPT FOR
MALIGNANCY.
365.................................. OTHER FEMALE REPRODUCTIVE SYSTEM
O.R. PROCEDURES.
394.................................. OTHER O.R. PROCEDURES OF THE
BLOOD AND BLOOD FORMING ORGANS.
401.................................. LYMPHOMA & NON-ACUTE LEUKEMIA W
OTHER O.R. PROC W CC.
471.................................. BILATERAL OR MULTIPLE MAJOR JOINT
PROCS OF LOWER EXTREMITY.
482.................................. TRACHEOSTOMY FOR FACE, MOUTH &
NECK DIAGNOSES.
486.................................. OTHER O.R. PROCEDURES FOR
MULTIPLE SIGNIFICANT TRAUMA.
488.................................. HIV W EXTENSIVE O.R. PROCEDURE.
491.................................. MAJOR JOINT & LIMB REATTACHMENT
PROCEDURES OF UPPER EXTREMITY.
493.................................. LAPAROSCOPIC CHOLECYSTECTOMY W/O
C.D.E. W CC.
499.................................. BACK & NECK PROCEDURES EXCEPT
SPINAL FUSION W CC.
501.................................. KNEE PROCEDURES W PDX OF
INFECTION W CC.
515.................................. CARDIAC DEFIBRILATOR IMPLANT W/O
CARDIAC CATH.
519.................................. CERVICAL SPINAL FUSION W CC.
529.................................. VENTRICULAR SHUNT PROCEDURES W
CC.
533.................................. EXTRACRANIAL VASCULAR PROCEDURES
WITH CC.
543.................................. CRANIOTOMY W IMPLANT OF CHEMO
AGENT OR ACUTE COMPLEX CNS PDX.
544.................................. MAJOR JOINT REPLACEMENT OR
REATTACHMENT OF LOWER EXTREMITY.
545.................................. REVISION OF HIP OR KNEE
REPLACEMENT.
556 **............................... PERCUTANEOUS CARDIOVASCULAR PROC
WITH NON-DRUG-ELUTING STENT
WITHOUT MAJOR CV DIAGNOSIS.
557 **............................... PERCUTANEOUS CARDIOVASCULAR PROC
WITH DRUG-ELUTING STENT WITH
MAJOR CV DIAGNOSIS.
------------------------------------------------------------------------
* One of the original 171 low-volume LTC-DRGs initially assigned to a
different low-volume quintile; reassigned to this low-volume quintile
in addressing nonmonotonicity (see step 4 below).
** One of the original 171 low-volume LTC-DRGs initially assigned to
this low-volume quintile; reassigned to a different low-volume
quintile in addressing nonmonotonicity (see step 4 below).
*** One of the original 171 low-volume LTC-DRGs initially assigned to
this low-volume quintile; removed from this low-volume quintile in
addressing nonmonotonicity (see step 4 below).

4. Steps for Determining the FY 2006 LTC-DRG Relative Weights
As we noted in the FY 2006 IPPS proposed rule (70 FR 23346), the FY
2006 LTC-DRG relative weights are determined in accordance with the
methodology established in the August 30, 2002 LTCH PPS final rule (67
FR 55989 through 55991). In summary, LTCH cases must be grouped in the
appropriate LTC-DRG, while taking into account the low-volume LTC-DRGs
as described above, before the FY 2006 LTC-DRG relative weights can be
determined. After grouping the cases in the appropriate LTC-DRG, we
calculated the relative weights for FY 2006 in this final 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 adjusted the
number of cases in each 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 LTC-DRG using the
hospital-specific relative value method described above.
Comment: A few commenters expressed concern regarding what they
believed to be a proposed change in the methodology to compute the LTC-
DRG relative weights. Specifically, they asserted that removing
statistical outlier cases and cases with a length of stay of 7 days or
less may inappropriately remove too many cases from the relative weight
calculations. The commenters believed that, by narrowing the universe
of cases used to compute the LTC-DRG relative weights, the principle of
averaging that is a fundamental feature of a PPS would be eroded or
distorted.
Response: We did not propose any policy change in the methodology
for determining the LTC-DRG relative weights for FY 2006 in the FY 2006
IPPS proposed rule. The commenters are mistaken in their belief that we
did. Rather, the six steps for determining the proposed FY 2006 LTC-DRG
relative weights presented in the FY 2006 IPPS proposed rule (70 FR
23346 through 23353) are the same steps that we have used to determine
the LTC-DRG relative weights since the implementation of the LTCH PPS
in FY 2003 (August 30, 2002 LTCH IPPS final rule (67 FR 55989 through
55991)). In every final rule in which we have updated the LTC-DRG

[[Page 47333]]

relative weights since the October 1, 2002 implementation of the LTCH
PPS (68 FR 45375 through 45385, and 69 FR 48989 through 49000), we
reiterated the same steps of our established methodology to determine
the annual update to the LTC-DRG relative weights. We continue to
believe that this methodology continues to be valid, and we do not find
any reason at this time to revise it.
As we explained in the FY 2006 IPPS proposed rule (70 FR 23346), we
believe it is appropriate to remove statistical outlier cases and cases
with a length of stay of 7 days or less because including those LTCH
cases in the calculation of the relative weights could result in an
inaccurate relative weight, and therefore an inappropriate payment
amount, that does not truly reflect relative resource use among the
LTC-DRGs. Specifically, we continue to believe that statistical outlier
cases may represent aberrations in the data that distort the measure of
average resource use and that, as we explained above, including them in
the calculation of the relative weights could result in an
inappropriate payment amount.
In the RY 2006 LTCH PPS final rule (70 FR 23346) and as we
discussed in greater detail in the FY 2005 IPPS final rule (69 FR
48990), we also explained that, generally, cases with a length of stay
7 days or less are not representative of either typical or perhaps even
appropriate LTCH patients. Furthermore, in general, in a hospital
established solely to treat very long-stay patients, and with a payment
system calibrated to reflect the costs incurred in treating such
patients, stays of 7 days or less would not fully receive or benefit
from treatment or the range of resource use that is typical in a LTCH
stay, and full resources are often not used in the earlier stages of
admission to a LTCH. We continue to believe that, if we were to include
stays of 7 days or less in the computation of the LTC-DRG relative
weights, the value of many relative weights would decrease and,
therefore, payments would decrease to a level that may no longer be
appropriate. Specifically, because LTCH cases with very short lengths
of stay (that is, 7 days or less) do not use the same amount or type of
resources as typical LTCH inlier cases (that is, cases in which
Medicare covered days exceed five-sixths of the geometric average
length of stay for the LTC-DRG) and the patient is discharged prior to
receiving a LTCH PPS high-cost outlier payment, our simulations
indicate that including these cases would significantly bias payments
against LTCH inlier cases to a point where LTCH inlier cases would be
underpaid (69 FR 48990). Thus, 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. Consequently, we disagree with the commenters that
removing aberrant LTCH cases (that is, statistical outlier cases and
cases with a length of stay of 7 days or less) undermines the averaging
principle upon which PPSs are developed.
Although we did not propose any change in the methodology for
determining the LTC-DRG relative weights for FY 2006, we disagree with
the assertions that removing statistical outlier cases and cases with a
length of stay of 7 days or less inappropriately narrows the universe
of cases used to compute the LTC-DRG relative weights, resulting in a
distortion of the principle of averaging. Rather, because each LTC-DRG
relative weight represents the average resources required to treat
cases in that particular LTC-DRG, relative to the average resources
used to treat cases in all LTC-DRGs, we believe that, by removing cases
that do not represent the ``average resource use'' of the mix of LTCH
cases within a DRG (that is, statistical outlier cases and cases with a
length of stay of 7 days or less), for the reasons explained above, we
are preserving the integrity of a system that is based on averages.
Therefore, in establishing the FY 2006 LTC-DRG relative weights in this
final rule, we have continued to remove statistical outlier cases and
cases with a length of stay of 7 days or less from the MedPAR data used
to compute the FY 2006 LTC-DRG relative weights.
Comment: Four commenters believed the estimated decrease in LTCH
PPS payments resulting from the proposed changes to the LTC-DRG
relative weights is inconsistent with the statutory mandate that the
LTCH PPS be maintained in a budget neutral manner. These commenters
recommended that we apply a budget neutrality adjustment to the LTC-DRG
relative weights in order to mitigate the estimated LTCH PPS payment
reductions that we estimated would result from the proposed changes to
the LTC-DRG relative weights for FY 2006. Two of those commenters cited
the statutory language authorizing the establishment of the LTCH PPS
and argued that the language requires that the LTCH PPS continue to
operate under ``budget neutrality.'' They further asserted that,
although we did not interpret this language as mandating budget
neutrality beyond the initial year of the LTCH PPS, the Secretary
should use his or her broad discretionary authority to assure ``the
same level of payments projected in the FY 2006 LTCH update
regulation'' by making a budget neutrality adjustment in developing the
FY 2006 LTC-DRG relative weights.
Response: We understand that these commenters are concerned about
the estimated decrease in payments under LTCH PPS based upon changes in
the LTC-DRG relative weights for FY 2006. However, we believe that this
issue is distinct from the Secretary's budget neutrality obligation
under the statute for the first year of implementation of the LTCH PPS.
After the first year of the LTCH PPS, the statute gives the Secretary
broad authority to determine the appropriateness of system updates and
matters such as annual updates and policy changes. As we discussed in
the FY 2005 IPPS final rule (69 FR 48999), with respect to budget
neutrality, we interpreted section 123(a)(1) of Pub. L. 106-113 to
require that total payments under the LTCH PPS during FY 2003 will be
projected to equal estimated payments that would have been made for
LTCHs' operating and capital-related inpatient hospital costs had the
LTCH PPS not have been implemented. Thus we believe the statute's
mandate for budget neutrality applies only to the first year of
implementation of the LTCH PPS (that is, FY 2003). Consistent with the
broad discretional authority conferred upon the Secretary under section
123(a)(1) of Pub. L. 103-116, as amended by section 307 of Pub. L. 106-
554, the Secretary is exercising his broad authority to make updates
the LTCH PPS in a nonbudget neutral manner after FY 2003 for various
components of the LTCH PPS, including the annual update of the LTC-DRG
classifications and relative weights.
Consistent with this budget neutrality requirement for the first
year of implementation of the LTCH PPS, under Sec. 412.523(d)(2) of
the regulations, an adjustment is made in determining the standard
Federal rate for FY 2003 so that aggregate payments under the LTCH PPS
are estimated to equal the amount that would have been paid to LTCHs
under the reasonable cost-based (TEFRA) payment system if the LTCH PPS
were not implemented. Therefore, in the August 30, 2002 LTCH PPS final
rule (67 FR 56027 through 56037), which implemented the LTCH PPS, in
order to maintain budget neutrality, we adjusted the LTCH PPS Federal
rate for FY 2003 so that aggregate payments under the LTCH PPS are
estimated to equal the amount that would have been paid to LTCHs under
the reasonable cost-based (TEFRA) payment system

[[Page 47334]]

had the LTCH PPS not been implemented.
As we stated in the FY 2005 IPPS final rule (70 FR 48999 through
49000), we continue to believe that section 123 of the Pub. L. 106-113
does not require that the annual update to the LTC-DRG classifications
and relative weights maintain budget neutrality. We believe we have
satisfied the budget neutrality requirement of section 123 of the Pub.
L. 106-113 by establishing the LTCH PPS Federal rate for FY 2003 under
Sec. 412.523(d)(2) so that aggregate payment under the LTCH PPS are
projected equal to estimated aggregate payments under the reasonable
cost-based payment system if the LTCH PPS were not implemented.
Therefore, we disagree with the commenters that a budget neutrality
adjustment to the LTC-DRG relative weights or to the LTCH PPS Federal
rate is required by statute or as a result of the annual update to the
LTC-DRGs under Sec. 412.517 for FY 2006.
We agree with the commenters that, under section 123 of the BBRA
and section 307 of the BIPA, the Secretary generally has broad
authority in developing the LTCH PPS, including whether and how to make
adjustments to the LTCH PPS. As we discussed in the RY 2006 LTCH PPS
final rule (70 FR 24188), we will consider whether it is appropriate
for us to propose a budget neutrality adjustment in the annual update
of some aspects of the LTCH PPS under our broad discretionary authority
under the statute to provide ``appropriate adjustments'' to the LTCH
PPS. As several commenters noted, LTCHs are still transitioning to a
PPS and, while coding practices continue to improve, the FY 2004 claims
data may ``not yet fully reflect the nature and types of services,
staff, and other resources'' that LTCH provide to their patients. In
the RY 2005 LTCH PPS final rule, we indicated that, until the 5-year
transition from reasonable cost-based reimbursement to prospective
payment is complete, we believe it may not be appropriate to update any
aspects of the LTCH PPS in a budget neutral manner. As noted above, the
most recent available LTCH PPS claims data are from discharges
occurring during FY 2004. These LTCH claims data are from the second
year of the LTCH PPS (FY 2004), which is the only first full year since
the LTCH PPS was implemented for cost reporting periods beginning on or
after October 1, 2002 (FY 2003). Because it is still early in the 5-
year LTCH PPS transition period, we continue to believe that it is
inappropriate to update any aspects of the LTCH PPS in a budget neutral
manner. A primary reason for waiting until after the transition is
complete before evaluating aspects of the LTCH PPS, including the
budget neutrality issue, is that the data available to analyze such
issues are very limited because the LTCH PPS is still relatively new
and there is a lag time in data availability. As several commenters
pointed out, the FY 2004 MedPAR data are the first full year of LTCH
PPS data since the LTCH PPS was implemented for cost reporting periods
beginning on or after October 1, 2002 (FY 2003). In addition, the fact
that a number of LTCHs were and some are still transitioning to 100
percent of the Federal prospective payment rate may make the available
data on which to base a budget neutrality adjustment even less
appropriate because LTCHs may still be modifying their behavior based
on their transition to prospective payment and, therefore, our data may
not yet fully reflect any operational changes LTCHs may have made in
response to prospective payment. We continue to believe that, once we
have progressed further through the 5-year transition period, we will
have a better opportunity to evaluate the impacts of the implementation
of this new payment system based on a number of years of LTCH PPS data,
which will most appropriately reflect LTCHs' experience under a PPS.
For the reasons stated above, we do not believe that a budget
neutrality adjustment to the FY 2006 LTC-DRG relative weights or to the
LTCH PPS Federal rate is necessary or appropriate. Accordingly, in
developing the FY 2006 LTC-DRGs and relative weights shown in Table 11
of the Addendum of this final rule, we have not applied an adjustment
for budget neutrality nor are we adjusting the 2006 LTCH PPS rate year
Federal rate established in the 2006 LTCH PPS final rule (70 FR 24180)
to account for the estimated change in LTCH PPS payments that will
result from the annual update to the LTC-DRG classifications and
relative weights for FY 2006.
Comment: Several commenters recommended implementing a ``dampening
policy,'' similar to that which was implemented for the Ambulatory
Payment Classification (APC) changes under the Hospital Outpatient PPS
(OPPS) in CY 2003, which would reduce the decrease in any relative
weight in excess of a threshold (for example, 15 percent) by half, to
mitigate instability in LTCH PPS payments because of the ``significant/
substantial'' decrease in many of the relative weights.
Response: A ``dampening policy,'' as recommended by the commenters,
would limit the decrease in any of the LTC-DRG relative weights to a
maximum amount, which would reduce the estimated decrease in LTCH PPS
payments that we projected in the FY 2006 IPPS proposed rule as a
result of the proposed changes to the LTC-DRG relative weights for FY
2006 (70 FR 23667). The commenters believed that the estimated decrease
in the LTCH PPS payments resulting from the proposed changes to the
LTC-DRGs for FY 2006 would create a ``destabilizing effect'' on LTCH
PPS payments. For the reasons discussed below, we do not believe the
estimated decrease in LTCH PPS payments resulting from the changes we
are making to the LTC-DRG relative weights for FY 2006 in this final
rule will lead to instability in LTCH PPS payments, and therefore, we
are not implementing a ``dampening policy,'' as recommended by the
commenters.
As discussed in the November 1, 2002 OPPS final rule (67 FR 66749
through 66750), we believed it was appropriate to implement the
``dampening policy'' under the OPPS referenced by the commenters
because many of the decreases in payment rates for some of the APCs
appeared to be linked to ``changes in the methodology for those drugs
and devices that will no longer be eligible for pass-through payments;
miscoding; restructuring of APCs (in which movement of a single code
from one APC to another may change the median cost of both APCs), or
use of data from the period following the implementation of the OPPS.''
Although Medicare payment for both hospital outpatient services and
inpatient LTCH services are reimbursed under a PPS (respectively),
there are significant distinctions between the two payment systems. For
instance, under the LTCH PPS, a single per LTC-DRG payment is made for
all inpatient hospital services provided to a patient for each stay,
where in contrast, under the OPPS, payments based on APCs may include
distinct payment methodologies for certain drugs and devices that are
eligible for pass-through payments. Thus, there are significant
distinctions between the two payment systems that warrant different
considerations when evaluating the need for a ``dampening policy.''
Below we discuss the reasons we believe that a ``dampening policy'' to
mitigate the effects of the changes in the LTC-DRG relative weights for
FY 2006 on LTCH PPS payments are not necessary or appropriate.
As noted by the commenters, many of the proposed FY 2006 LTC-DRG
relative weights decreased in

[[Page 47335]]

comparison to the FY 2005 LTC-DRG relative weights, which would result
in an aggregate estimated decrease in FY 2006 LTCH PPS payments. As we
explained in the FY 2006 IPPS proposed rule (70 FR 23667), we continue
to observe an increase of relatively lower charge cases being assigned
to LTC-DRGs with higher relative weights in the prior year. The
addition of these lower charge cases results in a decrease in the many
of the LTC-DRG relative weights from FY 2005 to FY 2006. This decrease
in many of the LTC-DRG relative weights, in turn, will result in an
estimated decrease in LTCH PPS payments. As we explained in that same
proposed rule, contributing to this increased number of 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. A further analysis of the LTCH claims in the March
2005 update of the FY 2004 MedPAR data, which we used to determine the
FY 2006 LTC-DRG relative weights in this final rule, continue to show
an increase of relatively lower charge cases being assigned to LTC-DRGs
with higher relative weights in the prior year. As we explained the FY
2006 IPPS proposed rule (70 FR 23667), 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, which, in
turn, results in an estimated aggregate decrease in LTCH PPS payments.
A few commenters acknowledged that with the move from cost-based
reimbursement to a PPS, LTCHs' coding practices are still undergoing
refinement. Specifically, two commenters stated that ``the LTCH PPS, in
its third year of implementation, is still in transition; the initial
5-year phase-in will end September 2006. During this time of
transition, LTCH coding and data are still undergoing improvement.''
Therefore, it is not unreasonable to observe relatively significant
changes (either higher or lower) in the average charge for many LTC-
DRGs as LTCHs' behavior coding continues to change in response to the
implementation of a PPS. As the transition progresses, we expect that
LTCH's behavior will result in fewer nonuniform changes in the average
charge of many LTC-DRGs, which may impact the LTC-DRG relative weights
from year to year.
As we discussed above, we believe that there are no systemic errors
in the LTCH FY 2004 MedPAR data, and we believe that the increase of
relatively lower charge cases being assigned to LTC-DRGs with higher
relative weights that we observed in the FY 2004 LTCH claims data
(which results in a decrease in the many of the LTC-DRG relative
weights) accurately represents current LTCH costs. Specifically, an
analysis of a comparison of the FY 2003 LTCH claims data (used to
develop the FY 2005 LTC-DRG relative weights) and the FY 2004 LTCH
claims data (used to develop the FY 2006 LTC-DRG relative weights)
shows that, of the 155 LTC-DRGs that are used on a ``regular basis''
(that is, nationally, LTCHs discharge, in total, 25 or more of these
cases annually), about 30 percent of those LTC-DRGs have experienced a
decrease in the average charge per case, which generally results in a
lower relative weight. In addition, about 45 percent of those LTC-DRGs
have experienced an increase in the average charge that is less than
the increase (16 percent) in the overall average charge across all LTC-
DRGs. In general, the LTC-DRG relative weights are determined by
dividing the average charge for each LTC-DRG by the average charge
across all LTC-DRGs. Accordingly, those LTC-DRGs with an increase in
average charge of less than 16 percent (that is, the increase in
average charge across all LTC-DRGs) will also experience a reduction in
their relative weight because the average charge for each of those LTC-
DRGs is being divided by a bigger number (that is, the average charge
across all LTC-DRGs). Therefore, because we believe the FY 2004 LTCH
claims data used to determine the FY 2006 LTC-DRG relative weights
accurately reflect the resources used by LTCHs to treat their patients,
and these data show either a decrease in the average charge of the LTC-
DRG or an increase in the average charge of the LTC-DRG that is less
than the overall increase in the average charge across all LTC-DRGs, we
believe that the decrease in many of the LTC-DRG relative weights is
appropriate.
The LTC-DRG relative weights are designed to reflect the average of
resources used to treat representative cases of the discharges within
each LTC-DRG. As we discussed in greater detail above, after our
extensive analysis of the FY 2004 MedPAR data, which we used to
determine the FY 2006 LTC-DRG relative weights, we concluded that there
are no systematic errors in that data. Therefore, we continue to
believe it is appropriate to base the FY 2006 LTC-DRG relative weights
on LTCH claims data in the FY 2004 MedPAR file. Furthermore, we believe
that the decrease in many of the LTC-DRG relative weights is
appropriate and is reflective of the changing behaviors of LTCHs'
response to a PPS environment. As we discussed above, we believe that
the LTCH claims data in the FY 2004 MedPAR file accurately reflects the
resources that are expended to treat LTCH patients in each LTC-DRG.
Although many of the LTC-DRG relative weights (and consequently
aggregate LTCH PPS payments, excluding the update to the LTCH PPS
Federal rate effective July 1, 2005 (70 FR 24217) will be lower in FY
2006 as compared to FY 2005, we do not believe that the payment rates
for those LTC-DRGs are inappropriate based on the LTCH claims data in
the FY 2004 MedPAR files. Rather, we believe that the lower LTC-DRG
relative weights (and consequently a reduction in aggregate LTCH PPS
payments) are appropriate, given that the average resources used to
treat a LTCH patient in a particular LTC-DRG are less than the average
resources used to treat a LTCH patient in a particular LTC-DRG based on
FY 2003 LTCH claims data. Therefore, we do not agree with the
commenters' assertion that the changes to the LTC-DRG relative weights
for FY 2006 will result in instability in LTCH PPS payments. Rather, we
believe that the changes to the LTC-DRG relative weights for FY 2006
will result in appropriate payments for the resources used to treat
LTCH patients in a particular LTC-DRG. Accordingly, for the reasons
discussed above, we are not implementing a ``dampening policy'' in
determining the FY 2006 LTC-DRG relative weights in this final rule. We
also note that the 4.2 percent decrease in LTCH PPS payments estimated
as a result of the changes we are making to the LTC-DRGs and relative
weights in this final rule for FY 2006 (see section VII. of the
Addendum to this final rule) is partially offset by the projected 5.7
percent increase in LTCH PPS payments estimated based on the updated
rates and factors effective for discharges occurring on or after July
1, 2005 established in the FY 2006 LTCH PPS final rule (70 FR 24217).
Below we discuss in detail the steps for calculating the FY 2006
LTC-DRG relative weights as presented in the FY 2006 IPPS proposed rule
(70 FR 23346 through 23353). We note that, as we stated above in
section II.D.3.b. of this preamble, as we proposed, we have excluded
the data of all-inclusive rate LTCHs and LTCHs that are paid in
accordance with demonstration projects

[[Page 47336]]

that had claims in the FY 2004 MedPAR file.
Step 1--Remove statistical outliers.
The first step in the calculation of the 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 relative weights. As noted above, we believe that
they may represent aberrations in the data that distort the measure of
average resource use. Including those LTCH cases in the calculation of
the relative weights could result in an inaccurate relative weight that
does not truly reflect relative resource use among the LTC-DRGs.
Step 2--Remove cases with a length of stay of 7 days or less.
The FY 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. As explained above, if we were
to include stays of 7 days or less in the computation of the FY 2006
LTC-DRG relative weights, the value of many relative weights would
decrease and, therefore, payments would decrease to a level that may no
longer be appropriate.
We do not believe that it would be appropriate to compromise the
integrity of the payment determination for those LTCH cases that
actually benefit from and receive a full course of treatment at a LTCH,
in order to include data from these very short-stays. Thus, as
explained above, in determining the 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 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 LTC-DRG for nonshort-stay
outlier cases. This has the effect of proportionately reducing the
impact of the lower charges for the short-stay outlier cases in
calculating the average charge for the LTC-DRG. This process produces
the same result as if the actual charges per discharge of a short-stay
outlier case were adjusted to what they would have been had the
patient's length of stay been equal to the average length of stay of
the LTC-DRG.
As we explained in the FY 2006 IPPS proposed rule (70 FR 23346
through 23347), counting short-stay outlier cases as full discharges
with no adjustment in determining the LTC-DRG relative weights would
lower the LTC-DRG relative weight for affected LTC-DRGs because the
relatively lower charges of the short-stay outlier cases would bring
down the average charge for all cases within a LTC-DRG. This would
result in an ``underpayment'' to nonshort-stay outlier cases and an
``overpayment'' to short-stay outlier cases. Therefore, in this final
rule, we adjust for short-stay outlier cases under Sec. 412.529 in
this manner because it results in more appropriate payments for all
LTCH cases.
Step 4--Calculate the FY 2006 LTC-DRG relative weights on an
iterative basis.
The process of calculating the LTC-DRG relative weights using the
hospital-specific relative value methodology is iterative. First, for
each LTCH case, we calculate a hospital-specific relative charge value
by dividing the short-stay outlier adjusted charge per discharge (see
step 3) of the LTCH case (after removing the statistical outliers (see
step 1)) and LTCH cases with a length of stay of 7 days or less (see
step 2) by the average charge per discharge for the LTCH in which the
case occurred. The resulting ratio is then multiplied by the LTCH's
case-mix index to produce an adjusted hospital-specific relative charge
value for the case. An initial case-mix index value of 1.0 is used for
each LTCH.
For each LTC-DRG, the FY 2006 LTC-DRG relative weight is calculated
by dividing the average of the adjusted hospital-specific relative
charge values (from above) for the LTC-DRG by the overall average
hospital-specific relative charge value across all cases for all LTCHs.
Using these recalculated LTC-DRG relative weights, each LTCH's average
relative weight for all of its cases (case-mix) is calculated by
dividing the sum of all the LTCH's LTC-DRG relative weights by its
total number of cases. The LTCHs' hospital-specific relative charge
values above are multiplied by these hospital-specific case-mix
indexes. These hospital-specific case-mix adjusted relative charge
values are then used to calculate a new set of LTC-DRG relative weights
across all LTCHs. In this final rule, this iterative process is
continued until there is convergence between the weights produced at
adjacent steps, for example, when the maximum difference is less than
0.0001.
Step 5--Adjust the FY 2006 LTC-DRG relative weights to account for
nonmonotonically increasing relative weights.
As explained in section II.B. of this preamble, the FY 2006 CMS
DRGs, on which the FY 2006 LTC-DRGs are based, contain ``pairs'' that
are differentiated based on the presence or absence of CCs. The LTC-
DRGs with CCs are defined by certain secondary diagnoses not related to
or inherently a part of the disease process identified by the principal
diagnosis, but the presence of additional diagnoses does not
automatically generate a CC. As we discussed in the 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 LTC-DRG
means that cases classified into a ``without CC'' LTC-DRG are expected
to have lower resource use (and lower costs). In other words, resource
use (and costs) are expected to decrease across ``with CC/without CC''
pairs of LTC-DRGs.
For a case to be assigned to a LTC-DRG with CCs, more coded
information is called for (that is, at least one relevant secondary
diagnosis), than for a case to be assigned to a LTC-DRG ``without CCs''
(which is based on only one principal diagnosis and no relevant
secondary diagnoses). Currently, the LTCH claims data include both
accurately coded cases without complications and cases that have
complications (and cost more), but were not coded completely. Both
types of cases are grouped to a LTC-DRG ``without CCs'' when only the
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

[[Page 47337]]

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 since the implementation of the LTCH PPS in FY 2003.
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'' LTC-DRG would
have a higher average charge than the ``with CC'' LTC-DRG. For this
final rule, using the LTCH cases in the March 2005 update of the FY
2004 MedPAR file (the best available data at this time), we identified
three types of nonmonotonic LTC-DRG pairs. As we stated in the August
30, 2002 LTCH PPS final rule (67 FR 55990), we believe this anomaly may
be due to coding inaccuracies and expect that, as was the case when we
first implemented the acute care hospital IPPS, this problem will be
self-correcting, as LTCHs submit more completely coded data in the
future.
The first category of nonmonotonically increasing relative weights
for FY 2006 LTC-DRG pairs ``with and without CCs'' contains one pair of
LTC-DRGs in which both the LTC-DRG ``with CCs'' and the LTC-DRG
``without CCs'' had 25 or more LTCH cases and, therefore, did not fall
into one of the 5 low-volume quintiles. For those nonmonotonic LTC-DRG
pairs, we combine the LTCH cases and compute a new relative weight
based on the case-weighted average of the combined LTCH cases of the
LTC-DRGs. The case-weighted average charge is determined by dividing
the total charges for all LTCH cases by the total number of LTCH cases
for the combined LTC-DRG. This new relative weight is then assigned to
both of the LTC-DRGs in the pair. In this final rule, for FY 2006, LTC-
DRGs 553 and 554 fall into this category.
The second category of nonmonotonically increasing relative weights
for LTC-DRG pairs ``with and without CCs'' consists of one pair of LTC-
DRGs that has fewer than 25 cases, and each LTC-DRG is grouped to
different low-volume quintiles in which the ``without CC'' LTC-DRG is
in a higher-weighted low-volume quintile than the ``with CC'' LTC-DRG.
For those pairs, we combine the LTCH cases and determine the case-
weighted average charge for all LTCH cases. The case-weighted average
charge is determined by dividing the total charges for all LTCH cases
by the total number of LTCH cases for the combined LTC-DRG. Based on
the case-weighted average LTCH charge, we determine within which low-
volume quintile the ``combined LTC-DRG'' is grouped. Both LTC-DRGs in
the pair are then grouped into the same low-volume quintile, and thus
have the same relative weight. In this final rule, for FY 2006, LTC-
DRGs 555, 556 and 557 fall into this category. (We note, 3 LTC-DRGs
make up this non-monotonic ``pair'' of LTC-DRGs because these
percutaneous cardiovascular procedure DRGs are further split depending
on the presence or absence of a drug eluting stint and the presence or
absence of a major ``CV'' (cardiovascular) diagnosis, which is similar
to the adjustment for non-monotonicity for DRGs 521, 522 and 523 in the
development of the FY 2005 LTC-DRG relative weights (69 FR 78922).
The third category of nonmonotonically increasing relative weights
for LTC-DRG pairs ``with and without CCs'' consists of one pair of LTC-
DRGs where one of the LTC-DRGs has fewer than 25 LTCH cases and is
grouped to a low-volume quintile and the other LTC-DRG has 25 or more
LTCH cases and has its own LTC-DRG relative weight, and the LTC-DRG
``without CCs'' has the higher relative weight. We removed the low-
volume LTC-DRG from the low-volume quintile and combined it with the
other LTC-DRG for the computation of a new relative weight for each of
these LTC-DRGs. This new relative weight is assigned to both LTC-DRGs,
so they each have the same relative weight. In this final rule, for FY
2006, LTC-DRGs 142 and 143 fall into this category.
Step 6--Determine a FY 2006 LTC-DRG relative weight for LTC-DRGs
with no LTCH cases.
As we stated above, we determine the relative weight for each LTC-
DRG using charges reported in the March 2005 update of the FY 2004
MedPAR file. Of the 526 LTC-DRGs for FY 2006, we identified 196 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 final 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 LTC-DRGs. Thus, in the process of determining the LTC-DRG
relative weights, we are unable to determine weights for these 196 LTC-
DRGs using the methodology described in steps 1 through 5 above.
However, because patients with a number of the diagnoses under these
LTC-DRGs may be treated at LTCHs beginning in FY 2006, we assign
relative weights to each of the 196 ``no volume'' LTC-DRGs based on
clinical similarity and relative costliness to one of the remaining 330
(526 - 196 = 330) LTC-DRGs for which we are able to determine relative
weights, based on FY 2004 claims data.
As there are currently no LTCH cases in these ``no volume'' LTC-
DRGs, we determined relative weights for the 196 LTC-DRGs with no LTCH
cases in the FY 2004 MedPAR file used in this final rule by grouping
them to the appropriate low-volume quintile. This methodology is
consistent with our methodology used in determining relative weights to
account for the low-volume LTC-DRGs described above.
Our methodology for determining relative weights for the ``no
volume'' LTC-DRGs is as follows: We crosswalk

[[Page 47338]]

the no volume LTC-DRGs by matching them to other similar 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 relative weight for
the applicable low-volume quintile to the no volume LTC-DRG if the LTC-
DRG to which it is crosswalked is grouped to one of the low-volume
quintiles. If the LTC-DRG to which the no volume LTC-DRG is crosswalked
is not one of the LTC-DRGs to be grouped to one of the low-volume
quintiles, we compare the relative weight of the LTC-DRG to which the
no volume LTC-DRG is crosswalked to the relative weights of each of the
five quintiles and we assign the no volume LTC-DRG the relative weight
of the low-volume quintile with the closest weight. For this final
rule, a list of the no volume FY 2006 LTC-DRGs and the FY 2006 LTC-DRG
to which it is crosswalked in order to determine the appropriate low-
volume quintile for the assignment of a relative weight for FY 2006 is
shown in the chart below.

No Volume LTC-DRG Crosswalk and Quintile Assignment for FY 2006
------------------------------------------------------------------------
Low-volume
LTC-DRG Description Cross-walked quintile
LTC-DRG assignment
------------------------------------------------------------------------
2............... CRANIOTOMY AGE >17 W/ 1 Quintile 5.
O CC.
3............... CRANIOTOMY AGE 0-17. 1 Quintile 5.
6............... CARPAL TUNNEL 251 Quintile 1.
RELEASE.
26.............. SEIZURE & HEADACHE 25 Quintile 1.
AGE 0-17.
30.............. TRAUMATIC STUPOR & 29 Quintile 2.
COMA, COMA <1 HR
AGE 0-17.
32.............. CONCUSSION AGE >17 W/ 25 Quintile 1.
O CC.
33.............. CONCUSSION AGE 0-17. 25 Quintile 1.
36.............. RETINAL PROCEDURES.. 40 Quintile 4.
37.............. ORBITAL PROCEDURES.. 40 Quintile 4.
38.............. PRIMARY IRIS 40 Quintile 4.
PROCEDURES.
39.............. LENS PROCEDURES WITH 40 Quintile 4.
OR WITHOUT
VITRECTOMY.
41.............. EXTRAOCULAR 40 Quintile 4.
PROCEDURES EXCEPT
ORBIT AGE 0-17.
42.............. INTRAOCULAR 40 Quintile 4.
PROCEDURES EXCEPT
RETINA, IRIS & LENS.
43.............. HYPHEMA............. 40 Quintile 4.
45.............. NEUROLOGICAL EYE 40 Quintile 4.
DISORDERS.
47.............. OTHER DISORDERS OF 40 Quintile 4.
THE EYE AGE >17 W/O
CC.
48.............. OTHER DISORDERS OF 40 Quintile 4.
THE EYE AGE 0-17.
49.............. ESOPHAGITIS, 64 Quintile 4.
GASTROENT & MISC
DIGEST DISORDERS
AGE 0-17.
50.............. SIALOADENECTOMY..... 63 Quintile 4.
51.............. SALIVARY GLAND 63 Quintile 4.
PROCEDURES EXCEPT
SIALOADENECTOMY.
52.............. CLEFT LIP & PALATE 63 Quintile 4.
REPAIR.
53.............. SINUS & MASTOID 63 Quintile 4.
PROCEDURES AGE >17.
54.............. SINUS & MASTOID 63 Quintile 4.
PROCEDURES AGE 0-17.
55.............. MISCELLANEOUS EAR, 63 Quintile 4.
NOSE, MOUTH &
THROAT PROCEDURES.
56.............. RHINOPLASTY......... 63 Quintile 4.
57.............. T&A PROC, EXCEPT 69 Quintile 1.
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY,
AGE >17.
58.............. T&A PROC, EXCEPT 69 Quintile 1.
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY,
AGE 0-17.
59.............. TONSILLECTOMY &/OR 69 Quintile 1.
ADENOIDECTOMY ONLY,
AGE >17.
60.............. TONSILLECTOMY &/OR 69 Quintile 1.
ADENOIDECTOMY ONLY,
AGE 0-17.
62.............. MYRINGOTOMY W TUBE 69 Quintile 1.
INSERTION AGE 0-17.
66.............. EPISTAXIS........... 69 Quintile 1.
70.............. OTITIS MEDIA & URI 69 Quintile 1.
AGE 0-17.
71.............. LARYNGOTRACHEITIS... 97 Quintile 2.
72.............. OTHER DIGESTIVE 73 Quintile 3.
SYSTEM DIAGNOSES
AGE 0-17.
74.............. OTHER EAR, NOSE, 69 Quintile 1.
MOUTH & THROAT
DIAGNOSES AGE 0-17.
81.............. RESPIRATORY 69 Quintile 1.
INFECTIONS &
INFLAMMATIONS AGE 0-
17.
84.............. MAJOR CHEST TRAUMA W/ 93 Quintile 2.
O CC.
91.............. ALCOHOL/DRUG ABUSE 90 Quintile 1.
OR DEPENDENCE W
REHABILITATION
THERAPY W/O CC.
98.............. BRONCHITIS & ASTHMA 97 Quintile 2.
AGE 0-17.
104............. CARDIAC VALVE & 110 Quintile 3.
OTHER MAJOR
CARDIOTHORACIC PROC
W CARDIAC CATH.
105............. CARDIAC VALVE & 110 Quintile 3.
OTHER MAJOR
CARDIOTHORACIC PROC
W/O CARDIAC CATH.
106............. CORONARY BYPASS W 110 Quintile 3.
PTCA.
107............. CORONARY BYPASS W 110 Quintile 3.
CARDIAC CATH.
108............. OTHER CARDIOTHORACIC 110 Quintile 3.
PROCEDURES.
109............. CORONARY BYPASS W/O 110 Quintile 3.
PTCA OR CARDIAC
CATH.
111............. MAJOR CARDIOVASCULAR 110 Quintile 3.
PROCEDURES W/O CC.
129............. CARDIAC ARREST, 110 Quintile 3.
UNEXPLAINED.
137............. CARDIAC CONGENITAL & 136 Quintile 2.
VALVULAR DISORDERS
AGE 0-17.
146............. ALCOHOL/DRUG ABUSE 148 Quintile 5.
OR DEPENDENCE W/O
REHABILITATION
THERAPY W/O CC.
147............. NASAL TRAUMA & 148 Quintile 5.
DEFORMITY.
149............. FX, SPRN, STRN & 176 Quintile 3.
DISL OF FOREARM,
HAND, FOOT AGE 0-17.
153............. MINOR SMALL & LARGE 152 Quintile 3.
BOWEL PROCEDURES W/
O CC.
155............. STOMACH, ESOPHAGEAL 154 Quintile 5.
& DUODENAL
PROCEDURES AGE >17
W/O CC.
156............. STOMACH, ESOPHAGEAL 154 Quintile 5.
& DUODENAL
PROCEDURES AGE 0-17.
158............. ANAL & STOMAL 157 Quintile 4.
PROCEDURES W/O CC.
159............. HERNIA PROCEDURES 177 Quintile 3.
EXCEPT INGUINAL &
FEMORAL AGE >17 W
CC.
160............. HERNIA PROCEDURES 177 Quintile 3.
EXCEPT INGUINAL &
FEMORAL AGE >17 W/O
CC.

[[Page 47339]]

162............. INGUINAL & FEMORAL 178 Quintile 3.
HERNIA PROCEDURES
AGE >17 W/O CC.
163............. HERNIA PROCEDURES 178 Quintile 3.
AGE 0-17.
164............. NUTRITIONAL & MISC 148 Quintile 5.
METABOLIC DISORDERS
AGE 0-17.
165............. CESAREAN SECTION W/O 148 Quintile 5.
CC.
166............. LYMPHOMA & NON-ACUTE 148 Quintile 5.
LEUKEMIA W OTHER
O.R. PROC W/O CC.
167............. MAJOR SMALL & LARGE 148 Quintile 5.
BOWEL PROCEDURES W/
O CC.
169............. MOUTH PROCEDURES W/O 185 Quintile 3.
CC.
184............. FX, SPRN, STRN & 183 Quintile 1.
DISL OF
UPARM,LOWLEG EX
FOOT AGE 0-17.
186............. DENTAL & ORAL DIS 185 Quintile 3.
EXCEPT EXTRACTIONS
& RESTORATIONS, AGE
0-17.
187............. DENTAL EXTRACTIONS & 185 Quintile 3.
RESTORATIONS.
190............. PERIANAL & PILONIDAL 189 Quintile 1.
PROCEDURES.
192............. PANCREAS, LIVER & 191 Quintile 4.
SHUNT PROCEDURES W/
O CC.
194............. BILIARY TRACT PROC 193 Quintile 3.
EXCEPT ONLY
CHOLECYST W OR W/O
C.D.E. W/O CC.
196............. CHOLECYSTECTOMY W 197 Quintile 3.
C.D.E. W/O CC.
198............. CHOLECYSTECTOMY 197 Quintile 3.
EXCEPT BY
LAPAROSCOPE W/O
C.D.E. W/O CC.
199............. HEPATOBILIARY 200 Quintile 5.
DIAGNOSTIC
PROCEDURE FOR
MALIGNANCY.
212............. HIP & FEMUR 210 Quintile 5.
PROCEDURES EXCEPT
MAJOR JOINT AGE 0-
17.
220............. LOWER EXTREM & HUMER 218 Quintile 5.
PROC EXCEPT
HIP,FOOT,FEMUR AGE
0-17.
224............. SHOULDER,ELBOW OR 227 Quintile 3.
FOREARM PROC,EXC
MAJOR JOINT PROC, W/
O CC.
229............. HAND OR WRIST PROC, 237 Quintile 1.
EXCEPT MAJOR JOINT
PROC, W/O CC.
232............. ARTHROSCOPY......... 237 Quintile 1.
234............. OTHER MUSCULOSKELET 237 Quintile 1.
SYS & CONN TISS
O.R. PROC W/O CC.
252............. SEPTICEMIA AGE 0-17. 253 Quintile 3.
255............. LIMB REATTACHMENT, 253 Quintile 3.
HIP AND FEMUR PROC
FOR MULTIPLE
SIGNIFICANT TR.
257............. TOTAL MASTECTOMY FOR 274 Quintile 3.
MALIGNANCY W CC.
258............. TOTAL MASTECTOMY FOR 274 Quintile 3.
MALIGNANCY W/O CC.
260............. SUBTOTAL MASTECTOMY 274 Quintile 3.
FOR MALIGNANCY W/O
CC.
261............. BREAST PROC FOR NON- 274 Quintile 3.
MALIGNANCY EXCEPT
BIOPSY & LOCAL
EXCISION.
267............. MAJOR HEAD & NECK 271 Quintile 3.
PROCEDURES.
275............. MALIGNANT BREAST 274 Quintile 3.
DISORDERS W/O CC.
279............. CELLULITIS AGE 0-17. 273 Quintile 1.
282............. TRAUMA TO THE SKIN, 281 Quintile 1.
SUBCUT TISS &
BREAST AGE 0-17.
286............. EXTREME IMMATURITY.. 292 Quintile 5.
289............. PARATHYROID 63 Quintile 4.
PROCEDURES.
291............. THYROGLOSSAL 63 Quintile 4.
PROCEDURES.
298............. PREMATURITY W MAJOR 297 Quintile 2.
PROBLEMS.
307............. PROSTATECTOMY W/O CC 306 Quintile 2.
309............. MINOR BLADDER 308 Quintile 3.
PROCEDURES W/O CC.
311............. TRANSURETHRAL 310 Quintile 4.
PROCEDURES W/O CC.
313............. URETHRAL PROCEDURES, 312 Quintile 1.
AGE >17 W/O CC.
314............. URETHRAL PROCEDURES, 305 Quintile 1.
AGE 0-17.
322............. FULL TERM NEONATE W 321 Quintile 1.
MAJOR PROBLEMS.
324............. NEONATE W OTHER 321 Quintile 1.
SIGNIFICANT
PROBLEMS.
326............. RECTAL RESECTION W/O 321 Quintile 1.
CC.
327............. RECTAL RESECTION W 321 Quintile 1.
CC.
329............. URETHRAL STRICTURE 305 Quintile 1.
AGE >17 W/O CC.
330............. URETHRAL STRICTURE 305 Quintile 1.
AGE 0-17.
333............. OTHER KIDNEY & 332 Quintile 2.
URINARY TRACT
DIAGNOSES AGE 0-17.
335............. MAJOR MALE PELVIC 345 Quintile 5.
PROCEDURES W/O CC.
337............. TRANSURETHRAL 306 Quintile 2.
PROSTATECTOMY W/O
CC.
338............. TESTES PROCEDURES, 336 Quintile 2.
FOR MALIGNANCY.
340............. TESTES PROCEDURES, 339 Quintile 4.
NON-MALIGNANCY AGE
0-17.
342............. CIRCUMCISION AGE >17 339 Quintile 4.
343............. CIRCUMCISION AGE 0- 339 Quintile 4.
17.
349............. BENIGN PROSTATIC 339 Quintile 4.
HYPERTROPHY W/O CC.
351............. STERILIZATION, MALE. 339 Quintile 4.
353............. PELVIC EVISCERATION, 339 Quintile 4.
RADICAL
HYSTERECTOMY &
RADICAL VULVECTOMY.
354............. UTERINE,ADNEXA PROC 339 Quintile 4.
FOR NON-OVARIAN/
ADNEXAL MALIG W CC.
355............. UTERINE,ADNEXA PROC 339 Quintile 4.
FOR NON-OVARIAN/
ADNEXAL MALIG W/O
CC.
356............. FEMALE REPRODUCTIVE 339 Quintile 4.
SYSTEM
RECONSTRUCTIVE
PROCEDURES.
357............. UTERINE & ADNEXA 339 Quintile 4.
PROC FOR OVARIAN OR
ADNEXAL MALIGNANCY.
358............. UTERINE & ADNEXA 339 Quintile 4.
PROC FOR NON-
MALIGNANCY W CC.
359............. UTERINE & ADNEXA 339 Quintile 4.
PROC FOR NON-
MALIGNANCY W/O CC.
361............. LAPAROSCOPY & 110 Quintile 3.
INCISIONAL TUBAL
INTERRUPTION.
362............. ENDOSCOPIC TUBAL 110 Quintile 3.
INTERRUPTION.
363............. D&C, CONIZATION & 110 Quintile 3.
RADIO-IMPLANT, FOR
MALIGNANCY.
367............. MALIGNANCY, FEMALE 110 Quintile 3.
REPRODUCTIVE SYSTEM
W/O CC.
370............. CESAREAN SECTION W 369 Quintile 3.
CC.
371............. APPENDECTOMY W 368 Quintile 2.
COMPLICATED
PRINCIPAL DIAG W CC.
372............. VAGINAL DELIVERY W 110 Quintile 3.
COMPLICATING
DIAGNOSES.

[[Page 47340]]

373............. VAGINAL DELIVERY W/O 110 Quintile 3.
COMPLICATING
DIAGNOSES.
374............. VAGINAL DELIVERY W 110 Quintile 3.
STERILIZATION &/OR
D&C.
375............. VAGINAL DELIVERY W 110 Quintile 3.
O.R. PROC EXCEPT
STERIL &/OR D&C.
376............. POSTPARTUM & POST 110 Quintile 3.
ABORTION DIAGNOSES
W/O O.R. PROCEDURE.
377............. POSTPARTUM & POST 110 Quintile 3.
ABORTION DIAGNOSES
W O.R. PROCEDURE.
378............. ECTOPIC PREGNANCY... 369 Quintile 3.
379............. THREATENED ABORTION. 110 Quintile 3.
380............. ABORTION W/O D&C.... 110 Quintile 3.
381............. ABORTION W D&C, 110 Quintile 3.
ASPIRATION
CURETTAGE OR
HYSTEROTOMY.
382............. FALSE LABOR......... 110 Quintile 3.
383............. OTHER ANTEPARTUM 110 Quintile 3.
DIAGNOSES W MEDICAL
COMPLICATIONS.
384............. OTHER ANTEPARTUM 110 Quintile 3.
DIAGNOSES W/O
MEDICAL
COMPLICATIONS.
385............. NEONATES, DIED OR 110 Quintile 3.
TRANSFERRED TO
ANOTHER ACUTE CARE
FACILITY.
386............. KIDNEY & URINARY 87 Quintile 4.
TRACT INFECTIONS
AGE 0-17.
387............. URINARY STONES W/O 87 Quintile 4.
CC.
388............. PREMATURITY W/O 110 Quintile 3.
MAJOR PROBLEMS.
389............. KIDNEY & URINARY 87 Quintile 4.
TRACT SIGNS &
SYMPTOMS AGE 0-17.
390............. VIRAL ILLNESS & 87 Quintile 4.
FEVER OF UNKNOWN
ORIGIN AGE 0-17.
391............. NORMAL NEWBORN...... 110 Quintile 3.
392............. SPLENECTOMY AGE >17. 197 Quintile 3.
393............. SPLENECTOMY AGE 0-17 197 Quintile 3.
396............. RED BLOOD CELL 399 Quintile 2.
DISORDERS AGE 0-17.
402............. APPENDECTOMY W 395 Quintile 2.
COMPLICATED
PRINCIPAL DIAG W/O
CC.
405............. ACUTE LEUKEMIA W/O 404 Quintile 2.
MAJOR O.R.
PROCEDURE AGE 0-17.
407............. MYELOPROLIF DISORD 408 Quintile 4.
OR POORLY DIFF
NEOPL W MAJ
O.R.PROC W/O CC.
411............. HISTORY OF 110 Quintile 3.
MALIGNANCY W/O
ENDOSCOPY.
412............. HISTORY OF 110 Quintile 3.
MALIGNANCY W
ENDOSCOPY.
414............. OTHER MYELOPROLIF 399 Quintile 2.
DIS OR POORLY DIFF
NEOPL DIAG W/O CC.
417............. APPENDECTOMY W/O 416 Quintile 3.
COMPLICATED
PRINCIPAL DIAG W/O
CC.
420............. FEVER OF UNKNOWN 419 Quintile 4.
ORIGIN AGE >17 W/O
CC.
422............. ADRENAL & PITUITARY 419 Quintile 4.
PROCEDURES.
446............. TRAUMATIC INJURY AGE 445 Quintile 1.
0-17.
448............. ALLERGIC REACTIONS 447 Quintile 2.
AGE 0-17.
450............. POISONING & TOXIC 449 Quintile 3.
EFFECTS OF DRUGS
AGE >17 W/O CC.
451............. POISONING & TOXIC 449 Quintile 3.
EFFECTS OF DRUGS
AGE 0-17.
455............. OTHER INJURY, 449 Quintile 3.
POISONING & TOXIC
EFFECT DIAG W/O CC.
478............. OTHER VASCULAR 110 Quintile 3.
PROCEDURES W CC.
479............. OTHER VASCULAR 110 Quintile 3.
PROCEDURES W/O CC.
481............. BONE MARROW 394 Quintile 5.
TRANSPLANT.
485............. OTHER HEART ASSIST 487 Quintile 4.
SYSTEM IMPLANT.
492............. APPENDECTOMY W/O 410 Quintile 4.
COMPLICATED
PRINCIPAL DIAG W CC.
494............. LAPAROSCOPIC 493 Quintile 5.
CHOLECYSTECTOMY W/O
C.D.E. W/O CC.
496............. COMBINED ANTERIOR/ 497 Quintile 4.
POSTERIOR SPINAL
FUSION.
498............. SPINAL FUSION W/O CC 497 Quintile 4.
504............. CHEMOTHERAPY W ACUTE 468 Quintile 5.
LEUKEMIA AS
SECONDARY DIAGNOSIS.
518............. PERCUTANEOUS 125 Quintile 3.
CARDIVASCULAR PROC
W/O CORONARY ARTERY
STENT OR AMI.
520............. CERVICAL SPINAL 497 Quintile 4.
FUSION W/O CC.
522............. CARDIAC DEFIB 521 Quintile 1.
IMPLANT W CARDIAC
CATH W AMI/HF/SHOCK.
523............. CARDIAC DEFIB 521 Quintile 1.
IMPLANT W CARDIAC
CATH W/O AMI/HF/
SHOCK.
525............. EXTENSIVE BURN OR 468 Quintile 5.
FULL THICKNESS
BURNS WITH MECH
VENT 96+ HOURS WITH
SKIN GRAFT.
528............. INTRACRANIAL 1 Quintile 5.
VASCULAR PROC W PDX
HEMORRHAGE.
530............. VENTRICULAR SHUNT 529 Quintile 5.
PROCEDURES W/O CC.
534............. EXTRACRANIAL 500 Quintile 4.
VASCULAR PROCEDURES
WITHOUT CC.
535............. ACUTE ISCHEMIC 515 Quintile 5.
STROKE WITH USE OF
THROMBOLYTIC AGENT.
536............. KIDNEY & URINARY 515 Quintile 5.
TRACT SIGNS &
SYMPTOMS AGE >17 W/
O CC.
538............. LOCAL EXCISION AND 228 Quintile 4.
REMOVAL OF INTERNAL
FIXATION DEVICES
EXCEPT HIP AND
FEMUR WITHOUT CC.
540............. LYMPHOMA AND 399 Quintile 2.
LEUKEMIA WITH MAJOR
O.R. PROCEDURE
WITHOUT CC.
546............. SPINAL FUSION EXCEPT 499 Quintile 5.
CERVICAL WITH
CURVATURE OF SPINE
OR MALIGNANCY.
------------------------------------------------------------------------

To illustrate this methodology for determining the relative weights
for the 201 LTC-DRGs with no LTCH cases, we are providing the following
examples, which refer to the 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 final rule for LTC-DRG 163 (Hernia Procedures Age 0-17). Since the
procedure is similar in resource use and the length and complexity of
the procedures and the length of stay are similar, we determined that
LTC-DRG 178 (Uncomplicated Peptic Ulcer Without CC), which is assigned
to low-

[[Page 47341]]

volume Quintile 3 for the purpose of determining the FY 2006 relative
weights, would display similar clinical and resource use. Therefore, we
assign the same relative weight of LTC-DRG 178 of 0.7637 (Quintile 3)
for FY 2006 (Table 11 in the Addendum to this final rule) to LTC-DRG
163.
Example 2: There were no LTCH cases in the FY 2004 MedPAR file used
in this final rule for LTC-DRG 91 (Simple Pneumonia and Pleurisy Age 0-
17). Since the severity of illness in patients with bronchitis and
asthma is similar in patients regardless of age, we determined that
LTC-DRG 90 (Simple Pneumonia and Pleurisy Age >17 Without CC) would
display similar clinical and resource use characteristics and have a
similar length of stay to LTC-DRG 91. There were over 25 cases in LTC-
DRG 90. Therefore, it would not be assigned to a low-volume quintile
for the purpose of determining the LTC-DRG relative weights. However,
under our established methodology, LTC-DRG 91, with no LTCH cases,
would need to be grouped to a low-volume quintile. We determined that
the low-volume quintile with the closest weight to LTC-DRG 90 (0.4970)
(refer to Table 11 in the Addendum to this final rule) would be low-
volume Quintile 1 (0.4499) (refer to Table 11 in the Addendum to this
final rule). Therefore, we assign LTC-DRG 91 a relative weight of
0.4499 for FY 2006.
Furthermore, we are establishing 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 LTC-DRGs with a zero volume of LTCH cases
based on the system will vary in the future. We used the best most
recent available claims data in the MedPAR file to identify zero volume
LTC-DRGs and to determine the relative weights in this final rule.
Table 11 in the Addendum to this final rule lists the LTC-DRGs and
their respective relative weights, geometric mean length of stay, and
five-sixths of the geometric mean length of stay (to assist in the
determination of short-stay outlier payments under Sec. 412.529) for
FY 2006.
5. Other Public Comments Relating to the LTCH PPS Payment Policies
Comment: One commenter submitted comments that addressed aspects of
the existing LTCH PPS, including the hospital-within-hospital policy,
which was discussed in the FY 2005 IPPS final rule (69 FR 49191), and
the June 2004 MedPAC recommendations concerning the definition of
LTCHs, which was discussed in the RY 2006 LTCH PPS final rule (70 FR
5757), for which we did not propose LTCH policy changes in the FY 2006
IPPS proposed rule.
Response: Because those comments pertain to specific aspects of the
existing LTCH PPS that were not specific proposed changes to the LTCH
PPS presented in the FY 2006 IPPS proposed rule, we are not responding
to them at this time. Rather, we believe it is more appropriate to
address the issues in the annual LTCH PPS proposed and final rules. We
will consider the issues raised in those comments in the context of
future rulemaking for the LTCH PPS.

E. Add-On Payments for New Services and Technologies

1. Background
Sections 1886(d)(5)(K) and (L) of the Act establish a process of
identifying and ensuring adequate payment for new medical services and
technologies under the IPPS. Section 1886(d)(5)(K)(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 FY 2006 DRG weights
in this final 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

[[Page 47342]]

(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, August 1, 2003), 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
Federal Register document that corrects the FY 2004 final rule (68 FR
57753, October 6, 2003), 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, August 11, 2004) 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 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 1886(d)(5)(K)(ii)(III) of the Act, as amended by section
503(d)(2) of Pub. L. 108-173, provides 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 this 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 Web site will also list the tracking forms completed
by each applicant.
2. Public Input Before Publication of a Notice of Proposed Rulemaking
on Add-On Payments
Section 1886(d)(5)(K)(viii) of the Act, as amended by section
503(b)(2) of Pub. L. 108-173, provides 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 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.

[[Page 47343]]

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 the FY 2006 IPPS 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 the 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 considered these
comments in our evaluation of each new application for FY 2006 in the
proposed rule and in this final 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 1886(d)(5)(K)(ix) of the Act, as added by section 503(c) of
Pub. L. 108-173, requires 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 DRG assignment is necessary or a new
technology add-on payment is appropriate when the reimbursement under
these currently assigned 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 final rule.
In this final 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.
Comment: Commenters argued that CMS' interpretation of the newness
criterion is inconsistent with the statute and that, as a result, CMS
is prematurely denying eligibility for many technologies. Commenters
believed that instead of basing the newness criterion on FDA approval
or market availability, CMS should start the 2-3 year period that a
technology can be considered new from the later of the date that the
technology is assigned an ICD-9-CM code or is approved by the FDA.
Commenters argued that neither the statutory language nor the
regulatory language refers to the date of FDA approval in determining
whether a technology is new. One commenter further argued that CMS
should ensure a maximum period of eligibility for new technology add-on
payments that takes into account a ``host of `newness' factors'' such
as production and distribution, negotiation with hospitals, and
physician education programs. The commenter proposed that CMS determine
newness, based on the latest of the following dates:
Date of ICD-9-CM code assignment;
Date of FDA approval plus six months; or
The time/date at which 50 percent of the Fiscal
Intermediaries are processing claims that include the technology in
question.
The commenter further recommended that, given the numerous
challenges of bringing a device to market, CMS should extend the period
that a product is considered new from two to three years to four or
five years.
Response: Section 1886(d)(5)(K)(vi) of the Act provides the
Secretary with broad discretion to define a ``new medical service or
technology.'' As we have indicated in prior rules (for example, see 66
FR 46914, September 7, 2001), we believe that a product should be
considered new 2 to 3 years from the date a product becomes available
on the market (generally from the date of FDA approval unless an
applicant can demonstrate that there was a delay in making the product
available on the market). Once a product becomes available on the
market, hospitals that use the new technology will begin including
charges for the product on their bills under either an existing or new
ICD-9-CM code. These charges will be used to set the DRG relative
weights two years later (that is, FY 2004 charge data are being used to
set the FY 2006 DRG relative weights). Therefore, 2 to 3 years after
the technology is available on the market, there will be a full year of
Medicare charge data used to set the relative weights that will reflect
the cost of the device. We note that a manufacturer can reasonably
predict when a product will become available on the market and, if
warranted, could request a new ICD-9-CM code in order to distinctly
identify the new technology in our data. In the FY 2005 final rule (69
FR 49002), we provided a detailed explanation for why using the date on
which a specific ICD-9-CM code is assigned to a technology is not an
appropriate test of newness. In that rule, we noted that, in many
instances, a technology may have been in use for several years, or even
several decades, prior to the assignment of a new code (69 FR 49003).
Thus, we believe it is appropriate to continue to determine newness
based on the date on which a product becomes available for use in the
Medicare population and the date when hospitals can begin to use either
an existing or new ICD-9-CM code to bill for the new service or
technology.
Comment: One commenter indicated that, because Medicare does not
pay for devices during clinical trials, ``little or no internal
Medicare claims data exist upon which to base an initial DRG assignment
for new technologies.'' To address this issue, commenters suggested
that CMS should accept external data while maintaining confidentiality
for proprietary data. Other commenters indicated that CMS decisions
regarding substantial clinical improvement have been largely subjective
and made without stakeholder input. Commenters requested that CMS
include ``a consistent and reasonable set of requirements for
manufacturers of novel technologies to meet'' in order to be eligible
for new technology add-on

[[Page 47344]]

payments. Several commenters indicated the process for applying for new
technology add-on payments is particularly burdensome for smaller
companies. Commenters urged CMS to provide a preliminary assessment of
substantial clinical improvement for each technology in the proposed
rule, in order for the public to respond CMS' findings during the
public comment period.
Response: With respect to the comment about the lack of Medicare
claims data for making a DRG assignment for a new medical product, we
believe that the new technology process is intended to address
precisely this issue. In our evaluation of a new technology
application, we consider any external data provided by the applicant to
make judgments as to whether a product meets the three criteria we have
established either to assign a new technology to a different DRG or to
approve a new technology for add-on payments. In addition, while we
generally do not pay for an experimental device itself when used as
part of a clinical trial, a hospital is not precluded from including an
existing or a newly assigned ICD-9-CM code or V-Codes on its bill for
Medicare covered services. Thus, we have been able to successfully
track devices that are (or were) in clinical trials in our MedPAR data,
and have used these data to determine whether several new technologies
have met the cost threshold for new technology payment. We addressed
the concerns over submissions of external data and proprietary
information in the FY 2005 final rule (69 FR 49004, August 11, 2004).
As indicated in that rule, we are continuing to consider this issue,
but we are not making any changes to our policy on the submission of
external data and proprietary information at this time.
We disagree that determinations regarding applications for add-on
payments are made without stakeholder input. There is ample opportunity
for applicants and other interested parties to make their views known
to us throughout the application process, at the public meeting, as
well as during the comment period on the proposed rule. We have had
numerous meetings with applicants where they have addressed our
concerns and/or brought further information to our attention on the
merits of their technology. Our initial new technology final rule (66
FR 46914, September 7, 2001) provides the specific guidelines we
consider to determine whether a technology is a substantial clinical
improvement. In that final rule, we indicated that, in order to meet
the substantial clinical improvement criteria, a new technology must be
able to offer a new treatment option for a patient population
unresponsive to, or ineligible for, currently available treatments;
diagnose a previously undetectable condition or allow for earlier
diagnosis; or significantly improve clinical outcomes. We provided
seven potential measures to evaluate this third standard. While our
regulations provide specific criteria for evaluating substantial
clinical improvement, by its very nature, this process involves
judgment. Before making a final judgment about substantial clinical
improvement, we carefully consider all of the information that is
provided to us in a new technology application, as well as the
viewpoints expressed through the public meeting, during the comment
period, and in meetings with individual applicants.
We do not believe that our criteria present an inordinately
cumbersome burden for smaller companies that want to apply for new
technology add-on payments. Several small companies have already
approached us seeking advice on how to apply for new technology add-on
payments FY 2007 and later years. We encourage potential applicants to
contact us before their technology is available on the market to become
familiar with the new technology application process.
With respect to providing preliminary determinations of substantial
clinical improvement in the proposed rule, we addressed this issue in
the FY 2006 proposed rule (70 FR 23359). We indicated that our decision
about new technology add-on payments follows a logical sequence of
determinations, moving from the newness criterion, to the cost
criterion and finally to the substantial clinical improvement
criterion. Therefore, we are reluctant to import substantial clinical
improvement considerations into the logically prior decisions about
whether technologies satisfy the newness and cost criteria. We
acknowledge that an applicant seeking new technology payment for a
product expected to receive FDA approval between the proposed and final
rule has an interest in knowing CMS' findings about substantial
clinical improvement. Nevertheless, we believe that FDA approval of a
product is a logical prior determination because substantial clinical
improvement is a higher standard to meet than either of the FDA
standards for allowing a product on the market. If a product does not
meet the FDA standards for a pre-market (``safe and effective'') or
humanitarian device exemption (``safe'') approval, it cannot be a
substantial clinical improvement. While we do not believe a
determination about substantial clinical improvement should be made
prior to FDA approval, two applicants have received FDA approval for
their products since the publication of the proposed rule. We met with
these two applicants during the public comment period to discuss our
concerns about substantial clinical improvement. As indicated below, we
are approving both of these technologies for new technology add-on
payments beginning in FY 2006.
3. FY 2006 Status of Technology Approved for FY 2005 Add-On Payments
a. INFUSE[supreg] (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[supreg] for add-
on payments under Sec. 412.88, effective for FY 2004. This approval
was on the basis of using INFUSE[supreg] 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[supreg] 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 interbody
spinal fusion device) and 84.52 (Insertion of recombinant bone
morphogenetic protein).
The FDA approved INFUSE[supreg] for use on July 2, 2002. For FY
2005, INFUSE[supreg] 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[supreg] 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 new technology final rule (66 FR 46915),
September 7, 2001 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

[[Page 47345]]

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[supreg] 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[supreg]. 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[supreg] 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, as we proposed, we are discontinuing new
technology add-on payment for INFUSE[supreg] for FY 2006. Because we
apply the same policies in making new technology payment for OP-1 Putty
as we do for INFUSE[supreg], we are also discontinuing new technology
add-on payment for OP-1 Putty for FY 2006.
Comment: Several commenters agreed with our proposal to terminate
add-on payment for INFUSE[supreg] bone graft for spinal fusions.
Response: We are finalizing our proposal to terminate new
technology add-on payments for INFUSE[supreg] bone graft for spinal
fusions in this final rule.
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 new
technology final rule (66 FR 46915, September 7, 2001), 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 the FY 2005 final rule, we also noted
that we would extend new technology add-on payments for CRT-D for the
entire FY 2005 even though the 2-3 year period of newness ended in May
2005 for CRT-D. 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, as we proposed, we are
discontinuing add-on payments for the CRT-D for FY 2006.
Comment: One commenter thanked CMS for approving add-on payments
for the CRT-D. The commenter also indicated that add-on payment for
this device had contributed significantly to patient access and broader
physician adoption of this new treatment. Another commenter requested
that CMS continue to make add-on payment for CRT-D to avoid financial
problems that hospitals will experience if payment is ceased.
Response: We appreciate the commenter's support of our decision to
approve add-on payments for CRT-D. Consistent with section
1886(d)(5)(K)(ii) of the Act, the regulations do not permit us to
extend payment for CRT-D beyond the 2-3 year period during which a
technology can be considered new. Therefore, we are finalizing our
proposal to discontinue add on payments for the CRT-D in 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 Soletra^TM, 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, followup, and programming
procedures for physicians.
The FDA approved the device in December 2003. 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
Soletra^TM, 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
Soletra^TM device. Because most patients would receive two
Soletra^TM devices if the Kinetra[supreg] device is not
implanted,

[[Page 47346]]

we believed data regarding the cost of Soletra^TM would give
a good measure of the actual costs that would be incurred. Medtronic
submitted data for 104 cases that involved the Soletra^TM
device (26 cases in DRG 1 (Craniotomy Age > 17 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 Soletra^TM in
DRGs 1 and 2 were $69,018 and $44,779, respectively. The mean
standardized charge for these Soletra^TM cases according to
Medtronic's data was $50,839.
Last year, we used the same procedure codes to identify 187 cases
involving the Soletra^TM 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 charges for cases that included implantation of the
Soletra^TM device were $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 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 does
not separately identify cases with the Kinetra[supreg] device and is
only 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 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, as we proposed, we are continuing add-on payments for
Kinetra[supreg] Implantable Neurostimulator for deep brain stimulation
for FY 2006.
Comment: Several commenters supported our decision to continue add-
on payments for Kinetra[supreg] Implantable Neurostimulator for deep
brain stimulation for FY 2006.
Response: In this final rule, we are finalizing our proposal to
continue add-on payments for the Kinetra[supreg] Implantable
Neurostimulator for deep brain stimulation for FY 2006.
4. FY 2006 Applications for New Technology Add-On
a. INFUSE[supreg] 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[supreg] Bone
Graft in open tibia fractures. In cases of open tibia fractures,
INFUSE[supreg] 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[supreg]. The FDA approved use

[[Page 47347]]

of INFUSE[supreg] for open tibia fractures on April 30, 2004.
Medtronic's first application for a new technology add-on payment
for INFUSE[supreg] 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[supreg] 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 comment on our decision that INFUSE[supreg] for open tibia
fractures was substantially similar to OP-1 Implant for recalcitrant
long bone non-unions. Medtronic stated that ``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[supreg]
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[supreg] 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[supreg]. Therefore, we denied new technology
add-on payments for INFUSE[supreg] for open tibia fractures for FY 2005
on the grounds that technology using 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 and to explain why this product should not affect our
consideration of the application for new technology add-on payments for
INFUSE[supreg]. 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[supreg] for open tibia fractures 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[supreg] are
substantially different. The application cites data from several
studies as evidence of the clinical superiority of INFUSE[supreg] over
OP-1. Medtronic presented studies at the February 2005 new technology
town hall meeting to provide evidence that INFUSE[supreg] is superior
to OP-1 in the time it takes for critical-sized defects to heal: in
radiographic assessment and mechanical testing of the repaired bone;
and in histology of the union for trial subjects receiving
INFUSE[supreg] 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[supreg] 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[supreg] 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[supreg]
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[supreg]
is a superior product to OP-1 because the INFUSE[supreg] 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[supreg] 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 over
existing technologies, 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

[[Page 47348]]

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[supreg] 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 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. Even if it were possible to
differentiate between patients who would be eligible to receive the OP-
1 Implant for nonunions or the INFUSE[supreg] bone graft for open tibia
fractures, the patient populations both fall into the same DRGs. In
addition, as we stated in last year's final rule in connection with our
decision to make add-on payments for both products when used for spinal
fusions, 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 of the relevant DRGs reflect
the costs of these products.
Prior to the publication of the FY 2006 IPPS proposed rule, we
received the following public comments on the application for add-on
payments for FY 2006.
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[supreg] 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 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[supreg] are indicated for use in different
populations and different conditions. According to Medtronic,
INFUSE[supreg] 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 there is 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 its first proposed criterion
has some relevance in determining whether products are substantially
similar. In evaluating the application for new technology add-on
payments for INFUSE[supreg] for open tibia fractures 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 should be controlling 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 both 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 logically 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.
Comment: In response to our request for comments on the issue of
substantial similarity in the Federal Register announcement of the new
technology town hall meeting, Medtronic also 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

[[Page 47349]]

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 new technology 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 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 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, in the FY 2006 IPPS proposed rule, we
solicited comments on the use of substantial similarity to determine
whether products qualify for new technology add-on payments while we
continued to consider these issues. The comments we received in
response to this request are addressed below in our discussion of
substantial similarity.
We note that, in support of its application for add-on payments for
FY 2006, Medtronic submitted data on 236 cases using INFUSE[supreg] 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[supreg]. Based on the data submitted by the applicant,
INFUSE[supreg] 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[supreg] in these DRGs would be $39,537. Therefore, the
applicant maintains that INFUSE[supreg] for open tibia fractures meets
the cost criterion.
However, because the costs of INFUSE[supreg] and OP-1 are already
reflected in the relevant DRGs, these products cannot be considered
new. Therefore, in the FY 2006 IPPS proposed rule we proposed to deny
new technology add-on payments for INFUSE[supreg] bone graft for open
tibia fractures for FY 2006.
During the 60-day comment period on the FY 2006 IPPS proposed rule,
we received the following comments on this application:
Comment: Several commenters wrote to support the application for
INFUSE[supreg] bone graft for open tibia fractures for new technology
add-on payments. These commenters disagreed with our assertion that the
costs for this technology are adequately reflected in the DRG weights.
The commenters argued that the data include few claims for OP-1 and do
not justify denying add-on payments to INFUSE[supreg]. Further,
commenters argued that the different types of FDA approval are relevant
to the discussion of newness and substantial clinical improvement of
the BMP products. Commenters pointed to the limited number of cases
that would have been eligible to receive OP-1 due to its limited FDA
humanitarian device exemption (HDE) approval. Commenters noted that an
HDE approval limits the number of patients that can receive the product
to 4,000 patients, and therefore the costs of the cases are not
adequately reflected in the DRG weights. According to the commenters,
CMS' own analysis supports this point because there were only 77 cases
in the FY 2004 MedPAR data, indicating that a patient received a BMP
product with no mention as to whether there were any cases in the
relevant DRGs for FY 2003. Therefore, commenters argued, the technology
is not used frequently enough to be adequately reflected in the DRG
weights. In addition, commenters argued that OP-1 is only indicated for
non-union fractures while INFUSE[supreg] is for open tibia fractures.
Response: We appreciate the commenters' input on this technology.
However, we continue to believe that INFUSE[supreg] is not a new
product because of its substantial similarity to OP-1. These products
are both designed to promote healing of broken bones even though they
are FDA approved for somewhat different indications. Furthermore,
treatment of open tibia fractures and non-unions of tibia fractures
will be paid using the same DRGs. Because the OP-1 Implant received FDA
approval in 2001 and INFUSE[supreg] is a similar product that will be
included in the same DRG, we do not believe that the product can be
considered new for the purposes of new technology add-on payments.
While the commenters argue that the MedPAR data do not include a
sufficient number of cases for CMS to argue that payment for BMP
products are included in the DRG weights, we do not believe that case
volume is a relevant consideration for making the determination as to
whether a product is new. Consistent with the statute, a technology no
longer qualifies as new once it is more than 2 to 3 years old
irrespective of how frequently it has been used in the Medicare
population. Thus, if a product is more than 2 to 3 years old, we
consider its costs to be included in the DRG relative weights whether
its use in the Medicare population has been frequent or infrequent. We
also recognize that, without financial incentive to code BMPs, it is
possible that hospitals may not have included procedure code 84.52 on
hospital bills for all instances when a BMP product was used.
Therefore, the incidence of actual use of BMPs for this period may be
higher than shown in the Medicare data. Nevertheless, even though
hospitals may not have coded all uses of procedure code 84.52, hospital
bills would still include charges for all items and services furnished
to a Medicare patient including use of a BMP product. Therefore, even
though we may be not be able to identify all uses of a BMP product in
the Medicare charge data, hospital charges for the DRG would continue
to reflect use of these products. In addition, we note that open tibia
fractures are not common among the elderly population, and we would
therefore not expect to find a high incidence of these cases in the
MedPAR data. Also, given the penetration that BMPs have made in DRGs
219 and 220, in addition to many other DRGs, we believe that the BMP
technology is adequately reflected in our MedPAR data that were used to
recalibrate the DRG weights for FY 2006. Therefore, the

[[Page 47350]]

technology can no longer be considered new for the purposes of new
technology add-on payments. In this final rule, we are finalizing our
proposal to deny add-on payments for INFUSE[supreg] bone graft for
tibia fractures.
Comment: As discussed above, prior to publication of the FY 2006
IPPS proposed rule, we received a comment offering suggestions for how
to define when products are ``substantially similar.'' We responded to
this comment in the proposed rule (70 FR 23359), and indicated that we
welcomed further comments on this issue. Several commenters raised
concerns about CMS' responses to this comment.
One commenter indicated that CMS ``is using the determination of
`substantial similarity' as a basis to support a preliminary
determination that these technologies are `not new' * * * when no such
criter[ion] exists in the threshold criteria.'' Another commenter
indicated that the discussion of substantial similarity creates
confusion between the issue of substantial similarity and the three
add-on payment criteria. This commenter indicated that the discussion
of this issue in the proposed rule implies that substantial similarity
is a subfactor of the newness criterion, while prior rules have implied
that it is a subfactor of the substantial clinical improvement
criterion or a replacement for all three criteria. To support this
point, the commenter stated that the new technology final rule (66 FR
46915) indicates that a substantially similar technology would still be
required to submit data showing that the technology was inadequately
paid and meets the criterion for being new, thus implying that
substantial similarity is a subfactor of the substantial clinical
improvement criterion. The commenter referenced the discussion in the
FY 2005 IPPS final rule (69 FR 49008-49009) indicating that new
technology add-on payments would be extended to OP-1 putty without the
submission of an application for add-on payments as evidence that
substantial similarity has replaced all three criteria. Commenters
further expressed concern over the detrimental effects that this
standard could have, denying patient access to therapies ``merely
because the therapy has the same mechanism of action as an existing
treatment.'' These commenters recommended that CMS eliminate
substantial similarity from our new technology add-on payment
deliberations, and grant add-on payments based solely on whether a
product satisfies the newness, cost, and substantial clinical
improvement criteria specified in the regulations.
Other commenters noted that CMS has no way to distinguish between
manufacturers when similar products use the same ICD-9-CM codes.
Therefore, the commenters argued, there is no need for competitors to
apply for their own new technology add-on payment if a product has
already been approved for add-on payments, despite the language
contained in the new technology final rule stating that the
manufacturers of substantially similar products would be required to
file a separate application for add-on payment (66 FR 46915).
Response: With respect to the discussion of substantial similarity
in the new technology final rule, we did indicate that a manufacturer
of a substantially similar product would have to submit an application
to be awarded add-on payments. However, we note that this statement was
made without any actual experience with the implementation of section
1886(d)(5)(K) of the Act. After reviewing and approving technologies
for add-on payment for several years, we have found that our original
policy did not adequately reflect the fact that substantially similar
products will use the same ICD-9-CM codes and that it would be
impractical to create manufacturer-specific codes and also require each
manufacturer to submit separate applications for products that are
essentially the same. Moreover, given that we cannot distinguish one
manufacturer from another when substantially similar technologies use
the same ICD-9-CM code, there is no practical purpose for manufacturers
of substantially similar products to apply separately for new
technology add-on payments. Therefore, we have not required that an
application for add-on payments be submitted for a substantially
similar product that uses the same ICD-9-CM code as a product that has
previously been approved for add-on payments. In addition, we have made
an effort to identify competitors that might be eligible to receive new
technology add-on payments for their devices. In fact, we note that we
have discussed several such technologies in this year's and previous
years' rules and have allowed for add-on payments for particular, new
classes of technologies that fall within the same ICD-9-CM code (for
example, CRT-D).
We believe that these commenters raise interesting and complex
policy issues regarding the application of the new technology add-on
payment policy to products that are substantially similar. While the
commenters generally appear to agree with our policy when we have
extended new technology add-on payments to substantially similar
products, they appear to disagree with our application of the concept
of substantial similarity when we have denied add-on payments. (We note
that one commenter disagreed with both the decision to extend new
technology add-on payments to OP-1 for spinal fusions and the decision
to deny them to INFUSE[supreg] for tibia fractures on the basis of
substantial similarity. Nevertheless, this same commenter has also
asked us to use the concept of substantial similarity to extend new
technology add-on payments to the Talent Endovascular Stent Graft.
This apparent policy contradiction is illustrated with the example
of INFUSE[supreg] and OP-1. We extended new technology add-on payments
to OP-1 for spinal fusions without a separate application because of
its substantial similarity to INFUSE[supreg] and without specifically
finding that the product met all three criteria for add-on payments. We
determined that OP-1 putty was substantially similar to another product
that had been approved for new technology add-on payments. OP-1 putty
was clearly new given the date it was approved by the FDA and was
substantially similar to another new product that had been approved for
new technology add-on payments. However, because the technology of
using BMPs for spinal fusions had already been found to meet the
newness, cost and substantial clinical improvement criteria, we did not
separately address these criteria. Rather, after determining that the
two products were substantially similar, we extended the approval of
add-on payments to OP-1. The commenters appear to agree with this
decision and the concept of extending new technology add-on payments to
substantially similar products so that our payment policy does not
bestow an advantage to the first applicant representing a particular
new technology to receive approval. However, the commenters appear to
disagree with our denial of new technology add-on payments to
INFUSE[supreg] for tibia fractures on the basis of its substantial
similarity to OP-1. Because OP-1 Implant for recalcitrant long bone
unions had been in use for 3 years and the costs for this technology
had been included in the weights for the DRGs where cases involving
INFUSE[supreg] for tibia fractures are assigned, in the final rule for
FY 2005, we determined that INFUSE[supreg] could not longer be
considered ``new.'' (69 FR 49012).
We believe that the concept of substantial similarity needs to be
applied consistently both in the context of extending and denying new

[[Page 47351]]

technology add-on payments. Thus, we believe it is important to clarify
whether a finding of substantial similarity among products constitutes
only a decision about the newness criterion or about all three
criteria. One commenter indicated that our decision to extend new
technology add-on payments to OP-1 for spinal fusions because of its
similarity to INFUSE[supreg] implies that our determination on
substantial similarity replaced consideration of the three criteria.
This commenter and others believed, however, that our determination on
substantial similarity between OP-1 and INFUSE[supreg] for tibia
fractures implies that we are applying the concept as a subfactor of
newness.
In both cases, we only made a determination about the similarity of
the products and did not specifically make a finding as to whether all
three criteria for add-on payments were met. When we denied new
technology add-on payments to INFUSE[supreg] for open tibia fractures,
we effectively made a logical prior determination about newness based
on our finding of substantial similarity and, as a result, we did not
need to evaluate either the cost or substantial clinical improvement
criteria. Similarly, when we extended new technology add-on payments to
OP-1 for spinal fusions on the grounds that it is substantially similar
to INFUSE[supreg], we effectively indicated that both products were new
but did not make a specific finding about cost and substantial clinical
improvement with respect to OP-1. Rather, we extended the existing
approval of add-on payments for the new technology of using BMPs in
spinal fusions to a substantially similar product in order to avoid
bestowing an advantage to the first product to receive an approval of
add-on payments for this particular new technology.
We see two policy options to address this issue. Under the first
option, we continue our current practice. That is, if we make a finding
of substantial similarity among two products, we will extend new
technology add-on payment without a further application from the
manufacturer of the competing product or a specific finding on cost and
clinical improvement. Also, we will deny new technology add-on payments
to substantially similar products if one of the products no longer
qualifies as a new medical technology without a specific finding on the
remaining two criteria. Under the second option, we would depart from
our current practice and only extend new technology add-on payment to
an applicant's product after making a determination that it meets the
newness, cost, and substantial clinical improvement criteria. As we
have indicated in the past, we believe that continuing our current
practice is the better policy because we avoid:
Creating manufacturer-specific codes for substantially
similar products.
Requiring different manufacturers of substantially similar
products from having to submit separate new technology applications.
Having to compare the merits of competing technologies on
the basis of substantial clinical improvement.
Bestowing an advantage to the first applicant representing
a particular new technology to receive approval.
The commenters also argued that the concept of substantial
similarity is being applied without having been defined in the
regulations. We do not believe that it would be appropriate at this
time to adopt rigid criteria to define substantial similarity. Such
criteria would restrict unduly our ability to make appropriate
determinations regarding whether a product should qualify for new
technology add-on payments. For example, if we were to use the
Medtronic definition of substantial similarity described above, each
manufacturer of a competing technology would have to submit a separate
application for an add-on payment and, potentially, we would have to
create separate codes for each manufacturer's product if we found that
one product met all of the criteria for an add-on payment while the
other did not. For instance, Medtronic supported the application of W.
L. Gore & Associates, Inc. for its Endovascular Graft Repair of the
Thoracic Aorta (GORE TAG). If this device were to be approved for new
technology add-on payments, Medtronic recommended that we extend these
payments to its Talent Endovascular Stent Graft once it is approved by
the FDA. As indicated below, we are approving for the GORE TAG device
for new technology add-on payments. If we were to use Medtronic's
criteria for defining substantial similarity, for us to extend new
technology add-on payments to its device for an endovascular thoracic
aortic aneurysm repair, we would have to make a determination that the
products: (1) Use the same or a similar mechanism of action to achieve
the therapeutic outcome; (2) are indicated for use in the same
population for the same condition; and (3) achieve the same level of
substantial clinical improvement. While it may be possible to make a
determination on the first of these two criteria based on a description
of the products and their FDA approved indications, we believe it would
not be possible to make a decision on the third criterion without a new
technology application and specific review in order to determine
whether the two products achieve the same level of substantial clinical
improvement. Applying Medtronic's criteria, we do not believe that new
technology add-on payments could be extended to a substantially similar
product in the middle of a fiscal year. Thus, for example, add-on
payments for Medtronic's Talent Endovascular Stent Graft, which has not
yet received FDA approval, could not begin until at least FY 2007.
Further, in the absence of a finding that the products achieve the same
level of substantial clinical improvement, we would need to establish a
specific code for the GORE TAG device that other manufacturers of
similar products could not use unless they also made a new technology
application and we made a finding on the three criteria for determining
substantial similarity suggested by Medtronic. Thus, in this
circumstance, application of Medtronic's suggested criteria for
defining substantial similarity would bestow an advantage to GORE TAG
until we could make a specific finding on the Talent Endovascular Stent
Graft.
In the proposed rule, we indicated that whether a product uses the
same or a similar mechanism of action to achieve the therapeutic
outcome has some relevance for determining substantial similarity. We
also indicated that the whether the products are assigned to the same
or a different DRG is also relevant for determining substantial
similarity and assessing if the hospital charge data used in developing
the relative weights of the relevant DRGs reflects the costs of these
products. In making a determination of substantial similarity, we
believe both of these criteria should be met. If only one of the
criteria is met, we do not believe the products should be considered
substantially similar and new technology add-on payments should not be
extended or denied on this basis. In the case of OP-1 and
INFUSE[supreg], both are bone morphogenetic products that are used to
induce bone growth (``use the same or similar mechanism of action to
achieve the therapeutic outcome'') assigned to the same DRGs (DRGs 497
and 498 for spinal fusions and DRGs 218 and 219 for tibia fractures).
Furthermore, both of these products can be described by the same ICD-9-
CM code (code 84.52, Insertion of recombinant bone morphogenetic
protein). Thus, our decisions to extend new technology add-on payments
to OP-1 for spinal fusions and deny them to INFUSE[supreg] for tibia
fractures on the

[[Page 47352]]

basis of substantial similarity, applied, the two above described
criteria consistently.
We believe the above discussion indicates that these are complex
issues. While the application of the above two criteria worked well in
the context of OP-1 and INFUSE[supreg] (as well as the GORE TAG and
Talent Endovascular Stent Graft), it is possible that we should have
the flexibility to consider these or other factors in some contexts but
not in others. For these reasons, we will continue to analyze the
question of substantial similarity, and welcome further public input on
this issue.
In this final rule, we are finalizing our proposal to deny add-on
payments for INFUSE[supreg] bone graft for open tibia fractures for the
reasons discussed above. b. Aquadex^TM 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 proposed 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 is used per case. Therefore, adding $5,182 for
the charge of the two 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-weighed 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 hospital length of 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 proposed 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 prior to publication of the FY 2006 IPPS proposed rule.
During the 60-

[[Page 47353]]

day comment period for the FY 2006 IPPS proposed rule, we also received
no comments. Therefore, we are finalizing our proposal to deny new
technology add-on payments for the System 100 because it does not meet
the newness criterion.
c. CHARIT[Eacute]^TM Artificial Disc
(CHARIT[Eacute]^TM)
DePuy Spine^TM submitted an application for new
technology add-on payments for the CHARIT[Eacute]^TM
Artificial Disc for FY 2006. This device is a prosthetic intervertebral
disc. DePuy Spine^TM stated that the
CHARIT[Eacute]^TM 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
CHARIT[Eacute]^TM 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 CHARIT[Eacute]^TM Artificial Disc
should have failed at least 6 months of conservative treatment prior to
implantation of the CHARIT[Eacute]^TM 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
CHARIT[Eacute]^TM 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
CHARIT[Eacute]^TM 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 cases using CHARIT[Eacute]^TM map to DRGs
499 and 500. The applicant submitted 68 actual cases from 35 hospitals
that used the CHARIT[Eacute]^TM. 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
CHARIT[Eacute]^TM 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. As
noted above, cases using the CHARIT[Eacute]^TM device group
to the DRGs for back and neck procedures that exclude spinal fusions
(DRGs 499 and 500). However, the applicant argues that the
CHARIT[Eacute]^TM 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 CHARIT[Eacute]^TM 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 CHARIT[Eacute]^TM 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 CHARIT[Eacute]^TM by 15
percent to $17,420. The applicant then added the average standardized
charge for surgical and medical supplies of the
CHARIT[Eacute]^TM to the standardized charge of the remaining
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 computation
resulted in 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 where these cases are grouped. 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 CHARIT[Eacute]^TM meets the
cost criterion.
Comment: The applicant commissioned two independent consultants to
conduct separate data analyses demonstrating with actual cases of
CHARIT[Eacute]^TM that the device meets the cost criterion.
The consultants found 308 cases using CHARIT[Eacute]^TM
including 9 Medicare cases. One consultant found 94 cases with average
standardized charges of $43,065, and the other consultant found 214
cases with average standardized charges of $45,791. As in the proposed
rule, the commenter noted that the average standardized charges per
case are well in excess of the threshold for DRG 499.
Response: We appreciate the commenter's submission of additional
data in support of its application. Based on these data, it appears
that the technology meets the cost criterion.
The applicant also contended that the CHARIT[Eacute]^TM
represents a substantial clinical improvement over existing technology.
Use of the CHARIT[Eacute]^TM 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 CHARIT[Eacute]^TM 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 CHARIT[Eacute]^TM 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 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

[[Page 47354]]

the CHARIT[Eacute]^TM 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 CHARIT[Eacute]^TM Artificial
Disc. Also, patients who received the CHARIT[Eacute]^TM
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 CHARIT[Eacute]^TM 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 follow up of 100 patients (minimum 10
years) who received the CHARIT[Eacute]^TM Artificial Disc,
the incidence of adjacent level DDD was 2 percent.
In the FY 2006 IPPS proposed rule, we indicated that we were
continuing to review the information on whether the
CHARIT[Eacute]^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 CHARIT[Eacute]^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. We also
are concerned about the prevalence of osteoporosis within the Medicare
population, because it is a contraindication for this device. In the FY
2006 IPPS proposed rule, we invited 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 noted in the FY 2006 IPPS
proposed rule that we were still considering whether it is appropriate
to approve new technology add-on payment status for the
CHARIT[Eacute]^TM Artificial Disc for FY 2006. If approved
for add-on payments, hospitals would be reimbursed for up to half of
the costs for the device. Because the manufacturer has stated that the
cost for the CHARIT[Eacute]^TM Artificial Disc would be
$11,500, the maximum add-on payment for the device would be $5,750.
We finally noted that the applicant requested a DRG reassignment
for cases of the CHARIT[Eacute]^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
CHARIT[Eacute]^TM is not a spinal fusion, we decided not to
include this procedure in these DRGs. However, in the FY 2006 IPPS
proposed rule, we indicated that we would continue to analyze this
issue and solicited public comments on both the new technology
application for the CHARIT[Eacute]^TM and the DRG assignment
for spinal disc prostheses.
We received no public comments regarding this application for new
technology add-on payments prior to the publication of the FY 2005 IPPS
proposed rule. However, we received the following comments during the
60-day comment period on the proposed rule.
Comment: The applicant noted that on July 15, 2005, two new
articles were published in the journal ``Spine.'' \3\ The applicant
maintained that the studies demonstrate the following conclusions:
---------------------------------------------------------------------------

\3\ A. Blumenthal et al., ``A Prospective, Randomized, Multi
Center FDA IDE Study of Lumbar Total Disc Replacement with the
CHARIT[Eacute]^TM Artificial Disc vs. Lumbar Fusion: Part
I--Evaluation of Clinical Outcomes.''
B. McAfee et al., ``A Prospective, Randomized, Multi Center FDA
IDE Study of Lumbar Total Disc Replacement with the
CHARIT[Eacute]^TM Artificial Disc vs. Lumbar Fusion: Part
II--Evaluation of Radiographic Outcomes and Correlation of Surgical
Technique Accuracy with Clinical Outcomes.''
---------------------------------------------------------------------------

The CHARIT[Eacute]^TM obviates the iliac crest
bone graft donor site morbidity.
The CHARIT[Eacute]^TM preserves segmental motion
in flexion/extension through 24 months post implantation.
The CHARIT[Eacute]^TM provided maintenance of
post operative disc height through 24 months compared to anterior
interbody fusion; disc space height was maintained in greater than 99
percent of CHARIT[Eacute]^TM subjects through 24 month
followup.
The CHARIT[Eacute]^TM has the potential to
reduce second surgical procedures for adjacent disc disease by
maintaining motion (the manufacturer intends to investigate this).
The CHARIT[Eacute]^TM provides early improvement
in pain and function as measured by the Oswestry Disability Index
compared to anterior interbody fusion at 6 weeks, 3 months, 6 months,
and 12 months.
The CHARIT[Eacute]^TM provides improvement in
pain reduction as measured by the Visual Analog Scale compared to
anterior interbody fusion at 6 weeks, 3 months, 6 months, and 12
months.
The CHARIT[Eacute]^TM provides improvement in
quality of life on the physical component score of the SF-36 outcomes
tool at 3 months, 6 months, and 24 months.
CMS requested comments on whether or not the results from the IDE
study can be generalized to the Medicare population. The commenter
commissioned a consultant to conduct a survey to capture clinical
information for the Medicare population 65 years or older and the
Medicare population that had been implanted with the
CHARIT[Eacute]^TM, noting that the under 65 Medicare disabled
population represents 14 percent of all Medicare beneficiaries or
approximately 5 million people. The consultant found data for 18
Medicare beneficiaries and submitted the following results: Surgeons
reported that 94.4 percent of the patients demonstrated improvement in
overall outcome, pain, and function after the
CHARIT[Eacute]^TM had been implanted. Surgeons also noted the
following: 100 percent of the patients reported an improved level of
activity; 50 percent of the patients achieved full recovery, the other
50 percent had an improved level of activity compared to their
preoperative status; and 100 percent of the surgeons recommended the
CHARIT[Eacute]^TM for other Medicare patients who meet the
clinical indications. The commenter believed that the above studies and
the IDE trial demonstrate that CHARIT[Eacute]^TM offers a
substantial clinical improvement over fusion for Medicare
beneficiaries.
The commenter also stated that Medicare beneficiaries with
disabilities make up 21.8 percent of all discharges in DRGs 496, 497,
and 498. It is likely that a significant number of these

[[Page 47355]]

patients could benefit from the CHARIT[Eacute]^TM. In
response to CMS' concern that CHARIT[Eacute]^TM is
contraindicated in patients with osteoporosis, the commenter noted that
spinal fusion surgery is also not indicated in this patient population.
Nevertheless, the commenter noted that the Medicare charge data
included nearly 98,000 spinal fusions in FY 2004.
The commenter further stated that, although many patients above the
age of 65 do have osteoporosis, implanting surgeons report seeing many
patients over the age of 65 who are extremely active and do not have
signs of osteoporosis, as validated by a Dexascan.
The commenter also requested that CMS apply the substantial
clinical improvement criteria consistently to
CHARIT[Eacute]^TM and INFUSE[supreg] bone graft for spinal
fusions. The commenter noted that in the FY 2004 IPPS final rule (68 FR
45388, August 1, 2003), CMS approved INFUSE[supreg] for new technology
add-on payment even though evidence was submitted for a small number of
Medicare aged patients treated with the product. CMS acknowledged that
there was some positive, though limited, evidence for generalized
application for the Medicare population, leading CMS to conclude that
based on ``[t]hese results, combined with the benefits of the
elimination of the need to harvest bone graft from the iliac crest (and
associated complications), INFUSE[supreg] does meet the substantial
clinical improvement criteri[on].'' The commenter added that, in
addition to eliminating the need for harvesting bone from the iliac
crest, the CHARIT[Eacute]^TM provides other significant
clinical improvements, including maintaining a more normal range of
motion, restoration of disc height, potential to reduce adjacent level
disc disease, earlier and sustained improvement in pain and function
and earlier return to normal activity and improvement in qualify of
life.
Based on the comments above, the commenter noted that the
CHARIT[Eacute]^TM meets all the criteria and should be
approved for new technology add-on payments.
Response: There have been a number of clinical studies conducted on
the CHARIT[Eacute]^TM (some of the studies referenced below
were also submitted by the applicant). One study showed unsatisfactory
long term results. Three studies \4\ \5\ \6\ demonstrated excellent or
good results, but did not explicitly compare the surgery to spinal
fusion. One study \7\ showed promising short-term results, but had no
long-term data and indicated the need for further study. After
reviewing all the information supplied by the applicant and in these
clinical studies discussed above, CMS acknowledges that the
CHARIT[Eacute]^TM may have potential benefit for certain
carefully selected Medicare beneficiaries. However, our medical
officers could not find sufficient evidence to support a finding that
this device meets the criteria for being a substantial clinical
improvement. Specifically, we are concerned about the lack of
comparative data beyond 24 months in the materials that were submitted
for review. While the clinical studies above cited by the manufacturer
suggest positive outcomes with the device for up to 24 months, other
studies cast doubt on both its short-term and long-term performance,
and raise troubling questions regarding longer term adverse outcomes.
Specifically, as mentioned above, one study \8\ included 27 patients
who received the device between 1989 and 2001. Of these patients, 12
reported some short-term benefit, while 14 others reported no benefit
at all. The study found that patients in this study had ``recurrent or
persistent back and leg pain [that] was caused mainly by disc
degeneration on neighboring levels, hyperlordosis of the operated
segment, subsidence and migration.'' In addition, the study indicated
that removal of the prosthesis is dangerous, and posterior fusion
without removing the prosthesis will give suboptimal results. The study
further suggested that the CHARIT[Eacute]^TM should be
considered experimental until long term results by unbiased observers
can indicate to the orthopedic community if the device is an acceptable
orthopedic procedure. We also are concerned about the very low number
of Medicare beneficiaries who have received the device (18). In
addition, aside from a lack of long-term clinical evidence that
demonstrates the effectiveness of the device, we also note significant
controversy within the orthopedic and spine surgery community regarding
the overall effectiveness and safety of this device regardless of a
patient's age, primarily based on the lack of long term data to support
its use. Therefore, due to the lack of good evidence of long-term
clinical benefit and safety, and because of the degree of controversy
surrounding the device within the orthopedic and spine surgery
community, we do not believe it meets the criterion for substantial
clinical improvement and we are denying the application for new
technology add-on payments for FY 2006.
---------------------------------------------------------------------------

\4\ David TJ. ``Lumbar disc prosthesis; Five years follow-up
study on 96 patients [abstract]'' Presented at the 15th Annual
Meeting of the North American Spine Society (NASS), New Orleans, LA,
2000.
\5\ Lemaire JP., ``SB Charite III intervertebral disc
prosthesis: Biomechanical, clinical, and radiological correlations
with a series of 100 cases over a follow-up of more than 10 years'',
Rachis [Fr]. 2002;14:271-285, cited in DePuy Spine, Inc.
Charit[eacute] Artificial Disc. Technical Monograph. SA01-030-000.
JC/AG. Raynham, MA: DePuy; November 2004.
\6\ Caspi I, Levinkopf M, Nerubay J., ``Results of lumbar disk
prosthesis after a follow-up period of 48 months'', Israel Medical
Association Journal. Volume 5, Issue 1, Pages 9-11, 2003.
\7\ A. Geisler FH, Blumenthal SL, Guyer Rd, et al.,
``Neurological complications of lumbar artificial disc replacement
and comparison of clinical results with those related to lumbar
arthrodesis in the literature: Results of a multicenter,
prospective, randomized investigational device exemption study of
Charit[eacute] intervertebral disc'', Journal of Neurosurgery (Spine
2) Volume 1 Number 2, Pages 143-154, 2004.
\8\ Van Ooij, Oner, ``Complications of Artificial Disc
Replacement.'', Verbout Journal of Spinal Disorders and Techniques,
Vol. 16 No. 4, p. 369-383, 2003.
---------------------------------------------------------------------------

We finally note that we believe we have applied a consistent
standard of evidence. While the applicant stated there may be
similarities between this device and INFUSE[supreg], as noted above, we
believe there are still many unanswered questions regarding
CHARIT[Eacute]^TM, including the lack of long-term clinical
evidence and the overall effectiveness of the device, which preclude us
from determining that it meets the substantial clinical improvement
criterion.
Comment: One commenter who had the CHARIT[Eacute]^TM
implanted supported approving the CHARIT[Eacute]^TM for new
technology add-on payments. The commenter explained that the device has
offered clinical benefits, such as pain relief, that other procedures
or surgeries were unable to achieve. Other commenters also supported
approval of the CHARIT[Eacute]^TM, indicating that the FDA
prospective study showed a reduction in length of stay of a half day
and patients also returned to normal activities in half of the time of
spinal fusion patients.
Response: As noted above, we acknowledge that the
CHARIT[Eacute]^TM may have potential benefit for certain
carefully selected Medicare beneficiaries. However, we do not believe
that one patient's experience is sufficient to show the substantial
clinical improvement criterion has been met. Further, while the
patient's experience indicates that there may be short-term benefits
from receiving treatment with CHARIT[Eacute]^TM, we remain

[[Page 47356]]

concerned that the data supplied by the applicant did not demonstrate
substantial clinical improvement long term, despite the product being
available on the European market since 1987. We are also concerned
about the degree of controversy surrounding the device within the
orthopedic and spine surgery community. Therefore, we are denying this
application for new technology add-on payments because we did not find
enough evidence that the product meets the substantial clinical
improvement criterion.
Comment: One commenter noted that CMS did not acknowledge that
section 1886(d)(5)(K) of the Act states:
``Before establishing any add-on payment * * * with respect to a
new technology, the Secretary shall seek to identify one or more
diagnosis-related groups associated with such technology, based on
similar clinical or anatomical characteristics and the cost of the
technology.''
The commenter explained that, in the proposed rule, CMS solicited
comment on whether to reassign ICD-9-CM code 84.65 and on the new
technology application for the CHARIT[Eacute]^TM. The
commenter added that, instead of considering these as two distinct
issues, CMS should consider a DRG change within the new technology
application as mandated by the statute.
Another commenter indicated that the purpose of the new technology
add-on program is to provide a cost-based bridge to compensate
hospitals for additional costs related to new technology. Consistent
with CMS' position not to consider DRG changes until sufficient data
became available in MedPAR to support it, the commenter believed it
would be premature to reassign spinal disc prostheses to DRGs 497 and
498 until further data become publicly available. The commenter added
that DRGs 497 and 498 are well established and any changes to these
DRGs, such as including cases of disc prosthesis in these DRGs without
more complete data could result in an inappropriate reduction to the
weight of these DRGs.
Response: We agree with the comments regarding section
1886(d)(5)(K) of the Act. If a product meets all of the criteria for
Medicare to pay for a product as a new technology, there is a clear
preference expressed in the statute for us to assign the technology to
a DRG based on similar clinical or anatomical characteristics and
costs. However, as stated above, we are denying new technology add on
payments for CHARIT[Eacute]^TM because we could not establish
that it meets the substantial clinical improvement criterion.
Nevertheless, we did evaluate whether to make a DRG change for
CHARIT[Eacute]^TM outside of the context of the new
technology process. We are providing a full analysis of this issue in
section II.B.6.d. of the preamble to this final rule.
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. (We refer
readers to Tables 6A through 6H in the Addendum to this final rule for
information regarding ICD-9-CM codes.)
At the time of the initial application, the FDA had not yet
approved this technology for general use. Subsequently, however, we
were notified that FDA approval was granted on March 23, 2005.
Therefore, GORE TAG meets the newness criterion. Although we discussed
some of the data submitted with the application for new technology add-
on payments, we were unable to include a detailed analysis of cost data
and substantial clinical improvement data in the FY 2006 IPPS 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.
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 prior to publication of the FY 2006 IPPS proposed rule.
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

[[Page 47357]]

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. In
the FY 2006 proposed rule, we indicated that we would consider these
comments regarding the substantial clinical improvement criterion in
the final rule if we determined 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: In the proposed rule, we responded that as we discussed
in the new technology 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 this case, we will determine whether the
GORE TAG device qualifies for new technology add-on payments in this
final rule. In the event that this technology satisfies all the
criteria, as we indicated in the FY 2006 IPPS proposed rule, 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. In the FY 2006 IPPS proposed rule, we solicited comments
regarding this technology in light of its recent FDA approval,
particularly with regard to the cost threshold and the substantial
clinical improvement criteria.
During the 60-day comment period for the FY 2006 IPPS proposed
rule, we received the following comments:
Comment: The applicant submitted an additional validation sample of
cases to confirm the costs associated with this technology. In this
sample, charges for the device ranged from approximately $7,000.00 to
$11,000.00 per device.
Response: We have reviewed the evidence presented above and have
determined that the manufacturer has demonstrated that this device
meets the cost threshold for the DRGs to which these cases will be
assigned. However, we note that we would expect there to be
significantly fewer hospital resources required to care for a patient
undergoing the endovascular procedure compared to an open thoracotomy.
Thus we are concerned that the cost of cases using this device is
unnecessarily high. We will continue to monitor the data associated
with the endovascular repair of a thoracic aortic aneurysm in the
future to obtain further information about this issue.
Comment: Several commenters encouraged CMS to approve the GORE TAG
device for new technology add-on payment approval. These commenters
indicated that this device is a significant advance in the treatment of
thoracic aortic aneurysms, particularly for elderly, frail patients who
are not candidates for the open procedure to correct life-threatening
aneurysms. They added that physicians pointed to the mortality and
comorbidity rates associated with the open procedure, stating ``even in
centers of excellence, the risk of either mortality or paraplegia
complicating surgery runs up to the 10 percent range.''
Response: We appreciate the commenters' input on the substantial
clinical improvement criterion, and we have determined that the GORE
TAG device meets the substantial clinical improvement criterion. In our
view, the GORE TAG device meets a number of the standards that we use
to evaluate whether a new technology is a substantial clinical
improvement. For instance, GORE TAG offers a treatment option for
patients with thoracic aortic aneurysms that are not candidates for
open surgery. Prior to endovascular treatment with this device, there
were no treatment options available for patients who were not
candidates for open repair of a thoracic aortic aneurysm. We also
believe that, relative to the open repair procedure, endovascular
aneurysm repair improves clinical outcomes through lower mortality and
complication rates, reduced overall length-of-stay, less intensive care
unit days and less operative complications. For the reasons stated
above, we find that the GORE TAG device meets the substantial clinical
improvement criterion.
As indicated earlier, GORE TAG meets both the newness and cost
criteria. Therefore, in this final rule, we are approving the GORE TAG
device for new technology add-on payment for FY 2006. These cases
generally are in DRGs 110 and 111. Cases involving the device should
code for the device using the newly created ICD-9-CM procedure code
39.73 (Endovascular implantation of graft in thoracic aorta). The cost
of a single device is $12,798. Because the average patient receives 1.8
endovascular prostheses, we estimate the cost of the device to be
$21,198 per patient. Therefore, beginning October 1, 2005, cases that
include code 39.73 will be eligible to receive new technology add-on
payments up to $10,599, or half the cost of the device.
Comment: In the proposed rule, we stated that ``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.''
Commenters argued that, CMS should not require, FDA approval to be
granted to substantially similar devices prior to the publication of
the final rule for CMS to extend new technology payments to these
products.
Response: We agree with the commenters. Any substantially similar
device that is FDA-approved after the publication of the final rule
that uses the same ICD-9-CM procedure code as GORE TAG and falls into
the same DRGs as those approved for new technology add-on payments
should also receive the new technology add-on payment associated with
this technology in FY 2006. The discussion of this issue in the
preamble to the proposed rule was intended to communicate that we would
extend new technology payments to any substantially similar product
that is assigned to the same ICD-9-CM code, as long as the applicant's
product received FDA approval prior to the final rule. For the reason
stated above, we have changed our position on this issue and will
extend add-on payment to any substantially similar products that are
assigned to the same ICD-9-CM code and that receive FDA approval either
before or during FY 2006.
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

[[Page 47358]]

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.
At the time of the FY 2006 proposed rule, this device had not yet
received approval for use by the FDA; however, another manufacturer had
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. The manufacturer
derived this estimate by identifying cases in the FY 2003 MedPAR that
reported procedure code 03.93 (Insertion or replacement of spinal
nerostimulators). 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'' and
could no longer be considered a new product (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), and
this code was also used to identify the predecessor technology in order
to perform the cost threshold analysis. 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. As discussed in the proposed rule,
the applicant applied for and was assigned a new ICD-9-CM code for
rechargeable neurostimulator pulse generator. (We refer readers to
Tables 6A through 6H in the Addendum to this final rule for information
regarding ICD-9-CM codes.) Because the Renew^TM SCS and
Restore[supreg] technologies appear 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. Medtronic contends that the Restore[supreg]
device 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 had not yet been received for this device, in
the proposed rule, we indicated that we were making no decision
concerning the Restore[supreg] application. We indicated that we would
make a formal determination if FDA approval occurs in sufficient time
for full consideration in this final FY 2006 rule. However, we noted
that we had 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 recognized the benefits of a more easily
rechargeable neurostimulator system, we believed that the
Restore[supreg] device might 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
received no public comments regarding this application for add-on
payments prior to the publication of the FY 2006 IPPS proposed rule. In
the proposed rule, we solicited comments on this application for add-on
payments, specifically regarding how the Restore[supreg] device may or
may not be significantly different from previous devices. We also
sought comments on whether the product meets the cost and significant
improvement criteria.
During the 60-day comment period for the proposed rule, we received
the following comments:
Comment: Several commenters supported the application for the
rechargeable implantable neurostimulator for add-on payment. Commenters
noted that there is a large difference between the radio frequency (RF)
devices and the rechargeable implantable neurostimulators. They argued
that there is little relief with the RF systems, because once the
transmitter/power source is removed, the therapy immediately ends.
Further, commenters argued that due to these restrictions and the
difficulty of ensuring patient compliance with this device, the pain
relief the RF system is intended to provide is not possible. As such,
the commenters argued that the rechargeable implantable device is a
much better option for many patients with high power needs than
previously available neurostimulators.
Commenters argued that the new, rechargeable, implantable
neurostimulators meet the substantial clinical improvement criterion by
eliminating surgeries to replace the

[[Page 47359]]

batteries, reducing the infection rate associated with greater
frequency of replacement surgeries, and providing more treatment
options for those patients that require high energy stimulation. In
addition, commenters noted the clinical improvement associated with the
ability to use two 16-electrode leads instead of the 8-channel leads
that are used in older neurostimulators. They pointed out that, by
using leads with more electrodes, the physician can place the leads so
that more coverage is provided to the spinal nerves, and the physician
is provided an option to reprogram the neurostimulator without further
invasive surgery if a lead migrates after the unit is installed.
Further, commenters argued that, by paying the higher up-front expenses
associated with these technologies, CMS will ultimately save money on
reduced surgical and physician encounters, while improving the care
that Medicare beneficiaries receive. Finally, the manufacturer
submitted an updated price for the Restore[supreg] rechargeable
implantable neurostimulator that reflects a decrease in total costs for
the new components associated with the device. Based on this change,
the manufacturer calculated the new maximum add-on payment amount to be
$9,320 if the application is approved.
Response: We appreciate these commenters' input regarding this
device. While the comments were submitted in support of a finding that
this device meets the substantial clinical improvement criterion, they
have also convinced us that the device is significantly different from
predecessor devices. Therefore, we are reversing our preliminary
determination that the Restore[supreg] Rechargeable Implantable
Neurostimulator is likely not new, and we have determined that it can
be considered new for the purposes of the new technology add-on payment
for this reason. The manufacturer also provided data from its device
registry demonstrating that nearly 34 percent of patients aged 65 and
older, who receive non-rechargeable devices, require a replacement
surgery within the first 10 years of implantation. In addition, of
those patients that require replacement surgeries, more than half of
those patients have high energy needs that deplete the battery within
the first 3 years. By avoiding the need for a battery replacement
surgery, we believe these data demonstrate that this device is a
substantial clinical improvement for a large proportion of the patients
who receive implantable neurostimulators. In addition, we agree that
the patient compliance issues with the predecessor devices that use of
RF as the recharging source are significant. The applicant has
demonstrated that there will not be the same patient compliance issues
with its product. Because of the elimination of the need for serial
battery replacement surgeries and in light of the information provided
by the manufacturer and commenters further clarifying the distinctions
and improvements of the Restore[supreg] technology when compared to
other devices, we believe that the device is a substantial clinical
improvement over prior technologies.
As stated in the proposed rule, we had previously determined that
Restore[supreg] in combination with the other devices that already
received FDA approval in 2004 and 2005, meets the newness and cost
threshold criteria. Therefore, we are approving new technology add-on
payments for rechargeable, implantable neurostimulators for FY 2006.
Cases involving these devices will be identified by the presence of
newly created ICD-9-CM code 86.98 (Insertion or replacement of dual
array rechargeable neurostimulator pulse generator). These cases are
generally included in the following DRGs: 7, 8, 499, 500, 531, or 532.
In the proposed rule, we stated that the maximum add-on payment for the
new components of the device would be $10,568, or half of $21,135. The
applicant reported a reduction in the price to $18,640 after
publication of the proposed rule, making the maximum add-on payment for
the device $9,320. Therefore, we are finalizing a maximum add-on
payment of $9,320 for cases that involve this technology.
f. Safe-Cross(r) 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. In
January 2004, the FDA approved the Safe Cross[supreg] for coronary
arteries. The device was also approved by the FDA for all native
peripheral arteries except carotids in August 2004. 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 $37,304 and a case-
weighted average standardized charge of $40,705. (We have updated the
case weighted threshold and case weighted average standardized charge
from the proposed rule due to an inadvertent clerical error in
reporting these figures in the proposed rule.) 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.

[[Page 47360]]

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 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, in the FY 2006 IPPS proposed rule, we noted 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, in the FY 2006 IPPS proposed rule, we proposed 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 sought further information
on whether this device meets the substantial clinical improvement
criterion, and indicated that we would consider any further information
prior to making our final determination in this final rule.
We received no public comments regarding this application for add-
on payments prior to the publication of the FY 2006 IPPS proposed rule.
During the 60-day comment period on the FY 2006 IPPS proposed rule, we
received the following comment:
Comment: One commenter expressed support for the Safe
Cross[supreg], explaining that the increased chance of crossing a CTO
enables the placement of drug-eluting stents and represents a
substantial clinical improvement for treating the most challenging
clinical subgroup with these conditions. Using the device also raises
the cost per case and, therefore, the commenter recommended that CMS
pay new technology add-on payments for this device.
Response: In a letter dated June 3, 2003 to the applicant, CMS
denied pass-through payments under the OPPS for the Safe Cross[supreg]
because it did not demonstrate a substantial clinical improvement. The
letter explained that the company has not yet provided intermediate to
long-term results regarding reocclusion of previously occluded vessels
after angioplasty with substantially improved patient outcomes, which
could demonstrate that the Safe Cross[supreg] technology leads to
significant clinical improvement for patients in comparison with other
available treatments. Given the similar criteria for making pass-
through payments under the OPPS and new technology add-on payments
under the IPPS, a finding that Safe Cross[supreg] does not

[[Page 47361]]

meet the OPPS criteria means that, in the absence of relevant new
information, it cannot qualify for new technology add-on payments under
the IPPS. Therefore, we are finalizing our proposal to deny new
technology add-on payments for the Safe Cross[supreg] in FY 2006
because it does not meet the substantial clinical improvement
criterion.
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.
In addition, we note that 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 final 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, in the FY
2006 IPPS proposed rule, we proposed to deny add-on payments for the
Trident[supreg] Ceramic Acetabular System for FY 2006.
The applicant submitted cost threshold information for the
Trident[supreg] Ceramic Acetabular System, stating that cases using the
system would be 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 prior to publication of the FY 2006 IPPS proposed rule.
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. In
the proposed rule, we indicated that we would consider these comments
regarding the substantial clinical improvement criterion. However,
based on the observations provided at the town hall meeting, we noted
that 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 the proposed rule, we
proposed 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 would review
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 stated that we would consider additional DRG
revisions to better capture the various types of joint procedures. We
also stated that 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. In the FY 2006 IPPS proposed
rule, we sought 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 and received the following comments
during the 60-day comment period.
During the 60-day comment period on the FY 2006 proposed rule, we
received the following comments:
Comment: Several commenters supported new technology add-on
payments for the Trident[supreg] ceramic on ceramic hip. Many of these
comments reiterated the comment from the device manufacturer,
disagreeing with our assertion that the technology represents only an
incremental improvement over other technologies. The commenters
emphasized that the Trident[supreg] Ceramic Acetabular System had been
evaluated in an extensive prospective, randomized, controlled clinical
study, and that the FDA Panel reviewing the

[[Page 47362]]

study commended it for its design, statistical report, and patient
followup. Therefore, the commenters argued, the product had shown
clinical superiority where other devices and improved designs had not
shown clinical superiority to the metal on polyethelene hip implants.
The commenter also cited a post-market study of a subset of the
original study patients that demonstrates continued good patient
outcomes at a mean of 5.2 years followup, as presented at the 2005
American Academy of Orthopedic Surgeons Annual Meeting.
Response: The Trident[supreg] Ceramic Acetabular 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. Prosthetic hip joints have been used to treat these
conditions for many years. The Trident[supreg] Ceramic Acetabular
System differs from its predecessor prosthetic hips only in the
materials that are used in the joint. Thus, the Trident[supreg] Ceramic
Acetabular System uses the same or a similar mechanism of action to
achieve a therapeutic outcome (that is, it replaces the joint to
address pain and related conditions for patients suffering from
arthritis or related conditions). Further, we note that the cases using
the Trident[supreg] Ceramic Acetabular System will go into new DRGs 544
or 545 (Major Joint Replacement, Revision of Hip or Knee Replacement),
the same DRGs as the patients that receive the older prosthetic hip
replacements. Therefore, because the Trident product appears to offer
only an incremental advance in the treatment of patients requiring a
total hip replacement, we find that it does not meet the substantial
clinical improvement criterion. We also note that in this final rule,
as proposed, CMS is splitting DRG 209 into two separate DRGs (544 and
545) in order to better reflect the higher costs of revising hip and
knee replacements.
Comment: Several commenters objected to our interpretation of the
period of new with regard to this technology. Several commenters noted
that there appeared to be inconsistency in the method CMS has used to
determine the period of ``newness'' for each technology, noting in
particular that both the CRT-D device and INFUSE[supreg] bone graft for
spinal fusion received new technology add-on payment beyond the 2-3
year period that the devices could be considered new. As noted in the
proposed rule, commenters argued that, by CMS' own rationale, payment
beyond this period was designed to provide payment predictability and
consistency for the entire fiscal year, rather than terminating
payments part way through the year. Commenters urged us to reconsider
whether this technology meets the newness criterion because it will not
be 3 years old until more than 6 months into FY 2006.
Response: We believe the commenters make a good point about
application of the newness criteria to the Trident[supreg] product. The
commenters are correct that we have generally followed a guideline that
uses a 6-month window before and after the start of the fiscal year to
determine whether to extend the add-on payment for an additional year.
In general, we extend add-on payments for an additional year if the 3
year anniversary date of the product's entry on the market occurs in
the latter half of the fiscal year.
In the case of the Trident[supreg] ceramic acetabular system, the
device was not available on the market until April, 2003. Thus, the
product will not have been available on the market for 3 years until
the second half of FY 2006. Thus, under policy, the Trident[supreg]
ceramic acetabular system could potentially qualify as new for FY 2006.
However, the device is very similar to existing products, only
differing in the composite material used in manufacturing. It is also
used in the same DRGs as these other similar technologies, and we
question whether it would be appropriate to deem this technology new
and substantially different from previous hip prosthetics. Thus, as
noted above, we continue to find that the device does not meet our
substantial clinical improvement criterion. Therefore, in this final
rule, we are finalizing our decision to deny new technology add-on
payments for this device for FY 2006.
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 did not believe it was
appropriate to present our full analysis on whether the technology
meets the individual criteria for the new technology add-on payment in
the proposed rule. 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

[[Page 47363]]

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 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, in the FY 2006 IPPS proposed rule, we proposed to deny
add-on payment for this new technology.
We received no public comments regarding this application for add-
on payments prior to the publication of the FY 2006 IPPS proposed rule.
During the 60-day comment period for the FY 2006 IPPS proposed
rule, we received the following comment:
Comment: One commenter, the applicant, commented that the
Wingspan^TM represents a substantial clinical improvement
over what is currently available to treat patients with intracranial
atherosclerotic disease, and who suffer from recurring stroke and
recommended that, upon FDA approval of the Wingspan^TM, CMS
determine the most appropriate payment for this new therapy.
Response: We thank the commenter for its comments and upon FDA
approval we encourage the applicant to reapply for new technology add-
on payments. However, because the Wingspan^TM does not have
FDA approval or Medicare coverage, we are finalizing our proposal to
deny add-on payment for this new technology.

III. Changes to the Hospital Wage Index

A. Background

Section 1886(d)(3)(E) of the Act requires that, as part of the
methodology for determining prospective payments to hospitals, the
Secretary must adjust the 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 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 adjustment for FY 2006 is
discussed in section II.B. of the Addendum to this final rule.
As discussed below in section III.H. 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 budget neutrality adjustment for FY
2006 is discussed in section II.B. of the Addendum to this final rule.
Section 1886(d)(3)(E) of the Act also provides for the collection
of data every 3 years on the occupational mix of employees for 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 occupational mix adjustment that we are applying
beginning October 1, 2005 (the FY 2006 wage index) appears under
section III.C. of this preamble.

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

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/

[[Page 47364]]

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 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. These hospitals will be considered rural
for reclassification purposes.
In addition, in the FY 2005 IPPS final rule (69 FR 49032 and
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 adoption of 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 does not prevent a decrease in wage index due to any reason
other than adoption of CBSAs, nor does 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, beginning in FY 2006,
we are providing that hospitals receive 100 percent of their wage index
based upon the new CBSA configurations. Specifically, we have
determined for each hospital a new wage index for FY 2006 employing
wage index data from FY 2002 hospital cost reports and using the CBSA
labor market definitions.
Comment: Commenters asked CMS to defer 100 percent adoption of the
new labor market area definitions to allow hospitals more time to
adjust to the significant reimbursement impact. Most commenters urged
CMS to maintain the current 50 percent CBSA/50 percent MSA blend. One
commenter proposed using a 75 percent CBSA/25 percent MSA blend.
Response: We have decided not to provide for a longer transition
because we have already, in effect, provided 1 year at a higher wage
index for hospitals by delaying full implementation of the new Census
designations. Given that the new designations are based on the most
recent Census data, whereas the prior labor market areas are based on
1990 Census data, we believe it is both reasonable and appropriate to
adopt the new designations for FY 2006.
Comment: One commenter noted that, while CMS provided urban
hospitals that became rural under the new definitions hold harmless
protection for 3 years, urban hospitals that remained in MSAs that
experienced large wage index reductions did not receive that same
protection. The commenter stated that, although all hospitals that
experienced a decrease in their wage index from the effects of the
labor market area changes received a 1-year blended transition, this
transition expires on September 30, 2005. The commenter urged CMS to
provide hold harmless protection to all hospitals that experienced a
wage index decrease of more than 10 percent as a result of the new
labor market areas, regardless of whether the hospital remained urban
or rural.
Response: We refer readers to the FY 2005 IPPS final rule for a
full discussion of our rationale for limiting hold harmless protection
to a particular group of hospitals (69 FR 49032).
Comment: A few commenters addressed the use of Micropolitan Areas
as geographic areas. They stated that because CMS assigns Micropolitan
Areas to the statewide rural area for purposes of the IPPS, several
hospitals, by virtue of now being in a Micropolitan county, are
reclassified as rural despite their previous designation as an urban
hospital. They noted that, although CMS provided a 3-year transition
period to help alleviate the decreased wage index payments for
hospitals that were previously classified as urban and are now in rural
areas based on the new definitions, this transition did not ameliorate
any reductions in DSH payments, because the transition did not affect a
hospital's urban/rural status. They emphasized that, while urban
hospitals of 100 or more beds have no cap on DSH payments, rural
hospitals of all sizes are capped at 12 percent for DSH payments.
Commenters offered various recommendations about how to protect these
hospitals from the changes in the labor market area definitions. Most
commenters advocated allowing counties that are reclassified as
Micropolitan Areas despite their previous urban designation to be
grandfathered into their previously urban MSA. Other commenters
recommended that CMS provide an exception to these hospitals under
section 1886(d)(5)(I)(i) of the Act. Further, commenters suggested that
CMS adopt OMB's new standards for use in defining labor market areas,
but lower the commuting threshold used by OMB to define CBSAs.

[[Page 47365]]

Response: We disagree with the commenters that hospitals that
changed status from urban to rural received no amelioration with
respect to DSH. As stated in the FY 2005 IPPS final rule (69 FR 49033),
the provisions of Sec. 412.102 provide special protections for
hospitals against abrupt reductions in DSH payments resulting from
transitions from urban to rural status. Specifically, as described in
Sec. 412.102, in the first year after a hospital loses urban status,
the hospital will receive an additional payment that equals two-thirds
of the difference between the urban disproportionate share payments
applicable to the hospital before its redesignation from urban to rural
and the rural disproportionate share payments applicable to its
redesignation from urban to rural. In the second year after the
hospital loses urban status, the hospital will receive an additional
payment that equals one-third of the difference between the urban
disproportionate share payments applicable to the hospital before its
redesignation from urban to rural and the rural disproportionate share
payments applicable to its redesignation from urban to rural. Because
hospitals are already receiving adequate relief with respect to DSH
payments, we do not believe it is necessary to address the commenters'
recommendations regarding grandfathering, exceptions, or use of lower
commuting thresholds. We refer readers to the explanation in the FY
2005 IPPS final rule for our adoption of the new Census designations as
well as the treatment of Micropolitan areas as rural (69 FR 49027).

C. Occupational Mix Adjustment to FY 2006 Index

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 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 final FY 2006 wage index, as proposed,
we are using 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 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 FY 2006 wage index. The FY 2006 wage index
includes occupational mix data from 3,541 out of 3,742 hospitals (94.6
percent response rate). The results of the occupational mix survey are
included in the chart below.

BILLING CODE 4120-01-P

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[GRAPHIC] [TIFF OMITTED] TR12AU05.000

[[Page 47367]]

[GRAPHIC] [TIFF OMITTED] TR12AU05.001

BILLING CODE 4120-01-C

Comment: Two commenters noted that the ``Medicare Occupational Mix
Survey Results'' table in the FY 2006 proposed rule (70 FR 23369) did
not include data pertaining to medical and clinical laboratory
services, all other occupations, and total hospital employees. The
commenters requested that CMS publish the complete table in the final
rule.
Response: We apologize for any inconveniences caused by the
misprint of the table in the proposed rule. The above table includes
the complete set of occupational mix survey results for the final FY
2006 wage index.
Comment: As a mechanism to achieve a higher response rate, one
commenter recommended that CMS reward hospitals that submit
occupational mix survey data. The commenter suggested that, for
hospitals that submit occupational mix data, CMS should apply a higher
percentage of the occupational mix adjustment if the adjustment results
in a positive impact, and a lower percentage if the adjustment results
in a negative impact.
Response: Although the commenter's suggestion pertaining to a
procedural mechanism by which CMS conducts the occupational mix survey
is not a subject of the final policies included in this final rule, we
note that we disagree with the suggestion. We do not believe that
hospitals should receive a special reward for completing and submitting
the occupational mix survey. Rather, a hospital should deem the
submission of occupational mix data as a necessary part of its
responsibility to provide complete and accurate data for the wage
index. We also note that implementing an occupational mix adjustment so
that it applies to reporting hospitals only when it is beneficial to
such hospitals would defeat the purpose of the occupational mix
adjustment.
2. Calculation of the FY 2006 Occupational Mix Adjustment Factor and
the FY 2006 Occupational Mix Adjusted Wage Index
For the final FY 2006 wage index, we used the same methodology that
we used to calculate the occupational mix adjustment to the FY 2005
wage index (69 FR 49042). We used the following steps for calculating
the 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 seven 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 seven general service categories. If the
hospital's adjusted rate

[[Page 47368]]

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 are calculated by
multiplying the hospital's total salaries and wage-related costs (from
Step 5 of the unadjusted wage index calculation in section III.F. of
this preamble) 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 seven 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 seven 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
III.F. of this preamble).
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
national occupational mix adjusted average hourly wage for FY 2006 is
$28.0272.
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 Steps 1 through 9 above. The Puerto Rico
occupational mix adjusted average hourly wage for FY 2006 is $12.7985.
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 FR 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 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 treating the wage data for hospitals that did not
respond to the survey in this same manner for the FY 2006 wage index.
In implementing an occupational mix adjusted wage index based on
the above calculation, the wage index values for 14 rural areas (29.8
percent) and 206 urban areas (53.4 percent) would decrease as a result
of the adjustment. Seven (7) rural areas (14.9 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, 4.2 percent.
Meanwhile, 32 rural areas (68.1 percent) and 179 urban areas (46.4
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 proposed rule, 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 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.
Comment: Several commenters provided recommendations for the design
and release of a revised occupational mix survey.
Response: We plan to release a revised occupational mix survey in
an upcoming Federal Register notice. We will address the design and
data collection issues, including the commenters' recommendations, as
part of that notice.
In our continuing efforts to meet the information needs of the
public, we provided via the Internet three additional public use files
for the proposed occupational mix adjusted wage index concurrently with
the publication of the FY 2006 IPPS proposed rule: (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). We also plan to
post these files via the Internet with future applications of the
occupational mix adjustment.

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

The 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 final 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).

[[Page 47369]]

The 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 final rule that hospitals must comply
with the requirements in 42 CFR 413.100, 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 Department of Labor and Internal Revenue
Service requirements. We believe that the Medicare instructions allow
for both consistent reporting among hospitals and for the development
of reasonable deferred compensation plan costs for purposes of the wage
index.
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.
Comment: A few commenters addressed our discussion regarding the
treatment of pension, post-retirement health benefits, and other
deferred compensation costs for purposes of the wage index. Two
commenters expressed concern that the instructions are a significant
change from our original instructions published September 1, 1994. The
commenters asserted that CMS provided no rationale for moving away from
using GAAP for developing these costs for the wage index, and requested
an additional opportunity for public comment. One commenter suggested
that using GAAP provides a more consistent methodology for capturing
these costs than Medicare reasonable cost principles. A fourth
commenter requested a more specific description of the treatment of
pension, post-retirement health benefits, and other deferred
compensation costs if there are other ``related Medicare program
instructions'' as we stated above.
Response: For cost reporting periods beginning prior to October 1,
1994, hospitals were required to include in the wage index only the
amount of actual payments that the hospital made to retirees in the
reporting year. For periods beginning on or after October 1, 1994, CMS
instructed hospitals to use GAAPs, an accrual method of accounting, for
developing pension, deferred compensation, and other wage-related costs
for wage index purposes. All other wage costs on Worksheet S-3 must
reflect costs that are actually expended by the hospital during the
cost reporting period. We believed then and continue to believe that
the use of accrual accounting allows hospitals to be more inconsistent
in their reporting of wage-related costs from year to year so that the
wage index could be more static.
Section 413.24 of the regulations also provides for the accrual
basis of accounting for developing costs under Medicare's cost finding
principles. However, a major difference between GAAP and Medicare
principles for recognizable pension and other deferred compensation
plan costs is an issue of funding. In Sec. 413.100 (and as discussed
in 60 FR 33126, June 27, 2005), we clarified and codified CMS'
longstanding requirement that, for purposes of program payment,
providers must timely liquidate their liabilities. GAAP does not
specify a time requirement for recognizing accrued costs.
In 2003, we updated the cost report instructions in section 3605.2
of the PRM, Part II, to also clarify the September 1, 1994 instructions
for the wage index. At the instructions for wage-related costs, lines
13 through 20, we noted that, ``Although hospitals must use GAAP in
developing wage-related costs, the amount reported for wage index
purposes must meet the reasonable cost provisions of Medicare.'' The
clarification was to ensure that a hospital includes in the wage index
only those pension and other deferred compensation plan costs that meet
the timely liquidation requirements for Medicare reasonable cost
principles. When CMS issued the September 1, 1994 instructions, CMS did
not anticipate nor intend for hospitals to include costs in the wage
index that have not been funded and may never be funded. Including
unfunded deferred compensation costs in the wage index can
significantly misrepresent an area's average hourly wage, especially if
the plan is never funded. In a May 4, 2005 Early Alert to CMS's
Administrator, the OIG stated that ``While some hospitals include
millions of dollars in unfunded pension and other postretirement
benefit costs in the annual wage data shown on their Medicare cost
reports, others include only funded amounts. As a result, the wage
indexes for the hospitals that include unfunded amounts are inflated,
which leads to an inadequate distribution of Medicare payments among
hospitals.'' In addition, the OIG warned that ``* * * the hospitals'
inclusion of costs related to unfunded liabilities could compromise the
reliability of the wage data that CMS uses to develop the market basket
* * *. Thus, the inclusion of costs related to unfunded liabilities in
hospitals' wage data could produce an inaccurate market basket index
for use in updating payments to hospitals.''
Regarding the comment requesting a specific description of the
treatment of pension, post-retirement health benefits, and other
deferred compensation costs if there are other ``related Medicare
program instructions,'' we included this phrase to set forth that
hospitals must also comply with any future instructions related to
these costs that may be initially issued through rulemaking or a one-
time notice before being included in the above PRM sections.

[[Page 47370]]

We believe that our discussion in the proposed rule was sufficient
notification for this policy clarification. Therefore, we do not agree
that CMS should provide another comment period for this matter. In
addition, we believe that hospitals and intermediaries should be able
to ensure that pension and other deferred compensation costs are
developed according to the above terms by the FY 2007 wage index, as
hospitals have been required, since cost reporting periods beginning
during FY 1995, to complete Form 339, a reconciliation worksheet
between GAAP and Medicare principles.
Consistent with the wage index methodology for FY 2005, the 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 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).
Comment: Two commenters recommended that CAHs be included in the
wage index. One commenter suggested that CMS should exclude the wage
data for a CAH only if it is designated a CAH during the base year for
the wage index calculation. MedPAC suggested that CMS should include
the wage data for all CAHs, even if the hospital is a CAH in the base
year that is used for calculating the wage index. In addition, MedPAC
stated the following:
The wage index should ideally reflect the data for all
providers that are similar in services and occupations to hospitals
receiving payment under Medicare's IPPS and OPPS. CAHs are similar to
other small rural hospitals and in many cases are located close enough
to IPPS hospitals to compete for the same workers.
About 500 hospitals converted to CAH status over the past
3 years. Since CAHs now dominate the rural areas for some states, the
data for CAHs may become critical for an accurate representation of
rural area wage levels. It is important to note that this
representation affects payment for not only the IPPS hospitals but also
for other providers that are paid under a Medicare prospective payment
system, such as SNFs, HHAs, and LTCHs.
MedPAC recommended that CMS begin collecting wage data from CAHs
this year.
Response: In the FY 2004 final rule (68 FR 45397), we provided a
complete discussion, rationale, and analysis of our policy for
excluding CAHs from the wage index. In that rule, we stated that CAHs
are not paid under the IPPS, and, like other non-IPPS providers such as
SNFs, HHAs, LTCHs, and children's hospitals, we have always excluded
non-IPPS providers from the wage index calculation. We also stated
that, due to their remote location and more limited services, CAHs
``are unique compared to other short-term acute care hospitals.'' Using
data collected from cost reporting periods beginning during FY 2000, we
further noted that, in most labor market areas with hospitals that
converted to CAH status some time after FY 2000, the average hourly
wage for CAHs was significantly lower than the average hourly wage for
other short-term hospitals in the area. As a result, with the FY 2004
wage index, we began excluding the data for any CAH, even if it was an
IPPS provider during the wage index base year.
We agree with MedPAC that CAHs have recently become more similar in
composition, services, and proximity to other rural hospitals, largely
due to the Pub. L. 108-173 (MMA). Section 405 of Pub. L. 108-173 allows
for more hospitals to now qualify and more seamlessly convert to CAH
status. However, because Pub. L. 108-173 was enacted in calendar year
2003, it would not affect the FY 2002 base year for the FY 2006 IPPS
wage index. In addition, our analysis of the FY 2006 wage index shows
that rural areas are not harmed by the exclusion of CAHs. For FY 2006,
we removed the wage data for 162 hospitals in 39 rural areas because
they became CAHs after they filed their FY 2002 cost reports as IPPS
hospitals. In all 39 rural areas, the average hourly wages for FY 2006
increased over those for FY 2005. For 76.9 percent of the rural areas,
the average hourly wage increase is 5 percent or greater.
Therefore, we continue to believe that it is prudent policy to
remove the data from CAHs from the wage index. As such, we have
excluded from the FY 2006 wage index in this final rule the wages and
hours for all hospitals that are currently designated as a CAH, even if
the hospital was paid under the IPPS during FY 2002, the cost reporting
period used in calculating the FY 2006 wage index. We will reconsider
our policy when we can collect and analyze wage data for a base year
that could be impacted by Pub. L. 108-173 changes for CAHs.
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. We note that in the
IPPS rules, we do not address comments pertaining to the wage indices
for non-PPS providers. Such comments should be made in response to
separate proposed rules for those providers.
In the FY 2005 IPPS 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 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

[[Page 47371]]

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 hospital would integrate the
facility into the main provider's outpatient department, since the
facility offers health care services of the same type as those
furnished by the main provider. In addition, because a physician's
office would not receive its own provider agreement or receive a
Medicare provider number under Sec. 489.2 unlike an FQHC or an RHC, it
cannot be considered a ``provider-based entity,'' rather it would be
considered a department of a provider. (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), 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.
Comment: Two commenters objected to our clarification of historical
policy that the salaries of employees working in provider-based clinics
should continue to be included in the wage index calculation. The
commenters referred to these facilities as ``hospital-owned provider-
based physician practices'' that may be qualified to participate in
Medicare as providers under Sec. 489.2 of the regulations, and
therefore, by definition, are not ``departments of a provider.'' They
argued that CMS should exclude ``hospital-owned provider-based
physician practices'' from the wage index because, similar to RHCs and
FQHCs, the services provided by these facilities are also not paid for
under the IPPS. The commenters alluded to the OIG 2004 Red Book
(October 22, 2004), which proposed that CMS should eliminate provider-
based designations for ``hospital-owned physician practices,'' since
hospitals treat these facilities as provider-based without CMS'
approval. The commenters questioned whether it would be ``more accurate
and practical'' to exclude all ``hospital-owned provider-based
physician practices'' from the wage index, in light of the OIG's
proposal. Lastly, the commenters asserted that CMS' statement that the
salaries and wages of hospital employees working in the outpatient
areas of the hospital have historically been included in the wage index
since those employees often work both in the inpatient and outpatient
areas of the hospital, is inaccurate with respect to ``hospital-owned
provider-based physician practices'' because the facilities do not
provide services to IPPS areas of the hospital.
Response: In the FY 2006 IPPS proposed rule (70 FR 23371), we
discussed whether to include the costs of provider-based clinics in the
wage index because we stated in a response to a comment in the FY 2005
IPPS final rule (69 FR 49049) that we would explore the matter in a
future rule. Thus, we considered the issue and concluded that it is
appropriate to include the salaries and hours of employees working in
provider-based clinics in the wage index calculation. We came to this
conclusion because provider-based clinics cannot qualify by themselves
to participate in Medicare as a provider under Sec. 489.2 of the
regulations and are, therefore, categorized as ``departments of a
provider'' under the provider-based regulations at Sec. 413.65.
Accordingly, they would be reported as part of the main provider's
outpatient department on line 60 of Worksheet C of the Medicare cost
report. In making this conclusion, we distinguished provider-based
clinics that are part of the hospital outpatient department and
included in the IPPS wage index from ``provider-based entities'' (such
as SNFs, RHCs, and FQHCs) that are excluded from the IPPS wage index
because, under the regulations at Sec. 413.65, they participate in
Medicare under their own provider agreements. Commenters are incorrect
when they asserted that RHCs and FQHCs would be included in the wage
index except for the fact that these entities are not paid under the
IPPS. Rather, wage data from RHCs and FQHCs are also not included in
the wage index because, although they may be provider-based, these
entities are providers in their own right and may, by themselves,
qualify to participate in Medicare as a provider under Sec. 489.2. As
a general rule, we do not include the wage data of facilities that are
providers in their own right in the IPPS wage index. Thus, the
commenters are also incorrect that ``hospital-owned provider-based
physician practices'' may, by themselves, be qualified to participate
in Medicare as a provider under Sec. 489.2 of the regulations, and
therefore, by definition, are not ``departments of a provider.'' We
note that Sec. 489.2 does not list ``hospital-owned provider-based
physician practice'' as one of the facilities that may participate in
Medicare as a provider. Further, while Sec. 489.2 does list
``clinics'' as a type of facility that can participate in Medicare as a
provider, Sec. 489.2(c) specifies that only clinics that furnish
outpatient physical therapy and speech pathology services may qualify
as providers. Therefore, if a hospital wishes that a physician practice
be considered provider-based, the physician practice, by definition,
must be categorized as part of hospital outpatient departments. As
such, the services provided in these provider-based clinics are paid
for by Medicare under the OPPS. Accordingly, it is appropriate that the
salaries and hours attributable to the provider-based clinics are
included in the IPPS wage index.
In response to the commenters' speculation as to whether it would
be ``more accurate and practical'' to exclude all ``hospital-owned
provider-based physician practices'' from the wage index, in light of
the OIG's proposal in the OIG 2004 Red Book (October 22, 2004), we
believe the commenter is confusing the policies regarding (a) who
should be considered provider-based and (b) whether salaries and hours
associated with provider-based clinics should be included in the wage
index. These are two different policy matters. On the first policy, we
agree that firm oversight and consistent audit procedures for
determining and monitoring provider-based status are necessary, since
our existing payment systems provide for more generous payment to
hospital outpatient departments than similar freestanding facilities.
However, the proposed rule discussed the second matter, not the first.
The purpose of the discussion in the proposed rule was not to debate

[[Page 47372]]

whether physician practices should ever be considered for provider-
based status. Certainly, we agree that freestanding physician offices,
or facilities that have been denied provider-based status by the CMS
Regional Office, should not be included in the wage index. Rather, the
purpose of the discussion in the proposed rule was to clarify our
longstanding policy that as long as a hospital reports, and the CMS
Regional Office approves, that a facility which might formerly have
been a freestanding physician office is provider-based, the proper
categorization of such a facility is as an outpatient department and
the wages and hours attributable to that outpatient department are
included in the IPPS wage index. Thus, we believe the commenters'
reference to the OIG Red Book is misplaced.
Further, the commenters' provide no support for their assertion
that workers in ``hospital-owned provider-based physician practices''
do not provide services to IPPS areas of the hospital. We have not seen
any evidence suggesting that the employees working in provider-based
clinics work exclusively there, or in other outpatient areas of the
hospital. Furthermore, we believe it would be extremely complicated and
unnecessary to attempt to distinguish between the salaries and hours of
employees that work in the various outpatient areas of hospitals, for
purposes of computing the IPPS wage index. Hospitals often maintain
provider-based facilities since the Medicare payment for services
provided in a hospital (provider-based) setting is typically more than
the payment would be for the same service provided in a freestanding
setting. Hospitals should not be permitted to treat these facilities as
part of the hospital for one purpose, and separate from the hospital
for purposes of the wage index. If hospitals wish to exclude certain
facilities from the wage index, they have the option to do so by
converting them to freestanding facilities. Therefore, as stated in the
FY 2006 proposed rule, consistent with our longstanding policy, we
continue to believe that it is appropriate to include the salaries and
hours of employees working in the outpatient departments, including
provider-based clinics, in the wage index calculation.
Comment: Two commenters expressed concern that the data used in
calculating the wage index are developed inconsistently across the
Nation. One of the commenters stressed the need for consistent
interpretation and application of all wage index policies by all fiscal
intermediaries. The commenters did not provide any specific examples of
cases where wage index data is developed inconsistently, or where
intermediaries are interpreting wage index policies inconsistently.
Response: We are equally concerned about consistent interpretation
and application of wage index policies by both intermediaries and
hospitals, as the wage index is a relative measure of area wage
differences. Throughout the years, we have revised and refined our
policy statements and cost reporting instructions in order to achieve
more accurate reporting of wage and hours data among hospitals and
intermediaries. In addition, we seek to close any loopholes in our
policies that may result in varied applications among hospitals. Our
work to ensure accuracy and consistency in the wage index is a
continuous effort. We encourage hospitals and intermediaries to bring
to our attention any instances of perceived inconsistencies. Also, we
remind hospitals that the wage data correction process is another
mechanism that is available for hospitals that require CMS'
intervention to settle disputes with intermediaries over wage index
policy interpretations (see section III.J. of this preamble).

E. Verification of Worksheet S-3 Wage Data

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 wage index includes FY
2002 data as of June 30, 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. While most of the
edit failures were resolved, we did remove the wage data of some
hospitals from the final FY 2006 wage index. For the final FY 2006 wage
index in this final rule, we removed the data for 235 hospitals from
our database: 201 hospitals became CAHs between February 20, 2004, the
cutoff date for exclusion of CAHs from the FY 2005 wage index, and
February 18, 2005, this year's cutoff date for the exclusion of CAHS
from the FY 2006 wage index, and 27 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 7 hospitals with incomplete or
inaccurate data resulting in zero or negative, or otherwise aberrant,
average hourly wages. As a result, the final FY 2006 wage index is
calculated based on FY 2002 wage data from 3,742 hospitals.
In constructing the 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 wage index in this final 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 (PUF) on February 25, 2005.
Comment: Two commenters expressed concern that the wage data for
two CAHs would not be removed from the final FY 2006 wage index. The
commenters explained that the effective date for conversion to CAH
status for both providers was in December 2004, but because of the
timing of the notification of the CAH status, the providers' wage data
was included in the February 25, 2005 PUF, and in Tables 2 and 4A that
accompanied publication of the proposed rule. The commenters noted
that, although CMS subsequently removed these providers' wage data from
the May 6, 2005 PUF, their wage data continued to be included in the
revised Table 2 that was posted June 1, 2005 on the CMS Web site. The
commenters asked for assurance that the wage data for these two CAHs
would not be included in the final FY 2006 wage index.
Response: As stated in the FY 2004 IPPS final rule (68 FR 45398),
we exclude providers from the wage index that were designated as CAHs
by 7 or more days prior to the posting of the preliminary PUF. This
year, since the preliminary PUF was posted on February 25, 2005, we
excluded providers that were designated as CAHs by February 18, 2005.
These hospitals were both designated as CAHs prior to February 18,
2005, and should not be included in the FY 2006 wage index
calculations. The commenters are correct that, initially, we did not
receive notification of the providers' CAH status in time to remove
their wage data from the February 25, 2005 PUF. We did not

[[Page 47373]]

include their wage data in the May 6, 2005 PUF. However, these
hospitals continued to be included in the updated Table 2 posted on the
CMS Web site on June 1, 2005 because these revisions to the wage data
were based on the February 25, 2005 PUF. However, the data for these
two CAHs are not included in the FY 2006 final wage index calculations.
We note that these two providers will continue to appear on Table 2
published along with the FY 2006 final rule because, although no
average hourly wage will be listed next to these providers for FY 2006,
they did have wage data that contributed to the wage index for their
CBSA in FY 2004 and FY 2005.

F. Computation of the FY 2006 Unadjusted Wage Index

The method used to compute the FY 2006 wage index without an
occupational mix adjustment follows:
Step 1--As noted above, we based the 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 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.

Midpoint of Cost Reporting Period
------------------------------------------------------------------------
Adjustment
After Before factor
------------------------------------------------------------------------
10/14/2001..................................... 11/15/2001 1.06469
11/14/2001..................................... 12/15/2001 1.06007
12/14/2001..................................... 1/15/2002 1.05566
01/14/2002..................................... 02/15/2002 1.05139
02/14/2002..................................... 03/15/2002 1.04725
03/14/2002..................................... 04/15/2002 1.04317
04/14/2002..................................... 05/15/2002 1.03907
05/14/2002..................................... 06/15/2002 1.03496
06/14/2002..................................... 07/15/2002 1.03083
07/14/2002..................................... 08/15/2002 1.02672
08/14/2002..................................... 09/15/2002 1.02261
09/14/2002..................................... 10/15/2002 1.01860
10/14/2002..................................... 11/15/2002 1.01478
11/14/2002..................................... 12/15/2002 1.01116
12/14/2002..................................... 01/15/2003 1.00757
01/14/2003..................................... 02/15/2003 1.00385
02/14/2003..................................... 03/15/2003 1.00000
03/14/2003..................................... 04/15/2003 0.99613
------------------------------------------------------------------------

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.

[[Page 47374]]

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 national average hourly wage is $28.0011.
Step 9--For each urban or rural labor market area, we calculated
the hospital wage index value by dividing the area average hourly wage
obtained in Step 7 by the national average hourly wage computed in Step
8.
Step 10--Following the process set forth above, we developed a
separate Puerto Rico-specific wage index for purposes of adjusting the
Puerto Rico standardized amounts. (The national Puerto Rico
standardized amount is adjusted by a wage index calculated for all
Puerto Rico labor market areas based on the national average hourly
wage as described above.) We added the total adjusted salaries plus
wage-related costs (as calculated in Step 5) for all hospitals in
Puerto Rico and divided the sum by the total hours for Puerto Rico (as
calculated in Step 4) to arrive at an overall average hourly wage of
$12.8063 for Puerto Rico. For each labor market area in Puerto Rico, we
calculated the Puerto Rico-specific wage index value by dividing the
area average hourly wage (as calculated in Step 7) by the overall
Puerto Rico average hourly wage.
Step 11--Section 4410 of 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. (For all-urban States, we established an imputed
floor (69 FR 49109). 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
174 hospitals in 63 urban areas. The areas affected by this provision
are identified by a footnote in Table 4A in the Addendum of this final
rule.
Comment: Numerous commenters were concerned with the proposed
change in step 4 of the wage index calculation in the FY 2006 IPPS
proposed rule (70 FR 23373). In order to allocate overhead wage-related
costs to areas of a hospital that are excluded from the IPPS, CMS uses
three steps: (1) Determine the ratio of overhead hours to revised (that
is, allowable) hours; (2) compute overhead wage-related costs by
multiplying the overhead hours ratio from Step 1 by wage-related costs;
and (3) multiply the overhead wage-related costs from Step 2 by the
excluded hours ratio (see Step 4 for more detail). The commenters noted
that, for FY 2006, the calculation of the overhead hours ratio in Step
1 will be modified to subtract hours attributable to excluded areas
(from line 8 for SNFs and line 8.01 for excluded areas of Worksheet S-
3, Part II of the Medicare cost report). The commenters observed that
this change results in a higher overhead hours ratio, which, in turn,
results in a greater amount of overhead cost being allocated to
excluded areas. The commenters believed that, because more costs are
being allocated to excluded areas, a hospital's average hourly wage
would decrease as a result of the proposal. One commenter added that
the proposed methodology is flawed, but did not indicate why. Other
commenters stated that the excluded area overhead hours ratio computed
with CMS' proposed methodology is ``dramatically high'' and does not
accurately reflect the hospital's overhead costs attributable to its
employee benefit amounts, but they did not offer an explanation or an
alternative for accurately identifying excluded overhead costs.
In general, the commenters, including the national hospital
association, were concerned that the proposed rule did not discuss the
impact of the change, and did not include a lengthy discussion of the
changes. These commenters believed that CMS should postpone the change
until a lengthy discussion of the proposal can be included in a future
proposed rule. The commenters further recommended that, because the
change in the wage index calculation caused confusion among hospitals
as to the correct average hourly wages, hospitals should be given an
opportunity to withdraw or reinstate their requests for geographic
reclassification within 30 days of the publication of the final rule.
Response: We have carefully considered the comments we received
regarding the proposed change in the FY 2006 IPPS proposed rule to the
methodology for removing overhead wage-related costs attributable to
areas of the hospital excluded from the IPPS. Overall, commenters
seemed to be more concerned that the proposed rule did not contain a
detailed discussion of the modification, rather than disagreeing in
principle with our modification. Therefore, we are adopting our
proposal without modifications because we believe the proposal most
accurately calculates the overhead wage-related costs that are
attributable to excluded areas. Historically, the wage index used to
adjust a hospital's payment under the IPPS has only reflected costs of
services that are provided in areas of the hospital that are covered
under the IPPS. That is, because certain areas of a hospital are
specifically excluded from the IPPS, such as hospital-based SNFs, or
distinct part rehabilitation and psychiatric units, the proportion of
the salaries paid to and the hours worked by employees in areas of the
hospital excluded from the IPPS are identified and removed from the
hospital's total salaries and hours. The remaining allowable salaries
and hours are used to compute the hospital's average hourly wage,
which, in turn, is used to calculate the wage index for the labor
market area in which the hospital is located.
In addition to removing salaries and hours that are directly
attributable to employees working in excluded areas, for each hospital
reporting both total overhead salaries and total overhead hours greater
than zero, we also remove any overhead (administrative and general)
costs and hours attributable to excluded areas by allocating overhead
costs and hours between the IPPS areas of the hospital and the areas of
the hospital excluded from the IPPS. We do this by determining the
``excluded rate'' for each hospital, which is the ratio of excluded
area hours to total hours (see Step 4 of the wage index calculation).
The ``excluded rate'' reflects the percentage of hours worked by
hospital employees in areas of the hospital excluded from the IPPS. For
example, an ``excluded rate'' of 0.15 means that approximately 15
percent of total employee hours was spent in excluded areas (and
therefore, about 85 percent of the employees' time worked was spent in
the IPPS areas of the hospital). We then determine the amount of
overhead salaries and hours to be allocated to the excluded areas by
taking the ``excluded rate'' and multiplying it by the

[[Page 47375]]

hospital's total salaries and hours attributable to overhead.
Next, because wage-related costs are separate from salaries, we
perform a similar calculation to determine the percentage of wage-
related costs attributable to overhead that should be allocated to the
excluded areas of the hospital. We do this by computing the ``overhead
rate,'' which is the percentage of allowable (that is, does not include
excluded area) overhead hours to total hours. The ``overhead rate'' is
multiplied by total wage-related costs to determine the amount of wage-
related cost attributable to overhead. Finally, the amount of wage-
related costs attributable to overhead is multiplied by the ``excluded
rate'' to determine the amount of overhead wage-related costs that are
associated with excluded areas, and, therefore, should be subtracted
from the total allowable wages used in the wage index. Obviously, the
larger the ``overhead rate,'' the greater the amount of overhead wage-
related costs to be allocated across the hospital, and the greater the
excluded area, the greater the amount of overhead wage-related cost
that is identified as being associated with excluded areas and that
should be subtracted from allowable wages.
Through FY 2005, in determining the ``overhead rate,'' we divided
the allowable overhead hours by the hospital's total hours, including
hours attributable to excluded areas, even though the latter hours are
excluded from the wage index. Last year, after publication of the FY
2005 IPPS final rule, we became aware of the mismatch between the
numerator and the denominator in the ``overhead rate'' calculation.
Specifically, because the numerator in the ``overhead rate''
calculation does not include excluded area overhead hours, and the
denominator in the ``overhead rate'' calculation does include the hours
attributable to excluded areas, this results in an understatement of
the amount of wage-related costs attributable to overhead that should
be allocated to the excluded areas. That is, because we had not
completely removed the amount of wage-related cost attributable to
excluded areas from the denominator, the ``overhead rate'' was lower
than it should be. A lower ``overhead rate'' has the unintended effect
of artificially raising a hospital's average hourly wage because a
lower amount of overhead attributable to excluded areas is removed from
total allowable salaries. To the extent that a hospital has a higher
``excluded rate'' (that is, they provide a significant amount of
services that are not covered under the IPPS, and therefore, have a
high percentage of employee hours related to the excluded areas), this
issue is more significant. For example, in the case of one hospital
with an ``excluded rate'' of 96 percent, under the FY 2005 calculation,
we identified (and removed) only 40 percent of the overhead wage-
related costs as being attributable to excluded areas, whereas under
the FY 2006 calculation, 93 percent of the hospital's overhead wage-
related costs has been identified as being attributable to excluded
areas, and therefore, are being removed for the FY 2006 wage index.
Clearly, in the case of this hospital which predominantly provides
services that are excluded from the IPPS, it is logical that the vast
majority of its overhead costs are attributable to excluded areas of
the hospital as well, and, therefore, these overhead costs should be
removed from the hospital's average hourly wage used to determine the
IPPS wage index.
Accordingly, in order to correct the discrepancy between the
numerator and the denominator in the overhead rate calculation, and to
correct the understatement of the excluded overhead wage-related costs,
we believe that it is more appropriate to determine the amount of
overhead wage-related costs associated with excluded areas that should
be excluded from the wage index based on the ratio of allowable costs
to allowable hours (that is, only hours related to IPPS areas of the
hospital). Specifically, we are not including the hours associated with
excluded areas in the denominator of the ``overhead rate'' calculation.
While hospitals with small excluded areas relative to their IPPS areas
should be minimally affected by the removal of the excluded area hours
from the calculation, this change will serve to lower the average
hourly wages of hospitals with relatively large excluded areas, more
closely aligning them with costs allowed under the IPPS.
We believe that, despite the absence of a lengthy discussion of the
policy in the proposed rule, the change in the overhead wage-related
cost allocation noted in the FY 2006 IPPS proposed rule (70 FR 23373)
provided hospitals with adequate notice of the change. Hospitals are
sufficiently sophisticated to understand the implications of a proposal
to exclude certain lines on the cost report from its calculations. In
addition, the Average Hourly Wage Calculator, which included the
revised overhead wage-related cost allocation, has been available on
our Web site: http://www.cms.hhs.gov/providers/hipps/ippswage.asp since
shortly after the proposed rule went on public display on April 24,
2005. The tables included with the FY 2006 proposed rule also showed
the average hourly wages and the wage indices resulting from the
proposed modification. Finally, clearly the fact that a hospital
association and other commenters provided comments on the proposal
demonstrates that hospitals had actual notice of the change. Some
commenters even computed the effect of the change on the calculation of
their wage indices for FY 2006. In addition, even if some hospitals
might object that they did not understand the change included in the FY
2006 proposed rule, we believe that the detailed steps used in
calculating the wage index are interpretive rules that are not subject
to the notice and comment rulemaking procedures of the Administrative
Procedure Act. Clearly, we do not include each of the detailed steps
and lines from the cost report in our regulations at Sec. 412.64(h),
the section of the regulations requiring CMS to adjust the ``proportion
of the Federal rate for inpatient operating costs that are attributable
to wages and labor-related costs for area differences in hospital wage
levels by a [wage index] factor.'' For these reasons, we believe that
we have provided sufficient notice of the change in the ``overhead
rate'' calculation.
Commenters are correct that some hospitals that wish to reclassify
for FY 2007 could also be affected by decreased average hourly wages.
However, we have analyzed our data, and have found that the impact of
the change is limited. Specifically, approximately 42 hospitals in 11
labor market areas are receiving a decrease of 1.0 to 5.5 percent in
their FY 2006 wage index as a result of this change in the calculation.
These labor market areas are primarily in the New England and East
North Central census regions. In addition, 10 rural hospitals and 18
urban hospitals are experiencing a decrease in their average hourly
wages of between 10 percent and 45 percent. However, the ``excluded
rates'' for these hospitals range between 74 percent up to and
including 100 percent. While we note that CMS did provide a 30-day
period after publication of the FY 2005 IPPS final rule (69 FR 49066)
allowing hospitals to reconsider their geographic reclassification
decisions, we provided this opportunity because of the number of
changes between the proposed and final rules and the apparent confusion
regarding application of the section 505 out-migration adjustment. We
do not believe a similar extension is warranted in this case. Further,
we do not agree that a 30-day window after publication of the final
rule is necessary in order to

[[Page 47376]]

allow cancellations or reinstatements of reclassifications. The FY 2006
proposed rule change was clearly reflected in the wage index tables
accompanying the proposed rule. Thus, hospitals were well aware of
their proposed average hourly wages and proposed wage indices for FY
2006. Hospitals could review these wage tables, find the proposed
average hourly wage and wage index listed for the hospital and wage
area, and on the basis of such information, determine whether they
wished to withdraw or retain a certain reclassification. Because of
such notice, there is no need to provide a subsequent 30-day period for
withdrawal or reinstatement. Further, we note that hospitals could use
the Average Hourly Wage Calculator on the CMS Web site to determine
exactly how the revised methodology affected the wage index. For the
reasons stated above, we are finalizing our proposed decision to remove
the excluded area hours on lines 8 and 8.01 from the overhead wage-
related cost allocation.

G. Computation of the FY 2006 Blended Wage Index

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 final 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).
As we proposed in the FY 2006 IPPS proposed rule, for FY 2006, we
are again adjusting 10 percent of the wage index factor for the
occupational mix. In computing the occupational mix adjustment for the
final 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.
As we did in the proposed rule, we also acknowledge the finding of
the District Court opinion in Bellevue Hospital Center v. Leavitt, No.
04-8639 (S.D.N.Y, March 2005). Given that the Government has appealed
the occupational mix portion of that decision, we believe it is
appropriate to continue with our policy of adopting the policy we
believe to be most prudent for occupational mix.
With 10 percent of the FY 2006 wage index adjusted for occupational
mix, the national average hourly wage is $28.0037 and the Puerto Rico
specific average hourly wage is $12.8055. The wage index values for 13
rural areas (27.7 percent) and 201 urban areas (52.1 percent) would
decrease as a result of

[[Page 47377]]

the adjustment. These decreases would be minimal; the largest negative
impact for a rural area would be 0.18 percent and for an urban area,
0.43 percent. Conversely, 31 rural areas (66.0 percent) and 176 urban
areas (45.6 percent) would benefit from this adjustment, with 1 urban
area increasing 2.2 percent and 1 rural area increasing 0.37 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
final FY 2006 wage index. (See Appendix A to this final rule for
further analysis of the impact of the occupational mix adjustment on
the final FY 2006 wage index.)
Comment: Most commenters supported our proposal to adjust only 10
percent of the FY 2006 wage index for occupational mix. However, one
commenter requested CMS to implement the occupational mix adjustment in
a way that ensures that the adjustment does not negatively impact his
hospital and other similar hospitals, providing no further elaboration
for his suggestion, while two other commenters opposed applying any
occupational mix adjustment at all until CMS performs a new survey. In
contrast, a few commenters representing hospitals that would benefit
from a 100 percent occupational mix adjustment to the wage index
recommended the policy that would most behoove them (that is, a full
implementation of the adjustment for the FY 2006 wage index). These
commenters supported their proposal by noting that: (1) For FY 2006,
hospitals were given an opportunity to revise or correct data
originally submitted; (2) occupational mix data from FY 2005 were
consistent with registered nurse and licensed practical nurse data from
a AHA annual survey of hospitals; and (3) Congress intended for 100
percent of the wage index to be adjusted for occupational mix beginning
October 1, 2004.
Response: We do not agree with the commenters recommending
elimination of the occupational mix adjustment. As we stated in the
proposed rule, given the FY 2005 and FY 2006 wage indices were based on
the first year of survey data, as well as other stated considerations
(see 70 FR 23375), we found survey results sufficiently robust to
support an adjustment to 10 percent of the wage index, but did not
believe it prudent to adjust the entire wage index by occupational mix.
We refer readers to the proposed rule for a full discussion of our
rationale. We continue to believe that the data are sufficient to
support applying the occupational mix to 10 percent of the wage index.
Moreover, we believe that by implementing the wage index in this
manner, we are carrying out the Congressional requirement to begin
applying an occupational mix to the wage index by October 1, 2004.
We do not agree with commenters that stated that the correction of
data permitted for FY 2006 is sufficient to allow for a 100 percent
adjustment in FY 2006. While hospitals were permitted to correct their
data for FY 2006, only 20 out of the 3,541 hospitals did so. Further,
the fact that hospitals were permitted to submit corrected data does
not alleviate concerns that (a) the data continued to be derived from
the first year of an occupational mix survey; or (b) that CMS had no
historical baseline data for developing a robust audit program for such
data. Given such concerns, we also believe it would be neither
equitable nor appropriate to adjust 100 percent of the wage index when
the occupational mix benefits hospitals, but 10 percent of the wage
index when it does not. Instead, we continue to believe that the
proposed, more moderate occupational mix adjustment is the most
equitable and appropriate approach. As such, the FY 2006 wage index in
this final rule is a blend of 10 percent of a wage index adjusted for
occupational mix and 90 percent of an unadjusted wage index.
Comment: One commenter expressed concern regarding CMS' statement
in the proposed rule that ``hospitals might be accounting for shortages
of physicians by hiring more registered nurses'' (70 FR 23375). The
commenter suggested that the statement is unsupported and implies a
``practice of downgrading care, especially since it uses 'registered
nurses', not even nurse practitioners.'' The commenter requested that
we delete the statement from the final rule.
Response: We did not intend to imply that hospitals that have
increased their reliance on registered nurses provide downgraded care.
Nursing schools and nursing associations acknowledge a significant
increase in the number of registered nurses who are pursuing or have
achieved advanced practice degrees as nurse practitioners, clinical
nurse specialists, nurse midwives, and certified registered nurse
anesthetists. Our statement merely acknowledged that hiring advanced
practice registered nurses helps to mitigate problems with physician
shortages by increasing the number of staff who are available to
provide primary care, and that such hiring practices may have
contributed to the higher than expected occupational mix reported by
many rural hospitals.
The wage index values for FY 2006 (except those for hospitals
receiving wage index adjustments under section 505 of Pub. L. 108-173)
are shown in Tables 4A, 4B, 4C, and 4F in the Addendum to this final
rule.
Tables 3A and 3B in the Addendum to this final rule list the 3-year
average hourly wage for each labor market area before the redesignation
of hospitals, based on FYs 2004, 2005, 2006 cost reporting periods.
Table 3A lists these data for urban areas and Table 3B lists these data
for rural areas. In addition, Table 2 in the Addendum to this final
rule includes the adjusted average hourly wage for each hospital from
the FY 2000 and FY 2001 cost reporting periods, as well as the FY 2002
period used to calculate the FY 2006 wage index. The 3-year averages
are calculated by dividing the sum of the dollars (adjusted to a common
reporting period using the method described previously) across all 3
years, by the sum of the hours. If a hospital is missing data for any
of the previous years, its average hourly wage for the 3-year period is
calculated based on the data available during that period.
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 final rule
include the occupational mix adjustment.

Other Public Comments

Comment: One commenter stated that an ongoing concern is that the
hospital wage index is applied to many provider types for which wage
data are excluded from the wage index calculation. The commenter
recommended that CMS separate wage indices for SNFs, IRFs, and IPFs by
modifying the way the wage index data are reported on the Medicare cost
report.
Response: We appreciate the comment, but note that the subject-
matter of this final rule is the IPPS system and not the PPSs governing
non-IPPS entities such as SNFs, IRFs, and IPFs. Therefore, we are not
responding to this comment at this time. We suggest that the commenter
raise his or her concerns as part of the rulemaking process for
updating the respective facility's PPS.

H. Revisions to the Wage Index Based on Hospital Redesignation

1. General
Under section 1886(d)(10) of the Act, the Medicare Geographic
Classification Review Board (MGCRB) considers applications by hospitals
for geographic reclassification for purposes of payment under the IPPS.
Hospitals must apply to

[[Page 47378]]

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 and 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 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,\9\ the wage index values were determined by
considering the following:
---------------------------------------------------------------------------

\9\ 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. For all-urban
States, CMS established an imputed floor (69 FR 49109). 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. 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 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'

[[Page 47379]]

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 are 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
section 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, in the
FY 2006 IPPS proposed rule, we proposed 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 are included in
the rural area's wage index, if including the urban hospital's data
increase the wage index of the rural area. Otherwise, the wage data are
excluded. Similarly, we proposed 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 are 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). In
the FY 2006 IPPS proposed rule, we stated that we believe this proposal
provides uniformity in the way geographic areas are treated under all
types of reclassifications. In addition, we further stated that our
proposal promotes predictability by alleviating fluctuations in the
wage indexes due to a section 401 redesignation.
No commenters objected to extending hold harmless protection to
urban hospitals that are redesignated as rural under section 401.
Therefore, in this final rule, we are finalizing the policy to extend
hold harmless protection to urban hospitals that are redesignated as
rural under section 401.
We are including in the Addendum to this final rule Table 9C, which
shows hospitals redesignated under section 1886(d)(8)(E) of the Act.
4. FY 2006 MGCRB Reclassifications
The MGCRB's review of FY 2006 reclassification requests resulted in
299 hospitals approved for wage index reclassifications 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, 631 hospitals are 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).
Under Sec. 412.273, hospitals that have been reclassified by the
MGCRB are permitted to withdraw their applications within 45 days of
the publication of a 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 2005 must be received by
the MGCRB within 45 days of the publication of the proposed rule. If a
hospital elects to withdraw its wage index application after the MGCRB
has issued its decision, but prior to the above date, it may later
cancel its withdrawal in a subsequent year and request the MGCRB to
reinstate its wage index reclassification for the remaining fiscal
year(s) of the 3-year period (Sec. 412.273(b)(2)(i)). The request to
cancel a prior withdrawal must be in writing to the MGCRB no later than
the deadline for submitting reclassification applications for the
following fiscal year (Sec. 412.273(d)). For further information about
withdrawing, terminating, or canceling a previous withdrawal or
termination of a 3-year reclassification for wage index purposes, we
refer the reader to Sec. 412.273, as well as the August 1, 2002, IPPS
final rule (67 FR 50065) and the August 1, 2001 IPPS final rule (66 FR
39887).
Changes to the wage index that result from withdrawals of requests
for reclassification, wage index corrections, appeals, and the
Administrator's review process have been incorporated into the wage
index values published in this final rule. These changes may affect not
only the wage index value for specific geographic areas, but also the
wage index value redesignated hospitals receive; that is, whether they
receive the wage index that includes the data for both the hospitals
already in the area and the redesignated hospitals. Further, the wage
index value for the area from which the hospitals are redesignated may
be affected.
Applications for FY 2007 reclassifications are due to the MGCRB by
September 1, 2005. We note that this is also the deadline for canceling
a previous wage index reclassification withdrawal or termination under
Sec. 412.273(d). Applications and other information about MGCRB
reclassifications may be obtained, beginning in Mid-July 2005, via the
CMS Internet Web site at: http://cms.hhs.gov/providers/prrb/mgcinfo.asp, or by calling the MGCRB at (410) 786-1174. The mailing
address of the MGCRB is: 2520 Lord Baltimore Drive, Suite L, Baltimore,
MD 21244-2670.
5. 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

[[Page 47380]]

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 the
redesignation areas for two counties that qualified for redesignation
under section 1886(d)(8)(B) of the Act. The list of rural counties
qualifying to be urban in that Chart 6 incorrectly listed the
redesignation CBSAs for 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 using for FY 2006. 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.
Comment: Several commenters urged CMS to permit hospitals located
in counties redesignated under section 1886(d)(8)(B) of the Act to
waive or reject the redesignation if the redesignation proves to be
detrimental or otherwise undesirable to the qualifying hospital. They
cited examples in which hospitals with special designations, such as
rural referral centers, SCHs, MDHs, and CAHs, where their status is
dependent on being located in a rural area, lost their special
designation when they were reclassified to an urban area under section
1886(d)(8)(B) of the Act.
Response: We considered this comment and are responding to it only
insofar as it relates to section 1886(d) hospitals, such as rural
referral centers, SCHs, and MDHs, located in Lugar counties. We refer
readers to the section on CAHs in this final rule for information on
how CMS treats CAHs in Lugar counties. The statute specifically states
that ``(f)or purposes of this subsection, the Secretary shall treat a
hospital located in a rural county adjacent to one or more urban areas
as being located in (a) urban metropolitan statistical area * * *.''
Therefore, all section 1886(d) hospitals located in Lugar counties are
deemed urban and such classification cannot be waived, except if a
hospital is eligible for an out-migration adjustment. In order for a
section 1886(d) hospital to retain its special designation when the
area in which it is located is redesignated from rural to urban, a
hospital must apply for reclassification under Sec. 412.103(a). We
encourage a hospital seeking reclassification under this section to
submit a complete application in writing to its CMS Regional Office.

Rural Counties Redesignated as Urban Under Section 1886(d)(8)(B) of the Act
[Based on CBSAs and Census 2000 Data]
----------------------------------------------------------------------------------------------------------------
Rural county CBSA
----------------------------------------------------------------------------------------------------------------
Cherokee, AL........................ Rome, GA.
Macon, AL........................... Auburn-Opelika, AL.
Talladega, AL....................... Anniston-Oxford, AL.
Hot Springs, AR..................... Hot Springs, AR.
Windham, CT......................... Hartford-West Hartford-East Hartford, CT.
Bradford, FL........................ Gainesville, FL.
Flagler, FL......................... Deltona-Daytona Beach-Ormond Beach, FL.
Hendry, FL.......................... West Palm Beach-Boca Raton-Boynton, FL.
Levy, FL............................ Gainesville, FL.
Walton, FL.......................... Fort Walton Beach-Crestview-Destin, FL.
Banks, GA........................... Gainesville, GA.
Chattooga, GA....................... Chattanooga, TN-GA.
Jackson, GA......................... Atlanta-Sandy Springs-Marietta, GA.
Lumpkin, GA......................... Atlanta-Sandy Springs-Marietta, GA.
Morgan, GA.......................... Atlanta-Sandy Springs-Marietta, GA.
Peach, GA........................... Macon, GA.
Polk, GA............................ Atlanta-Sandy Springs-Marietta, GA.
Talbot, GA.......................... Columbus, GA-AL.
Bingham, ID......................... Idaho Falls, ID.
Christian, IL....................... Springfield, IL.
DeWitt, IL.......................... Bloomington-Normal, IL.
Iroquois, IL........................ Kankakee-Bradley, IL.
Logan, IL........................... Springfield, IL.
Mason, IL........................... Peoria, IL.
Ogle, IL............................ Rockford, IL.
Clinton, IN......................... Lafayette, IN.
Henry, IN........................... Indianapolis, IN.
Spencer, IN......................... Evansville, IN-KY.

[[Page 47381]]

Starke, IN.......................... Gary, IN.
Warren, IN.......................... Lafayette, IN.
Boone, IA........................... Ames, IA.
Buchanan, IA........................ Waterloo-Cedar Falls, IA.
Cedar, IA........................... Iowa City, IA.
Allen, KY........................... Bowling Green, KY.
Assumption Parish, LA............... Baton Rouge, LA.
St. James Parish, LA................ Baton Rouge, LA.
Allegan, MI......................... Holland-Grand Haven, MI.
Montcalm, MI........................ Grand Rapids-Wyoming, MI.
Oceana, MI.......................... Muskegon-Norton Shores, MI.
Shiawassee, MI...................... Lansing-East Lansing, MI.
Tuscola, MI......................... Saginaw-Saginaw Township North, MI.
Fillmore, MN........................ Rochester, MN.
Dade, MO............................ Springfield, MO.
Pearl River, MS..................... Gulfport-Biloxi, MS.
Caswell, NC......................... Burlington, NC.
Granville, NC....................... Durham, NC.
Harnett, NC......................... Raleigh-Cary, NC.
Lincoln, NC......................... Charlotte-Gastonia-Concord, NC-SC.
Polk, NC............................ Spartanburg, NC.
Los Alamos, NM...................... Santa Fe, NM.
Lyon, NV............................ Carson City, NV.
Cayuga, NY.......................... Syracuse, NY.
Columbia, NY........................ Albany-Schenectady-Troy, NY.
Genesee, NY......................... Rochester, NY.
Greene, NY.......................... Albany-Schenectady-Troy, NY.
Schuyler, NY........................ Ithaca, NY.
Sullivan, NY........................ Poughkeepsie-Newburgh-Middletown, NY.
Wyoming, NY......................... Buffalo-Niagara Falls, NY.
Ashtabula, OH....................... Cleveland-Elyria-Mentor, OH.
Champaign, OH....................... Springfield, OH.
Columbiana, OH...................... Youngstown-Warren-Boardman, OH-PA.
Cotton, OK.......................... Lawton, OK.
Linn, OR............................ Corvallis, OR.
Adams, PA........................... York-Hanover, PA.
Clinton, PA......................... Williamsport, PA.
Greene, PA.......................... Pittsburgh, PA.
Monroe, PA.......................... Allentown-Bethlehem-Easton, PA-NJ.
Schuylkill, PA...................... Reading, PA.
Susquehanna, PA..................... Binghamton, NY.
Clarendon, SC....................... Sumter, SC.
Lee, SC............................. Sumter, SC.
Oconee, SC.......................... Greenville, SC.
Union, SC........................... Spartanburg, SC.
Meigs, TN........................... Cleveland, TN.
Bosque, TX.......................... Waco, TX.
Falls, TX........................... Waco, TX.
Fannin, TX.......................... Dallas-Plano-Irving, TX.
Grimes, TX.......................... College Station-Bryan, TX.
Harrison, TX........................ Longview, TX.
Henderson, TX....................... Dallas-Plano-Irving, TX.
Milam, TX........................... Austin-Round Rock, TX.
Van Zandt, TX....................... Dallas-Plano-Irving, TX.
Willacy, TX......................... Brownsville-Harlingen, TX.
Buckingham, VA...................... Charlottesville, VA.
Floyd, VA........................... Blacksburg-Christiansburg-Radford, VA.
Middlesex, VA....................... Virginia Beach-Norfolk-Newport News, VA.
Page, VA............................ Harrisonburg, VA.
Shenandoah, VA...................... Winchester, VA-WV.
Island, WA.......................... Seattle-Bellevue-Everett, WA.
Mason, WA........................... Olympia, WA.
Wahkiakum, WA....................... Longview, WA.
Jackson, WV......................... Charleston, WV.
Roane, WV........................... Charleston, WV.
Green, WI........................... Madison, WI.
Green Lake, WI...................... Fond du Lac, WI.
Jefferson, WI....................... Milwaukee-Waukesha-West Allis, WI.
Walworth, WI........................ Milwaukee-Waukesha-West Allis, WI.
----------------------------------------------------------------------------------------------------------------

[[Page 47382]]

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 were permitted to compare the
reclassified wage index for the labor market area in Table 4C in the
Addendum of the May 4, 2005 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 were
provided the opportunity to withdraw from an MGCRB reclassification
within 45 days of the publication of the FY 2006 IPPS proposed rule
(May 4, 2005).
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.
Comment: Some commenters indicated that hospitals currently
receiving a section 508 reclassification are eligible to reclassify to
that same area under the standard reclassification process as a result
of the new labor market definitions that we adopted for FY 2005. The
commenters pointed out that the governing regulations indicate that
``if a hospital is already reclassified to a given geographic area for
wage index purposes for a 3-year period, and submits an application to
the same area for either the second or third year of the 3-year period,
that application will not be approved.'' These commenters expressed
concern that the MGCRB will deny these hospitals reclassification for
FY 2007 if there is no change in the regulations to address this issue.
Response: We appreciate the commenters' interest in this matter.
Hospitals that indicate in their MGCRB applications that they agree to
waive their section 508 reclassification for the first 6 months of FY
2007 if they are granted a 3-year reclassification under the
traditional MGCRB process will not be subject to the regulation cited
above. Thus, in applying for a 3-year MGCRB reclassification beginning
in FY 2007, hospitals that are already reclassified to the same area
under section 508 should indicate in their MGCRB reclassification
requests that if they receive the MGCRB reclassification, they will
forfeit the section 508 reclassification for the first 6 months of FY
2007.
Comment: Many commenters expressed concern regarding the timing
overlaps between section 508 of Pub. L. 108-173 and the FY 2007
reclassifications. The commenters pointed out that section 508 of Pub.
L. 108-173 required the Secretary to develop a one-time special
reclassification procedure that allowed hospitals meeting specified
criteria to be reclassified from April 1, 2004, through March 31, 2007.
They further stated that some hospitals that qualified for
reclassification under section 508 may qualify for geographic
reclassification under one of the opportunities available under the
regulations in 42 CFR part 412, subpart L. Because pending
reclassifications will expire in the middle of a Federal fiscal year,
the commenters requested that CMS clarify when the hospitals should
apply for reclassification under an opportunity under subpart L.
Commenters stated that, unless CMS establishes an accommodation for
section 508 hospitals, hospitals will be confronted with a difficult
dilemma: Forfeiting 6 months of section 508 reclassification to be able
to reclassify for FY 2007; or postponing reclassification until FY 2008
and being without reclassification for the 6 months between April 1 and
September 30, 2007. The commenters believed that both of these options
would carry significant financial consequences for hospitals. The
commenters urged CMS to implement a solution that does not require
hospitals to make such a difficult choice, and would provide them with
the full benefits of the section 508 reclassification.
Response: We appreciate the commenters' suggestions and their
interest in this matter. Under 1886(d)(10)(D)(v) of the Act, CMS has
the authority to ``establish procedures'' under which a hospital may
elect to terminate a reclassification before the end of a 3-year
period. Based on comments and on a careful review of the statute, we
have decided to exercise this authority to establish a procedural rule
for section 508 hospitals to retain their section 508 reclassification
through its expiration on March 31, 2007 and reclassify under a subpart
L opportunity for the second half of FY 2007. The following procedural
rules will apply for section 508 hospitals that wish to reclassify for
the second half of FY 2007:
For section 508 hospitals applying for individual reclassification
under 42 CFR 412.230--
(1) Hospitals must apply for reclassification through the MGCRB by
the September 1, 2005 deadline.
(2) Section 508 hospitals that are approved by the MGCRB for
reclassification will have 45 days from the date the FY 2007 IPPS
proposed rule is published to cancel their section 1886(d)(10)
reclassifications for either the first 6 months of FY 2007 or for the
entire fiscal year. Hospitals should note that if they fail to cancel
their section 1886(d)(10) reclassification by the deadline, they will
not receive their section 508 wage adjustment in FY 2007. To further
clarify--
Hospitals that cancel their section 1886(d)(10)
reclassification for the first 6 months receive their section 508
reclassifications for October 2006 through March 2007 and their section
1886(d)(10) reclassifications for April through September 2007.
Hospitals that cancel their section 1886(d)(10)
reclassification for the entire year will receive their section 508
reclassification for October 2006 through March 2007 and their home
area wage index for April through September 2007.
Hospitals that do not cancel their section 1886(d)(10)
reclassifications will receive their section 1886(d)(10)
reclassification, not their section 508 reclassification, for the
entire fiscal year.
Hospital groups that include a section 508 hospital would also be
permitted to submit section 1886(d)(10) reclassification applications
by the September 1, 2005 deadline. However, in order for a group
reclassification to be approved, either of the following conditions
would need to be met:
(1) The section 508 hospital that is part of the group must waive
its section 508 reclassification for the first half of FY 2007. This is
necessary because the regulations at Sec. Sec. 412.232 and 412.234
state that all hospitals in a county must apply for reclassification as
a group. The hospitals either agree to receive the same
reclassification or they fail to qualify as a group. The Administrator
upheld this policy in an MGCRB appeal for FY 2006.
(2) Each member of the group agrees in writing, at the time the
application is submitted September 1, 2005, that they cancel the group
reclassification if granted for the first 6 months of FY 2007. The
section 1886(d)(10) reclassification will be effective only

[[Page 47383]]

April through September 2007. Under this scenario, the section 508
hospital receives its section 508 reclassification from October 2006
through March 2007 and the remainder of the group receives the home
wage index for that time period. For April through September 2007, the
section 508 hospital and the remainder of the group receive the group
reclassification. The group will have the opportunity to cancel the
April through September 2007 group reclassification within 45 days of
publication of the proposed rule.
We would apply a similar rule for purposes of the out-migration
adjustment. The statute states that a hospital cannot receive an out-
migration adjustment if it is simultaneously reclassified under section
1886(d)(10) of the Act. Therefore, hospitals that are not reclassified
during any part of FY 2007 will, by default, receive an out-migration
adjustment during that time period.
We show the reclassifications effective under the one-time appeal
process in Table 9B in the Addendum to this final rule.

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

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 under section 1886(d)(3)(E) or section
1886(d)(8)(D) of the Act.
Comment: One commenter proposed that CMS allow hospitals that
reclassify and receive a diluted wage index to receive the out-
migration adjustment provided it does not exceed the actual wage index
for the area to which they are reclassified.
Response: The statute specifically states that hospitals that
receive an out-migration adjustment are ineligible for reclassification
under section 1886(d)(8) or section 1886(d)(10) of the Act.
Hospitals located in counties that qualify for the wage index
adjustment will receive an increase in the wage index that is equal to
the average of the differences between the wage indices of the labor
market area(s) with higher wage indices 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 indices in making these calculations.
Hospitals located in the qualifying counties identified in Table 4J
in the Addendum to this final 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 will
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 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 employed in any higher wage index area.
The adjustments calculated for qualifying hospitals are listed in
Table 4J in the Addendum to this final rule. These adjustments are
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 are 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 sections 1886(d)(8) or (d)(10) of the Act, or
under section 508 of Pub. L. 108-173, unless they waive such out-
migration adjustment. As announced in the FY 2005 final rule as well as
the proposed rule for FY 2006, hospitals redesignated under section
1886(d)(8) of the Act or reclassified under section 1886(d)(10) of the
Act or under section 508 of Pub. L. 108-173 were deemed to have chosen
to retain their redesignation or reclassification, unless they
explicitly notified CMS that they elected to receive the out-migration
adjustment instead within 45 days from the publication of the FY 2006
IPPS proposed rule (May 4, 2005). Under Sec. 412.273, hospitals that
have been reclassified by the MGCRB were permitted to terminate
existing 3-year reclassifications within 45 days of the May 4, 2005
proposed rule. Hospitals that are eligible to receive the out-migration
wage index adjustment and that withdraw their application for
reclassification automatically receive the wage index adjustment listed
in Table 4J in the Addendum to this final rule. Requests for withdrawal
of an application for reclassification or termination of an existing 3-
year reclassification will be effective in FY 2006 and had to have been
received by the MGCRB within 45 days of the publication of the FY 2006
IPPS proposed rule. Requests to waive section 1886(d)(8) redesignations
for FY 2006 had to have been received by CMS within 45 days of the
publication of the FY 2006 IPPS proposed rule. In addition, hospitals
that wished to retain their redesignation/reclassification under
section 1886(d)(8), section 1886(d)(10), or section 508 (instead of
receiving the out-migration adjustment) for FY 2006 did not need to
submit a formal request to CMS; they automatically retain their
redesignation/reclassification status for FY 2006.
Comment: Commenters expressed opposition to and support of CMS'
interpretation of the law that hospitals will receive the same out-
migration adjustment in each of the 3 years of eligibility for the
adjustment. One

[[Page 47384]]

commenter recommended that CMS maintain its policy to keep the out-
migration adjustment unchanged to minimize uncertainties and
instability in Medicare reimbursement to hospitals. Other commenters
recommended that CMS revise its policy so that the out-migration
adjustment will be recalculated each year based on updated wage data
and the new wage indices.
Response: We appreciate the comments we received regarding this
issue. The governing statute specifically states that the wage index
increase ``shall be effective for a period of 3 fiscal years.'' We have
interpreted this to mean that the adjustment shall be identical for 3
years. If we were to recalculate the out-migration adjustment each year
based on updated wage data as suggested, counties could potentially be
deemed ineligible for the wage index adjustment if the average hourly
wage for all hospitals in the labor market area exceeded the average
hourly wages for all hospitals in the county. Therefore, we have
elected to maintain our policy to keep the out-migration adjustment
associated with a particular county unchanged.
Comment: One commenter requested that we clarify the removal of
several providers from Table 4J between the May 4, 2005 Federal
Register publication and the revised table posted on the CMS Web site
on June 1, 2005.
Response: There were some errors for CBSAs and imputed rural floors
and these errors had an effect on the out-migration calculations shown
in Table 4J of the proposed rule. We posted the corrected adjustments
on the CMS Web site on June 1, 2005. Hospitals were also notified of
the corrected out-migration adjustments via the Listserv and a Hospital
Open Door Forum on June 2, 2005.
Comment: Commenters requested that CMS make available the hospital
commuting data used to compute the out-migration adjustment.
Response: We plan to make the data used for determining the
qualifying counties and the out-migration adjustment available after
the publication of this final rule on the CMS Web site at: http://www.cms.gov.
Comment: Commenters requested that CMS implement a policy similar
to the policy established for FY 2005 that allows hospitals to withdraw
or reinstate their geographic applications within 30 days of the date
that the final rule is published. Several commenters believed there is
still a likelihood that revisions made between the proposed and final
rules may affect a hospital's choice of whether to accept the out-
migration or a reclassification.
Response: First, we note that cancellation and reinstatement rules
for geographic reclassifications are procedural rules that are not
subject to notice and comment rulemaking. Second, we note that it has
been our longstanding policy that our procedural rules on withdrawals
or terminations of reclassifications require such terminations and
withdrawals be made within 45 days of the proposed rule (Sec.
412.273). However, FY 2005 was an exceptional circumstance due to the
extensive changes to the wage index as a result of our adoption of the
new labor market areas. We noted that this was a limited circumstance,
and we did not expect to extend the withdrawal date beyond 45 days
after the proposed rule in future years. We do not believe the
exceptional circumstance that existed for FY 2005 exists for FY 2006,
given the changes to the labor market areas have been adopted.
Therefore, we are continuing with our longstanding policy that
terminations of reclassifications are required to be made within 45
days of the proposed rule. As we have explained in previous preamble
discussions (see, for example, 56 FR 43241, August 30, 1991), the 45-
day deadline provides a reasonable time to take withdrawals or
terminations into account in developing the final wage index and
prospective payment rates.

J. Requests for Wage Index Data Corrections

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 transmitted 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
disagreed with the fiscal intermediary's policy interpretations was
April 22, 2005.
Hospitals were also instructed to examine Table 2 in the Addendum
to

[[Page 47385]]

the proposed rule. Table 2 of the proposed rule contained 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 noted that the hospital average
hourly wages shown in Table 2 only reflected changes made to a
hospital's data and transmitted to CMS by February 23, 2005.
The final wage data public use file was released in early May 2005
to hospital associations and the public on the Internet at http:/
www.cms.hhs.gov/providers/hipps/ippswage.asp. The May 2005 public use
file was made available solely for the limited purpose of identifying
any potential errors made by CMS or the fiscal intermediary in the
entry of the final wage data that result from the correction process
described above (revisions submitted to CMS by the fiscal
intermediaries by April 15, 2005). If, after reviewing the May 2005
final file, a hospital believed 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 was provided the opportunity to send a letter to
both its fiscal intermediary and CMS that outlined why the hospital
believed an error exists and to provide all supporting information,
including relevant dates (for example, when it first became aware of
the error). These requests had to be received by CMS and the fiscal
intermediaries by no later than June 10, 2005. The fiscal intermediary
reviewed requests upon receipt and contacted CMS immediately to discuss
its findings.
After the release of the May 2005 wage index data file, changes to
the hospital wage data were only 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 accepted 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) have been
incorporated into the final wage index of this final rule and are
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 did 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) and Palisades General Hospital v. Thompson,
No. 99-1230 (D.D.C. 2003.) We refer the reader also to the FY 2000
final rule (64 FR 41513) for a discussion of the parameters for
appealing to the PRRB for wage index data corrections.
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 had access to the final wage index data by
early May 2005, they had the opportunity to detect any data entry or
tabulation errors made by the fiscal intermediary or CMS before the
development and publication of the final FY 2006 wage index in this
final rule, and the implementation of the FY 2006 wage index on October
1, 2005. If hospitals availed 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 Web site 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.
In the FY 2006 IPPS proposed rule, we proposed 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 proposed 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 made this proposed revision to Sec.
412.64(k)(2) because we believe that it 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

[[Page 47386]]

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, we indicated that the proposed provision would
not be available to a hospital seeking to revise another 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 making 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 final
retroactive correction will 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 will still apply in those
instances where a judicial decision reverses a CMS denial of a
hospital's wage data revision request.
In addition, in the FY 2006 IPPS proposed rule, we proposed 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 proposed 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.''
Comment: Several commenters supported CMS' proposal to correct the
FY 2005 wage index retroactive to October 1, 2004, using the authority
provided under section 903(a)(1) of Pub. L. 108-173 on a one-time only
basis for the limited circumstance where a hospital meets the first two
criteria specified in the proposal. However, the commenters requested
that CMS amend the proposed policy to delete the third criterion that
CMS must have agreed before October 1 that the fiscal intermediary or
CMS made an error in tabulating the hospital's wage data. The
commenters were concerned that if CMS could not notify hospitals before
October 1 that the wage data would be corrected, the hospital would not
be eligible for the retroactive correction to the FY 2005 wage index.
Response: We believe it is important to retain the requirement that
CMS must have notified the hospital before October 1 that an error was
made in calculating the wage index for an area for the correction to be
made retroactively to October 1. The October 1 date is relevant because
it is the first day of the new fiscal year. Once the fiscal year
begins, we believe it is important to only make changes to the wage
index prospectively, as has been CMS' longstanding policy as stated in
the FY 1984 IPPS final rule (49 FR 258, January 3, 1984), unless it is
clear that CMS determined that either it or the fiscal intermediary
made an error prior to the beginning of the fiscal year and intended to
pay hospitals using a different wage index. With respect to the
specific requirements for making FY 2005 wage index corrections
retroactive to October 1, 2004, we will accept letters, e-mails, and
other written evidence from hospitals demonstrating that, prior to
October 1, 2004, CMS agreed that an error was made to the wage index
and intended to pay the hospital at the corrected wage index effective
October 1, 2004.
Comment: Two commenters urged CMS to retroactively apply the policy
that we are finalizing in this final rule to extend hold harmless
protections to urban hospitals that are redesignated as rural under
section 401 to the FY 2005 IPPS wage index.
Response: Retroactive wage corrections are intended to correct
errors made in a previous year. In this case, we made a change to the
regulations prospectively. Because the regulation change is unrelated
to errors that were not corrected, we do not believe a retroactive wage
index correction is warranted.
Comment: One commenter, a group of hospitals within a single CBSA,
believed that the proposed retroactive wage index corrections should be
expanded to include geographic classification errors. The commenter
indicated that CMS made an error in tabulating the FY 2005 wage index
data for the CBSA when it incorrectly categorized one provider as
belonging to another CBSA. The commenter added that the geographic
classification error had the effect of lowering the wage index of the
CBSA and inflating the wage index for the other CBSA. The commenter
indicated that CMS was given notice of the error prior to October 1,
2004, but the correction was changed prospectively effective January 1,
2005, rather than retrospectively.
Response: We agree that both geographic classification and
reclassification technical errors should be corrected retroactive to
the beginning of the fiscal year and that the special rule for FY 2005
should apply if the circumstances are the same as those that we are
applying to the wage index. This would apply in cases where the wage
index of an area has been miscalculated because of the improper
assignment of a particular hospital to a labor market area.
Beginning with FY 2006, a hospital could receive a retroactive
adjustment to its wage index for a geographic classification or
reclassification error if the circumstances included in Sec.
412.64(k)(2) exist. Generally stated, the following circumstances must
be present.
For classification/reclassification errors made during the proposed
rule:
(1) CMS made a technical error in assigning the hospital to a
geographic labor market area. (The error made must be truly technical
in nature and could not include any disputes about policy or cases
where a hospital disagrees with

[[Page 47387]]

the MGCRB or CMS' reclassification decisions.)
(2) The hospital notifies CMS of the technical error using the
formal comment process and during the comment period on the proposed
rule. (This period is different from the period for requesting wage
index corrections, as wage index data are posted on the CMS Web site
and must follow a certain schedule set by CMS--for example, for FY
2006, tabulation errors were required to have been identified by June
10, 2005.)
(3) The error was not corrected in the final rule.
(4) The hospital again notifies CMS of the geographic assignment
error, via written correspondence or e-mail following the publication
of the final rule, and CMS agrees prior to October 1 that an error was
made.
For classification/reclassification errors made for the first time
during the final rule:
(1) CMS made a technical error in the final rule in assigning the
hospital to a geographic labor market area; and
(2) The hospital notifies CMS of the error via written
correspondence or e-mail, following the publication of the final rule,
and CMS agrees prior to October 1 that an error was made.
In addition, we also agree that geographic classification or
reclassification errors that resulted in an incorrect wage index for FY
2005 should also be corrected 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. Again, we believe it would not be in the public
interest for us to pay hospitals using an incorrect wage index when the
geographic classification/reclassification error was brought to our
attention and we agreed prior to the beginning of FY 2005 that the
error should be corrected. For FY 2005, we will make corrections to the
wage index for geographic classification errors retroactive to October
1, 2004 in the following circumstances:
For classification/reclassification errors made during the FY 2005
IPPS proposed rule:
(1) CMS made a technical error in the tables of the FY 2005
proposed rule (69 FR 28752, May 18, 2004) in assigning a hospital to a
geographic labor market area;
(2) The hospital notified CMS of the error, via written
correspondence or e-mail during the comment period on the proposed rule
and using the procedures for submitting formal comments;
(3) The error was not corrected in the tables accompanying the FY
2005 final rule (69 FR 49690); and
(4) The hospital notified CMS of the error via written
correspondence or e-mail following the publication of the final rule,
CMS agreed prior to October 1, 2004, that an error was made, CMS agreed
that the error 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 such fiscal year.
For geographic assignment errors made for the first time during the
FY 2005 final rule:
(1) CMS made a technical error in the tables of the FY 2005 final
rule (69 FR 49690) in assigning a hospital to a geographic labor market
area; and
(2) The hospital notified CMS of the error via written
correspondence or e-mail following the publication of the final rule,
CMS agreed prior to October 1, 2004, that an error was made, CMS agreed
that the error 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 such fiscal year.

IV. Rebasing and Revision of the Hospital Market Baskets

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 final rule, we are shifting 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 final 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

[[Page 47388]]

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 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 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.''

Chart 1.--Major Cost Categories Found in Medicare Cost Reports
------------------------------------------------------------------------
FY 1997-based FY 2002-based
Major cost categories market basket market basket
------------------------------------------------------------------------
Wages and salaries...................... 48.965 45.590
Employee benefits....................... 10.597 11.189
Contract labor.......................... 2.094 3.214
Professional Liability Insurance 0.840 1.589
(Malpractice)..........................
Pharmaceuticals......................... 5.416 5.855
Blood and blood products................ 0.875 1.082
All other............................... 31.213 31.481
------------------------------------------------------------------------

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 sources are scheduled for publication every 5
years, but may 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, as we proposed in the FY 2006 IPPS proposed rule,
we use the 1997 Benchmark I-O data in the 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 rebased hospital
market basket, it was 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

[[Page 47389]]

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 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.

Chart 2.--FY 2002-Based PPS Hospital Market Basket Cost Categories, Weights, and Proxies With FY 1997-Based
Market Basket Used for Comparison
----------------------------------------------------------------------------------------------------------------
Rebased FY
FY 1997-Based 2002-based
Expense categories hospital hospital Rebased FY 2002-based hospital
market basket market basket market basket price proxies
weights weights
----------------------------------------------------------------------------------------------------------------
1. Compensation............................... 61.656 59.993 ................................
A. Wages and Salaries*.................... 50.686 48.171 ECI--Wages and Salaries,
Civilian Hospital Workers.
B. Employee Benefits*..................... 10.970 11.822 ECI--Benefits, Civilian Hospital
Workers.
2. Professional Fees*......................... 5.401 5.510 ECI--Compensation for
Professional, Specialty &
Technical Workers.
3. Utilities.................................. 1.353 1.251 ................................
A. Fuel, Oil, and Gasoline................ 0.284 0.206 PPI Refined Petroleum Products.
B. Electricity............................ 0.833 0.669 PPI Commercial Electric Power.
C. Water and Sewerage..................... 0.236 0.376 CPI-U Water & Sewerage
Maintenance.
4. Professional Liability Insurance........... 0.840 1.589 CMS Professional Liability
Insurance Premium Index.
5. All Other.................................. 30.749 31.657 ................................
A. All Other Products..................... 19.537 20.336 ................................
(1) Pharmaceuticals................... 5.416 5.855 PPI Prescription Drugs.
(2) Direct Purchase Food.............. 1.370 1.664 PPI Processed Foods & Feeds.
(3) Contract Service Food............. 1.274 1.180 CPI-U Food Away From Home.
(4) Chemicals......................... 2.604 2.096 PPI Industrial Chemicals.
(5) Blood and Blood Products**........ 0.875 .............. ................................
(6) Medical Instruments............... 2.192 1.932 PPI Medical Instruments &
Equipment.
(7) Photographic Supplies............. 0.204 0.183 PPI Photographic Supplies.
(8) Rubber and Plastics............... 1.668 2.004 PPI Rubber & Plastic Products.
(9) Paper Products.................... 1.355 1.905 PPI Converted Paper & Paperboard
Products.
(10) Apparel.......................... 0.583 0.394 PPI Apparel.
(11) Machinery and Equipment.......... 1.040 0.565 PPI Machinery & Equipment.
(12) Miscellaneous Products**......... 0.956 2.558 PPI Finished Goods less Food and
Energy.
B. All Other Services..................... 11.212 11.321 ................................
(1) Telephone Services................ 0.398 0.458 CPI-U Telephone Services.
(2) Postage........................... 0.857 1.300 CPI-U Postage.
(3) All Other: Labor Intensive*....... 5.438 4.228 ECI--Compensation for Private
Service Occupations.
(4) All Other: Non-Labor Intensive.... 4.519 5.335 CPI-U All Items.
--------------------------------
Total..................................... 100.000 100.000 ................................
----------------------------------------------------------------------------------------------------------------
* Labor-Related.
** Blood and blood products, previously a separate cost category, is now contained within Miscellaneous Products
in the FY 2002-based market basket. See discussion in section IV.B.2.r., miscellaneous products, as well as
comment and response on blood and blood products that follow this section.

a. Wages and Salaries
For measuring the price growth of wages in the FY 2002-based market
basket, as we proposed, we used 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 FY 1997-based market basket.
b. Employee Benefits
The 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

[[Page 47390]]

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 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. We have not yet
identified a preferred option. Therefore, we did not make any changes
to the proxy in this rule.
h. Pharmaceuticals
The percentage change in the price of prescription drugs as
measured by the PPI (PPI Code PPI32541DRX) 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 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 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 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 market
basket. The weight for this cost category is higher than in the FY
1997-based market basket 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 market basket, and within miscellaneous products.
These categories use as proxies the following PPIs: the PPI for blood
and blood derivatives, the PPI for chemicals, and the PPI for finished
goods less food and energy, respectively. Of these three market
baskets, the market basket with blood in miscellaneous products and its
associated proxy, the PPI for finished goods less food and energy,
moved very similar to the market basket with blood as a separate
category. 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.
Comment: Some commenters questioned the CMS proposal to remove
blood and blood products as a separate cost category and add its weight
to the miscellaneous products cost category of

[[Page 47391]]

the hospital market basket. A few commenters supported this move only
as a temporary measure until a more appropriate blood and blood
products PPI can be developed by the BLS.
Response: We studied different cost categories that might be used
until we have had the opportunity to evaluate whether the BLS' PPI for
Blood and Organ Banks (NAICS 621991), which is still in development,
may be an appropriate price proxy that could be proposed for blood and
blood products. The alternative cost categories we considered were
Blood and Blood Products, Chemicals, and Miscellaneous Products. We
considered placing blood and blood products in the ``other products''
subcategory because blood is a product purchased by hospitals. From
2001 to 2003 the percent changes in the price proxies for these
respective cost categories were:

Chart 3.--Annual Growth Rates for Three Possible Price Proxies
----------------------------------------------------------------------------------------------------------------
Cost category Proxy 2001-2002 2002-2003
----------------------------------------------------------------------------------------------------------------
Chemicals..................................... Industrial Chemicals............ -0.9 11.3
Blood......................................... Blood and Derivatives........... -7.2 -11.4
Miscellaneous Products........................ Finished Goods less Food and 0.1 0.2
Energy.
----------------------------------------------------------------------------------------------------------------

In discussions with the blood banking industry we were presented
data that the cost of blood had been increasing over the 2001-2003
period. In addition, an analysis of Medicare Cost Report data indicated
that the cost weight for blood was increasing had increased from 1.023
in 2001 to 1.082 in 2002. Neither of these data sources supported the
trends in the PPI for blood and derivatives over this period. In
addition, we had previously determined that the PPI for Industrial
Chemicals was not an appropriate price proxies for the change in blood
prices (67 FR 50035). We believed the PPI for finished goods less food
and energy was an appropriate proxy because it has a more stable
measure than the others considered, and had not exhibited negative
price movements in recent periods and currently serves as a proxy for
all product costs that are small or without a specific price proxy.
We ran test market baskets using the most recent forecast (2005q2,
with history through 2005q1). The three market baskets were identical,
except that the blood weight was in its own cost category, in
chemicals, or in miscellaneous products, respectively. As shown in
Chart 4, the annual increases in the market baskets were similar,
regardless of which cost category contained the market basket weight
for blood and blood products. Therefore, even if blood and blood
products were its own cost category, it would have little effect on the
market basket update factor.

Chart 4.--Market Basket Increase With Blood and Blood Products located in:
----------------------------------------------------------------------------------------------------------------
Blood and Miscellaneous
blood products Chemicals products
----------------------------------------------------------------------------------------------------------------
2000............................................................ 3.2 3.3 3.2
2001............................................................ 4.2 4.2 4.1
2002............................................................ 3.7 3.6 3.7
2003............................................................ 3.9 4.2 4.0
2004............................................................ 3.9 4.0 3.9
Average: 2000-2004.............................................. 3.8 4.0 3.8
----------------------------------------------------------------------------------------------------------------

We are adopting the PPI for finished goods less food and energy as
the price proxy for blood and blood products because our analysis shows
that this price proxy most accurately reflects changes in costs of
blood products. We note that the BLS is developing a Producer Price
Index for Blood and Organ Banks. We look forward to evaluating this
index when it is ready for use.
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 47392]]

Chart 5.--FY 1997-Based and FY 2002-Based Prospective Payment Hospital
Operating Index Percent Change, FY 2000 Through FY 2008
------------------------------------------------------------------------
Rebased FY
2002-based FY 1997-based
Fiscal year (FY) hospital market basket
market basket
------------------------------------------------------------------------
Historical data:
FY 2000............................. 3.2 3.3
FY 2001............................. 4.1 4.3
FY 2002............................. 3.7 3.8
FY 2003............................. 4.0 3.9
FY 2004............................. 3.9 3.9
Average FYs 2000-2004............... 3.8 3.8
Forecast:
FY 2005............................. 4.2 4.2
FY 2006............................. 3.7 3.7
FY 2007............................. 3.1 3.2
FY 2008............................. 2.9 3.0
Average FYs 2005-2008............... 3.5 3.5
------------------------------------------------------------------------
Source: Global Insight, Inc. 2nd Qtr 2005, @USMACRO/CNTL0605 @CISSIM/
TL0505.SIM

Prior to the publication of the FY 2006 IPPS proposed rule, we had
been actively working with our forecasting firm, Global Insight, Inc.
(GII), to improve the forecasting accuracy of the market baskets. GII
is a nationally recognized economic and financial forecasting firm that
contracts with CMS to forecast the components of the market baskets.
Among other services GII provides to CMS, GII calculates projected
inflation factors for price proxies using models that take into account
national and global economic trends.
Over the last several years, dramatic fluctuations in the price of
certain costs have made it difficult to forecast price proxy inflation.
This uncertainty has resulted in market basket forecast error greater
than 0.25 percentage points in FY 2001, FY 2003, and FY 2004. The
driving force behind much of this uncertainty has been the instability
of energy costs, which, in a global economy, have an indirect effect on
wages and other costs as well as a direct effect on utility prices.
With our input and consultation, GII recently evaluated and modified
their forecasting models to help improve their accuracy. Using these
improved forecasting models, GII calculated updated inflation factors
for the major cost categories in Chart 6.

Chart 6.--Comparison of the 4 Quarter Moving Average Percent Changes for Several Cost Category Weights Between
the FY 2006 IPPS Proposed and Final Rules
----------------------------------------------------------------------------------------------------------------
GII 2004q4 GII 2005q2
FY 2002-based forecast of FY forecast of FY
Expense category cost weights 2006 (Proposed 2006 (Final
Rule) Rule)
----------------------------------------------------------------------------------------------------------------
Total--PPS02.................................................... 100.000 3.2 3.7
Compensation................................................ 59.993 3.5 3.9
Utilities................................................... 1.251 0.8 3.6
Professional Fees........................................... 5.510 3.6 4.3
Professional liability insurance............................ 1.589 8.4 7.8
All Other................................................... 31.657 2.4 3.0
All Other Products.......................................... 20.336 2.3 3.2
All Other Services.......................................... 11.321 2.4 2.6
----------------------------------------------------------------------------------------------------------------

In the FY 2006 IPPS proposed rule, we forecasted a market basket
update of 3.2 percent. Based on our updated forecasting model, we are
forecasting a market basket update of 3.7 percent for FY 2006.
Comment: Several commenters requested that CMS review and revise
the methodology used to determine the projected FY 2006 market basket.
They are concerned that the previously proposed FY 2006 update of 3.2
percent is a dramatic underestimation. They emphasized the importance
of a reliable projection methodology in order to ensure equitable
payments.
Response: We recognize the importance of a reliable forecasting
methodology. As discussed above, we have worked with our forecasting
firm, GII, to modify and improve GII's forecasting models to help
improve their accuracy. The final FY 2006 update of 3.7 percent
reflects these modifications.
Comment: Several commenters requested that CMS make the calculation
of the projected FY 2006 available to the public.
Response: We have summarized our calculation of the market basket
update in Chart 6 above.
3. Labor-Related Share
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

[[Page 47393]]

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.
As we proposed in the FY 2006 IPPS proposed rule, we are continuing to
use our current methodology of defining the labor-related share as the
national average proportion of operating costs that are attributable to
wages and salaries, fringe benefits, professional fees, contract labor,
and labor intensive services. Therefore, we calculate the labor-related
share by adding the relative weights for these operating cost
categories. We continue to believe, as we have stated in the past, that
these operating cost categories likely are related to, are influenced
by, or vary with the local markets. Our definition of the labor-related
share therefore continues to be consistent with section 1886(d)(3) of
the Act. As we proposed, we are removing postage costs from the FY
2002-based labor-related share.
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, in
this final rule, we are implementing 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.''
Comment: One commenter suggested that we decrease the labor-related
share from 62 percent to 50 percent for those hospitals with wage
indices under 1.0.
Response: As stated above, the 62 percent labor-related share
provision was established by section 403 of Pub. L. 108-173. This
provision was mandated by Congress and, therefore, CMS has no authority
to modify it.
As we proposed, we also are updating the labor-related share for
Puerto Rico. Consistent with our methodology for determining the
national labor-related share, we 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 use the national
weights. In the proposed rule, we observed that, rather than using a
Puerto Rico-specific labor-related share, another option would be to
apply the national labor-related share to the Puerto Rico-specific
rate. In the proposed rule, we also noted that we were still reviewing
our data and had not yet calculated the updated Puerto Rico-specific
labor-related share percentage. Therefore, in the proposed rule, the
labor-related and nonlabor-related portions of the Puerto Rico-specific
standardized amount listed in Table 1C of the Addendum to the proposed
rule reflected the current FY 2005 labor-related share for Puerto Rico
of 71.3 percent. We solicited comments on our proposal to update the
labor-related share for Puerto Rico.
After publication of the proposed rule, we calculated an updated
labor-related share of 58.7 percent for Puerto Rico and posted it on
the CMS Web site at http://www.cms.hhs.gov/providers/hipps. We did not
receive any public comments on the proposed updated labor-share for
Puerto Rico. Accordingly, we are adopting an updated Puerto Rico labor-
related share of 58.7 percent, which is reflected in the Table 1C of
the Addendum of this final rule.
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 7
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 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.

Chart 7.--Labor-Related Share: FY 1992-Based and FY 2002-Based
----------------------------------------------------------------------------------------------------------------
FY 1992-based FY 2002-based
Cost category weight weight Difference
----------------------------------------------------------------------------------------------------------------
Wages and salaries.............................................. 50.244 48.171 -2.073
Fringe benefits................................................. 11.146 11.822 0.676
Nonmedical professional fees.................................... 2.127 5.510 3.383
Postal services*................................................ 0.272 .............. -0.272
Other labor-intensive services**................................ 7.277 4.228 -3.049
-----------------
Total labor-related......................................... 71.066 69.731 -1.335
=================
Total nonlabor-related.................................. 28.934 30.269 1.335
----------------------------------------------------------------------------------------------------------------
*No longer considered to be labor-related.
**Other labor-intensive services includes landscaping services, services to buildings, detective and protective
services, repair services, laundry services, advertising, auto parking and repairs, physical fitness
facilities, and other government enterprises.

Although we are continuing 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 sufficient information available to make this
determination.

[[Page 47394]]

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. In our initial
regression specification (in log form), Medicare operating cost per
Medicare discharge was the dependent variable and the independent
variables were the area wage index, the case-mix index, the ratio of
residents per bed (as proxy for IME status), and a dummy variable that
equaled one if the hospital was 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 appeared 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 whether 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 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. In the FY 2006 IPPS proposed rule, we solicited
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 used an
edit that 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

[[Page 47395]]

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.
In the FY 2006 IPPS proposed rule, we solicited comments on this
approach, 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 locally.
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 locally, regionally, or
nationally. The results were quite consistent across all of the
hospitals, indicating most advertising and legal services are purchased
locally or regionally and nearly all management and consulting services
are purchased nationally. Although the results of our research are
instructive, as we have stated in the past, we believe that items
should not be excluded from the labor-related share merely because they
could be purchased nationally (68 FR 45467). We do plan to expand our
efforts in this area to determine whether it would be appropriate in
the future to modify our methodology for calculating the labor-related
share. In the FY 2006 IPPS proposed rule, we solicited data or studies
that would be helpful in this analysis. However, we indicated that we
were unsure if we would be able to finish this analysis in time for
inclusion in this FY 2006 IPPS final rule.
Comment: Several commenters objected to our proposal to change the
labor-related share to 69.7 percent and requested that CMS maintain a
labor-related share of 71.1 percent. The commenters provided similar
reasons for rejecting this provision of the proposed rule. Generally,
the commenters were concerned that the new lower labor share would
negatively impact urban hospitals and several commenters stated that
CMS should postpone changing the labor share until the agency has
finished researching they are finished researching different labor-
related share methodologies. In addition, commenters noted that the
budget neutral manner in which CMS proposed to implement this labor
share change would increase the standardized amount for all hospitals.
They believed this is unfair as the increased amount would provide an
additional benefit to rural hospitals that are already advantaged by
many provisions of Pub. L. 108-173, including section 403 which sets
the labor share at 62 percent for hospitals with a wage index less than
or equal to 1.0.
Response: Section 404 of Pub. L. 108-173 requires the Secretary to
update the weights used in the IPPS operating and capital market
baskets, including the labor-related share, to reflect the most current
available data. Therefore, we are directed by statute to update the
labor share and cannot maintain the labor share at the outdated
percentage of 71.1. Since the FY 2003 IPPS final rule was issued, CMS
has continued to evaluate alternative labor-related share
methodologies. Given this research, we believe our existing methodology
of calculating the labor-related share is the most appropriate
methodology at this time. Our alternative methodologies did not produce
the sound evidence needed to justify changing our existing methodology.
Specifically, our regression results were inconsistent and highlighted
underlying data problems that were not evident in our market basket
labor-related share methodology. We are confident that our current
model is the best method presently available to appropriately capture
the changing cost structures hospitals have faced over the last ten
year period (1992 to 2002). Therefore, we are establishing the labor
share at 69.7 percent.
In addition, we are implementing this revised and rebased labor
share in a budget neutral manner, but consistent with section
1886(d)(3)(E) of the Act, we are not taking into account the additional
payments that will be made as a result of hospitals with a wage index
less than or equal to 1.0 being paid using a labor-related share lower
than the labor-related share of hospitals with a wage index greater
than 1.0. Section 1886(d)(3)(E) of the Act directs us to determine a
labor related share that reflects the ``proportion * * * of hospitals''
costs which are attributable to wages and wage-related costs.'' In
addition, section 1886(d)(3)(E) of the Act requires that we implement
the wage index adjustment in a budget neutral manner. However, section
403 of Pub. L. 108-173, which sets the labor-related share at 62
percent for hospitals with a wage index less than or equal to 1.0, also
provides that the Secretary shall calculate the budget neutrality
adjustment for the wage index as if the Pub. L. 108-173 had not been
enacted. Therefore, for purposes of the budget neutrality adjustment,
section 403 of Pub. L. 108-173 prohibits us from taking into account
the additional payments that will be made as a result of hospitals with
a wage index less than or equal to 1.0 being paid using a labor-related
share of 62 percent. While we recognize that this does have the effect
of increasing the standardized amount applicable to all hospitals, the
statute requires this implementation methodology.
As mentioned previously in the proposed rule, we proposed 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. Using this methodology, we
calculated a labor-related share of 69.731, which we are using for FY
2006.
Comment: One commenter requested that CMS continue to include
postage in the labor-related share.
Response: We do not believe that we should continue to include
postage costs in the labor-related share as postage fees are set at
nationally uniform rates and are not affected by local purchasing power
of hospitals. The cost of postage is primarily

[[Page 47396]]

influenced by weight of the package and the distance the package is
traveling (National Zone Chart Program Technical Guide 2003-2004,
http://www.ribbs.usps.gov/files/Zone_Charts/ZCTECHNICAL_GUIDE.PDF,
page 2). For example, the cost of mailing a package from Boston, MA to
Baltimore, MD (approximately 450 miles) is the same price as mailing a
package from Long Beach, NC to Baltimore, MD (approximately 450 miles)
(http://postcalc.usps.gov/).
Comment: One commenter argued that geographical differences in
costs of goods and services such as food, energy, telephone services,
pharmaceuticals, and supplies are attributable to local differences in
wages and hence should be included in the labor-related share.
Response: We believe that the commenter may have misunderstood a
statement in the notice of proposed rulemaking. Previously, we stated
that our current methodology is to define the labor-related share as
the national average proportion of operating costs that are related to,
influenced by, or vary with local labor markets. As we have stated in
previous rules and clarified in this final rule, it is more accurate to
say that we define the labor-related share as the national average
proportion of operating costs that are attributable to wages and
salaries, fringe benefits, professional fees, contract labor, and labor
intensive services. These costs are included in the labor-related share
because they are labor intensive, and therefore, are ``hospitals''
costs that are attributable to wages and wage-related costs.'' As was
stated previously, we believe that, with the exclusion of postage, the
costs included in the labor-related share are, in fact, related to,
influenced by, or vary with local labor markets. However, hospital
costs are not necessarily ``attributable to wages and wage-related
costs ``merely because they may be related to, may be influenced by, or
may vary with local labor markets. Therefore, it would be incorrect to
say that all costs that are related to, influenced by, or vary with the
local labor market must be included in the labor-related share merely
because they are related to, influenced by, or vary with the local
labor market.
We include only labor-intensive inputs in the labor-related share
(55 FR 36046). Although the costs of goods and services such as food,
pharmaceuticals, energy, telephone services, and supplies may vary by
geographic area, these items are not labor-intensive inputs. Thus, we
disagree with the commenter's argument that these items should be
included in the labor-related share.
Comment: Several commenters suggested that we include professional
liability insurance (PLI) in the labor-related share since these costs
are included in the wage index. The commenters also claimed that
professional liability insurance costs are wage related.
Response: The wage index includes, as a fringe benefit cost, PLI
for those policies that list actual names or specific titles of covered
employees (59 FR 45358). The benefit cost weight in the market basket,
included in the labor-related share, is also based on the same wage
index benefit data. Therefore, the labor-related share includes these
PLI costs. General PLI coverage maintained by hospitals is not
recognized as a wage-related cost for purposes of the wage index or
labor-related share.
Although general PLI costs do vary by geographic region, they are
not labor-intensive inputs. The variance in general PLI costs is
primarily influenced by state legislation and risk level, not by local
wage rates. In fact, areas with high wage indices may have low relative
PLI costs. For example, the malpractice geographic price indices, used
in the Medicare physician payment system, for San Francisco, Los
Angeles, and Boston regions are below 1, while their hospital wage
indices for comparable areas are much greater than 1.
Comment: Several commenters requested that CMS explain why the
labor-related share is fluctuating between FYs 1992, 1997, and 2002-
based market baskets. They stated these changes raise questions about
the (1) veracity of the data, (2) the change in base cost data, (3)
effect of proxy changes on the trending, (4) consistency of CMS'
methodology, and (5) other factors. They specifically requested that
CMS explain in more detail the change in the other labor-intensive
services cost weight.
Response: In addition to the official market basket weights
published in the Federal Register, CMS also analyzed the weights based
on different trimming methodologies and on a matched sample of
hospitals over time. These weights exhibited the same trends as our
published weights. Specifically, the compensation cost weight, the
largest component in the labor-related share, from 1997 to 2002
steadily declined in all instances.
The decline in the nonmedical professional fees from 1992 to 1997
reflects hospital purchasing patterns' and a change in the data source
used to derive this weight. The FY 1992-based market basket used the
American Hospital Association Survey data while the FY 1997-based
market basket used the 1997 Bureau of Economic Analysis' Annual I-O
Tables. As stated in the FY 2003 IPPS final rule (67 FR 50034), if CMS
had used the Annual I-O Tables to calculate the FY 1992 nonmedical
professional fees component, the proportion would have been similar to
the FY 1997 share. The FY 2002 nonmedical professional fees cost
category is based on 1997-Benchmark I-O data trended forward using the
ECI for Compensation for Private Service Occupations.
The decline in the other labor intensive cost category from 1997 to
2002 is a result of hospitals purchasing patterns and substituting the
1997 Benchmark I-O data for the 1997 Annual I-O data. 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
1997-Benchmark I-O is also based on the 1997 North American Industrial
Classification System while the 1997 Annual I-O is based on the 1987
Standard Industrial Classification System.
CMS has maintained a relatively consistent methodology for
calculating the hospital market basket cost weights. However, the
methodology is periodically modified to include more comprehensive data
sources and/or price proxies. These methodological changes, as well as
their impacts, are published in the Federal Register. In most
instances, the modifications have a small effect on the total market
basket update.
Finally, approximately 85 percent of the labor-related shares (FY
1992, FY 1997, and FY 2002) are based on Medicare Cost Report data
submitted by hospitals.

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

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,

[[Page 47397]]

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 an 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 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).
In the FY 2006 IPPS proposed rule, we indicated that because IRFs,
LTCHs, and some IPFs are now paid under a PPS, we were considering
developing a separate market basket for these hospitals that contains
both operating and capital costs. (The IPF PPS was implemented recently
for cost reporting periods beginning on or after January 1, 2005;
therefore, all IPFs will soon be paid under the IPF PPS.) We indicated
that we would publish any proposal to use a revised separate market
basket for each of these types of hospitals when we propose the next
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, in the FY 2006
IPPS proposed rule, we did not propose 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
proposed to use the FY 2002 IPPS operating market basket percentage
increase to update the target amounts for children's and cancer
hospitals and the market basket for RNHCIs under Sec. 403.752(a) of
the regulations. This proposal reflected 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, as proposed, for
this final rule we are using the IPPS operating market basket to update
the target amounts for children's and cancer hospitals and the market
basket for RNHCIs under Sec. 403.752(a) of the regulations. However,
when we compare the weights for LTCHs and IPFs to the weights for IPPS
hospitals, we did not find them comparable. Therefore, we did not
believe it was appropriate to use the IPPS market basket for LTCHs and
IPFs to update the portion of their payment that is based on reasonable
cost.
For similar reasons, we indicated in the proposed rule that 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. As indicated
in the proposed rule, 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
1 or 3 additional years (1 year for LTCHs paid under a blend
methodology since some LTCHs only have 1 year remaining in their
transition, and 3 years for IPFs since existing 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 under current law. 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 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.
Comment: One commenter supported CMS evaluation of a potential new
market basket for LTCHs and other post-acute care providers. However,
they cautioned CMS to look at the distinct attributes and price inputs
of various providers, claiming the price inputs of LTCHs are linked
more closely to those of acute care hospitals than other types of
providers. They also recommended that CMS use FY 2002 hospital data to
calculate the excluded hospital with capital market basket in the 2007
LTCH rate year payment update.
Response: In the RY 2007 LTCH proposed rule, we plan to propose a
new market basket for updating the LTCH prospective payments which may
be based on 2002 data. The proposed methodology used to create this
market basket will be described in detail and is likely going to be
similar to the market basket described in the IRF FY 2006 proposed
rule. We will also present any additional analysis we have conducted on
the differing cost structures of LTCHs

[[Page 47398]]

and other types of providers. This proposed rule will be subject to
comments.
Comment: Several commenters disagreed with CMS proposal to use the
FY 2002 IPPS operating market basket to update the target amounts for
children's and cancer hospitals. One commenter recommended CMS
implement a separate market basket for cancer hospitals that would
recognize the actual cost increases experienced by these institutions.
The commenters contended that the existing excluded market basket falls
short of reflecting the annual cost increases actually experienced by
cancer hospitals. They have determined this shortfall to be specific
cost weights and relative price proxies of pharmaceuticals and
compensation. Another commenter recommended using the excluded hospital
market basket until new market baskets are implemented for IRFs, IPFs,
and LTCHs.
Response: Due to the small number of children's and cancer
hospitals and RNCHIs (less than 80 in 2002) and limited reporting, we
believe we are unable to create a representative market basket for
those hospitals still being paid based solely on their reasonable
costs, subject to target amounts. Therefore, we proposed to use the FY
2002 IPPS operating market basket percentage increase to update the
target amounts for children's and cancer hospitals and the market
basket for RNHCIs under Sec. 403.752(a) of the regulations because
this market basket most closely represented the cost structure of
children's and cancer hospitals and RNHCIs.
Chart 8 compares the limited data available on median salary,
median pharmaceutical, and median professional liability insurance
(PLI) cost weights (as a percent of operating costs) for cancer and
children's hospitals and RNCHTs; IPPS hospitals; and IRFs, LTCHs, and
IPFs. As indicated, the cost structure for cancer and children's
hospitals and RNCHIs is more like the cost structure for IPPS hospitals
than that for IRFs, LTCHs, and IPFs. Because both the excluded and IPPS
market baskets use the same price proxies, a difference in update would
be due to the base cost structure. Therefore, by choosing a market
basket that most closely represents the cost structures of cancer and
children's hospitals and RNCHIs, we are reflecting the annual cost
increases experienced by these hospitals.

Chart 8.--Comparison of 2002 Median Cost Weights From the Medicare Cost
Reports
------------------------------------------------------------------------
Cancer and
children's IPPS IRFs,
hospitals hospitals LTCHs, and
and RNCHIs IPFs
------------------------------------------------------------------------
Salary Cost Weight.................. 49.486 46.278 55.263
(Number of providers)............... (68) (3889) (591)
Pharmaceutical Cost Weight.......... 6.053 5.453 4.992
(Number of providers)............... (56) (3891) (585)
PLI Cost Weight..................... 1.050 1.099 0.922
(Number of Providers)............... (75) (2341) (279)
------------------------------------------------------------------------
\1\ Costs were included if they were greater than zero and less than
operating costs.
\2\ Salary cost weights exclude contract labor costs.
\3\ The cost weights presented here are medians, which is different than
the market basket cost weights which are means (they are calculated by
dividing total expenditures for all hospitals by total operating costs
for all hospitals).

We will continue to monitor the cost structures of children's and
cancer hospitals and RNHCIs to ensure the IPPS hospital market basket
adequately reflects these hospitals purchasing patterns. We do not
believe it is necessary to postpone the implementation of the IPPS
market basket to update the target limits for children's and cancer
hospitals and RNCHIs until a new market basket has been implemented to
update IRFs, LTCHs, and IPFs payments. The latter group of hospitals
are, or soon will be, reimbursed under a PPS that will not affect the
reimbursement of children's and cancer hospitals and RNCHIs.
Chart 9 compares the updates for the FY 2002-based IPPS operating
market basket, the index we proposed to use 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 use the market basket that most
closely reflects the cost structure of children's and cancer hospitals
and RNCHIs. In the FY 2006 IPPS proposed rule, we invited 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.
The forecasts are based on the GII 2nd quarter, 2005 forecast with
historical data through the 1st quarter of 2005, incorporating two more
quarters of historical data than published in the FY 2006 IPPS proposed
rule. (As we indicated earlier, GII is a nationally recognized economic
and financial forecasting firm that contracts with CMS to forecast the
components of the market baskets.)

[[Page 47399]]

Chart 9.--FY 2002-Based IPPS and FY 2002-Based Excluded Hospital
Operating Index Percent Change, FYs 2000 Through 2007
------------------------------------------------------------------------
Rebased FY FY 2002-based
2002-based excluded
Fiscal year IPPS operating hospital
market basket market basket
------------------------------------------------------------------------
Historical Data:
FY 2000............................. 3.2 3.3
FY 2001............................. 4.1 4.3
FY 2002............................. 3.7 4.2
FY 2003............................. 4.0 4.1
FY 2004............................. 3.9 4.0
�����������������������������������������
Forecast:
FY 2005............................. 4.2 4.2
FY 2006............................. 3.7 3.8
FY 2007............................. 3.1 3.4
�����������������������������������������
------------------------------------------------------------------------
Source: Global Insight, Inc, 2nd Qtr. 2005; @USMACRO/CONTROL0605
@CISSIM/TL0505.SIM.

2. Excluded Hospitals Paid Under a Blend Methodology
As we discuss in greater detail in Appendix B to this final 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, existing LTCHs
and existing 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. In general, 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, 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, an existing 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
is paid based on 100 percent of the standard Federal rate. Effective
for cost reporting periods beginning on or after January 1, 2005, IPFs,
as defined in Sec. 412.426(c), 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), is 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 sections 1886(b)(3)(A) and (b)(3)(B)
of the Act, as was proposed, for LTCHs and IPFs that are transitioning
to the fully Federal prospective payment rate, we are using the rebased
FY 2002-based excluded hospital market basket to update the reasonable
cost-based portion of their payments. The market basket update is
described in detail below. We do not believe the IPPS operating market
basket should be used for the 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. Chart 8 compares
the median salary, median pharmaceutical, and median professional
liability insurance cost weights for IPPS hospitals and IRFs, LTCHs,
and IPFs.
Comment: One commenter endorsed the CMS proposal to rebase the
excluded hospital market basket, stating that rebasing the excluded
hospital market basket improves accuracy and predictability of the LTCH
PPS. The commenter also hoped that the forecast for the final rule for
FY 2006 will be higher than the proposed rule's forecast of 3.2
percent.
Response: We agree that the market baskets should be periodically
rebased to ensure they adequately reflect the purchasing patterns of
hospitals and the price increases associated with providing hospital
services. The 2002-based excluded hospital's FY 2006 forecast was run
on the GII second quarter forecast for 2005, with historical data
through the first quarter of 2005, incorporating two more quarters of
historical data than published in the FY 2006 IPPS proposed rule. The
forecast for FY 2006 for the FY 2002-based excluded hospital market
basket is 3.8 percent.
3. Development of Cost Categories and Weights for the FY 2002-Based
Excluded Hospital Market Basket
a. Medicare Cost Reports
In this final rule, as was proposed, the major source of
expenditure data for developing the rebased and revised excluded
hospital market basket cost weights is the FY 2002 Medicare cost
reports. We chose 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

[[Page 47400]]

cost report data. These cost reports are from rehabilitation,
psychiatric, long-term care, children's, cancer, and RNHCIs. 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 RNHCIs. 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, as we proposed, in this
final rule, we are using 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 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.
As was proposed, cost weights for benefits, contract labor, and
blood and blood products were derived using the 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 excluded hospital wages and salaries cost weight to
derive a benefit cost weight for the excluded hospital market basket.

Chart 10.--Major Cost Categories Found in Excluded Hospital Medicare
Cost Reports
------------------------------------------------------------------------
FY 1997-based FY 2002-based
excluded excluded
Major cost categories hospital hospital
market basket market basket
------------------------------------------------------------------------
Wages and salaries...................... 51.998 57.037
Professional Liability Insurance 0.805 1.504
(Malpractice)..........................
Pharmaceuticals......................... 6.940 5.940
All other............................... 40.257 35.519
------------------------------------------------------------------------

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 may 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, as
was proposed, for this final rule, 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 used the 1997 Benchmark I-O data in the 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. As was
proposed, the methodology we used to age the data for this final rule
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. FY 2002-Based Excluded Hospital Market Basket--Selection of Price
Proxies
After computing the FY 2002 cost weights for the 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, as
was proposed, 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

[[Page 47401]]

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 made no changes to the proposed price proxies in
this final rule. 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 11 sets forth the complete 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.

Chart 11.--FY 2002-Based Excluded Hospital Market Basket Cost Categories, Weights, and Proxies With FY 1997-
Based Excluded Hospital Market Basket Used for Comparison
----------------------------------------------------------------------------------------------------------------
FY 1997-based FY 2002-based
excluded excluded
Expense categories hospital hospital FY 2002-based excluded hospital
market basket market basket market basket price proxies
weights weights
----------------------------------------------------------------------------------------------------------------
1. Compensation............................... 63.251 71.035
C. Wages and Salaries*.................... 51.998 57.037 ECI--Wages and Salaries,
Civilian Hospital Workers.
D. Employee Benefits*..................... 11.253 13.998 ECI--Benefits, Civilian Hospital
Workers.
2. Professional Fees*......................... 4.859 3.543 ECI--Compensation for
Professional, Specialty &
Technical Workers.
3. Utilities.................................. 1.296 0.804
A. Fuel, Oil, and Gasoline................ 0.272 0.132 PPI Refined Petroleum Products.
B. Electricity............................ 0.798 0.430 PPI Commercial Electric Power.
C. Water and Sewerage..................... 0.226 0.242 CPI-U Water & Sewerage
Maintenance.
4. Professional Liability Insurance........... 0.805 1.504 CMS Professional Liability
Insurance Premium Index.
5. All Other.................................. 29.790 23.114
B. All Other Products..................... 19.680 15.836
(1) Pharmaceuticals........................... 6.940 5.940 PPI Prescription Drugs.
(2) Direct Purchase Food...................... 1.233 1.070 PPI Processed Foods & Feeds.
(3) Contract Service Food..................... 1.146 0.759 CPI-U Food Away From Home.
(4) Chemicals................................. 2.343 1.347 PPI Industrial Chemicals.
(5) Blood and Blood Products**................ 0.821
(6) Medical Instruments....................... 1.972 1.242 PPI Medical Instruments &
Equipment.
(7) Photographic Supplies..................... 0.184 0.118 PPI Photographic Supplies.
(8) Rubber and Plastics....................... 1.501 1.289 PPI Rubber & Plastic Products.
(9) Paper Products............................ 1.219 1.225 PPI Converted Paper & Paperboard
Products.
(10) Apparel.................................. 0.525 0.253 PPI Apparel.
(11) Machinery and Equipment.................. 0.936 0.364 PPI Machinery & Equipment.
(12) Miscellaneous Products**................. 0.860 2.230 PPI Finished Goods less Food and
Energy.
B. All Other Services..................... 10.110 7.279
(1) Telephone Services........................ 0.382 0.295 CPI-U Telephone Services.
(2) Postage................................... 0.771 0.836 CPI-U Postage.
(3) All Other: Labor Intensive*............... 4.892 2.718 ECI-Compensation for Private
Service Occupations.
(4) All Other: Non-Labor Intensive............ 4.065 3.430 CPI-U All Items.
--------------------------------
Total..................................... 100.000 100.000
----------------------------------------------------------------------------------------------------------------
* Labor-Related
** Blood and blood products, previously a separate cost category, is now contained within Miscellaneous
Products in the FY 2002-based excluded hospital market basket.

a. Wages and Salaries
For measuring the price growth of wages in the FY 2002-based
excluded hospital market basket, we used 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 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

[[Page 47402]]

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.
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 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
making any changes to the proxy in this final rule.
h. Pharmaceuticals
The percentage change in the price of prescription drugs as
measured by the PPI (PPI Code PPI32541DRX) 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. These three market

[[Page 47403]]

baskets moved similarly. 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.
We received several comments on including blood and blood products
costs in miscellaneous products cost weight. These comments were
addressed in section IV.B.1.b.2 of this final rule and are applicable
to the FY 2002-based excluded hospital market basket as well because
our rationale for how we treat blood and blood products in the IPPS
market basket is the same as in the FY 2002-based excluded hospital
market basket.
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).
Chart 12 compares the updates for the FY 2002-based excluded
hospital market basket (based on the cost structures of IRFs, LTCHs,
IPFs, children's and cancer hospitals, and RNCHIs), the index we
proposed to use to update the reasonable cost-based portion of IPF and
LTCH payments and which we are adopting in this final rule, with a FY
1997-based excluded hospital market basket (based on the cost structure
of IRFs, LTCHs, IPFs, and children's and cancer hospitals).

Chart 12.--FY 1997-Based and FY 2002-Based Excluded Hospital Operating
Index Percent Change, FY 2000 Through FY 2008
------------------------------------------------------------------------
FY 2002-based FY 1997-based
excluded excluded
Fiscal Year (FY) hospital hospital
market basket market basket
------------------------------------------------------------------------
Historical data:
FY 2000............................. 3.3 3.3
FY 2001............................. 4.3 4.3
FY 2002............................. 4.2 3.9
FY 2003............................. 4.1 4.0
FY 2004............................. 4.0 3.9
�����������������������������������������
Forecast:
FY 2005............................. 4.2 4.2
FY 2006............................. 3.8 3.8
FY 2007............................. 3.4 3.2
FY 2008............................. 3.2 3.0
�����������������������������������������
------------------------------------------------------------------------
Source: Global Insight, Inc. 2nd Qtr 2005, @USMACRO/CNTL0605 @CISSIM/
TL0505.SIM

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
final 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 final rule discusses the research we have done
to fulfill this requirement, and sets forth 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

[[Page 47404]]

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 used in determining this frequency.
ProPAC, one of MedPAC's predecessor organizations, submitted 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, as we proposed in the FY
2006 IPPS proposed rule, we would 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).
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 and blood products).
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 13 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.

Chart 13.--Expected Future Data Availability for Major Data Sources Used in the Hospital Market Basket
----------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------
PPS FY Update................................. FY 2006 FY 2007 FY 2008 FY 2009 FY 2010 FY 2011
Market Basket Base Year....................... FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007
Medicare Cost Report Data Available........... FY 2002 FY 2003 FY 2004 FY 2005 FY 2006 FY 2007
I-O Data Available............................ 1997 1997 1997 1997 1997 2002
BES Data Available............................ 1997 1997 1997 1997 1997 2002
Number of Years Data Must Be Aged............. 5 6 7 8 9 5
----------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------
FPS FY Update............................................ FY 2012 FY 2013 FY 2014 FY 2015 FY 2016
Market Basket Base Year.................................. FY 2008 FY 2009 FY 2010 FY 2011 FY 2012
Medicare Cost Report Data Available...................... FY 2008 FY 2009 FY 2010 FY 2011 FY 2012
I-O Data Available....................................... 2002 2002 2002 2002 2007
BES Data Available....................................... 2002 2002 2002 2002 2007
Number of Years Data Must Be Aged........................ 6 7 8 9 5

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.
For instance, we have aged the 1997 Benchmark I-O data for this final
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

[[Page 47405]]

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 one or two years), 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 systematically examined 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 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.
It is clear from this analysis that neither the 3-year nor 4-year
rebasing frequencies optimize the timeliness of the data relative to
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 using in this
final rule. Chart 14 shows the weights from these hypothetical market
baskets:

BILLING CODE 4120-01-P

[[Page 47406]]

[GRAPHIC] [TIFF OMITTED] TR12AU05.002

BILLING CODE 4120-01-C
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, 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 47407]]

impact of rebasing every 5 years. Chart 15 shows the results of these
comparisons.

Chart 15.--Comparison of Hypothetical Market Baskets, FY 1997 Through FY 2002 Base Years, Percent Changes, FY 1998 Through FY 2004
--------------------------------------------------------------------------------------------------------------------------------------------------------
Percent Change in Hypothetical Market Baskets
Federal Fiscal Year -----------------------------------------------------------------------------------------------
FY 1997-based FY 1998-based FY 1999-based FY 2000-based FY 2001-based FY 2002-based
--------------------------------------------------------------------------------------------------------------------------------------------------------
1998.................................................... 2.7 2.6 2.6 2.6 2.6 2.6
1999.................................................... 2.7 2.5 2.5 2.5 2.5 2.5
2000.................................................... 3.2 3.3 3.3 3.3 3.3 3.2
2001.................................................... 4.2 4.2 4.2 4.2 4.2 4.1
2002.................................................... 3.8 3.8 3.8 3.7 3.7 3.7
2003.................................................... 3.9 4.0 4.0 4.0 4.0 4.0
2004.................................................... 3.9 3.8 3.9 3.8 3.9 3.9
���������������������������������������������������������
--------------------------------------------------------------------------------------------------------------------------------------------------------
Source: Global Insight, Inc, 2nd Qtr. 2005;@USMACRO/CNTL0605 @CISSIM/TL0505.SIM.

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 require adequate time to research and reply to all comments
submitted. The last part of the regulatory process is the 60-day
requirement that is, 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 and resources
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.
Comment: A few commenters stated there is no compelling reason to
rebase the market basket for the FY 2006 update. They requested that
CMS begin its 4-year rebasing schedule, beginning with the FY 2007
update (4 years after the last rebasing of the hospital market for the
FY 2003 update).
Response: Section 404(a) of Pub. L. 108-173 directs the Secretary
to establish a frequency for rebasing the market basket after updating
the weights used in the IPPS operating and capital market baskets to
reflect the most current available data. Section 404(b) of the Pub. L.
108-173 provides that the Secretary shall include his explanation of
the reasons for the frequency of market basket updates in the FY 2006
IPPS final rule. We believe that section 404 of Pub. L. 108-173
requires that we rebase the market basket in the FY 2006 IPPS final
rule because we are required to establish a schedule for rebasing the
market basket in the FY 2006 IPPS final rule, but may not establish the
schedule until after we have rebased the market basket to reflect the
most current data available.
Comment: MedPAC urged the Secretary to propose legislation to
repeal section 404 of Pub. L. 108-173 requiring the more frequent
updating of the market basket. CMS' analysis shows that updating the
weights more frequently then every 5 years would make only small
differences in its market basket forecasts. In addition, some of the
data used in developing the market basket is only available every 5
years, thus a 4-year rebasing schedule could make the market basket
weights even more out of date due to the timing of these data sources.
Therefore, MedPAC concluded that updating the weights more often than
once every 5 years is unnecessary and potentially counterproductive.
Other commenters also requested that CMS continue with a 5-year
rebasing schedule.
Response: As described in this rule, we agree with the commenters
that rebasing the hospital market basket more frequently than every 5
years is unnecessary. However, section 404 of Pub. L. 108-173 requires
a shorter frequency, which CMS has set at every 4 years.

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.

[[Page 47408]]

In this final rule, we are revising and rebasing 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
FY 2002-based CIPI. The first set of weights identifies the proportion
of hospital capital expenditures attributable to each expenditure
category, while the second set of weights is a set of relative vintage
weights for depreciation 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 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 used 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 derived 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 applied 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 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 16 presents a comparison of the FY 2002-based CIPI capital
cost weights and the FY 1997-based CIPI capital cost weights.

Chart 16.--Comparison of FY 1997-Based and FY 2002-Based CIPI Cost Category Weights
----------------------------------------------------------------------------------------------------------------
FY 2002 FY 1997
Expense categories weights weights Price proxy
----------------------------------------------------------------------------------------------------------------
Total...................................... 100.00 100.00
Total depreciation......................... 74.58 71.35
Building and fixed equipment depreciation.. 36.23 34.22 Boeckh Institutional Construction
Index--vintage weighted (23
years).
Movable equipment depreciation............. 38.35 37.13 PPI for machinery and equipment--
vintage weighted (11 years).
Total interest............................. 19.86 23.46
Government/nonprofit interest.............. 14.90 19.94 Average yield on domestic municipal
bonds (Bond Buyer 20 bonds)--
vintage weighted (23 years).
For-profit interest........................ 4.97 3.52 Average yield on Moody's Aaa bonds--
vintage weighted (23 years).
Other...................................... 5.55 5.19 CPI-U--Residential Rent.
----------------------------------------------------------------------------------------------------------------

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.

[[Page 47409]]

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 expect
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.
Between the publication of the FY 2006 IPPS proposed rule and this
final rule, we conducted a further review of the methodology used to
derive the useful life of an asset. Based on this brief analysis into
the capital cost structures of hospitals, we are not changing the
expected life of fixed and moveable assets for the final rule.
As proposed, we used 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 used 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 each of the
twenty-eight 11-year periods. We used 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 used 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 FY 2002 CIPI are presented
in Chart 17.

[[Page 47410]]

Chart 17.--FY 1997 and FY 2002 Vintage Weights for Capital-Related Price Proxies
--------------------------------------------------------------------------------------------------------------------------------------------------------
Building and fixed equipment Movable equipment Interest
-----------------------------------------------------------------------------------------------
Year FY 1997 23 FY 2002 23 FY 1997 11 FY 2002 11 FY 1997 23 FY 2002 23
years years years years years years
--------------------------------------------------------------------------------------------------------------------------------------------------------
1....................................................... 0.018 0.021 0.063 0.065 0.007 0.010
2....................................................... 0.021 0.022 0.068 0.071 0.009 0.012
3....................................................... 0.023 0.025 0.074 0.077 0.011 0.014
4....................................................... 0.025 0.027 0.080 0.082 0.012 0.016
5....................................................... 0.026 0.029 0.085 0.086 0.014 0.019
6....................................................... 0.028 0.031 0.091 0.091 0.016 0.023
7....................................................... 0.030 0.033 0.096 0.095 0.019 0.026
8....................................................... 0.032 0.035 0.101 0.100 0.022 0.029
9....................................................... 0.035 0.038 0.108 0.106 0.026 0.033
10...................................................... 0.039 0.040 0.114 0.112 0.030 0.036
11...................................................... 0.042 0.042 0.119 0.117 0.035 0.039
12...................................................... 0.044 0.045 .............. .............. 0.039 0.043
13...................................................... 0.047 0.047 .............. .............. 0.045 0.048
14...................................................... 0.049 0.049 .............. .............. 0.049 0.053
15...................................................... 0.051 0.051 .............. .............. 0.053 0.056
16...................................................... 0.053 0.053 .............. .............. 0.059 0.059
17...................................................... 0.057 0.056 .............. .............. 0.065 0.062
18...................................................... 0.060 0.057 .............. .............. 0.072 0.064
19...................................................... 0.062 0.058 .............. .............. 0.077 0.066
20...................................................... 0.063 0.060 .............. .............. 0.081 0.070
21...................................................... 0.065 0.060 .............. .............. 0.085 0.071
22...................................................... 0.064 0.061 .............. .............. 0.087 0.074
23...................................................... 0.065 0.061 .............. .............. 0.090 0.076
-----------------
Total............................................... 1.000 1.000 1.000 1.000 1.000 1.000
--------------------------------------------------------------------------------------------------------------------------------------------------------

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 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 hospital
capital costs that meet our selection criteria of relevance,
timeliness, availability, and reliability. We ran the 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 proxies are presented in Chart 18.

Chart 18.--Comparison of FY 1997-Based and FY 2002-Based Capital Input
Price Index, Percent Change, FY 1998 Through FY 2007
------------------------------------------------------------------------
CIPI, FY 1997- CIPI, FY 2002-
Federal fiscal year based based
------------------------------------------------------------------------
1998.................................... 0.9 1.0
1999.................................... 0.9 0.9
2000.................................... 1.1 1.0
2001.................................... 0.9 0.9
2002.................................... 0.8 0.7
2003.................................... 0.6 0.5
2004.................................... 0.6 0.5
Forecast:
2005................................ 0.6 0.5
2006................................ 1.0 0.8
2007................................ 1.0 0.9
Average:
FYs 1998-2004....................... 0.8 0.8
FYs 2005-2007....................... 0.9 0.7
------------------------------------------------------------------------
Source: Global Insight, Inc, 2nd Qtr. 2005; @USMACRO/CONTROL0605
@CISSIM/TL0505.

Global Insight, Inc. forecasts a 0.8 percent increase in the FY
2002-based CIPI for 2006, as shown in Chart 17. This is the result of a
1.4 percent increase in projected depreciation prices (building and
fixed equipment, and movable equipment) and a 3.3 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 19. Accordingly, for FY 2006, we have adopted a 0.8 percent
increase in the CIPI.

[[Page 47411]]

Chart 19.--CMS Capital Input Price Index Percent Changes, Total and Components, FYs 1995 Through 2007
--------------------------------------------------------------------------------------------------------------------------------------------------------
Depreciation,
Total building and Depreciation,
Fiscal Year Total depreciation fixed movable Interest Other
equipment equipment
--------------------------------------------------------------------------------------------------------------------------------------------------------
Weights FY 2002......................................... 1.000 0.7458 0.3623 0.3835 0.1986 0.0556
---------------------------------------------------------
Vintage-Weighted Price Changes
--------------------------------------------------------------------------------------------------------------------------------------------------------
1995.................................................... 1.7 2.7 4.0 1.6 -1.2 2.5
1996.................................................... 1.4 2.5 3.8 1.4 -1.8 2.6
1997.................................................... 1.3 2.3 3.7 1.2 -2.0 2.8
1998.................................................... 1.0 2.1 3.4 0.9 -2.6 3.2
1999.................................................... 0.9 1.9 3.2 0.7 -2.6 3.2
2000.................................................... 1.0 1.7 3.1 0.4 -1.7 3.4
2001.................................................... 0.9 1.5 3.0 0.2 -2.2 4.3
2002.................................................... 0.7 1.3 2.9 0.0 -2.4 4.3
2003.................................................... 0.5 1.3 2.8 -0.2 -3.0 3.1
2004.................................................... 0.5 1.3 2.8 -0.2 -3.3 2.7
Forecast:
2005................................................ 0.5 1.3 2.8 -0.1 -3.7 3.0
2006................................................ 0.8 1.4 2.7 0.0 -2.3 3.3
2007................................................ 0.9 1.3 2.6 0.0 -2.0 3.2
--------------------------------------------------------------------------------------------------------------------------------------------------------

Rebasing the CIPI from FY 1997 to FY 2002 decreased the percent
change in the FY 2006 forecast by 0.2 percentage point, from 1.0 to
0.8, as shown in Chart 14. 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 two-tenths of a percentage point difference between the FY
2002-based CIPI and the FY 1997-based CIPI.
We did not receive any public comments on the CIPI.

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

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

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 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 FY 1999 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
FY 1999 IPPS 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 FY
1999 IPPS final rule, these 10 DRGs were selected in

[[Page 47412]]

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 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 noted 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 FY 2005 IPPS 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

[[Page 47413]]

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 was required to
meet all of the criteria to be included under the policy in subsequent
fiscal years. The geometric mean length of stay for DRG 263 showed only
a 6-percent decrease since 1999. As a result, DRG 263 did not qualify
to be included in the policy for FY 2005 under the criteria that were
applied in last year's final 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.

------------------------------------------------------------------------
DRG DRG Title
------------------------------------------------------------------------
12................................... Degenerative Nervous System
Disorders.
14................................... Intracranial Hemorrhage and
Stroke with Infarction.
24................................... Seizure and Headache Age >17 With
CC.
25................................... Seizure and Headache Age >17
Without CC.
88................................... Chronic Obstructive Pulmonary
Disease.
89................................... Simple Pneumonia and Pleurisy Age
> 17 With CC.
90................................... Simple Pneumonia and Pleurisy Age
>17 Without CC.
113.................................. Amputation for Circulatory System
Disorders Except Upper Limb and
Toe.
121.................................. Circulatory Disorders With AMI
and Major Complication,
Discharged Alive.
122.................................. Circulatory Disorders With AMI
Without Major Complications
Discharged Alive.
127.................................. Heart Failure & Shock.
130.................................. Peripheral Vascular Disorders
With CC.
131.................................. Peripheral Vascular Disorders
Without CC.
209.................................. Major Joint and Limb Reattachment
Procedures of Lower Extremity.
210.................................. Hip and Femur Procedures Except
Major Joint Age >17 With CC.
211.................................. Hip and Femur Procedures Except
Major Joint Age >17 Without CC.
236.................................. Fractures of Hip and Pelvis.
239.................................. Pathological Fractures and
Musculoskeletal and Connective
Tissue Malignancy.
277.................................. Cellulitis Age >17 With CC.
278.................................. Cellulitis Age >17 Without CC.
294.................................. Diabetes Age>35.
296.................................. Nutritional and Miscellaneous
Metabolic Disorders Age >17 With
CC.
297.................................. Nutritional and Miscellaneous
Metabolic Disorders Age >17
Without CC.
320.................................. Kidney and Urinary Tract
Infections Age >17 With CC.
321.................................. Kidney and Urinary Tract
Infections Age >17 Without CC.
395.................................. Red Blood Cell Disorders Age >17.
429.................................. Organic Disturbances and Mental
Retardation.
468.................................. Extensive O.R. Procedure
Unrelated to Principal
Diagnosis.
541 (formerly 483)................... Tracheostomy with Mechanical
Ventilation 96+ Hours or
Principal Diagnosis Except Face,
Mouth and Neck Diagnoses With
Major O.R. Procedure.
542 (formerly 483)................... Tracheostomy with Mechanical
Ventilation 96+ Hours or
Principal Diagnosis Except Face,
Mouth and Neck Diagnoses Without
Major O.R. Procedure.
------------------------------------------------------------------------

For the FY 2006 IPPS proposed rule, we conducted an extensive
analysis of the FY 2003 and FY 2004 MedPAR data to monitor the effects
of the postacute care transfer policy. We also conducted an overall
assessment of the postacute care transfer policy since its inception in
FY 1999. Specifically, we 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 considering our experience under
the current policy. We also 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 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:

[[Page 47414]]

------------------------------------------------------------------------
Percent change Percent change
in geometric in postacute
DRG DRG Title mean length of care
stay utilization
------------------------------------------------------------------------
1................ Craniotomy Age >17 5.26 2.70
With CC.
6................ Carpal Tunnel Release 4.76 56.92
15............... Nonspecific CVA and 30.00 27.75
Precerebral
Occlusion Without
Infarction.
40............... Extraocular 12.50 15.47
Procedures Except
Orbit Age >17.
42............... Intraocular 12.75 6.71
Procedures Except
Retina, Iris, and
Lens.
51............... Salivary Gland 5.56 20.00
Procedures Except
Sioloadenectomy.
55............... Miscellaneous Ear, 11.11 22.22
Nose, Mouth, and
Throat Procedures.
113.............. Amputation for 2.04 21.25
Circulatory System
disorders Except
Upper Limb and Toe.
118.............. Cardiac Pacemaker 11.11 30.29
Device Replacement.
223.............. Major Shoulder/Elbow 4.76 36.17
Procedure or Other
Upper Extremity
Procedure With CC.
317.............. Admittance for Renal 20.00 80.84
Dialysis.
319.............. Kidney and Urinary 4.76 24.49
Tract Neoplasms
Without CC.
345.............. Other Male 11.11 94.34
Reproductive System
O.R. Procedure
Except for
Malignancy.
447.............. Allergic Reactions 5.56 16.81
Age >17.
494.............. Laparoscopic 5.26 26.39
Cholecystectomy
Without C.D.E.
Without CC.
------------------------------------------------------------------------

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, we found that 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 had
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 we proposed a
change to the postacute care transfer payment policy in the FY 2006
proposed rule. 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 did not propose 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 did not propose any changes to the postacute care
transfer policy for these DRGs for FY 2006.
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 did not propose any change to how we would 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 231 DRGs. In the proposed rule, we stated that 223 DRGs were
included in this analysis, but subsequently posted a change to the
number of eligible DRGs on our Web site. This change reflected that we
had inadvertently excluded 8 DRGs. Of these 231 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, in the FY 2006
proposed rule, we indicated that we believed these DRGs have
characteristics that make them appropriate for inclusion in the
postacute care transfer policy. We also indicated that we believed it
is appropriate to consider major revisions to the criteria for
including a DRG within the postacute care transfer policy. First, our
analysis called 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 indicated 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 suggested 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 did 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 FY 2004 IPPS 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 indicated that we would
retain the criterion that at least 10 percent of all cases that are
transferred to postacute care should be short-stay cases where the
patient is transferred before the

[[Page 47415]]

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
precludes 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, for the FY 2006 IPPS proposed rule, we considered
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 we indicated in the FY 2006 IPPS proposed rule, as a result of
our analysis, we considered two options for revising the current
criteria. Option 1 was 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 in the proposed rule
and above in this final rule, 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. Therefore,
lowering the limit below 3.0 days would have little or no effect on
payment for DRGs with geometric mean lengths of stay in this range.
The second option that we considered in the FY 2006 IPPS proposed
rule was 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.
As explained above, option 2 would expand the application of the
postacute care transfer policy to 231 DRGs (rather than 223 DRGs as
stated in the proposed rule) that have both a relatively high volume
and a relatively high proportion of postacute care utilization. We
proposed this change to avoid applying the postacute care transfer
policy to DRGs with only a small number or proportion of cases
transferred to postacute care. We believe that the analysis that we
conducted suggests that substantial revisions to the criteria for
including a DRG within the postacute care transfer policy are
warranted. Therefore, in the FY 2006 IPPS proposed rule, we formally
proposed Option 2 as presented above. However, we invited comments on
both of the options and on the analysis that we had presented.
Comment: Many commenters expressed opposition to the postacute care
transfer policy in general. Some of these commenters argued that the
policy is contrary to the premise of the DRG system, which is to pay
the average of all cases in a DRG, regardless of cost and length of
stay. Some commenters also contended that the transfer policy is based
on a false assumption of gaming by providers, and that it punishes
providers for providing the appropriate level of care in the most
appropriate setting. Other commenters argued that the rationale for the
policy no longer exists because most of the providers of postacute care
services in question have transitioned from cost-based reimbursement to
PPSs themselves (SNFs as of October 1, 1998; HHAs as of October 1,
2000; IRFs as of January 1, 2002; LTCHs as of October 1, 2002; and IPFs
as of January 1, 2005). Further, commenters noted that each of these
postacute care payment systems have admission criteria to ensure that
patients are not discharged prematurely to a lower level of care.
Other commenters contended that the policy creates a geographic
bias against regions that have access to greater capital resources and
postacute care facilities and that traditionally have had shorter
lengths of stay for their patients than other regions of the country.
Some commenters argued that the provision creates a perverse incentive
for hospitals to keep their patients longer and to deny them the
appropriate care in postacute care facilities when it is needed.
Commenters continued to argue that this policy undermines the incentive
for hospitals to reduce lengths of stay. Several commenters pointed to
the tremendous administrative burden placed on hospitals with the
expansion of the policy, particularly with regard to transfers to HHAs.
Other commenters noted the administrative burdens of time, resource
utilization, and delay of payments already associated with these types
of transfers and subsequent claims corrections and reprocessing with
the existing 30 DRGs.
Response: We do not agree that the postacute care transfer policy
is inappropriate or contrary to the principles of prospective payment.
The policy is fully consistent with the principles of prospective
payment because the operative averaging principle in such systems
assumes that the full extent of care is consistently provided in an
acute care hospital. The averaging principle would be undermined if the
system did not provide for adjustments in cases where a large
proportion of the patient's care is provided by another entity. Thus,
the statute appropriately provides for treating discharges to postacute
care from certain DRGs as transfer cases. The statute also gives the
Secretary the discretion to select appropriate DRGs to which this
policy should be applied on the basis of a high volume of discharges to
postacute care and a disproportionate use of post discharge services.
Although it is true that many postacute settings to which the policy
applies are now subject to a prospective payment methodology, this fact
in no way undermines the appropriateness of a postacute transfer
policy. Rather, such a policy serves to ensure that Medicare does not
make full payments under two different payment systems when a patient's
full course of treatment is divided between two facilities. It is just
as inappropriate for Medicare to pay for the treatment of patients in
these cases, at the full DRG amount at the IPPS hospital and under
either a per discharge or per diem prospective payment in the postacute
care setting as it is to pay the full DRG payment twice

[[Page 47416]]

when a patient is transferred from one acute care hospital to another.
Therefore, because the majority of short-stay transfer cases receive
the majority of their care at postacute care facilities (except for
those DRGs that we have identified as having high costs on the first
day and that are paid under a special payment methodology), we continue
to believe that full payment to those facilities and reduced payment to
acute facilities for these cases are merited. Numerous studies of the
postacute care transfer policy by MedPAC, the Office of Inspector
General, and other health-related entities continue to support the need
for the policy, and some studies have supported expansion of the policy
to additional DRGs where appropriate.
Comment: Most commenters objected to the proposed alternate
criteria for DRGs to be included in the postacute care transfer policy.
Some commenters objected to our proposing changes in the qualifying
criteria for the postacute care transfer policy for the third
consecutive year. These commenters argued that such frequent changes in
policy gives the appearance of a contrived policy to suit CMS' desires
and makes the regulatory process unpredictable and unfair. Many
commenters asserted that there was little analytical support for
changing the criteria, and in particular that CMS had presented little
analytical support for the proposed thresholds of 2,000 and 20 percent
of cases transferred to postacute care. Some commenters also contended
that the proposed criteria appeared contrived to ensure that the
proposal would meet specific budgetary goals. Many commenters expressed
dismay that CMS would lower the limit so drastically from 14,000
postacute care transfer cases to 2,000, a ``dramatic drop of 86
percent.'' Many commenters also believed that the proposed alternate
criteria did not meet the standards established in the statute.
Specifically, these commenters indicated that the proposed threshold of
2,000 transfer cases does not constitute a ``high volume of
discharges'' under the statute. Similarly, many commenters stated that
a threshold of 20 percent of postacute transfer cases does not
constitute a ``disproportionate use of post-discharge services.'' These
commenters argued that, by definition, disproportionate use of
postacute care should be well above the norm. One commenter added that
it ``is a statistical impossibility for half of the universe of DRGs to
have `disproportionate use of post-discharge services.' '' Some
commenters suggested that CMS consider using alternatives to the newly
proposed criteria. One commenter proposed that CMS establish thresholds
at least one standard deviation above the average to determine when
DRGs meet a disproportionate use of postacute care. Another commenter
noted that thresholds of one standard deviation are employed elsewhere
in Medicare policy. One commenter noted that, under the original
implementation of the policy, the 10 DRGs that were included had a
postacute care utilization rate of at least 45.3 percent (not including
pairs) and when the policy was expanded to 30 DRGs, the lowest
percentage of postacute care utilization (not including pairs) was
34.86. Therefore, this commenter contended that a reasonable figure
that might represent a disproportionate use of postacute care
utilization would be no less than 34.0 percent.
Response: We do not agree that the proposed thresholds were
inappropriate or without analytical support. In particular, we do not
agree that the threshold of 2,000 discharges to postacute care falls
short of the statutory standard that DRGs included within the policy
must have a ``high volume of discharges.'' In analyzing the total
number of discharges to postacute care in each DRG, we found that the
median DRG had approximately 1,600 discharges to postacute care. Thus,
our proposed criteria of 2,000 discharges to postacute care is well
above the median DRG's number of discharges to postacute care and can
easily be argued to meet the statutory criteria of a ``high volume of
discharges.'' Nevertheless, in response to the many comments on the
proposed new thresholds, we have reexamined the data concerning the
volume and the proportions of discharges to postacute care across DRGs.
Our goal was to select thresholds that are appropriate to the purposes
of the postacute care transfer policy and that clearly meet the
statutory standards cited by the commenters.
We began by considering the suggestion of several commenters that
it might be appropriate to establish thresholds at levels of one
standard deviation above the average to determine high volume and
disproportionate use of postacute care services. As one commenter
pointed out, we have used such a standard for similar purposes in other
areas of the Medicare program. However, our examination of the DRG data
indicated that the average, or mean, is not the most appropriate
measure of central tendency in these cases. The distributions of
discharge volume and postacute care usage across DRGs are positively
skewed. As a result, a relatively small number of DRGs with very high
volume and rates of postacute care utilization have a disproportionate
impact on the average or mean. Therefore, a better measure of central
tendency in these cases is the median, or 50th percentile in the
rankings of discharges and rates of postacute care utilization from
highest to lowest. However, employing the median rather than the mean
makes it impossible to employ the standard deviation in setting an
appropriate threshold. In lieu of using the mean and standard deviation
as suggested by the commenter, it is possible to select a percentile
ranking in each array as an appropriate measure of ``high volume'' and
``disproportionate use.'' By definition, any volume of discharges above
the 50th percentile can be considered a high volume in the context of
the ranking from highest to lowest. Similarly, any rate of postacute
care utilization above the 50th percentile can also be considered
disproportionate use of such services. However, we agree with those
commenters who recommended thresholds based on standard deviations
above the mean, that it is appropriate to establish levels somewhat
above the measures of central tendency as thresholds for high volume
and disproportionate use. Therefore, we have determined that the 55th
percentile is an appropriate level at which to establish these
thresholds.
In the course of examining the relevant data, we also considered
several alternatives to the ratio of postacute care discharges to total
discharges as the most appropriate measure of the rate of postacute
care utilization across DRGs. We came to the conclusion that a more
appropriate measure of postacute care utilization is the proportion of
discharges to postacute care that occur prior to the geometric mean
length of stay for a DRG. We believe that the proportion of such short-
stay discharges is a more appropriate measure in this context than the
overall proportion of discharges to postacute care because only these
discharges are affected by the postacute care transfer policy.
Specifically, under the formula employed to determine payments for
transfer cases, discharges that occur at or after the mean length of
stay receive payments that equal the full DRG payment. Furthermore, we
believe a focus on short-stay discharges to postacute care is more
consistent with the statutory criteria of ``disproportionate use of
post-discharge services.'' These short-stay cases are atypical in that
they are discharged

[[Page 47417]]

before the geometric mean length of stay and result in the majority of
care being provided at postacute care facilities.
Therefore, we examined the percentile rankings of DRGs inVersion
23.0 of the DRG Definitions Manual (FY 2006) in relation to the volume
of discharges to postacute care, and the ratio of short-stay discharges
to postacute care. We employed the March 2005 update of FY 2004 MedPAR
data, the most recent data available to us. We determined that the
median number of discharges to postacute care across all DRGs was
1,619, and the 55th percentile was 2,050. The median proportion of
short-stay discharges to postacute care was 4.8 percent, and the 55th
percentile was 5.5 percent. Therefore, in place of the first two
criteria that we proposed in the FY 2006 IPPS proposed rule, we are
establishing the following two criteria in this final rule, effective
October 1, 2005:
The DRG has at least 2,050 postacute care transfer cases;
At least 5.5 percent of the cases in the DRG are
discharged to postacute care prior to the geometric mean length of stay
for the DRG.
In response to the comments suggesting that we provided little data
or analytic support for our proposal, we provided detailed analysis of
our findings on these issues in both the FY 2006 IPPS proposed rule and
this final rule. The data underlying our analysis are publicly
available through the CMS Web site at: http://www.cms.hhs.gov/data/order/default.asp.
Comment: Many commenters also objected to our proposal to eliminate
the requirement that a DRG experience a decline in length of stay.
These commenters contended that there was no evidence provided that
hospitals are changing their behavior, transferring patients earlier,
or taking advantage of the payment system. Another commenter argued
that removal of the requirement that DRGs experience a decline in
length of stay was contrary to the intent of the statute. This
commenter argued that the objective of the policy was ``to adjust
inpatient PPS payments to account for reduced hospital lengths of stay
due to a discharge to another setting.'' Therefore, the commenter
argued, if the MedPAR data demonstrates that postacute care utilization
for a DRG does not contribute to a significant decrease in the
geometric mean length of stay, the DRG should not be subject to the
policy. In general, commenters recommend a different approach to
further expansions of the postacute care transfer policy that they
assert would more accurately reflect the costs of patient care provided
in acute care hospitals.
Response: The statute does not establish any requirement that we
consider declining length of stay as a standard in selecting
appropriate DRGs for inclusion under the postacute care transfer
policy. We originally adopted such a standard because we found a
relationship between declining lengths of stay and increasing use of
postacute care services. As we discussed in the proposed rule, and
again above, our more recent analysis has called into question the
basis for the requirement that a DRG experience a decline in the
geometric mean length of stay over the most recent 5-year period. Our
finding that some DRGs with increases in postacute care utilization
during the past several years have also experienced increases in
geometric mean length of stay indicates that this criterion is no
longer effective to identify those DRGs that should be subject to the
postacute care transfer policy. Therefore, we are finalizing our
proposal to discontinue the current criterion for inclusion in the
policy that requires a DRG to experience a decline of at least 7
percent over the last 5 years in the geometric mean length of stay.
Comment: Some commenters objected to our current criterion that 10
percent of the postacute care transfer cases within a DRG must be
short-stay cases in order for the DRG to be included in the policy.
Some of these commenters argued that this would effectively mean that
up to 90 percent of all discharges within a DRG are not short-stay
discharges, and therefore, these DRGs would not meet the
disproportionate use requirement as provided in the statute.
Response: We do not agree with the commenters that inclusion of
this criterion in the policy was inappropriate. To the contrary, for
the reasons we have discussed above and in previous rules, we believe
that some consideration of the proportion of short-stay discharges to
postacute care--the discharges actually affected by the application of
the policy--is an appropriate component of the criteria employed to
determine the scope of the policy. However, we have decided not to
retain that specific criterion under the revised policy that we are
adopting in this final rule. This criterion is unnecessary because we
decided to adopt the criterion that at least 5.5 percent of cases in
the DRG must be discharged to postacute care prior to the geometric
mean length of stay for the DRG. By including this criterion as a
measure of disproportionate use of postacute care services, we believe
that it becomes redundant to retain another measure that uses short-
stay transfer cases.
Comment: Many commenters also did not support the criterion of
including paired DRGs in the policy, citing that most hospitals have
switched to a coding system that interfaces with the coder
electronically, thereby reducing the probability that a coder would
remove a CC code in order to change the payment for a case that was
transferred to postacute care. Further, some commenters noted that it
might be inappropriate to include paired DRGs in the special payment
methodology, as the transfer payment for the first day for many of the
CC DRGs in the CC/non-CC pair is typically higher than the full DRG
payment for the non-CC pair. As a result, these commenters contended
that coders would not have any incentive to exclude a CC from the
hospital's bill. Therefore, these commenters suggested that CMS
consider adopting a policy that excludes ``the non-CC of a paired DRG
when the transfer weight of the CC DRG would be greater than the full
DRG payment of the non-CC DRG.'' They noted that, by following this
recommendation, the policy would agree with CMS' rationale for the
inclusion of paired DRGs and also exclude those DRGs that do not meet
the qualifying criteria.
Response: It has been our practice to include paired DRGs since the
inception of the policy in 1998. This practice is in compliance with
Sec. 412.4(d)(1)(iv) of the regulations. While it is possible that
technical advances have resulted in electronic systems and more
automated coding, the selection of codes to include on the bill remain
within the responsibility and authority of the hospital and its staff.
Thus, we believe the coder will have the ability to select whether to
include or exclude a CC secondary diagnosis code on the hospital's bill
when a patient is transferred to postacute care. We include both DRGs
from a paired-DRG combination because if we were to include only the
more complex DRG (that is, the ``with CC'' DRG from a ``with/without
CC'' DRG combination) in the transfer policy, there might be an
incentive for hospitals not to include any code that would identify a
complicating or cormorbid condition. In our analysis of the included
pairs in our data, we have not found support for the commenter's
assertion that, in some instances, the transfer adjusted payment for a
``CC'' DRG is greater than the full payment for the non-transfer
adjusted ``without CC'' DRG. In cases where a ``CC:'' DRG is
transferred after a one day length of stay, the estimated transfer
adjusted payments for the ``CC'' DRGs

[[Page 47418]]

are less than the full payments for the ``without CC'' DRGs. As this
could introduce improper coding incentives, we continue to believe our
approach of identifying either DRG from a paired-DRG combination
individually for inclusion in the policy is appropriate.
Comment: Some commenters argued that including a transfer-adjusted
case weight in the DRG relative weight calculation has the effect of
maintaining the DRG weight at an artificially high level. Other
commenters indicated that, in the absence of this adjustment, the lower
costs of short-stay postacute care transfers will be reflected in lower
DRG case weights, making a postacute care transfer payment policy
unnecessary. Another commenter stated that the cost savings realized
through shorter lengths of stay, including those from transfer cases,
have already been considered and accounted for by Congress each year
when it sets the market basket update.
Response: We agree with the commenters that a high proportion of
short-stay to total cases in DRGs that are not subject to the postacute
care transfer policy will likely result in lower weights for these
DRGs. However, we believe these commenters actually support our
argument for expanding the postacute care transfer policy to more DRGs
where there is disproportionate use of postacute care services. While
including all cases in the relative weight calculation without any
adjustment would likely result in a lower DRG weight and payment for a
short-stay transfer case, it would also result in lower payments for
all of the remaining cases in the DRG where the hospital used more
resources to care for the patient. To the extent that there is
disproportionate use of postacute care services, hospitals would be
disadvantaged in the relative weight calculation and their payments
when the patient is not discharged early if we were to make no
adjustment for a transfer case when setting the DRG relative weight. By
reducing the impact that short-stay cases have on the DRG relative
weight, we believe our payment will more accurately reflect all of the
resources provided by a hospital during a typical stay. Thus, the
payment will better reflect all of the costs a hospital expends for the
stay when a full course of treatment is provided and our postacute care
transfer policy will appropriately provide less payment for a transfer
case in recognition of the lower cost of an abbreviated hospital stay.
Comment: Some commenters objected to the method by which CMS
proposed the change in the criteria for DRGs to qualify to be included
in the postacute care transfer policy. They argued that CMS should have
proposed the criteria, accepted comment on the alternate criteria, and
made appropriate changes based on those comments before applying them
to any additional DRGs. Instead, commenters contended that CMS
seemingly arbitrarily created the alternate set of criteria and applied
them to new DRGs in the same rule.
Response: We are making the change to our postacute care transfer
policy through a notice and comment rulemaking procedure before
applying the new policy to any DRGs. The implication in these comments
that we have already expanded the policy to additional DRGs is
incorrect. We will be applying the revised postacute care transfer
policy for discharges occurring on or after October 1, 2006, after
having provided notice of our proposal to revise the policy in the
proposed rule; allowing for a 60-day public comment period; and making
changes to the policy in response to public comment.
Comment: Some commenters objected to the implication that early
discharges to postacute care are done for economic reasons instead of
patient need. Other commenters believed hospitals may keep patients in
the hospital longer to avoid the reduced IPPS payment. These commenters
indicated that the policy would increase, not reduce, Medicare spending
to treat the same patients. Other commenters encouraged CMS to complete
its analysis of the MedPAC recommendation to adopt severity DRGs before
expanding the postacute care transfer policy. These commenters argued
that CMS should apply the postacute care transfer policy to DRGs
consistent with the goal of ``aligning patient severity with payment.''
These commenters argued that, if severity DRGs were implemented, there
would be no need for a postacute care transfer policy because the
system would recognize higher payment for more resource intensive
patients.
Response: Our proposal to expand the postacute care transfer policy
was not intended to imply that hospitals will prematurely discharge
patients early to postacute care for financial reasons. Rather, our
policy recognizes that hospitals expend fewer resources for patients
who are discharged prior to the geometric mean length of stay and
Medicare's payment should be less. We do note that some of the
commenters themselves imply that hospitals will react to the financial
incentives of the revised postacute care transfer policy by keeping
patients in the hospital longer to avoid payment reductions that will
occur if patients are discharged early to postacute care. If true, it
is hard to understand what the hospitals would accomplish because even
though they would receive the full DRG payment, they would also have
costs associated with retaining patients who would be more
appropriately discharged to another setting in the hospital.
It is not clear to us why an analysis of MedPAC's recommendation
that we adopt severity DRGs is relevant to the postacute care transfer
policy. To our knowledge, such a change to the DRG system would be
intended to result in better recognition of severity levels in making
DRG assignments, but would not involve any direct consideration of
whether a hospital provides the full course of treatment to a patient.
We are unaware that a severity DRG system, such as the APR-DRGs, would
use length of stay and early discharge to postacute care as a basis for
making a DRG assignment. Nevertheless, we will consider this issue as
we study the MedPAC recommendation.
Comment: Commenters argued that we should not further expand the
postacute care transfer payment policy until a full analysis of last
year's changes to the policy is completed. According to the commenters,
we should analyze whether the postacute care transfer policy has led to
unnecessarily extended hospital stays in order to avoid the adjustment
and affected quality of care. Commenters also noted that studies show
that the majority of patients who use postacute care have longer (7.51
days), not shorter (4.93 days), hospital stays. These commenters argued
that CMS should focus its efforts on improving quality of care, not on
further expanding the postacute care transfer provision.
Response: In the FY 2005 IPPS final rule (69 FR 49073), we
established a policy for how to apply the criteria for the postacute
care transfer policy to cases that were previously assigned to a DRG
that has split, when the split DRG qualified for inclusion in the
postacute care transfer policy. This policy was a rather limited change
to our postacute care transfer policy that has little bearing on the
changes that we are making for FY 2006. Thus, we do not believe further
analysis of this change is necessary before undertaking the changes we
are adopting in this final rule.
We believe the point made by the commenter provides further grounds
to expand the postacute care transfer policy. The policy only applies
to patients that are discharged from the hospital at least one day
before the geometric mean length of stay. The policy does not apply to
the longer stay patients that are, according to the

[[Page 47419]]

commenter, more resource intensive. Thus, we make a reduced payment
only for those short-stay patients transferred to postacute care that
are, following the logic of the comment, less costly to the hospital.
Comment: Some commenters argued that studies have shown that many
rural areas now have the same types of postacute care facilities as
urban hospitals and expanding the postacute care transfer policy will
harm rural areas by reducing payments to rural hospitals. Many
commenters suggested that, if CMS is determined to make an expansion to
the policy without providing analysis supporting the changes, any
changes should be made in a budget neutral manner. Other commenters
suggested that we should implement the policy expansion over 3 years to
lessen the financial impact in the first year. Commenters also disputed
our savings estimates indicating that once the effects of IME,
disproportionate share, capital and outlier payments are taken into
consideration, the total annual reduction would be closer to $894
million. They argued that hospitals can ill-afford this kind of
reduction in payments at a time when they are already experiencing
nursing shortages, incurring losses for treating Medicare
beneficiaries, and expecting tremendous increases in costs associated
with the aging baby boom generation.
Commenters also indicated that the policy should not apply in
situations where a patient is living in a SNF. In these cases, the
commenters argued that an early discharge of the patient to a SNF is
really a discharge to the patient's home and the policy should not be
applied.
Response: We do not believe that the law permits us to distinguish
between urban and rural areas when applying this policy. Furthermore,
we do not believe there is a policy basis for such a distinction
because the principle of making lower payments to the acute care
hospital based on the majority of care being provided in a postacute
care setting would apply equally to urban and rural hospitals. The law
does not require or authorize us to make these changes over a
transitional period or in a budget neutral manner as suggested by the
commenters. For this reason, we are implementing the policy as we have
described. We note that our savings estimates have been updated to
reflect the policies we are adopting in this final rule. With respect
to a discharge to a SNF, we note that section 1886(d)(5)(J)(ii)(II) of
the Act makes clear that the postacute care transfer policy must apply
in this situation.
The impact section in Appendix A of this final rule discusses our
findings on the effects of adopting our final rule policy. The DRG
relative weights in Tables 5 and 7 of the Addendum to this final rule
also include the effect of changing the postacute care transfer policy.
We note that we will 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 final rule,
additional transfer cases will 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.
In summary, after consideration of the comments received, in this
final rule, we have revised the criteria that we proposed for
determining which DRGs qualify for postacute care transfer payments.
The final policy, which we are incorporating into the regulations at
Sec. 412.4, specifies that, effective October 1, 2005, we are making a
DRG subject to the postacute care transfer policy if, based on the
Version 23.0 GROUPER (FY 2006), using data from FY 2004, the DRG meets
the following criteria:
The DRG must have a geometric mean length of stay of at
least 3 days;
The DRG must have at least 2,050 postacute care transfer
cases;
At least 5.5 percent of the cases in the DRG are
discharged to postacute care prior to the geometric mean length of stay
for the DRG; 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 three criteria above.
If a DRG meets the above criteria based on the Version 23.0 GROUPER
and FY 2004 MedPAR data, we are making the DRG subject to the postacute
care transfer policy. We will not revise the list of DRGs subject to
the postacute care transfer policy annually unless we are making a
change to a specific DRG. Using the version of the Medicare GROUPER for
the year when a new or revised DRG first becomes effective, we will
make the DRG subject to the postacute care transfer policy if its total
number of discharges and proportion of short-stay discharges to
postacute care exceed the 55th percentile for all DRGs. We are
establishing this policy to promote certainty and stability in the
postacute care transfer payment policy. Annual reviews of the list of
DRGs subject to the policy would likely lead to great volatility in the
payment methodology with certain DRGs qualifying for the policy in one
year, deleted the next year, only to be readded the following year.
However, over time, as treatment practices change it is possible that
some DRGs that currently qualify for the policy will no longer exhibit
a disproportionate use of postacute care. Similarly, there may be other
DRGs that currently have a low rate of discharges to postacute care,
but which will have very high rates in the future. For these reasons,
we expect to periodically review the criteria that are used to make a
DRG subject to the postacute transfer policy. At this time, we have not
decided on how frequently to perform this review but are considering
undertaking this analysis every 5 years. We welcome public comments on
this issue.
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 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, in the past,
three of the DRGs subject to the postacute care transfer policy have
exhibited 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.
Comment: Commenters indicated there was not a clear explanation for
when a DRG would be subject to the special payment methodology. For
example, commenters indicated that DRGs 107 (Coronary Bypass with
PTCA), 108 (Coronary Bypass with Cardiac Catheterization) and 109
(Coronary Bypass without PTCA or Cardiac Catheterization) are all
related, but only DRG 109 is paid using the special payment
methodology. The commenters argued that resource utilization for all
three of these surgical DRGs would be similar, and therefore, all three
DRGs should be paid using the special payment methodology.
Response: To identify DRGs that are subject to the special payment
methodology, we compare the average charges for all cases with a length
of stay of 1 day to the average charges of all cases in a particular
DRG. To qualify for the alternative methodology, the average charges of
the 1-day discharge

[[Page 47420]]

cases must be at least 50 percent of the average charges for all cases
in the DRG. We only apply this methodology to those DRGs that have a
mean length of stay that is greater than 4 days because cases with a
shorter average length of stay will receive the full DRG payment for
the case on the second day of the stay regardless of the payment
methodology used. In addition, if a DRG in a paired set of DRGs based
on the presence or absence of a comorbidity or complication meets the
criteria for being included in the postacute care transfer policy and
qualifies for the special payment methodology, we include both DRGs in
the special payment methodology in order to eliminate any incentive to
code incorrectly to receive a higher payment for a case. We have
identified those additional DRGs that are subject to the special
payment methodology in Table 5 of the Addendum to this final rule.

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

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: 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. The Hospital Compare Web site has also been developed to
provide information appropriate for Medicare beneficiaries. The
consumer Web site is intended to be an important tool for individuals
to use in making decisions about health care options. The information
in this Web site assists beneficiaries by providing comparison
information for consumers who need to select a hospital. It also serves
as a way to encourage accountability of hospitals for the care they
provide to patients.
The 10 measures that are 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 chose these 10 quality
measures in order to collect data 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 have participated
in the National Voluntary Hospital Reporting Initiative (NVHRI), and
are continuing to submit 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 is currently done. 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, when developed, the Federal health
architecture data standards, and to ensure that the data necessary for
quality measures are captured. 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. In the FY 2006 IPPS proposed rule, we indicated that we
were exploring requirements and other options to encourage the
submission of electronically produced data, and invited comments on
such requirements and options.
Comment: One commenter expressed support for the creation of a
system to move information from electronic health records to a CMS data
repository.
Response: We agree, and this is one of the reasons why we proposed
the question in the preamble of the Notice. We appreciate this
commenter's support and will strive to minimize data burdens while
improving hospital quality by moving to an industry-accepted system of
electronic health records.
Comment: One commenter supported the use of a single national
database of quality measures that could be used by all stakeholders.
However, this commenter believed that the business case for the
investment in electronic medical records is not clear.
Response: CMS strives to minimize data reporting burdens, while
working with providers to improve hospital

[[Page 47421]]

quality. We will study and assess cost, burden, and benefits of moving
to an industry-accepted system of electronic health records.
Comment: Several commenters suggested that CMS should provide
financial support and appropriate technical assistance to hospitals
prior to, or in conjunction with any requirements for hospitals to
implement electronic medical records and submit the data directly to
the CMS data warehouse. The commenter added that, eventually, using
electronic medical records to submit data would add additional burdens
to the hospital, such as cost and the need for additional resources.
Response: We do not currently have the authority to pay for
electronic data submission. However, we do appreciate the challenges
and work that lie ahead to achieve the vision of using electronic
medical records to submit data. We will keep these issues in mind as we
move forward pursuing electronic data submission.
This method of collecting data, if well designed, should expedite
the submission of quality data. We found in the Surgical Care
Improvement Project (SCIP) that hospitals with electronic records were
able to abstract SCIP data in as little as 10 minutes. It may require
designing a report specifically for the Medicare measures, but after
that work is complete, we would expect no increase in resources in
hospitals with electronic records. At worst, hospitals with EMRs should
only have the additional expense of printing the patient record. After
that is done, the abstraction cost would be no greater burden on the
hospital.

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'' section of the Web site. 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 participated 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 QIO.
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
tool 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
information 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, to begin
submissions 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.
We proposed in the FY 2006 IPPS proposed rule, and are adopting as
final policy in this rule, that, for FY 2006, 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 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 had 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 were no errors in the submitted
data. The warehouse was closed at that time in order to draw the
validation sample and to begin preparing the public file for the
Hospital Compare public reporting Web site. Data from fourth quarter
2004 discharges (October through December 2004) are the last quarter of
data with a submission deadline (May 15, 2005) preceding 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 on
the 10 measures.
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 full annual payment
updates will be based on the successful submission of data to CMS via
the QIO Clinical Warehouse by the established deadlines.
For FY 2005, hospitals could have withdrawn 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 to qualify for the full update each 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
proposed to place the following additional requirements on hospitals
for the data for the FY 2006 payment update. We are finalizing the
proposed additional requirements in this rule. These requirements, as
well as additional information on validation requirements, are being
placed on QualityNet Exchange.
The hospital must pass our validation requirement of a
minimum of

[[Page 47422]]

80 percent reliability, based upon our chart-audit validation process,
for the third quarter data of calendar year 2004. These data were due
to the clinical warehouse by February 15, 2005. We use appropriate
confidence intervals as explained in the proposed rule to determine if
a hospital has achieved an 80-percent reliability. The use of
confidence intervals allows us to establish an appropriate range below
the 80-percent reliability threshold that demonstrates a sufficient
level of validity to allow the data to still be considered valid. We
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
reliability, the hospital data are considered validated. As proposed,
we are using 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 use a two-step process to determine if a hospital is submitting
valid data. In the first step, we calculate the percent agreement for
all of the variables submitted in all of the charts. If a hospital
falls below the 80 percent cutoff, we then restrict the comparison to
those variables associated with the 10 measures required under section
501(b) of Pub. L. 108-173. We recalculate the percent agreement and the
estimated 95 percent confidence interval and again compare to the 80
percent cutoff point. If a hospital passes under this restricted set of
variables, the hospital is considered to be submitting valid data for
purposes of the RHQDAPU.
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 does
not meet the required 80 percent threshold, the hospital has 10 days to
appeal these results to their QIO. The QIO will review the appeal with
the hospital and make a final determination on the appeal. If the QIO
does not agree with the hospital's appeal, then the original results
stand. 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 needed to submit the charts
requested for reabstraction by 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 not 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 score very high.
We believe we have adopted the most suitable statistical tests for
the hospital data we are trying to validate. However, in the FY 2006
IPPS proposed rule, we invited public comments on this and any other
approaches. We expressed particular interest 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 have indicated that 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.
Comment: Several commenters requested that we provide additional
time for the hospitals to appeal their validation determinations. Many
commenters stated that the current timeframe of 10 days is not
sufficient time to decide to appeal the results. Commenters also asked
CMS to specify if the 10-day time period is measured in calendar days
or business days.
Response: The 10 days are business days. This timeframe is designed
to provide sufficient time for hospitals to gather relevant
information. Hospital will not need to produce more information in
deciding whether or not to appeal the results of the abstraction.
Hospitals are required only to submit their request for appeal form
within the 10-day time period. We believe 10 business days is
sufficient time for a hospital to decide whether or not it wants the
contractor to review its original abstraction. However, it does
expedite the final determination and minimizes data lag for public
reporting and payment determination.
Comment: Four commenters requested that CMS allow more time for the
hospital to produce the medical record and submit the record for the
validation review.
Response: We believe the timeframe provides sufficient time for
hospitals to gather the medical record and copy and forward it to the
contractor. After the warehouse closes for quarterly submissions, a
sample of five charts is selected for validation. The CDAC requests the
charts from the hospital. Hospitals are provided 30 days, as stated in
the Hospital Validation Flow Chart which can be found on QNet Exchange
Web site. Upon completion of validation, the hospital receives a
submission report that states whether the five charts meet the
validation criteria. If the hospital fails validation, the hospital is
provided 10 business days to notify the QIO that it wishes to appeal
the validation decision. This timeframe helps expedite the final
determination and minimizes data lag for public reporting and payment
determination.
Comment: Four commenters requested that CMS delay hospital
reporting until we have aligned our definitions and abstraction
guidelines with JCAHO.
Response: The third quarter 2004 definitions and abstraction
guidelines are better aligned to JCAHO than previous quarters, and with
these third quarter 2004 definitions and abstraction guidelines, we
believe we have made great strides in the long-term alignment process
with JCAHO. Although CMS and JCAHO will not be fully aligned with third
quarter and fourth quarter discharges, validation results for these
periods are calculated from only those

[[Page 47423]]

aligned data elements. We anticipate full alignment with first quarter
2005 discharges.
Comment: Many of the comments requested requiring only submission
of hospital reporting data in order to be eligible for the full annual
payment update, and separating the process of validation from
eligibility for the market basket update. Commenters frequently cited
difficulties with the data infrastructure, specifically the
communication of validation results to the hospital that was causing
confusion for the hospitals. The commenters also cited technical
difficulties with data submission to the warehouse.
Response: A production problem occurred while releasing the first
set of third quarter 2004 validation results. A CMS contractor had
forwarded individual validation results with the wrong data to a small
number of hospitals. The run was discontinued immediately upon
discovery. All hospitals involved were notified of the error and have
verified the destruction of the files. In addition, hospitals also
encountered abstraction and processing issues in this process. CMS and
its contractors readily resolved these issues and there has not been a
negative impact on hospitals or their patients. Ninety-eight percent of
the hospitals that submitted data for the third quarter of 2004 that
are eligible for the market basket update will receive the full update
based on validation results. The production problem did not contribute
to the 2 percent of the hospitals whose data did not validate. We
believe that it is important for the data in the clinical warehouse on
which full payment is determined to be reliable and valid.
Comment: Three commenters stated that five charts per hospital for
validation is not a sufficient number to judge the quality of the care
delivered in the hospital.
Response: CMS factored cost, burden, and precision of the
validation results when deciding to implement the current validation
sampling methodology. The goal of the chart audit validation process is
to ensure that the hospital is abstracting and submitting accurate
data. In order to calculate quality measures, which are used to
determine the standard of care, we need to have complete and accurate
data. Errors of omission and transcription errors contribute to the
overall errors in calculating quality measures. We agree that it is
important to differentiate between these errors in order to provide
feedback to hospitals. The process we have in place to provide this
feedback gives each hospital the detailed abstraction results from the
CDAC reabstraction so that hospital staff may determine the types of
errors and take appropriate action.
The five sampled charts usually yield 100 data elements that are
used to determine the validation rate. This sample of data elements is
sufficient to produce reliable validation rate estimates. Analysis of
previous quarters' submitted data indicates that the clustering effect
caused by the five chart sample boosts sampling variability by a
relatively small proportion. Despite this increase in sampling
variability, the sample still produces reliable validation rate
estimates. The relative sampling variability is largely determined by
the number of data elements abstracted, while incorporating the
increased variability caused by the number of records. Analysis of
previous quarters' submitted data indicates that the sampling
variability is increased by a relatively small proportion.
Comment: Seven commenters requested that we use a test process for
our data submission and our validation parameters.
Response: We agree that there should be a test process. In order to
address this concern, we encourage hospitals to submit data
continuously throughout the quarter; thereby data submission problems
can be addressed and corrected early. Also, CMS, JCAHO, and the
Hospital Reporting QIOSC conduct National calls once a month with
vendors to provide further assistance. The calls give vendors the
opportunity to ask questions and get timely feedback to make necessary
changes to the data file prior to submission.
Hospitals have continued access to view and change their own data
in the warehouse up to the time the warehouse is closed. The hospitals
can pull the validation sample and begin preparing the file used for
public reporting on the Hospital Compare Web site at http://www.HospitalCompare.hhs.gov. CMS encourages hospitals to test their
data submission processing during this time by submitting quality data
into the QIO clinical warehouse before the deadline and reviewing their
submission reports to ensure that all data were successfully submitted
into the warehouse.
The validation parameters for the CART software are extensively
tested through internal quality assurance and independent validation
and verification. The CMS contractor uses an internal quality control
process to verify that all applications and data processes produce the
results outlined in the specifications. CMS provides further quality
assurance in some areas using an Independent Validation & Verification
(IV&V) process by another contractor. CMS will extend IV&V to all areas
involving the annual payment update. In addition, a pre production
check has been implemented and will be enhanced to review any output
prior to production release. Finally, CMS has a QualityNet Help Desk
that can assist providers with questions or concerns.
Comment: One commenter suggested that CMS resolve all of the vendor
upload issues prior to increasing the reimbursement for pay-for-
performance programs.
Response: The hospital-to-vendor relationship is external to CMS.
Therefore, hospitals are responsible for selecting and ensuring that
vendors submit valid data into the QIO clinical warehouse. CMS does not
have contractual agreements with vendors. Communication with vendors is
the hospitals' responsibility. CMS holds hospitals responsible for
submitting accurate data. Therefore, hospitals that have a contractual
agreement with a vendor must collaborate with the vendor to ensure the
data file is submitted accurately. When the data are uploaded to the
QIO Clinical Warehouse, we encourage providers to access their Data
Submission report. To access this report, log in to QNet Exchange and
click on the QIO Clinical Warehouse Feedback Reports. The Data
Submission report will give the provider a detailed summary of the
cases that entered the clinical warehouse.
Comment: Sixteen commenters recommended that CMS state submission
and validation parameters clearly and document them. They also
recommended that CMS provide 120-day notice prior to any changes to the
parameters. The commenters added that there should be less frequent
changes to the requirements.
Response: CMS and its contractors strive to give providers
sufficient time to incorporate changes to submission and validation
parameters. However, processing and logistical issues sometimes require
more expedited implementation of these changes, because measure and
policy changes frequently occur. To address this issue, CMS and JCAHO
released an aligned manual on January 1, 2005. This release occurred
108 days prior to implementation of any of the provisions in the
manual. Since that time, CMS and JCAHO have agreed to release documents
at a minimum of 120 days prior to implementation. All manuals contain
data file submission requirements and programming formats for each
quarter.
Comment: Eight commenters requested that CMS be consistent when
releasing any communications related to

[[Page 47424]]

hospital reporting, and that there should be one central point for all
of these communications.
Response: Hospitals are required to establish relationships with
the Quality Improvement Organizations for their States and,
furthermore, must establish a formal relationship with the QIO Clinical
Data Warehouse and its Web site, http://www.QNetexchange.org. All
policies and procedures concerning hospital reporting are communicated
to the hospital community through these two channels. CMS communicates
information about hospital reporting directly to the QIOs through the
QIO Hospital Public Reporting contact for each State, using a formal
system of memoranda (``SDPS memos'') which can be viewed at http://qionet.sdps.org. The QIOs are then responsible for dissemination of the
information to the appropriate hospital staff in each State. Responses
to specific questions are addressed through the Quest system; CMS
monitors responses and clarifications that are published on Quest. QIOs
are expected to provide technical assistance, as well as provide e-mail
blasts to all hospitals on any important topics and developments
pertinent to reporting hospitals. Hospitals also receive direct
communication or can seek assistance from the QIO Clinical Data
Warehouse, by Internet (through QNet Exchange).
CMS and the JCAHO have formally agreed to work together to maintain
common performance measures and to ensure that any communication
concerning these measures is coordinated and consistent.
In addition to this formal system of communication, hospitals can
obtain information or seek answers to specific questions on the monthly
Hospital Open Door Forum (see http://www.cms.hhs.gov/opendoor/schedule.asp for schedule) on the hospital quality initiative.
Hospitals can also monitor CMS's activities to promote quality of care
in hospitals by checking http://www.cms.hhs.gov/quality/hospital/. This
site includes information about CMS's involvement in the Hospital
Quality Alliance, a public-private partnership to promote hospital
public reporting (see http://www.hospitalcompare.hhs.gov).
Comment: A few commenters suggested that the only requirement to
receive the full market basket update should be submission of data to
the warehouse. These commenters stated the intent of the law was to
limit the requirement to data submission, and not require validation.
In addition, there were comments that the validation process is flawed
and any link to payment should be delayed until data infrastructure and
processes are improved.
Response: We disagree with the comments indicating that section
501(b) of Pub. L. 108-173 only requires the submission of data. The
commenters stated that additional requirements were not contemplated by
Congress. However, the validation process does not contradict Pub. L.
108-173. Section 501 (b) also states the submission of the data is to
be in the ``form and manner specified by the Secretary''. We believe
that validation requirements fall under this broad authority. This
requirement does not appear to be to stringent based on validation
results showing 98 percent of providers that submitted data for the
third quarter 2004 are eligible for the full market basket update.
While hospitals did encounter abstraction and processing issues, these
problems were immediately resolved. CMS' policy on validation
requirements are very lenient, and offer hospitals several
opportunities to validate their data in order to receive the full
update.
Comment: Two commenters recommended using the first quarter 2005 as
the first quarter in which the validation process is used for
calculating the full payment to occur in 2007.
Response: We appreciate the comment and will incorporate this
comment into the decisionmaking process for the FY 2007 payment
determination. It has been our intention to use continuous quarters of
data, but CMS and JCAHO measures differed in several substantial areas
(pre-alignment) prior to the third quarter 2004 calendar year. Based
largely on these differences in measures, we chose to use validation
results from third and fourth quarter 2004 calendar year discharges
only using aligned measures to provide the highest possibility for
validation for hospitals. The CMS and JCAHO measures were approximately
95 percent aligned for the third quarter 2004 calendar year discharges.
Our validation results for this period were calculated from only those
aligned data elements.
Comment: Two commenters stated that misalignment with the JCAHO
measures caused many issues with the initial submission of the 10
starter measures.
Response: As of July 1, 2004 discharges, all data elements within
the 10 starter set were aligned. CMS and its contractors worked
diligently to ensure that alignment issues did not impact eligibility
for receiving the market basket update. All providers can review their
quality data in the clinical warehouse after submitting their data.
Hospitals also have the opportunity to appeal their validation results
if their validation rate is below 80 percent. Therefore, hospitals are
provided the opportunity to appeal if it appears validation was denied
due to an alignment issue. CMS and JCAHO continue to work
collaboratively to accomplish full alignment across all of the quality
measures. We anticipate full alignment with first quarter 2005
discharges.
Comment: One commenter suggested that there be better communication
between the abstractors and providers. Providers do not know
appropriate standards for abstraction.
Response: CMS contracts with the QIO in each State to provide
technical assistance and to work with providers on the abstraction
process. We believe this State-level conduit provides local, accurate,
and accessible communication to providers about the abstraction
process. In addition to the QIO assistance, guidelines for abstraction
prior to discharges January 1, 2005 were available on the QNet Exchange
Web site under the CART Content link under Related Resources. These
guidelines were in a downloadable PDF format. These Topic Specific
Resources were designed to assist abstractors in determining how a
question should be answered. The abstractor should first refer to the
specific notes and guidelines under each data element. All of the
allowable values for a given question were outlined, and notes and
guidelines were often included which provided the necessary direction
for abstracting a data element. Beginning with discharges January 1,
2005, the guidelines all abstractors use are published in the
Specifications Manual for National Hospital Quality Measures. These
guidelines are available to all providers in a PDF format and can be
downloaded from the QNet Exchange Web site at https://qnetexchange.org/public/hdc.do?hdcPage=rltd-rsrcs. CMS also has an online questions and
answers database that provides a centralized and standard solution for
the management of questions and answers submitted by the user
community. This database may be accessed on the QNet Exchange Web site
mentioned above by selecting the ``Resources'' heading at https://qnetexchange.org/public/home.do. CMS welcomes comments from the
provider and QIO communities on additional ways to improve
communication.
Comment: Seven commenters stated that the validation process should
only incorporate data associated with the 10 specified measures.

[[Page 47425]]

Response: Although hospitals are urged to submit more than the
starter set of measures, hospitals submitting quality data will only be
denied the full market basket update in the validation process if the
10 specified measures do not meet the 80 percent upper bound of a 95
percent confidence interval. The current process allows CMS to
incorporate the reliability of both the 22 HQA measures as a whole, and
exclusively the 10 specific measures.
Comment: Five commenters stated that we have to be careful not to
withhold the full update from hospitals due to errors on the part of
abstractors or CMS.
Response: We agree that it is important not to withhold the full
update from hospitals due to such errors. With this in mind, in the
chart audit validation process, the CDAC reabstracts the medical
records and compares it to the original abstraction submitted. The
abstraction is compared at the element level and a percent agreement is
calculated. The chart audit validation process determines a hospital's
reliability score. The score is the number on which an appeal is based.
If a provider does not meet the 80-percent reliability threshold, it
can appeal. Beginning with third quarter 2004 validation results, the
final appeal decision will be made by the QIOs. This allows for an
independent review and it is designed to find coding errors on the part
of abstractors. In this process, the QIO can either uphold or reverse
the CDAC validation decision. The QIO receives from the hospital the
element or elements that are to be evaluated during the appeal process,
along with the hospital rationale for the difference between the
hospital's abstraction and the CDAC's abstraction. The QIO has
available to it the hospital's answer and the CDAC decision when it
reviews the hospital rationale and a copy of the medical record sent to
it by the CDAC. The QIO then makes a final decision on the response to
the element or elements. This final decision is whether the element(s)
response will remain as the CDAC indicated or whether the QIO will
reverse the CDAC's decision and agree with the hospital's response.
QIOs are obligated to make appeal decisions based on the data that was
submitted to the clinical warehouse from the hospitals. In addition,
the abstraction guidelines are clear and straight forward. The
information requested by each question in the abstraction tool is
either there, as stated, or it is not. We have devoted a great deal of
resources to ensuring that the CDAC abstraction process is consistent
and accurate through our training and internal quality assurance. We
consistently achieve inter-rater reliability rates approaching 100
percent in the CDAC.
Comment: Two commenters stated that hospitals should not fail
validation based on the parent element not validating, and therefore
the child element not validating.
Response: Parent/child relationships are defined in the analytic
flows. The responses to the parent element, and possibly the child
element, determine the measure category assignment. The response to
this ``parent'' element also determines whether the ``child'' questions
are then answered or not. Validation follows this same relationship. In
validation, if the parent response causes a ``stop abstraction,'' then
no further elements are answered. Only the elements answered (parent
only) are included in the validation score. If the parent response
causes the child element(s) to be answered, then both the parent and
child elements are validated and count in the validation score. For
example, the parent is Working Diagnosis of Pneumonia and the response
is no, the measure category assignment is ``B'' (not in the measure
population), this record would not need to be processed through the
individual measure algorithms. In another example, the parent is
Working Diagnosis of Pneumonia and the response is ``yes.'' Per the
algorithm, if the ``child'' element is Comfort Measures Only and if the
response is ``no,'' continue to the ``child'' element Transfer From
another ED and if that response is no, continue to the next ``child''
element Admission Source and continue through the algorithm based on
the response to each ``child'' question.
Comment: One commenter stated that the current validation process
does not match the intended outcome. The commenter believed that the
intended outcome is to validate that the publicly reported numbers are
accurate. The commenter indicated that, currently, it is only an
element by element validation of data abstraction.
Response: The purpose of the validation of these data is to
determine the hospital's ability to correctly abstract and report
clinical data as evidenced by the consistency between what the hospital
reports, and reabstraction by the CDAC. Because these data are used for
quality improvement, public reporting, and also for determining
eligibility for the APU, it is important for CMS to assess the
reliability of this information. It is not a validation of the quality
of the care exhibited by the measures. All of the elements used for
determining data validation are used to calculate the quality measures.
The brief history of hospital submission and validation indicates that
hospitals are improving the element level rate of validation. We expect
this improvement to continue over time. As this rate increases, we
believe that the overall accuracy of the measures will also improve
over time. In the near future, CMS and its contractors will assess the
accuracy of these hospital submitted measures, relative to surveillance
sample data abstracted by CDAC. This process is necessary to eventually
improve quality of care for patients.
Comment: One commenter stated that an additional component of
variability that is attributable to CMS ratings should be factored into
the computation of the confidence interval for the agreement statistic.
Response: The validation rates are based on the reliability of
hospital submitted data, relative to an independent abstraction of the
sampled charts by the CDAC. The CDAC abstraction is considered to be a
gold standard, relative to the hospital abstracted data. We believe
that the percentage agreement between the hospital's submitted elements
and CDAC-abstracted elements is a valid estimator of a hospital's
submitted data.
Comment: One commenter requested that there be accommodation for
exceptions to be included in the design of measurement requirements.
Response: The fundamental reason for standardized reporting is to
identify a means for hospitals, consumers and others to compare
hospital performance using a common metric. The measures are defined to
a very detailed level (``microspecifications''), which include flow
diagrams that portray acceptable documentation. In the current
microspecifications of the measures, the ``accommodation for
exceptions'' is built into the measures through identification of
exclusionary factors and excluded populations. Hospitals and readers
can view the technical descriptions of the measures in the
Specifications Manual for National Hospital Quality Measures at http://qnetexchange.org/public/hdc.do?hdcPage=rltd-rsrcs for the most
definitive description of the inclusion and exclusion criteria for each
reported measure.
Comment: Three commenters requested that CMS clarify the validation
process and clearly state the parameters.
Response: We appreciate the comment and will strive to clarify the
existing documentation about the validation process on the QualityNet

[[Page 47426]]

Exchange internet site. CMS also contracts with QIOs to work with
hospitals in explaining the validation process and its parameters.
Since the publication of the proposed rule, we have added additional
information to the Qnet exchange Web site explaining the application of
the confidence interval to the overall validation results. The data are
being validated at several levels. There are consistency and internal
edit checks to ensure the integrity of the submitted data; there are
external edit checks to verify expectations about the volume of the
data received. Beginning with data for the fourth quarter of 2002
(October through December), there will be chart level audits to ensure
the reliability of the submitted data.
Web sites where additional information related to Hospital Data
Validation can be found:
Quality Net Exchange: https://qnetexchange.org/public/hdc.do
CMS Hospital Quality Initiative: https://qnetexchange.org/public/
hdc.do
The purpose of patient level record validation is to verify that
the data abstracted by the hospitals is consistent and reproducible.
CMS will identify the universe of abstracted data submitted by the
hospital, draw a small, simple random sample, obtain access to the
identified charts, and have the CDAC reabstract the clinical measures.
The CDAC reabstractions will be compared to the original hospital
abstractions and the results shared with the QIO and the affected
hospital. The hospitals will be deemed certified as submitting valid
data based upon the percent agreement between the hospital and CDAC
abstractions. The QIO will be responsible for making all final appeal
decisions and for providing assistance to improve hospital
abstractions.
All data that has been successfully submitted and is in the QIO
Clinical Warehouse is subject to the hospital data validation process.
An overview of the processes that make up the entire hospital data
validation process is described below:
For each calendar quarter, all hospitals submitting
abstracted data will be identified.
For each hospital, all abstracted charts will be
enumerated.
A simple random sample of five charts per quarter will be
identified from all hospitals with a minimum of six discharges in the
QIO Clinical Warehouse. The sample is selected from all the cases
submitted and is not topic-specific.
The CMS CDAC will request the paper medical records for
each of the sampled charts.
The CDAC will reabstract the chart using the CMS CART. The
relevant differences will be identified and the CDAC will assign a
reason code to each difference noted.
The results of the reabstraction will be stored in the QIO
Clinical Warehouse and made available to the QIO to provide feedback to
each hospital.
Hospitals will receive educational feedback including an
overall reliability rate and case details on each abstraction.
Based upon the CDAC reabstraction, the percent agreement
at the element level will be calculated. Hospitals that reach or exceed
the 80 percent threshold will be considered to be supplying valid data
for that quarter.
Measures for which there are found to be significant
errors may not be posted on the Web site.
Comment: Two commenters requested that the optional elements
validated by the CDAC not be included in determining validation and
reimbursement.
Response: All of the elements used for determining data validation
are used to calculate the quality measures. It is the responsibility of
each vendor (and ultimately, of the hospital) to adhere to skip logic
as defined in the CMS measures. For third quarter 2004, the ten CMS
measures used for market basket update were largely aligned with JCAHO.
CMS is currently working with the JCAHO to completely align exclusion
criteria and missing data treatment that covers skip logic with the
JCAHO. CMS policy is if a measure is submitted to the warehouse, that
data is subject to validation. For example, AMI test measures are
optional only in the sense that you had the choice of whether to
include those test measures in your abstraction, or not to include them
in your abstraction. The Specifications for Calculating Hospital Data
Validation document that was updated June 21, 2005, on QNet Exchange
states ``The CDAC will abstract elements for all measures (indicators)
based on the measure sent in the original (hospital) xml file.'' If the
indicator for T1a (LDL Cholesterol Assessment) is included, then the
corresponding data elements should be included.
Hospitals submitting quality data will be considered not eligible
for full market basket update in the validation process only if the ten
specified measures do not meet the 80 percent upper bound of a 95
percent confidence interval. The current process allows CMS to
incorporate the reliability of both the 22 HQA measures as a whole, and
exclusively the 10 specific measures. To protect the integrity of the
data in the QIO Clinical Warehouse, we believe if a measure is
submitted to the warehouse that data is subject to validation.
Comment: One commenter expressed concern over a lack of an
independent review process outside of the CDAC review system for a
hospital's appeal.
Response: Beginning with third quarter 2004 validation results, the
final appeal decision will be made by the QIOs. This allows for an
independent review, since the QIOs and CDACs are not connected with
each other. In this process, the QIO can either uphold or reverse the
CDAC validation decision. QIOs are obligated to make appeal decisions
based on the data that was submitted to the clinical warehouse by the
hospital. The abstraction guidelines are clear and straight forward.
The information requested by each question in the abstraction tool is
either there, as stated, or it is not.
Comment: One commenter suggested that CMS continue to improve
communications with hospitals and vendors. We should also improve the
quality of the phone calls so that participants can hear CMS and JCAHO
officials.
Response: We welcome suggestions on how to improve our processes
and communications. CMS and its contractors currently conduct monthly
calls with vendors, and separate monthly calls with QIOs. We also
encourage hospitals to participate in the quality section of the
Hospital Open Door Forums (ODF) that are held once a month. Information
on these ODF can be found at http://www.cms.hhs.gov/opendoor/hospitals.asp. We will strive to improve the quality of these phone
calls. We recommend that callers press the ``mute'' button to minimize
outside noise during these calls.
Comment: One commenter stated that data validation should be
directed more at care, and not just at abstraction.
Response: It is the hospitals' performance on the measures that
reflect the quality of care a hospital provides to patients with any of
these clinical conditions, not the abstraction process itself.
Validation of these data is to determine the hospitals' ability to
correctly abstract and report clinical data. All of the elements used
for determining data validation are used to calculate the quality
measures. These quality measures are designed to estimate the quality
of care.
Comment: One commenter expressed concern over incorrect abstraction
by the CDACs due to the fact that hospitals keep charts differently.
The commenter is concerned that this inconsistency is

[[Page 47427]]

resulting in an erroneously high rate of non-validation.
Response: It is every hospital's responsibility to abstract valid
data and provide, upon request, a complete medical record for
validation. The same abstraction guidelines are used by the CDAC and
the hospital. Therefore, the results of the abstraction should be the
same regardless of how the hospital maintains its records. It is every
hospital's responsibility to abstract valid data. The measures and
exclusion criteria are created by expert panels of medical and
technical professionals. The CDAC abstraction guidelines are designed
to minimize these ambiguities encountered by the CDAC abstractors.
Comment: One commenter suggested the only validation criteria
should be submission of four consecutive quarters of data, or 12
months' worth of data. If the hospital submits 4 consecutive quarters
of data, and the data passes the warehouse edits, the hospital should
be given credit for the submission.
Response: It is CMS' goal for FY 2007 to use the four consecutive
quarters' validation results as the validation criteria.
Comment: One commenter stated that vendors working with the
hospital should employ the same skip logic in their software that is
used by the CDAC.
Response: The hospital-to-vendor relationship is external to CMS.
Therefore, hospitals are responsible for selecting and ensuring that
vendors submit valid data into the QIO clinical warehouse. We suggest
that hospitals exercise due diligence in selecting vendors to abstract
and submit quality data. It is the responsibility of each vendor (and
ultimately, of the hospital) to adhere to skip logic as defined in the
CMS measures.
Comment: One commenter stated that hospitals should be able to
submit documentation to us to prove that care took place. This followup
documentation should be accepted after the hospital validation results
have been published.
Response: The medical chart is the basis of information for
conducting CDAC abstractions. Using supplementary information that
differs greatly by hospital would create greater ambiguity in the
abstraction process. The abstraction guidelines are written to use the
medical chart to objectively abstract the necessary information.
Hospitals are given 30 days to submit the medical records to the CDAC
for validation abstractions. The request for the medical records
happens approximately 5 months after the close of the quarter that is
being validated. We believe this provide sufficient time for hospitals
to collate all necessary documents for the medical record. It is
important for the hospitals to submit all necessary documentation for
validation as part of the medical records upon the request of the CDAC.
Comment: One commenter stated that we should add outcome measures
to the hospital reporting initiatives to align our efforts with those
of private purchases to financially reward high quality providers for
improving outcomes of care.
Response: We are engaged in a number of activities to develop
meaningful, actionable measures of the outcomes of care, including
various research and demonstration projects. In addition, CMS is
participating in the Hospital Quality Alliance (HQA), a pubic-private
collaboration to promote public reporting on hospital quality. The HQA
is currently considering the feasibility of adding outcome measures
that would complement the current set of 20 process measures that are
reported publicly. However, there are no definite plans to add outcome
measures at this time.
Comment: One commenter stated that hospitals should be able to
appeal mismatches even if their data reached the 80 percent validation
mark. The commenter added that all appeals should be reviewed by a
clinician.
Response: Hospitals are reviewed by QIO staff. This staff is made
up of health care professionals. We have determined that providers with
a reliability score of 80 percent and above have met the chart audit
validation requirement and therefore no appeal is necessary. The
appeals process is designed to provide feedback to those hospitals that
did not meet the 80 percent validation rate. Workload and other issues
prevent CMS from implementing this process for all providers. The goal
is to have reliable data in the warehouse at the 80 percent element
level.
Comment: One commenter recommended that CMS describe the
credentials of the staff the agency uses for chart abstraction,
describe the training of those staff, and facilitate the development of
materials that hospitals could use to hire and train their own
personnel. The commenter also recommended that CMS should have clinical
staff study the inter-rater reliability of its own abstractor's
determinations.
Response: The CDAC staff are professional abstractors specifically
trained to abstract these data as described in the measures and
validation criteria. The measures and exclusion criteria are created by
expert panels of medical and technical professionals. CDAC abstractors
must have at least 2 years of experience in work involving hospital
medical record review. Once hired, the abstractors undergo a rigorous
training program. The multiphase CDAC training program consists of
knowledge transfer, simulation, evaluation and feedback. Employees must
demonstrate a high level of proficiency before ``graduating'' to live
production abstraction. During production, inter-rater reliability and
data accuracy are monitored continuously through the CDAC quality
control process. We consistently achieve inter-rater reliability rates
approaching 100 percent in the CDAC. CMS and its contractors monitor
the performance of the CDAC abstractions, and perform quality assurance
to ensure that their abstraction is of the highest quality.
Comment: One commenter stated that there are many data elements
that are subject to interpretation.
Response: It is every hospital's responsibility to abstract valid
data. The measures and exclusion criteria are created by expert panels
of medical and technical professionals. A Data Dictionary is posted for
abstractors to utilize in the abstraction of each element for the
measures. As questions are received, the data elements are reviewed to
determine if additional clarification would improve the reliability of
the abstraction. Revisions are made in conjunction with the JCAHO and
released with each new version of the Specifications Manual.
Comment: One commenter suggested that we should automatically
compute the match rate confidence interval for the entire submitted
data set and for the 10 starter measures only. We should then
automatically assign the higher score to the hospital, even if both are
passing rates.
Response: The sequential rate calculation process is designed to
provide hospitals with the opportunity to be eligible to receive the
full market basket update. Hospitals are eligible if the 95 percent
upper bound of either CI rate is 80 percent or greater. CMS uses this
rate for the sole purpose of determining payment eligibility.
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

[[Page 47428]]

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, as we proposed, we are
establishing a requirement for 2 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 3 quarters
of calendar 2004 in September 2005. For the FY 2006 update, we 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 September 2005 publications. Allowances will 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. The fiscal intermediaries will provide information on new
hospitals to the QIO in the State in which the hospital has opened for
operations as a Medicare provider as soon as possible so that the QIO
can enter the provider information into its Program Resource System
(PRS) and follow through with ensuring provider participation with the
requirements for quality data reporting under this rule.
Comment: Two commenters expressed support for the validation of the
hospital reporting data.
Response: We appreciate the commenters' support. The Hospital
Quality Data for Annual Payment Update initiative has been an evolving
process that we are dedicated to improving. We want to acknowledge our
appreciation to QIOs, hospitals and stakeholders. We strive to provide
hospitals and the public with valid quality data for quality
improvement, and better consumer information about hospital quality.
Comment: Three commenters stated that the reports resulting from
the reporting do not provide clear information to determine the
numerator and the denominator and percent of agreement.
Response: Hospital Validation Reports are available on QualityNet
Exchange. These reports have been modified with third quarter 2004
validation results. They now reflect all elements that count toward the
numerator and the denominator and the percent of agreement. The
Hospital Validation Case Detail report provides administrative,
demographic, and clinical information at the element level; it will
only include a mismatch reason and educational information if the
elements are a true mismatch affecting the numerator and denominator
calculation from the CDAC abstracted records.
Comment: Three commenters expressed support for the Hospital
Reporting initiative and the subsequent quality improvement that will
result from this effort.
Response: We agree and appreciate these commenters' support. We
will strive to provide hospitals and the public with valid quality data
for quality improvement, as well as better consumer information about
hospital quality.
Comment: One commenter expressed concern over access to individual
hospital data. The commenter noted that employees of the hospital
system may not have access to data necessary to do their jobs.
Response: Privacy restrictions to patient-level data must be
strictly enforced. It is each hospital's responsibility to ensure that
only appropriate parties within their management structure are able to
access the quality data as well as make available the results of the
quality data for quality improvement activities as appropriate
throughout the hospital. We refer readers to the HIPAA regulations at
45 CFR Parts 160 and 164 or the individual institution's Privacy or
HIPAA Specialist. We believe there should be no reason for an employee
not to have the necessary data to do their jobs.
Comment: One commenter stated that the proposed rule change would
add to the significant adverse reimbursement actions that are
threatening the viability of hospitals that bear the brunt of caring
for the uninsured and underinsured.
Response: All hospitals eligible for Medicare reimbursement are
responsible for keeping sufficient records and documentation about the
quality of care. The purpose of this change is to help hospitals
improve the quality of care that they provide to all patients.

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

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 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,

[[Page 47429]]

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 405, 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 FY 2001 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 FY 1991 IPPS 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 a 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 a hospital-specific rate if the Federal rate
is adjusted by a lower wage 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 paid under section 1886(d)
of the Act whose reimbursement is based

[[Page 47430]]

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 (Sec.
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, in the FY 2006 IPPS proposed rule, we revisited this
policy. After further consideration of these issues, as we proposed, we
are removing the wage index component from the budget neutrality
adjustment applied to the hospital-specific rates for hospitals paid
under section 1886(d) of the Act. The DRG reclassification and
recalibration factor component of the budget neutrality adjustment will
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 will
not remove the prior years' budget neutrality adjustment factors. This
will satisfy the statutory requirement that estimated aggregate
payments after the changes in the DRG relative weights equal estimated
aggregate payments prior to the changes. As we proposed, the wage index
portion of the budget neutrality adjustment will not be applied to
hospital-specific amounts, as these amounts are not adjusted by an area
wage index. While this may result in the application of a slightly
higher budget neutrality adjustment 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.
Comment: Several commenters requested that CMS provide more
detailed information regarding the impact of the proposed change on FY
2006 payments as well as the impact of the proposed change if it were
imposed retroactively.
Response: The impact of this provision can be found in column 10 of
the impact section (Appendix A) of both the FY 2006 proposed rule and
this final rule. Our analysis shows that the impact on FY 2006 payments
will be minimal.
With respect to applying this policy retroactively, section 903 of
Pub. L. 108-173 prohibits us from issuing retroactive rulemaking unless
it is necessary to comply with statutory requirements or failure to
apply the change retroactively would be contrary to public interest. We
do not believe this policy meets either of the conditions for making
the policy retroactive. Therefore, we have not assessed the fiscal
impact of this policy if it were to be imposed retroactively.
After consideration of the public comments received, as we
proposed, we are adding 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. The text of these new provisions reflects changes to the way
CMS applies the budget neutrality adjustment to hospitals paid under
section 1886(d) of the Act based on a hospital-specific rate.
Specifically, it indicates that the budget neutrality adjustment made
to hospitals paid under section 1886(d) of the Act based on a hospital-
specific rate will only account for the DRG reclassification and
recalibration factor component. The budget neutrality adjustment will
no longer include the wage index factor component.
3. Technical Change
In the FY 1991 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.
In the FY 2006 IPPS proposed rule, we indicated that we had
discovered that, in making the changes to Sec. 412.92 in the FY 1991
IPPS 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. We proposed to make a
technical correction by revising paragraph (d)(3). We did not receive
any

[[Page 47431]]

comments on this proposed correction. Therefore, in this final rule, we
are adopting the proposed technical correction as final.

D. Rural Referral Centers (Sec. 412.96)

Under the authority of section 1886(d)(5)(C)(i) of the Act, the
regulations at Sec. 412.96 set forth the criteria that a hospital must
meet in order to qualify under the IPPS as a rural referral center. For
discharges occurring before October 1, 1994, rural referral centers
received the benefit of payment based on the other urban 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
national and regional case-mix index values is set forth in regulations
at Sec. 412.96(c)(1)(ii). The national median case-mix index value for
FY 2006 includes all urban hospitals nationwide, and the 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 values are based on
discharges occurring during FY 2004 (October 1, 2003 through September
30, 2004) and include bills posted to CMS' records through March 2005.
In the FY 2006 IPPS proposed rule, (70 FR 23428) [May 4, 2005] we
proposed that, in addition to meeting other criteria, if they are to
qualify for initial rural referral center status for cost reporting
periods beginning on or after October 1, 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. (See the table set
forth in the FY 2006 IPPS proposed rule at 70 FR 23430.)
Based on the latest data available (FY 2004 bills received through
March 2005), in addition to meeting other criteria, hospitals with
fewer than 275 beds, if they are to qualify for initial rural referral
center status for cost reporting periods beginning on or after October
1, 2005, must have a case-mix index value for FY 2004 that is at
least--
1.3721; or
The median case-mix index value (not transfer-adjusted)
for urban hospitals (excluding teaching programs as identified in Sec.
412.105) calculated by CMS for the census region in which the hospital
is located.
The final median case-mix index values by region are set forth in
the following table:

------------------------------------------------------------------------
Case-mix
Region index value
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).................... 1.2300
2. Middle Atlantic (PA, NJ, NY)............................ 1.2469
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)..... 1.3277
4. East North Central (IL, IN, MI, OH, WI)................. 1.2762
5. East South Central (AL, KY, MS, TN)..................... 1.2911
6. West North Central (IA, KS, MN, MO, NE, ND, SD)......... 1.2252
7. West South Central (AR, LA, OK, TX)..................... 1.3532
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............... 1.3620
9. Pacific (AK, CA, HI, OR, WA)............................ 1.3241
------------------------------------------------------------------------

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

[[Page 47432]]

(PS&R) System. In keeping with our policy on discharges, these case-mix
index values are computed based on all Medicare patient discharges
subject to DRG-based payment.
2. Discharges
Section 412.96(c)(2)(i) provides that CMS will set forth the
national and regional numbers of discharges in each year's annual
notice of prospective payment rates for purposes of determining rural
referral center status. As specified in section 1886(d)(5)(C)(ii) of
the Act, the national standard is set at 5,000 discharges. In the FY
2006 IPPS proposed rule (70 FR 23428), we proposed to update the
regional standards based on discharges for urban hospitals' cost
reporting periods that began during FY 2002 (that is, October 1, 2001
through September 30, 2002), which is the latest available cost report
data we had at that time.
Therefore, in the FY 2006 IPPS proposed rule, we proposed that, in
addition to meeting other criteria, a hospital, if it is to qualify for
initial rural referral center status for cost reporting periods
beginning on or after October 1, 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. (See the table set
forth in the FY 2006 IPPS proposed rule at 70 FR 23430.)
Based on the latest discharge data available at this time, that is,
for cost reporting periods that begin during FY 2003, the final median
number of discharges for urban hospitals by census region area are as
follows:

------------------------------------------------------------------------
Number of
Region discharges
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT).................... 7,494
2. Middle Atlantic (PA, NJ, NY)............................ 9,332
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)..... 10,001
4. East North Central (IL, IN, MI, OH, WI)................. 8,261
5. East South Central (AL, KY, MS, TN)..................... 7,812
6. West North Central (IA, KS, MN, MO, NE, ND, SD)......... 7,084
7. West South Central (AR, LA, OK, TX)..................... 7,093
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)............... 9,288
9. Pacific (AK, CA, HI, OR, WA)............................ 6,885
------------------------------------------------------------------------

We note that the median number of discharges for hospitals in each
census region is greater than the national standard of 5,000
discharges. Therefore, 5,000 discharges is the minimum criterion for
all hospitals.
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, as we proposed in the FY 2006
IPPS proposed rule (70 FR 23428), we are revising 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)

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 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

[[Page 47433]]

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 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, as we proposed in the FY 2006 IPPS proposed rule, in this
final rule we are extending 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 believe that it
is appropriate 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).
Comment: One commenter supported a continuous adjustment rather
than the application of the same percentage adjustment to all
qualifying low-volume hospitals. The commenter indicated that the
continuous adjustment should use an empirically-based formula to lower
the adjustment for hospitals as their volume increase. By extending the
adjustment to hospitals with slightly more than 200 discharges and by
phasing out the adjustment through the use of a declining continuous
adjustment, the commenter added, hospitals may be less likely to
experience significant year-to-year variation in payments; especially
if a hospital has slightly less than 200 discharges one year and
slightly more than 200 discharges the next. The commenter indicated
that such an adjustment might also alleviate any possible payment
inequities for hospitals with just over 200 discharges in comparison to
those with less than 200 discharges within any given year.
Response: Our analysis for the low-volume adjustment included an
investigation of the use of a continuous formula. Neither the payment-
to-cost ratios nor the regressions models of standardized costs per
discharge and total discharges revealed any pattern that could be used
to model a continuous formula given the constraints on the maximum
adjustment. As mentioned above, the descriptive analysis of the data
indicates 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. When looking at the FY 2002 data,
the mean payment-to-cost ratio for hospitals with between 175 and 199
total discharges was 0.79. Therefore, there is some empirical evidence
that the maximum adjustment of 25 percent is appropriate even for
hospitals with slightly less the 200 hospitals. In addition, as
indicated above, our analysis, including both the regressions and
payment-to-cost ratios, did not support adjustments for hospitals with
200 or more discharges. Thus, the evidence does not suggest that there
would be an inequity in our policy for hospitals with more than 200
discharges. We also do not have any evidence from hospitals of
significant year-to-year variation in payments due to the low-volume
adjustment. Therefore, the most empirically justifiable adjustment that
we found was to give the maximum percentage adjustment to all low-
volume hospitals with less than 200 discharges.
Comment: Commenters suggested that it is not necessary to update
the analysis and adjustment for the low-volume adjustment every year.
The rationale

[[Page 47434]]

behind this comment is that the adjustment should reflect the long-term
relationship between volume and costs, which should not change
significantly from year to year.
Response: Because the IPPS policy environment can significantly
change from year to year, we do believe that is important to regularly
investigate the relationship between hospitals' standardized costs per
discharge and volume of discharges for purposes of the low-volume
adjustment. In addition, 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)

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 IPPS-Excluded 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) resident 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, in the FY 2006 IPPS proposed rule (70 FR
23432), we proposed 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 the FTE cap base year and that
subsequently became subject to the IPPS. We clarified and proposed 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 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 formerly IPPS-excluded
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 regulation.
Finally, there may be situations where the data necessary to carry
out this policy are not available. For example, under our 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. In the FY 2006 IPPS proposed rule, we specifically solicited
comments as to whether and how hospitals believe this is a problem that
needs to be addressed.

[[Page 47435]]

Comment: Commenters pointed out that the proposed rule applies to
an IPPS excluded hospital that is subsequently certified as an acute
hospital and is subject to IPPS. However, the commenters added, the
proposed rule is silent on the applicability of the proposed
methodology to adjust the IME resident cap of an acute hospital that
had an excluded unit and the unit subsequently becomes subject to the
IPPS. Some commenters believed CMS should apply the same methodology
and treat these formerly IPPS-excluded units in the same way as the
freestanding IPPS-excluded hospitals that are subsequently certified as
acute care hospitals subject to the IPPS. One commenter maintained that
the situations are comparable because, if a teaching hospital in 1996
had residents training in a rehabilitation department that was not an
excluded unit, those residents would have been included in the
hospital's IME cap. However, the commenter added that if the
rehabilitation unit was excluded from the IPPS during the FTE cap base
year, the hospital was not permitted to include the resident counts
from the excluded unit in its IME cap calculation. Therefore, the
commenter contended that an acute care hospital that no longer has a
separately certified IPPS-excluded unit should be able to add the
resident count of the formerly excluded unit to the hospital's IME cap.
The commenter noted that adding the FTE count from the formerly
excluded unit to the acute care hospital's existing IME cap avoids a
discrepancy between the direct GME and IME resident caps.
Response: In the case where a psychiatric or rehabilitation unit
within the hospital is no longer separately certified from the acute
care hospital, we do not believe it is appropriate to recalculate the
acute care hospital's IME cap to include the IME FTE resident count
from the base year for which the hospital's FTE limits were previously
established. Section 1886(d)(5)(B)(v) of the Act has already
established the methodology for determining an acute care hospital's
IME cap. We note that if the hospital creates a new rehabilitation or
psychiatric unit within the acute care IPPS hospital, the hospital's
IME cap is not adjusted, because the cap is established for the
hospital based on the number of residents it was training in 1996. In
the case of an acute care hospital that ``closes'' its IPPS-excluded
unit, at best it is only adding beds to the existing acute care IPPS
hospital. In instances where an acute care hospital adds or removes
beds, the previously established IME cap remains unaffected. We note
further that the hospital's direct GME cap is unaffected by the closure
of the unit because the direct GME limit was established based on the
FTE residents training in the hospital complex, including the IPPS-
excluded unit. Furthermore, such units are nonetheless provider-based
as defined in 42 CFR 413.65 and, therefore, have always been integrally
related to the hospital. While commenters have argued that the
transition of IPPS-excluded units into acute care hospitals is
comparable to the transition of freestanding IPPS-excluded hospitals to
the IPPS, we believe the more accurate comparison is the one we have
presented above. That is, when a former IPPS-excluded unit is subsumed
within an acute care hospital and, thereby, becomes subject to the
IPPS, it is equivalent to an expansion in the bed size of the acute
care hospital. Therefore, we believe the acute care hospital's
established IME FTE resident cap should remain unaffected as consistent
with bed size expansions under other circumstances.
Regarding the possibility of a discrepancy between the IME and
direct GME FTE resident caps, we note that, by virtue of the statute
and our regulations, the rules differ for counting of FTE residents for
purposes of IME and GME, and many hospitals currently have different
FTE resident caps for IME and direct GME payments.
Comment: In response to our expression of concern about the
potential that FTE resident information may no longer be available to
establish an IME FTE cap for a 1996 base year, and our solicitation of
comments on that issue, some commenters recommended that CMS make IME
cap determinations based on more current data than the cost reports
ending on or before December 31, 1996. The commenters supported using
either or both of the following cost reporting periods: (1) The most
recent cost report period prior to November 15, 2004, which CMS used in
the policy to establish the adjustments to the PPS payments due to
``teaching status'' for the IPF PPS; and (2) the most recent cost
report period prior to November 15, 2003, which CMS proposed for the
IRF PPS.
One commenter pointed out that teaching hospitals have changed
significantly since 1996, the year on which caps are based. Therefore,
the commenter believed it would be unfair to establish new IME caps on
hospitals' situations from 10 years ago.
Some commenters supported our proposal to base the IME cap on the
data from cost reports ending on or before December 31, 1996.
Response: We agree with the commenters that using data from 1996 to
establish the IME cap for IPPS-excluded hospitals converting to the
IPPS many years after 1996 could be problematic. However, section
1886(d)(5)(B)(v) of the Act explicitly requires that ``the total number
of full-time equivalent interns and residents * * * may not exceed the
number * * * of such full-time equivalent interns and residents in the
hospital with respect to the hospital's most recent cost reporting
period ending on or before December 31, 1996.'' Therefore, the statute
requires that the IME cap be based on the 1996 data. However, because
FTE residents are counted differently for purposes of IME and direct
GME payments (for example, in 1996, FTE residents were not counted in
an IPPS-excluded unit for IME and, therefore, would not have been
included in determining the IME cap) even where the hospital has an
existing direct GME FTE cap that was determined for the IPPS-excluded
hospital based on data from the hospital's 1996 cost report, an
appropriate IME FTE resident count must be determined based on data
from the hospital's most recent cost reporting period ending on or
before December 31, 1996. In some instances, the necessary data from
1996 to determine the IME cap may no longer be available. Accordingly,
where 1996 documentation is no longer available, we will use the
following methodology. In order to be consistent with the statute that
requires IPPS IME FTE caps to be determined based on the 1996 cost
reporting period data, we will use the hospital's direct GME cap, which
is from the 1996 cost reporting period, be used as a starting point for
determining the IME cap. However, because the rules for counting FTEs
for direct GME differ somewhat from the rules for counting FTEs for
IME, particularly prior to the BBA of 1997, IME data from the
hospital's most recent cost reporting period ending on or before
December 31, 2004, will be used to adjust the 1996 direct GME cap in
order to establish the hospital's 1996 IME cap. For example, since in
1996, residents training in nonhospital sites could be counted for
direct GME but not for IME, if the data from the hospital's most recent
cost reporting period ending on or before December 31, 2004, showed
that residents spent 10 percent of their time training at nonhospital
sites, then the 1996 direct GME cap would be reduced by 10 percent to
reflect that in 1996, residents training in nonhospital sites

[[Page 47436]]

would not have been included in the IME count.
Comment: One commenter requested that CMS make it clear that any
new IME cap for a hospital that was excluded from the IPPS will be
based on the count of FTEs rotating both within the hospital and in
qualifying nonhospital sites.
Response: We disagree with the commenter and clarify that the IME
cap for formerly IPPS-excluded hospitals will not include FTE counts of
residents training at nonhospital sites. The IME cap will be
established for the base year in accordance with the IME regulations
that were in effect in 1996. Those regulations did not allow residents
training at nonhospital sites to be included in the IME FTE count.
Accordingly, only residents training in the inpatient (the portion of
the hospital subject to IPPS) and outpatient departments of the
hospital can be counted to establish the IME FTE cap for 1996. The BBA
revised the statute to allow residents training at nonhospital sites to
be counted for purposes of IME payments only effective October 1, 1997.
Therefore, the hospitals' FTE count in 1996, the base year for
establishing the IME cap, may not include any residents training at
nonhospital sites.
Comment: One commenter interpreted our proposal in the proposed
rule to mean the hospital's IME cap would equal the resident count that
was used to establish the direct GME cap.
Response: We believe the commenter misunderstood our proposal.
Under the proposed rule, we would have determined the IME cap based on
the FTE resident data in the most recent cost reporting period ending
on or before December 31, 1996. Because FTE residents are counted
differently for purposes of IME and direct GME payments (for example,
FTE residents are not counted in an IPPS-excluded unit for IME), we
note that the FTE resident data for computing the IME cap would have
come from the same cost reporting period used to establish the direct
GME cap, but not necessarily be the direct GME cap itself.
Comment: Some commenters opposed the reduction in the FY 2006 IME
formula and urged CMS to maintain the formula at its current
percentage.
Response: We did not propose any changes in policy concerning this
issue.
In summary, we are changing the policy in response to comments
regarding the base year to use to establish the IME cap for a hospital
that was excluded from the IPPS and that subsequently becomes subject
to the IPPS. In order to be consistent with the statute at section
1886(d)(5)(B)(v), which requires the limit on the total number of FTE
residents for payment purposes to be based on the 1996 cost reporting
period, we believe it is appropriate to determine the IME cap based on
the hospital's data from 1996 when the data are available. However, in
instances where IME-specific 1996 data are unavailable, the IME data
for the most recent cost reporting period ending on or before December
31, 2004, must be used to determine the 1996 IME cap. 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 (which we distinguish
from a merger that results in an IPPS hospital with an excluded unit).
In such cases, CMS policy is that the FTE resident cap for the
surviving IPPS 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 FTE
resident 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 resident count for the IPPS-excluded hospital would not
have been determined previously. As we proposed, we are clarifying and
codifying in regulations our existing policy that, in such cases, the
fiscal intermediary would determine an IME FTE resident 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
resident 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 IME FTE resident 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 resident cap to the aggregate FTE resident 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 policy, have an IME FTE resident cap.
In this final rule, we are incorporating in the regulations at
Sec. Sec. 412.105(f)(1)(xiii) and (f)(1)(xiv) (proposed Sec.
412.105(f)(1)(xiii) in the proposed rule) CMS' existing policy in
situations that provide 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 providing that, in such
a situation, the fiscal intermediary will determine an IME FTE cap for
the hospital, applicable beginning with the 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 will 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. We note that, while we are finalizing
the policy under which the fiscal intermediary will determine an IPPS
IME FTE cap for an IPPS-excluded hospital that merges with an IPPS
hospital if no IPPS-excluded unit is created, we will be vigilant to
ensure that this policy is not inappropriately manipulated. For
example, in a merger between an IPPS hospital and an IPPS-excluded
hospital where no IPPS-excluded unit is created initially, and the
surviving IPPS hospital benefits from the determination of an IPPS IME
FTE cap relating to the formerly IPPS-excluded hospital, we would
continue to monitor whether the hospital ultimately creates an IPPS-
excluded unit. If the hospital did create an IPPS-excluded unit, we
would closely examine the facts to determine whether the unit was
created ``as a result of the merger'' and, therefore, the determination
and application of an IPPS IME FTE cap was not appropriate.

[[Page 47437]]

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 any adjustments to
its direct GME FTE cap that are available only to rural hospitals
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 (as can
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. In the FY 2006 IPPS
proposed rule, we proposed that, effective with discharges occurring on
or after October 1, 2005, hospitals that rescind their section
1886(d)(8)(E) rural reclassifications and return to being urban could
not retain permanently the 30-percent increases in their IME caps.
Rather, any adjustments the hospitals received to their IME FTE
resident 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.\10\
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\10\ We note that the proposed policy would have no effect on
rural track resident training programs. 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 payments 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.
---------------------------------------------------------------------------

Comment: Several commenters commended CMS and supported our
proposal to revise the current regulations that would allow a rural
hospital redesignated as urban as a result of the changes to CBSA that
were effective October 1, 2004, to retain any cap adjustments that it
received as a rural hospital. However, some commenters recommended
that, under certain circumstances, an urban teaching hospital that
reclassifies under section 1886(d)(8)(E) of the Act to become rural and
then subsequently withdraws its election to return to urban status
should be allowed to retain any IME FTE cap adjustments it might have
received while rural, if that hospital has been reclassified as rural
for a significant period of time (for example, 5 or 10 years). The
commenter believed that, in such a scenario, the urban hospital
obviously did not reclassify merely as a means of receiving an increase
to its IME FTE caps and, therefore, should be allowed to keep any
increase to its FTE caps.
Response: We appreciate the commenters' concerns. We agree with the
commenters that, if an urban hospital were reclassified as rural for a
significant amount of time, the urban hospital should be allowed to
retain any adjustments to its IME FTE cap. However, we believe 10 years
is a more appropriate time period than 5 years. A 10-year time period
is most similar to the period in which the OMB reassesses its urban and
rural designations, and we have historically reviewed our geographic
designations. Thus, hospitals generally maintain their urban or rural
status (absent any action on their part to reclassify) for 10 years. In
other words, because the census is taken every 10 years, and revisions
to the labor market areas are based on such census data, hospitals
generally will maintain urban or rural status for a period of 10 years,
and changes would occur only once new census figures have been issued.
Any shorter time period would treat hospitals that voluntarily obtain
rural status through section 1886(d)(8)(E) of the Act differently from
hospitals assigned rural status solely due to our implementation of
revisions to the OMB labor market areas. Thus, we believe it is most
equitable to utilize a 10-year period, and we are providing in this
final rule that, effective October 1, 2005, 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 if that hospital
were reclassified as rural for fewer than 10 years. We are amending the
regulations at Sec. 412.105 by adding a new paragraph (f)(1)(xv) to
provide that a hospital that maintained a section 1886(d)(8)(E)
reclassification for fewer than 10 years and that rescinds such
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 for fewer than 10 years 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 (due to the
cap adjustment under Sec. 413.79(e)(1)(iii) or (e)(3), which is only
applicable to rural hospitals) 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).

[[Page 47438]]

Comment: One commenter requested clarification regarding whether
the urban hospital that rescinded its section 1886(d)(8)(E) rural
reclassification under our proposal would also forfeit new program IME
FTE cap adjustments that it received while reclassified as rural.
Response: In the proposed rule, we stated that an urban hospital
that reclassifies under section 1886(d)(8)(E) of the Act is treated as
rural for payment purposes under section 1886(d) of the Act and, as
such, can receive a 130-percent IME FTE cap adjustment and can also
receive IME FTE resident cap adjustments based on new programs. We
proposed that an urban hospital that rescinds its section 1886(d)(8)(E)
reclassification would forfeit any increases to its IME cap that it
received as a result of being reclassified as rural.
As mentioned above in this final rule, we are modifying our
proposal to state that only an urban hospital that had reclassified as
rural for fewer than 10 years will forfeit the cap adjustments that it
received as a result of being reclassified as rural. Therefore, in
response to the commenter, where the hospital had been reclassified as
rural under section 1886(d)(8)(E) of the Act for fewer than 10 years
and then rescinds its rural reclassification, the hospital's IME FTE
resident cap would be adjusted to eliminate any adjustment for training
residents in a new program. Only rural hospitals may receive a cap
adjustment at any time for starting new programs. Unless the urban
hospital qualifies for a cap adjustment for new programs under Sec.
413.79(e)(1), an urban hospital that begins training residents in a new
program cannot receive an adjustment to their IME FTE resident caps.
For the reasons stated above, in this final rule we are amending
the regulations at Sec. 412.105 by adding a new paragraph (f)(1)(xv)
(changed from proposed paragraph (f)(1)(xiv) in the proposed rule) to
provide that a hospital that rescinds its section 1886(d)(8)(E)
reclassification and that has been reclassified under such section for
fewer than 10 years will forfeit any adjustments to its IME FTE
resident cap it received due to its rural status. Thus, as stated in
the example given above, 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 FTE 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 IME FTE resident cap would have been increased by an
additional 6 FTEs to 19 FTEs (that is, 13 FTEs + 6 FTEs). However, if
the hospital maintains its rural status for a period of fewer than 10
continuous years, once the hospital rescinds its reclassification under
section 1886(d)(8)(E) of the Act to become urban again, its IME FTE
resident cap would return to 10 FTEs (its original pre-reclassification
IME FTE cap).

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

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] TR12AU05.009

2. Implementation of Section 951 of Pub. L. 108-173 (MMA)
In the FY 2006 IPPS proposed rule (69 FR 23434), we proposed to
implement a mechanism for implementing section 951 of Pub. L. 108-173,
which 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 interpret 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 interpret
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.
3. Calculation of the Medicare Fraction
The first component of the Medicare DSH patient percentage
calculation is the Medicare fraction. 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

[[Page 47439]]

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 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, as we proposed
in the FY 2006 IPPS proposed rule, we are changing 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 will
arrange to furnish, consistent with the Privacy Act, 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 will 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 2
Federal fiscal years that encompass the hospital's cost reporting
period. Under this provision, the hospital will be able to 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 will 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 changes
will 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.
Comment: Several commenters supported our proposal to release
information from the MedPAR LDS to hospitals so that they can verify
their Medicare DSH calculation. The commenters also supported our
proposal to allow hospitals to choose whether they prefer to have their
calculations performed using data from the Federal fiscal year or the
hospital's cost reporting period. In addition, most commenters agreed
with our proposal to eliminate the need for a pending appeal in order
to receive the data and to eliminate the corresponding fee.
Several commenters requested that CMS expedite the publication of
the updated routine use for the MedPAR system of records, which will
reflect the changes necessary to implement section 951 of Pub. L. 108-
173. One commenter urged CMS to eliminate the fee associated with data
requests for all years and not just years that span December 8, 2004.
In addition, the commenter recommended the elimination of the appeals
requirement for all years, including those that occur before the cost
reporting period that includes December 8, 2004.
One commenter recommended that CMS clarify how hospitals will
receive the SSI/Medicare data for both the Federal fiscal year and the
hospital's cost reporting period. The commenter also asked whether CMS
expected or would require hospitals to elect the same time period from
year to year. Another commenter requested that CMS provide specific
guidance to hospitals and fiscal intermediaries on how to use this
information to support the Medicare DSH calculation. One commenter
requested that CMS clarify whether the data provided to the hospitals
will be patient-specific and whether the data will include the date of
discharge.
Response: We appreciate the commenters' support for our proposed
policies and kept their views in mind in developing the final
regulations set forth below. We understand hospitals' need for more
information on the updated routine use and data use agreement and are
working to release these documents as soon as possible. As we stated in
the FY 2006 IPPS proposed rule, the new routine use and data use
agreement will require neither a fee nor a properly pending appeal
before the fiscal intermediary or the PRRB for us to furnish
information from the MedPAR LDS to hospitals. Hospitals must submit a
written request to CMS through the fiscal intermediary to receive this
information. With respect to applying this policy retroactively,
section 903 of Pub. L. 108-173 prohibits us from issuing retroactive
rulemaking unless it is necessary to comply with statutory
requirements, or failure to apply the change retroactively would be
contrary to public interest. We do not believe this policy meets either
of the conditions for making the policy retroactive to cost reporting
periods prior to those that span December 8, 2004.
We expect that hospitals will use these data to calculate and
verify their DSH Medicare fraction, and to decide

[[Page 47440]]

whether they prefer to have the fraction determined on the basis of
their cost reporting period rather than a Federal fiscal year. The
information from the MedPAR LDS released to hospitals will contain the
matched patient-specific Medicare Part A inpatient days/SSI eligibility
data on a month-to-month basis for the 2 Federal fiscal years that
comprise a hospital's cost reporting period. At this time, we are not
requiring hospitals to select either the Federal fiscal year or their
cost reporting period and use that selection for each subsequent year.
A hospital may opt to use the data from either time period each year.
Regardless, a hospital will continue to be required under the
regulations at Sec. 412.106(b)(3) to submit a written request to CMS,
through its fiscal intermediary, if it prefers to use its cost
reporting period data instead of the Federal fiscal year data in
determining the DSH Medicare fraction. The resulting fraction will
become the hospital's official DSH Medicare fraction for that period
and will be binding for that cost reporting period.
Comment: One commenter cautioned that, while access to the data
could reduce the number of appeals to the PRRB on the DSH calculation,
CMS must respond in a timely manner to hospital requests for the SSI/
Medicare data for this policy to be effective.
Response: We understand that it is imperative that we release
information from the MedPAR LDS to hospitals in a timely manner to
ensure that they can calculate their Medicare DSH fraction. When we
publish the updated routine use, we will indicate the timeframes within
which we expect to make these data available to hospitals. Currently,
we publish the prior Federal fiscal year's DSH Medicare fractions (also
called ``SSI ratios'') for all providers in August of each year.
Comment: Several commenters suggested that we release the data file
of SSI eligibility information provided to CMS by SSA. The commenters
indicated that hospitals need access to the SSI eligibility file in
order to compute their own Medicare DSH adjustment. One commenter
suggested that CMS modify the routine use to allow SSI eligibility
information to be provided directly to hospitals.
Response: In accordance with the published routine use for the SSI
system of records maintained by the SSA, CMS signs a data use agreement
with SSA to receive the SSI data file for the sole purpose of
administering the Medicare and Medicaid programs. While we understand
the commenters' concern, CMS is strictly prohibited from disclosing SSI
eligibility information. In addition, SSA is prohibited from disclosing
this information by Federal law and regulations. While we cannot
release the SSI eligibility information provided by SSA, we are
permitted to disclose the results of the data match of SSI eligibility
information with the Medicare inpatient hospital billing data as a
routine use for the MedPAR LDS system of records. The routine use
allows us to release the information to hospitals that sign a data use
agreement that limits the uses and protects the privacy of the SSI/
MedPAR LDS match information.
Comment: One commenter stated that SSA has expressed a willingness
to provide CMS with updated SSI eligibility information that may
include retroactive grants or denials of eligibility, which would then
be used by CMS to revise calculations of hospitals' DSH Medicare
fractions.
Response: We understand that many hospitals are concerned that
later data matches may produce a different Medicare fraction. However,
we believe that there needs to be administrative finality to the
calculation of a hospital's Medicare fraction. CMS has previously
stated that its goal is to obtain reasonably accurate but not perfect
calculations (51 FR 16777). Additionally, our data have shown that 98
to 99 percent of SSI eligibility determinations are made and remain
unchanged 6 months after the end of the Federal fiscal year. There will
be a minimum of 6 months between the end of the hospital's cost
reporting period and the April 1 date that we receive SSI eligibility
information. The time lag between the close of a hospital's cost
reporting period and the April 1 date that we obtain the eligibility
information could actually be much longer for many hospitals. For a
hospital with an October 1 to September 30 cost reporting period, we
will use SSI eligibility information from 6 months after its year ends.
However, we will be using SSI eligibility 17 months after a hospital's
year ends with a November 1 to October 31 cost reporting period. Given
the time between the end of hospital cost reporting periods and when we
are furnished with SSI eligibility information for that period, we
believe it is highly unlikely that a subsequent data run will produce
data that is significantly different than one completed 6 months after
the end of the Federal fiscal year.
Therefore, we will use the SSI eligibility information provided to
CMS by SSA 6 months after the end of the Federal fiscal year (or April
1) to calculate the DSH Medicare fraction. We will match these data to
the MedPAR system once and conduct no further matches after that time.
For cost reporting periods that span 2 Federal fiscal years, a hospital
will receive the data for the 2 Federal fiscal years once the data from
the second year have been matched against the SSI data available to CMS
6 months after the end of that year. Although it is possible that these
data will be available up to 17 months after the cost reporting period
has ended, hospitals will continue to be permitted to use the data to
determine whether they prefer to base their calculation on data from
the Federal fiscal year or their cost reporting period. The calculation
from the requested time period will be used in the final settlement for
the cost reporting period. This policy will be reflected in the updated
routine use and in the data use agreement, which hospitals will sign
with CMS to obtain the privacy protected MedPAR LDS data match. As
previously mentioned, we will publish the updated notice of routine use
for the MedPAR system of records in a future Federal Register document.
Comment: One commenter requested that CMS allow hospitals to choose
the data field CMS would use to conduct the SSI eligibility/MedPAR LDS
data match. The commenter suggested that hospitals be allowed to
request that the data match be made by social security number, health
insurance claim account number (HICAN), name, gender, date of birth, or
Title II identifier, or a combination of these factors.
Response: We do not use social security numbers to conduct the SSI/
MedPAR data match because social security numbers are used on a ``wage
earner'' basis that is not necessarily specific to an individual
Medicare beneficiary (or hospital patient). The HICANs are unique to
each beneficiary. Because of this, we do not have social security
numbers for every Medicare beneficiary in the MedPAR data.
In addition, we do not agree that individual hospitals should be
given the choice to run the SSI/MedPAR data match by alternative
criteria. Such variation between providers would result in an
inconsistent matching methodology, and inconsistent DSH Medicare
fraction calculations, among providers.
Comment: One commenter suggested that, in place of using the MedPAR
system, CMS use the Provider Statistical and Reimbursement (PS&R) data
file to determine the denominator of the Medicare fraction.
Response: We believe it is appropriate to continue to use the
MedPAR for Medicare DSH calculations. Principally, as documented in the
Federal Register,

[[Page 47441]]

the MedPAR system has been the Medicare Part A data source for the
Medicare DSH calculation since the implementation of the DSH
adjustment. More importantly, the MedPAR system and the PS&R do not
necessarily contain the same data. The MedPAR system contains utilized
days and the PS&R contains days paid to the provider by Medicare. The
PS&R does not contain certain types of days that should be included in
the denominator of the Medicare fraction, such as covered days that
were paid by a Medicare managed care organization (``MCO''). For these
reasons, we are not proceeding with the commenter's recommendation at
this time.
Comment: Several commenters suggested that CMS allow a hospital to
submit additional days that it believes were omitted in error from the
SSI/MedPAR system data match. One commenter acknowledged that the
hospital would bear the burden of proving SSI/Medicare entitlement for
each patient day claimed.
Response: If a hospital disagrees with the fiscal intermediary's
determination regarding the final amount of Medicare DSH payment to
which it is entitled, the hospital has the right to appeal the fiscal
intermediary's decision in accordance with the procedures set forth in
the regulations at 42 CFR Part 405, Subpart R, which concern provider
payment determinations and appeals. Generally, during the first stage
of the appeals process, a fiscal intermediary will consider any
documentation a hospital has submitted for review. The fiscal
intermediary will assess whether the information provided is sufficient
to warrant a reconsideration of the DSH Medicare fraction at that point
in the appeals process.
Comment: One commenter requested that CMS clarify ``Medicare days''
included in the Medicare fraction and explain how the MedPAR system
captures all of the days that should be included, especially if
Medicare did not pay the claim. The commenter specifically requested
that CMS address the treatment of MCO or ``Medicare Advantage'' days,
dual-eligible with exhausted Medicare Part A benefits, dual-eligible
without SSI, and third party payer patient days.
Response: Although we believe that this comment is generally out of
the scope of the FY 2006 IPPS proposed rule regarding the
implementation of section 951 of the MMA, we understand the commenter's
concern regarding the possible exclusion of certain days from the
Medicare DSH calculation. Due to this concern, we are currently
examining our system to ensure that all appropriate days are included
in the DSH Medicare fraction.
In addition, on several occasions we have stated our policies
concerning the treatment of MCO, dual-eligible with exhausted Medicare
Part A benefits, dual-eligible without entitlement to SSI, and third
party payer patient days in the Medicare DSH calculation. We suggest
that the commenter refer to the FY 2005 IPPS final rule for our policy
on dual-eligible patient days, including those with exhausted Medicare
Part A hospital coverage and MCO days (69 FR 49098 and 49099).
Commenters may also review the IPPS final rule for FY 1991 regarding
when the MedPAR was updated to include MCO days (55 FR 35994, September
4, 1990). Regarding third party payer days, we refer commenters to the
IPPS final rule for FY 1987, which states our policy prior to our FY
2005 policy change (51 FR 31460, September 3, 1986). For FY 2005 and
subsequent fiscal years, we have updated the regulations at Sec.
412.106(b) to reflect the inclusion of days for which Medicare was not
the primary payer.
4. Calculation of the Medicaid Fraction
The second component of the Medicare DSH patient percentage
calculation is the Medicaid fraction. 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.\11\
---------------------------------------------------------------------------

\11\ 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

[[Page 47442]]

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 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 payers, 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 continue to 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.
Comment: Several commenters encouraged CMS to amend the Medicaid
State plan requirements to require States to furnish Medicare
eligibility data to requesting hospitals. Several commenters believed
that variability in how State Medicaid agencies collect and manage
Medicaid data make the process to convert and match hospital records to
State Medicaid records extremely time-consuming and complex. The
commenter believed that requiring every State to report Medicaid
eligibility data in the same manner would decrease hospitals'
administrative work. Several other commenters suggested that CMS not
make any change to the States' requirements at this time, but continue
to consider this idea as an option for the future. Another commenter
suggested that CMS amend the State plan requirements to include a
requirement that the States must make Medicaid eligibility information
available in a timely manner, such as 90 days after receipt of a
hospital's request. This commenter believed that States should be
prohibited from charging hospitals a fee for accessing the data.
Several commenters suggested that CMS modify the Medicaid State plan
requirements to require that any contract between the State Medicaid
agency and an MCO specify that the MCO would be required to submit
reliable utilization data to the State to verify managed care days/
patients.
Response: We are dedicated to working with the State Medicaid
agencies to ensure that hospitals have access to data to verify
Medicaid eligibility. While the commenters expressed concern that some
hospitals find it burdensome to adapt the Medicaid eligibility data
available from the States to their records, we do not believe these
types of data processing concerns are significant enough to warrant
changes to the State plan requirements. We are also aware that not all
State agencies have the resources available to modify their systems in
a standardized way. We note that the Center for Medicaid and State
Operations in CMS has communicated CMS' expectation of compliance with
hospitals' requests for Medicaid eligibility information to the State
Medicaid agencies. If the State Medicaid agencies refuse to provide
data to enable hospitals to calculate their DSH Medicaid fraction and
meet their obligations under our regulations at Sec.
412.106(b)(4)(iii), we will consider amending the Medicaid State plan
requirements to require the State agency to release the information to
the requesting hospitals.
We also do not believe that we have the authority to require State
Medicaid agencies to provide the Medicaid eligibility information free-
of-charge. However, we do note that the State Medicaid Manual already
requires that States not impose unreasonable fees on hospitals seeking
eligibility information.
With respect to Medicaid MCO utilization, State Medicaid agencies
must maintain Medicaid eligibility information on beneficiaries
enrolled in MCOs in order to make payments to those MCOs. Because
hospitals are seeking Medicaid eligibility information and not
inpatient hospital utilization information, we do not believe that it
is appropriate for CMS to oblige the State Medicaid agencies to record
and make available to hospitals MCO utilization data.
Comment: Several commenters argued that Congress intended that CMS
provide the Medicaid eligibility data to aid hospitals in calculating
their own Medicare DSH patient percentage.
Response: While we are aware that section 951 requires that CMS
provide the data necessary for hospitals to calculate their Medicare
DSH patient percentage, we stand by our belief that hospitals are in a
better position to verify Medicaid eligibility with the State Medicaid
agencies through their established mechanisms. Therefore, we believe
hospitals have available to them the data necessary to calculate the
Medicaid fraction for their Medicare DSH patient percentage. CMS will
continue to work with State Medicaid agencies to ensure that Medicaid
eligibility information is made available to hospitals.
Comment: Several commenters indicated that some State Medicaid
agencies are refusing to provide hospitals with Medicaid eligibility
information.
Response: We are not aware of any State Medicaid agency that is
refusing to provide hospitals with current Medicaid eligibility
information, and the commenters did not cite any such circumstances.
However, we are aware that several State Medicaid agencies have
previously expressed concern regarding hospital requests for historic
Medicaid eligibility information. We note that section 2080.18 of the
State Medicaid Manual limits the timeframe within which the State
Medicaid agencies may provide eligibility information to requesting
hospitals. Section 2018.18 clearly specifies that State Medicaid
agencies may only provide eligibility information for dates within 12
months of the date of the request. Therefore, many States have
expressed concern that responding to requests for eligibility data
outside of that 12-month window would be in violation of CMS' policy.
In light of past and pending appeals and litigation, we are working
with the States to make sure historic information is available to
requesting hospitals. The Center for Medicaid and State Operations
released a memo to the CMS Regional Offices to be shared with the
Medicaid State agencies. This memo, dated September 9, 2003, requested
the full cooperation of the State Medicaid agencies in responding to
hospital requests for historic Medicaid eligibility information. The
States were specifically encouraged to retain Medicaid eligibility
records in order to be able to comply with hospital requests for
historic data, even if their normal record retention schedule would
have allowed the destruction of such records. CMS' request to Medicaid
State Agencies to provide hospitals with

[[Page 47443]]

historical Medicaid eligibility data represents an exception to the
general rule as stated in section 2080.18 of the State Medicaid Manual
intended to assist hospitals to respond to the past and pending appeals
and litigation.
Comment: Several commenters stated that the data provided to
hospitals from the Medicaid State agencies are often inaccurate. They
noted that several fiscal intermediaries have refused to accept data
from hospitals, which was obtained from the State Medicaid agencies.
Response: The Medicaid State agencies maintain eligibility
information on Medicaid recipients. To date, we have been made aware of
accuracy problems insofar as the data requested are historic and the
complete records may no longer be available. As previously noted, we
have requested that the State Medicaid agencies comply with hospital
requests for historic data and modify their record retention schedules
appropriately. We suggest that hospitals experiencing problems with the
quality of current Medicaid eligibility data work with their fiscal
intermediaries and State Medicaid agency to address the specific
problems the hospital is encountering.
Comment: One commenter suggested that CMS establish a formal
process for hospitals to report States that are not complying with
hospital requests for Medicaid eligibility information. The commenter
proposed that CMS dedicate an area on the CMS Web site for hospitals to
report problems encountered with State Medicaid agencies.
Response: We are interested in the commenter's proposals and will
consider this for future modification of the CMS Web site. Although we
are not adopting the proposal at this time, we ask that hospitals that
experience difficulty obtaining Medicaid eligibility information from a
State Medicaid agency contact the appropriate CMS Regional Office. We
will continue to work with the individual State agencies to ensure that
hospitals have access to such information.
Comment: One commenter suggested that the fiscal intermediaries
process hospital requests for Medicaid eligibility data and work with
the State Medicaid agencies to obtain such data.
Response: Under the regulations at Sec. 412.106(b)(4)(iii),
hospitals bear the burden of furnishing data adequate to provide
eligibility for each Medicaid patient day claimed in the Medicare DSH
calculation. This includes verifying with the State that a patient was
eligible for Medicaid on each of the claimed days. As stated above, the
information provided to CMS by the Regional Offices indicated that
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. In light of this, we do not believe that fiscal
intermediaries should be made responsible for verifying Medicaid
eligibility with the State Medicaid agencies.
Comment: One commenter suggested that CMS issue explicit
instructions to fiscal intermediaries indicating that hospitals may
submit their own data to support the days included in the Medicaid
fraction.
Response: While hospitals do bear the burden of verifying Medicaid
eligibility for the patient days they submit to be included in
calculation of their DSH Medicaid fraction, the State Medicaid agency
must verify that, for those days, the particular patient was eligible
for inpatient hospital benefits under an approved Medicaid State plan
or section 1115 waiver program. If a hospital believes that the State
Medicaid agency did not correctly determine the Medicaid eligibility of
a patient on a specific day for which the hospital has additional and
distinct evidence to indicate that the patient was in fact eligible for
Medicaid on that day, the hospital may submit this information for
review by the fiscal intermediary. The fiscal intermediary retains the
right to determine whether the documentation is sufficient to warrant
the inclusion of the days in the Medicaid fraction. While we currently
have no plans to issue instructions to fiscal intermediaries on the
verification of Medicaid eligibility, we will consider addressing this
concern in future communication with fiscal intermediaries.
Comment: One commenter stated that certain Medicaid eligibility
information must be made available to hospitals through the State
Medicaid agencies. The commenter indicated that solely providing
whether a patient is eligible for Medicaid is not sufficient to
determine whether the hospital days associated with that patient should
be included in the DSH Medicaid fraction calculation. Specifically,
this commenter indicated that the State must also provide: the dates of
eligibility for Medicaid or whether the patient was eligible for
Medicaid during an inpatient stay, whether the recipient has met spend
down requirements (if applicable), and the type of Medicaid benefits
the recipient received. The commenter indicated that this information
is critical in determining the days that should be included in the DSH
Medicaid fraction calculation.
Response: We encourage hospitals to continue working with
individual State Medicaid agencies to ensure that they have access to
the information needed to determine Medicaid eligibility for purposes
of the DSH Medicaid fraction. If hospitals are unable to obtain from
the Medicaid State agencies data needed to calculate their DSH Medicaid
fraction, we encourage them to notify their CMS Regional Office for
assistance.
Comment: One commenter suggested that CMS establish a more
efficient method for hospitals to verify dual eligibility using the
Common Working File (CWF).
Response: We encourage hospitals to continue working with
individual State Medicaid agencies and fiscal intermediaries to ensure
that they have access to the information needed to determine Medicaid
eligibility for purposes of the DSH Medicaid fraction. If hospitals are
unable to obtain data from the Medicaid State agencies needed to
calculate their DSH Medicaid fraction, we encourage them to notify
their CMS Regional Office for assistance.

H. Geographic Reclassifications (Sec. Sec. 412.103, 412.230, and
412.234)

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

[[Page 47444]]

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.
Comment: One commenter sought clarification as to whether a
hospital can apply for and be granted MGCRB reclassification for a
future year if the hospital is currently designated rural under section
1886(d)(8)(E) of the Act but also received an approved notice canceling
its rural designation from the CMS Regional Office.
Response: Section 412.230(a)(5)(iii) of the regulations specifies
that ``an urban hospital that has been granted redesignation as rural
under Sec. 412.103 cannot receive an additional reclassification by
the MGCRB based on the acquired rural status as long as such
redesignation is in effect.'' If a hospital, at the time of applying to
the MGCRB, has written notice from the CMS Regional Office
demonstrating that its rural redesignation will cancel prior to the
effective date of the MGCRB decision, the MGCRB should approve the
hospital for reclassification, assuming all other criteria have been
satisfied. For purposes of subpart L of Part 412 of the regulations,
the hospital will be considered urban because it is physically located
in an urban area and will longer be in rural status upon the effective
date of the MGCRB decision. Thus, the hospital will be subject to
reclassification rules that apply to urban hospitals for individual
hospital reclassification applications under Sec. 412.230 and
countywide group reclassification applications under Sec. 412.234. We
note that Sec. 412.230(a)(5)(iv) may imply that a hospital cannot
receive a reclassification by the MGCRB while it has acquired rural
status under Sec. 412.103. We are modifying Sec. 412.230(a)(5)(iv) to
indicate that a hospital may not be granted reclassification by the
MGCRB for a year in which ``such designation'' is in effect.
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, in
the FY 2006 IPPS proposed rule, we proposed 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.
412.230(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 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 proposed 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. 412.230(d)(2). We proposed to
establish 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 proposed to
apply these new criteria to geographic reclassification applications

[[Page 47445]]

that were received by September 1, 2004, and that will take effect for
FY 2006.
We proposed 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.
Comment: Many commenters supported our proposal to allow reporting
of campus-specific wage data using a supplemental Worksheet S-3 for
campuses of multicampus hospitals that are located in a wage area that
is different from the wage area in which the main provider is located.
The commenters stated that the proposal would provide equitable
treatment for these hospitals under the reclassification rules.
However, one commenter expressed concern that the proposal may
encourage an individual hospital that is part of a multicampus hospital
to seek reclassification to different labor market areas. The commenter
believed that this option should only be available in cases where an
individual campus is requesting reclassification for purposes of
reclassifying to an area where another one of the campuses is located.
Another commenter recommended that CMS modify its policy and
include only salaries and hours of the workforce attributable to the
campus or campuses located in the area in order to calculate an area
wage index. The commenter recommended that CMS require that all
multicampus hospitals with campuses in more than one wage area complete
the manual Worksheet S-3 by area. If reporting wage data by campus
proves to be administratively burdensome, the commenter suggested that
all of the multicampus hospital's wage data be included in the area in
which the majority of the multicampus hospital's employees work.
Other commenters questioned how the manual Worksheet S-3s would be
reviewed and when and how often (that is, once a year or every 3 years)
the hospitals would be required to submit the manual Worksheet S-3s.
Response: We appreciate the commenters' suggestions and their
interest in this matter. We are finalizing our proposal for FY 2006
reclassifications to allow a campus of a multicampus hospital to use
the average hourly wage data submitted for the entire multicampus
hospital as its wage data under Sec. 412.230(d)(2), if that campus
applied for reclassification for FY 2006 and it otherwise meets all of
the reclassification criteria. For FY 2007 and subsequent year
reclassifications, we proposed that a campus of a multicampus hospital
that seeks geographic reclassification to another labor market area
must submit a manual version of Worksheet S-3 of the Medicare cost
report that allocates the wage data by individual campus. We also
stated that before the data could be used for a reclassification, the
hospital's fiscal intermediary would have to review the allocation of
the entire hospital's wage data among the individual campuses. Based on
the public comments, we have further considered the potential burden to
hospitals and fiscal intermediaries that the use of a manual Worksheet
S-3 would entail. We have realized that the proposal concerning the
manual Worksheet S-3 presents certain difficulties, particularly when
considering that the MGCRB's deadline for informing hospitals of
whether their reclassification applications are approved is February 1.
In particular, because the information on the Worksheet S-3 flows from
and is linked to other worksheets in the Medicare cost report, it would
not be sufficient for campuses to submit only the Worksheet S-3; other
worksheets would need to be submitted manually as well. In addition,
since beginning with FY 2005, hospitals' wage data include an
occupational mix adjustment, reporting of campus-specific occupational
mix data would also be necessary. Because hospitals currently do not
report their wage or occupational mix data by individual campus, we
believe it could be difficult for hospitals to prepare and submit the
appropriate information between the time that this final rule is
published and the September 1, 2005 deadline for FY 2007
reclassifications. Furthermore, the submission of manual cost report
data would require a lengthy and tedious manual audit process for
fiscal intermediaries, making it extremely difficult for them to
complete these supplemental reviews and for CMS to calculate the
average hourly wages of these campuses in time for the MGCRB to make
its decisions by February 1, 2006.
We also note that our process for collecting wage index data
precludes us from adopting changes to the cost report for FY 2008
reclassifications. The wage data that will be used for an FY 2008
reclassification will be data from a hospital's FY 2003 cost report,
which is used to determine the FY 2007 wage index. Hospitals have
already submitted their FY 2003 cost reports to their fiscal
intermediaries and the CMS data reporting systems. The process for
reviewing and auditing these data will begin in October 2005. Thus, the
cost report changes that would be necessary to report wage index data
by individual campus would have needed to be in place for campus-
specific wage data to be subject to the same reporting and audit
requirements that apply generally to hospitals' wage data. While making
formal changes to the Medicare cost report to allow multicampus
hospitals to electronically report their wage data by individual campus
is a possibility for future years, it is certainly not a feasible
option for the FY 2007 or FY 2008 reclassification applications.
In addition to burden that would be associated with requiring a
manual cost report, we also considered several other issues when
deciding on a final policy. We believe that it is appropriate to have
the campus use the average hourly wage data submitted on the cost
report for the entire multicampus hospital for several reasons.
First, under the criteria for geographic reclassification, a
hospital must already demonstrate a close proximity to the area to
which it seeks reclassification. When the campus meets such proximity
requirements, it is reasonable to speculate that the average hourly
wages for an individual campus and the whole hospital are similar
because the two (or more) campuses are operating as a single entity
under one Medicare provider number, are under common ownership and
control, and are clinically and financially integrated. Accordingly,
when the facilities are in close proximity to each other (and share a
common labor market area and are within normal commuting distance), we
believe there may not be a wide range of salaries for the same
occupational categories within the same institution. (In contrast, if,
when, using the wage data of the entire hospital, the campus cannot
meet either the proximity criteria of Sec. 412.230(b) or the wage
comparison criteria of Sec. 412.230(d), the campus cannot be
reclassified. The failure to meet either of these criteria indicates
that either (a) the campus is not sufficiently proximate to assume
similar wage data, or (b) the data of the entire hospital is either not
sufficiently comparable to the reclassification area or is not
sufficiently different from the area in which the campus is already
located, to warrant a reclassification. It would be inappropriate to
assign a campus the wage index of an area that the entire hospital
would not qualify to receive, if not for the fact that one campus of
that hospital happens to be located within the boundaries of a
geographic area with a higher wage index.)

[[Page 47446]]

Second, the use of the entire hospital's wage data is practical and
administratively feasible for hospitals, CMS, and the fiscal
intermediaries because wage data for all campuses are reported together
on a single cost report under a single Medicare provider number.
Third, we note that use of the wage data for the entire multicampus
hospital is consistent with our treatment of multicampus hospitals for
calculating area wage index values, GME, DSH, and provider-based
purposes, under which multicampus hospitals operating under a single
Medicare provider number are treated as a single hospital for payment
purposes.
For the reasons described above, we have decided not to finalize
our proposed policy to require a campus of a multicampus hospital to
submit manual Worksheet S-3s with campus-specific wage data to support
a reclassification application at this time. Rather, we are extending
the policy that we had proposed for FY 2006 reclassifications to FY
2007 and FY 2008. That is, for FY 2006, FY 2007, or FY 2008, for a
campus of a multicampus hospital that wishes to seek reclassification
to a geographic wage area where another campus(es) is located, we are
requiring that a campus of a multicampus hospital use the average
hourly wage data submitted on the cost report for the entire
multicampus hospital as its wage data under Sec. 412.230(d)(2). We are
modifying the regulations at Sec. 412.230(d)(2)(iv) accordingly. We
will continue to explore options that will allow individual campuses of
multicampus hospitals to submit wage data necessary for geographic
reclassification without undue administrative burden. We will also
monitor the number of multicampus hospitals affected by this provision.
The proposal to allow campuses of multicampus hospitals to
reclassify was intended to mitigate the negative effects the new labor
market areas had on multicampus hospitals that were previously located
in a single MSA and are now located in more than one CBSA. Although
this proposal was an outgrowth of the change to the new labor market
areas, we have decided to apply this provision to any multicampus
hospitals with campuses in more than one labor market area. We believe
the same opportunity to reclassify should be available to all
multicampus hospitals in this situation, even those that were located
in different wage areas prior to the change in the OMB definitions.
Further, we will only allow a campus of a multicampus hospital to use
the average hourly wage for the entire hospital to reclassify to the
labor market area where the other campus(es) is located. We believe
this limitation is warranted because, currently, the data available for
which the campus to base a reclassification on are the wage data
reported for the entire hospital on the Medicare cost report. We will
consider further the comments that recommend that we modify our policy
to include only salaries and hours of the employees actually working in
a particular labor market area when determining the wage index for that
area. We believe this recommendation presents certain logistical
challenges that we would like to consider in the context of possible
permanent cost report changes to accommodate the electronic reporting
of separate wage data by individual campus. We anticipate having a full
discussion of these issues as part of a future rulemaking.
3. Urban Group Hospital Reclassifications
Section 412.234(a)(3)(ii) of the regulations sets forth criteria
for urban hospitals to be reclassified as a group for FY 2006 and
thereafter. Under such criteria, ``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.''
As a result of adopting the new labor market area definitions, we
reexamined in the proposed rule whether to retain old standards that
allowed proximity to be determined on the basis of being included in
the same CMSA (under the standards published by the OMB on March 30,
1990). Based on our experiences now that the new labor market areas
have been in effect for one year, we no longer believe it is necessary
to use 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, in the
FY 2006 IPPS proposed rule, we proposed to delete Sec.
412.234(a)(3)(ii) to remove reference to the CMSA eligibility
criterion. For reclassifications beginning FY 2007, we proposed 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 believed 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. We also proposed to make a conforming
change by eliminating the term ``NECMA'' from the regulations at Sec.
412.234(b)(1).
Comment: Many commenters opposed CMS' proposal to eliminate the
CMSA criterion for urban county group reclassifications. They were
concerned that eliminating the CMSA criterion would result in a
reduction in the number of hospitals eligible for reclassification.
Some commenters suggested that CMS postpone eliminating this criterion
until at least FY 2008, which would coincide with the expiration of a
3-year transition period for hospitals that changed status from urban
to rural as a result of the redefined labor market areas.
Response: We continue to believe that it is reasonable to use the
area definitions that are based on the most recent definitions. The new
designations were released on June 6, 2003. In essence, we have already
delayed the implementation of the new Census information. Consistent
with our proposal to use the area definitions announced by OMB on June
3, 2003, we are also further modifying Sec. 412.234(b)(1) to eliminate
``or NECMA'' for purposes of the wage data comparison. Because New
England County Metropolitan Areas (NECMAs) are no longer used in our
area wage definitions, we believe this term should be deleted from the
regulations.
We note that the ``3-year transition'' to which commenters refer
was not in any way related to MGCRB reclassifications and was solely
directed toward the wage index that would be received by hospitals that
changed status from urban to rural as a result of the redefined labor
market areas--a limited group of hospitals that is not representative
of the broader hospital community. Therefore, we are finalizing the
proposed policy in this final rule.
Comment: A group of hospitals in New England protested an MGCRB
decision under which they were denied reclassification. The hospitals
believed they were unfairly denied an opportunity to reclassify for
Medicare

[[Page 47447]]

wage purposes for FY 2006 because of a narrow interpretation of the
urban county group reclassification regulations by the MGCRB. The
hospital group applied for reclassification for FY 2006, but was
subsequently denied by the MGCRB, and the decision was later upheld by
the Administrator on the basis that the applying county did not meet
the regulatory requirements in Sec. 412.234(a)(3)(ii). The county was
neither part of the same CMSA (1990 Standard) or CSA as the requested
area (2000 Standard). The hospital group argued that the county would
have been included in the same CMSA as Boston if the CMSA standards had
been applied at the county-level rather than at the township level in
New England. The hospital group requested that CMS grant their
reclassification request for FY 2006 through FY 2008.
Response: We are not granting the hospital group's request. The
hospital has asked us to reverse an Administrator decision. However,
Administrator decisions are considered to be the final decision of the
Department (Sec. 412.278(f)(3)) and are subject to reopening only in
very limited circumstances which are not present in this case. In
addition, we note that Administrator decisions are not subject to
judicial review (Sec. 412.278(f)(4)). As the Administrator has already
found, the hospitals did not meet the regulatory requirements of Sec.
412.234 to be reclassified to the Boston-Worcester-Lawrence CMSA. A
Boston-Worcester-Lawrence CMSA existed under the 1990 township-based
MSA system in New England. However, approximately one-half of the
townships in the applicant county fall outside of the CMSA boundaries
(including at least two of the three townships where the applicant
hospitals are located). Therefore, as the Administrator has already
held, the applicant county is not within the Boston CMSA, and there is
no provision in the regulations that will allow us to reclassify the
Bristol County hospital to the Boston-Worcester-Lawrence CMSA.
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.
In the FY 2006 IPPS proposed rule, we proposed to update the
Medicare regulations at Sec. 412.103(a)(1) to incorporate this change
in the identification of rural census tracts. We also proposed to
update the Web site and the agency location at which the RUCA codes are
accessible.
Comment: Two commenters indicated that the use of RUCA codes
results in an inaccurate classification of their rural communities as
urban. They urged CMS to work with the Office of Rural Health Policy to
address problems in the methodology and to ensure that rural areas are
not inadvertently classified as urban.
Response: We appreciate the comments regarding use of the RUCA
codes. CMS will continue to work closely with the ORHP to ensure the
adequacy of rural health policy issues.
Comment: Commenters stated that they had difficulty locating the
Rural-Urban Commuting Area codes on the Web site identified in the
proposed rule. They requested a more detailed Web site reference as a
link to the codes.
Response: The Rural-Urban Commuting Area codes are maintained by
the Office of Rural Health Policy (ORHP). Since Web site links are
subject to change, we encourage commenters to contact the ORHP directly
for information regarding the RUCA codes. Commenters may also request
copies of the RUCA codes from the 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.
Comment: Commenters urged CMS to provide grandfather status to
protect hospitals that were redesignated as rural based on the old
Goldsmith Modification criteria and no longer qualify under the new
RUCAs. They indicated that a loss of rural status would be devastating
for many hospitals, particularly CAHs.
Response: Currently Sec. 412.103(a)(1) requires that hospitals be
located in a rural census tract of a Metropolitan Statistical Area
(MSA) as determined under the most recent version of the Goldsmith
Modification. The RUCAs are the most recent of the Goldsmith
Modification. Therefore, hospitals must qualify on the basis of the new
RUCAs. CMS will continue to monitor how the new standards affect
hospitals' rural status.
In this final rule, we are adopting as final, without modification,
our proposal to update the regulations at Sec. 412.103(a)(1) to
incorporate the change in the identification of rural census tracts and
to update the Web site 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 changing the cross-references to the
definitions of ``urban'' and ``rural'' to reflect their current
locations in Subpart D of Part 412, as applicable.

Other Comments

Comment: We received a number of suggestions for revising the
geographic reclassification rules that were independent from the
policies we proposed. Some commenters recommended that CMS develop
criteria that would allow areas within CBSAs to qualify as core urban
areas and for all providers located in those areas to receive their own
wage indices. In

[[Page 47448]]

addition, they suggested that CMS develop MGCRB criteria through which
hospitals not located in the core urban area, but within the same CBSA,
could apply for reclassification into the core urban area. Other
commenters requested that CMS expand the urban group reclassification
eligibility criteria to allow hospitals in counties that are in the
same CBSA as the urban area to which they seek redesignation to qualify
as meeting the proximity requirement. One commenter proposed
alternative reclassification criteria by which a hospital in a single
hospital Metropolitan Statistical Area could apply for reclassification
to a noncontiguous urban area for wage index purposes.
Response: In the FY 2006 IPPS proposed rule, we did not propose any
changes that are specific to these comments. Because these proposals
would have a negative effect on some hospitals or might appear
inequitable to similarly situated hospitals, we do not believe it would
be prudent to adopt any of them in this final rule without first
opening them up for public comment.
Comment: One commenter stated that a Pennsylvania hospital in a
single hospital MSA surrounded by rural counties is at a competitive
disadvantage because the rural hospitals that surround the hospital
have been reclassified to higher wage index areas or have been
designated as rural referral centers, SCHs, MDHs, or CAHs. The urban
hospital is ineligible for reclassification to a higher wage area
either as an individual hospital or as a group under current
regulations. The commenter advocated a change to the urban county group
reclassification regulations whereby a hospital in a single hospital
MSA surrounded by rural counties would be able to reclassify to the
closest urban area which is part of a Combined Statistical Area (CSA)
located in the same state as the hospital.
Response: As we indicated above, we did not propose any changes
that are specific to these comments in the FY 2006 IPPS proposed rule
and do not believe it would be prudent to adopt any of them in this
final rule without first opening them up for public comment and being
able to fully consider the effect on other hospitals that are similarly
situated. For this reason, we are unable to address this issue at this
time without further study. We note that the comment raises a point
about the hospital competing with other rural hospitals that are able
to reclassify under special access rules that apply to RRCs and SCHs.
Rural referral centers and SCHs are eligible for special access rules
under section 1886(d)(10)(D)(i)(III) of the Act. Under these
provisions, where a hospital is the sole source of inpatient hospital
care or is the only provider of needed tertiary services in rural
areas--as, by definition, RRCs and SCHs are--special proximity rules
apply in cases of reclassification, in order to ensure access to care.
These rules were implemented in a 1992 rulemaking and are specific to
RRCs and SCHs. (See the June 4, 1992 proposed rule (57 FR 23618 and
23634) and the September 1, 1992 final rule (57 FR 39746 and 39769).)
We will consider this issue further and whether future rulemaking
is warranted to address this situation.

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

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 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

[[Page 47449]]

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 a 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 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 portions of 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

[[Page 47450]]

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, in the FY 2006 IPPS proposed rule, we proposed 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 or transitional year training program.
We noted 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 did not propose 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 proposed 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 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.
Comment: Several commenters commended and supported our proposal to
revise the current regulations to state that a resident who initially
matches only to an advanced program without simultaneously matching to
a clinical base year program will have his or her IRP determined based
on the number of years required for the advanced program. A number of
commenters suggested that we implement a standard second-year policy in
which the resident's IRP would always be based on the specialty that a
resident enters in his or her second year of training, regardless of
what occurred during the residents first year of GME training. These
commenters suggested that a ``second year'' policy would be less
complicated, less administratively burdensome, and could be applied
more universally, as many residents enter an advanced program in their
second year of training without being involved in the match process.
The commenters also added that this seems more consistent with
legislative intent as stated in the Conference report language
accompanying section 712 of Pub. L. 108-173. That language states that
``the initial residency period for any residency for which the ACGME
requires a preliminary or general clinical year of training is to be
determined the resident's second year of training.''
Response: We appreciate the commenters' support for our proposal.
However, we do not agree with the comment that we should revise the
regulations and establish a ``second year'' policy for determining the
IRP for residents. As we indicated in the FY 2005 IPPS final rule (69
FR 49171), we considered proposing a change in policy to determine the
IRP for a resident who participates in a clinical base year program
based on the specialty associated with the resident's second year of
training as suggested by the Conference Committee language. We
ultimately rejected this policy because we believe that, if we were to
establish a ``second year'' policy, there would be no way to
distinguish between those residents who matched to a specialty program
for a second year of training prior to beginning their first year of
training, and those residents who simply switched specialties in their
second year. Because section 1886(h)(5)(F) of the Act provides that the
IRP must be determined ``as of the time the resident enters the
residency training program,'' we believe the IRP needs to be determined
based on the ``initial'' or first program in which a resident trains.
Thus, we are not adopting the commenters' suggestion that we ignore the
specifics of the first year of training and wait to establish the
``initial'' residency period based solely on the program in which the
resident is training during his or her second year. The policy
advocated by the commenter would lead us to establish the IRP based on
the period of board eligibility for a specialty training program the
resident entered in the second year even where the resident had clearly
switched specialties in the second year. We do not believe this would
be consistent with legislative intent.
Comment: Some commenters stated that a resident who enters into a
transitional year program or a preliminary training year program in an
internal medicine residency should be assigned an IRP based on the
program that the resident enters in his or her second year of training,
since such a resident could never receive certification from his or her
clinical base year of training.
Response: In the FY 2005 rule, we finalized an IRP policy stating
that for a resident that matches in a clinical base year program and
simultaneously matches in a specialty training program, Medicare will
use the period of board eligibility of the specialty training program
to determine the resident's IRP. In this final rule, we are revising
our policy to state that the IRP for a resident who initially matches,
prior to beginning any residency training, only to an advanced program
without simultaneously matching to a clinical base year or transitional
year program, will have his or her IRP determined based on the period
of board eligibility for the advanced program.
In the limited circumstance where a resident trains in the
transitional year program without matching in a specialty

[[Page 47451]]

program for the second year, we would, in fact, establish the IRP in
the second year of the resident's training because there is no
specialty associated with transitional year programs, and even though
the resident would have ``entered'' a residency training program, we
would be unable to identify any specialty with the transitional year
program for purposes of determining the IRP. Because training in a
transitional year program cannot lead by itself to certification in any
specialty, the earliest that Medicare is able to determine such a
resident's IRP is when the resident ``enters'' a specialty program in
the resident's second year of training. Thus, in the limited
circumstance of a resident that trains in a transitional year program
without having matched into a specialty program that begins in the
second year, we believe it is necessary, and therefore appropriate, to
look to the resident's second year of training to identify the
specialty that should be used for the purpose of determining the IRP.
We note that the situation of the resident in the transitional year
program is substantially different from the situation where the
resident begins training in other preliminary year programs, such as
internal medicine. In the case of preliminary year programs, there is a
specialty associated with the training, and we could, therefore,
establish an IRP based on the period of board eligibility for that
program. Therefore, it would not be necessary for us to wait until the
second year to establish the resident's IRP. Under the policy revision
we proposed, the IRP for a resident that enters a preliminary year in
internal medicine and continues training in an advanced specialty is
established based on the period of board eligibility for the advanced
specialty if the hospital documents that the resident had matched to
the advanced specialty program prior to commencement of any residency
training. Without such documentation, as mentioned before, CMS would
have no way to distinguish between those residents who matched or
planned to train in a particular advanced specialty program prior to
entering their first year of training in an internal medicine or other
``preliminary year,'' and those residents who simply switched
specialties in their second year.
Comment: One commenter noted that we indicated in the proposed rule
that this proposal best reflects our original intent in revising the
IRP rule effective October 1, 2004, and recommended that we clarify our
current proposal to also be effective October 1, 2004.
Response: As stated in the proposed rule, we were ``proposing to
revise Sec. 413.79(a)(10)'' and that this is a ``policy change.''
While this policy change is similar to the policy change we made last
year regarding simultaneous matches, nevertheless it is a change in
policy. Accordingly, the change will not be effective October 1, 2004,
but rather the effective date for the final policy change in this final
rule is for portions of cost reporting periods occurring on or after
October 1, 2005.
Comment: One commenter requested clarification as to what type of
documentation would be needed to demonstrate that a resident matched to
the advanced residency prior to beginning any training program. The
commenter was concerned that there may be confusion during audits if no
documentation standard was established. In particular, the commenter
mentioned that, although it is fairly easy to acquire such
documentation from the National Resident Matching Program (NRMP), it is
harder to acquire such documentation from the San Francisco Matching
Program. This commenter requested that we identify documentation from
the San Francisco Matching Program that would be consistent with the
NRMP documentation.
Response: As we understand it, the San Francisco Matching Program
sends letters to providers indicating which residents matched into
which specialty programs. This letter would be sufficient documentation
to show that, prior to beginning any residency training program, a
resident matched into an advanced program for the second residency
year.
Comment: Two commenters requested clarification and provided
recommendations on issues relating to residency training programs that
were not addressed in the proposed rule.
Response: Because we did not propose any changes in policy
concerning the issues addressed by the commenters in the FY 2006 IPPS
proposed rule, we are not responding to those issues in this final
rule.
Comment: One commenter noted that CMS did not mention which PRA
would be applied to a resident training in his or her clinical base
year versus which PRA would be applied once that resident enters his or
her second year of training.
Response: We believe it is appropriate to finalize a policy that
treats residents consistently in terms of the specialty program in
which they are considered to be training. For this reason, we are
finalizing our proposal from the FY 2006 proposed rule that for a
resident who initially matches only to a specialty program, to begin in
the resident's second year of training, without simultaneously matching
to a clinical base year or transitional year program, the IRP is
established in the resident's first year of training based on the
period of board eligibility associated with the specialty program, that
is, the program in which the resident will seek certification. Because
those specialties that require a clinical base year are not primary
care specialties, the specialty that the IRP is based on in the first
year of training would be a non-primary care specialty. We believe it
is only consistent to apply the non-primary care PRA during the first
clinical base year of training as well.
Comment: One commenter suggested that residents training in their
clinical base year should be assigned a Med School number of 8888 for
IRIS diskette purposes. The commenter indicated that this would be
similar to foreign residents who are currently identified with a 9999
Med School number on the IRIS diskette.
Response: In implementing this policy change, we will consider
within CMS the need for and possibility of implementing such a change
to the IRIS diskette.
Comment: One commenter requested clarification on how the IRP would
be determined for a resident who, at the end of his or her clinical
base year, decides to enter a different subspecialty that does not
require a clinical base year.
Response: Medicare establishes the IRP based on the specialty
associated with the program that the resident ``enters'' in his or her
first year of training (unless, prior to beginning any training
program, the resident matches to an advanced specialty program for the
second year of training, in which case the IRP is based on the
specialty program). The resident retains this IRP for the remainder of
his or her residency training, even if the resident decides later to
train in a different specialty training program. Therefore, consider,
for example, a resident who matched prior to beginning any residency
training to a radiology program that would begin in the second
residency year. The resident then completes training in an internal
medicine clinical base year program, and decides that instead of
continuing into the radiology program, he or she will continue training
in the internal medicine program. Under our policy, the IRP for this
resident would have already been established in the first year of
training at 5 years, based on the period of board eligibility for
radiology. Thus, even after

[[Page 47452]]

the resident decides to continue training in internal medicine, the
resident would maintain the IRP that was established in the first year
of training.
After consideration of the comments received, we are adopting as
final, without modification, our proposal to revise Sec. 413.79(a)(10)
to indicate that, when a hospital can document that a resident matched
prior to commencement of any residency training in an advanced
residency training program beginning in the second residency year, 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.
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 26336), 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 discussion 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).
In the FY 2006 IPPS proposed rule, we proposed 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 the proposed
policy change would allow new urban teaching hospitals flexibility to
start new teaching programs without jeopardizing their ability to count
additional FTE

[[Page 47453]]

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 proposed to revise 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 proposed 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
specifically solicited comments on the proposed change.
We would like to clarify a statement made at 70 FR 23440 of the FY
2006 IPPS proposed rule in which we state, ``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)'' (emphasis added). The sentence could be read to
mistakenly imply that the new teaching Hospital A is not permitted to
affiliate only once its cap becomes effective beginning with the fourth
program year of the new program. In fact, the new teaching Hospital A
cannot affiliate from the time it begins training residents in the
newly accredited program(s).
Comment: Numerous commenters agreed with the proposed policy change
to allow new urban teaching hospitals to enter into a Medicare GME
affiliation agreement if the adjustment results in an increase in their
direct GME and IME caps. Some of the commenters stated that the
proposal allows new urban teaching hospitals the flexibility to start
new teaching programs without ``jeopardizing their ability to count
additional FTE residents training at the hospital under an affiliation
agreement.'' These commenters stated that an increase in Medicare
payments received by the new urban teaching hospital when residents
from existing teaching hospitals rotate to the new urban teaching
hospital is necessary to cover both direct and indirect costs incurred
``to train the `in rotating' residents from other hospital teaching
programs.''
Response: We appreciate the comments in support of our proposal to
allow for new urban teaching hospitals to join a Medicare GME
affiliated group if, under the agreement, there is a positive increase
to the FTE cap of the new teaching hospital. We agree that our proposal
will allow new urban teaching hospitals greater flexibility in starting
new teaching programs without endangering their ability to train other
FTE residents from existing programs under an affiliation agreement.
Comment: One commenter urged CMS to consider ``replacing the
permanent exclusion of negative adjustments for new urban teaching
facilities with a temporary exclusion for the first 3 to 5 years.'' The
commenter believed that such a replacement would permit new urban
teaching facilities flexibility similar to that allowed for new rural
teaching facilities and allow for adjustments due to ``unforeseen
future circumstances.''
Response: We disagree with the commenter's suggestion. We continue
to be concerned that hospitals with existing medical residency training
programs could affiliate with a new teaching hospital to circumvent the
statutory FTE caps by establishing new programs at the new teaching
hospital, and move the additional FTE slots to its own hospital, thus
receiving an upward adjustment to its FTE caps. For this reason, we
limited our proposal to revise 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 cap.
Comment: One commenter believed CMS's proposal to permit an
affiliation agreement as long as it results in an increase in the new
teaching hospital's resident cap is a ``positive'' change but stated
that the proposal does not address the issue that ``all teaching
programs must meet specific teaching requirements'' and often need to
rotate residents to other facilities in order to meet those
requirements. The commenter believed that, because the ``used'' portion
of the teaching hospitals' direct GME and IME FTE resident caps were
reduced by 75 percent in accordance with section 422 of Pub. L. 108-
173, new teaching facilities may have difficulty finding a hospital
that will accept their residents for the necessary rotations without an
affiliation agreement. The commenter believed that, unless it could
aggregate its FTE resident limit with other hospital(s) through a
Medicare GME affiliation agreement, it may become necessary for the new
teaching hospital to pay for training the residents in the new program
at another hospital in order for another hospital to agree to provide a
training site for the residents. The commenter suggested CMS revise the
regulations to allow new teaching hospitals to join an affiliated group
and allow for a cap decrease as long as the new teaching facility can
document that, at a minimum, 75 percent of the total training hours for
each resident was completed at the new teaching facility, and no more
than 25 percent of training was done at another hospital site during
the cost report period.
Response: We disagree with the commenter's suggestions. We continue
to be 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
some of the new residency program to its own hospital, thereby
receiving an upward adjustment to its FTE caps. For this reason, we
limited our proposal to revise 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 a Medicare GME affiliation agreement that would produce a negative
adjustment to its FTE cap,
Comment: Several commenters requested that CMS consider
``broadening its proposed changes to the affiliation agreement
requirement.'' The commenters believed that CMS' concerns regarding
possible gaming are unnecessary and therefore the policy is ``too
restrictive.'' The commenters indicated that hospitals do not decide to
become teaching hospitals and become involved with the accreditation
process with the intention of ``gaming'' the system. The commenters
stated that CMS has not provided any evidence ``that this type of
gaming has ever

[[Page 47454]]

occurred.'' The commenters further asserted that, in imposing
restrictions on affiliation agreements for new urban teaching hospitals
to prevent gaming, CMS has not considered the safeguards that are
already in place to avert gaming. They added that the ``intensive
process'' of accreditation by an appropriate accrediting body is one of
the several existing safeguards against gaming. The commenters believed
that an additional safeguard against gaming is the requirement that a
hospital ``must maintain its new program for a period of three years
before it qualifies to receive a permanent FTE cap.'' Referring to the
previous sentence, the commenters believed that ``establishing a
program requires concerted action by staff throughout a facility, which
actions must be sustained for a subsequent period of time. It is
unlikely that many institutions would undertake such action merely to
help another hospital to obtain a purported improper gain in its GME
payment.'' The commenters stated that additional protection against
gaming is provided through changes CMS has made over time to
affiliation agreement requirements. They gave as an example of such
changes to affiliation agreement requirements the requirement that
there be ``a bona fide shared rotational arrangement between two
hospitals as a pre-condition to entry into an affiliation agreement.''
The commenters asserted that CMS' affiliation agreement policy
could have a negative impact on medical education. The commenters
stated that, due to circumstances that are unforeseen, a hospital may
need to shift a group of residents to another hospital in its
affiliated group. The commenters believed that CMS would penalize the
receiving hospital for circumstances beyond its control by disallowing
the receiving hospital to increase its FTE cap ``through a shift of a
portion of the new teaching hospital's FTE cap.'' The commenters
believed that this lack of flexibility will ``discourage parties from
entering into affiliation agreements with new teaching hospitals
because of the fear of adverse financial implications arising from
unforeseen circumstances.'' The commenters requested that CMS
reconsider the policy to allow a new teaching hospital to enter into
affiliation agreements only when they result in an increase in the new
hospital's FTE cap.
Response: We appreciate, but disagree with, the commenter's views.
Despite the commenters' examples of safeguards against gaming, we
continue to be 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 FTE slots to its own hospital, thus receiving an
upward adjustment to its FTE caps. In order to prevent the artificial
expansion of the aggregate FTE limits for all teaching hospitals that
could otherwise result, we proposed a limited revision to 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 a Medicare GME affiliation agreement
that would produce a negative adjustment to its FTE resident cap.
We would also like to clarify, from an operational perspective,
what a Medicare GME affiliation agreement would look like between an
existing urban teaching hospital with a 1996 cap and a new urban
teaching hospital that is receiving a permanent cap adjustment for a
newly approved program. Because, under Sec. 413.79(e)(1)(ii), the new
teaching hospital does not have permanent FTE caps within the first 3
years of the new program's existence, the new teaching hospital would
affiliate with its FTE caps of zero. That is, the affiliation agreement
between the new teaching hospital and the existing teaching hospital
would show a positive adjustment to the new teaching hospital's 1996
FTE cap of zero. However, once the FTE caps have been permanently
established beginning with the fourth program year of the new program's
existence, the affiliation agreement between the new teaching hospital
and the existing teaching hospital would show a positive adjustment to
the new teaching hospital's adjusted cap resulting from the new
program(s).
Comment: One commenter urged CMS to make the provision allowing new
urban teaching hospitals to enter into affiliation agreements only if
there is an increase in direct GME and IME cap(s) ``effective for
affiliation agreements entered into on or after October 1, 2005, and be
noted in the final rule.''
Response: Although this final rule generally takes effect on
October 1, 2005, because hospitals must affiliate by July 1 of a given
year, as a practical matter, the new policy will be effective for
affiliation agreements entered into on or after July 1, 2006, which is
the first academic year that new teaching hospitals could affiliate
under these new rules.
Comment: Two commenters requested clarification and provided
recommendations on topics not addressed in the proposed rule. One
commenter requested guidance on how the increases in FTE resident
limits under section 422 of Pub. L. 108-173 would be applied. On a
different subject-matter, the commenter recommended that we perform an
analysis to determine the validity of the Council on Graduate Medical
Education's recommendations that CMS gradually increases its resident
caps in the face of a possible physician shortage in the future.
Another commenter requested clarification on how CMS would treat two
affiliation agreements for payment purposes where Hospital A, Hospital
B, Hospital C, and Hospital D agree to affiliate and then Hospital D
and Hospital E enter into a separate affiliation agreement that
specifically states the agreement's intent not to include Hospital E as
part of the agreement between Hospitals A, B, C, and D.
Response: In the FY 2006 IPPS proposed rule, we did not propose any
changes that are specific to these comments. Therefore, we are not
responding to them at this time.
In this final rule, we are adopting as final, without modification,
our proposal 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. This
provision is effective for affiliation agreements entered into on or
after October 1, 2005.
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

[[Page 47455]]

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.)
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 affect 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

[[Page 47456]]

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, as we proposed in the FY 2006
IPPS proposed rule, we are clarifying in this final rule our policy
that hospitals that became urban in FY 2005 due to the new labor market
areas will 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 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. As we proposed in the FY 2006 IPPS proposed rule,
we are adding a new paragraph (k)(7) to Sec. 413.79 to incorporate
this policy.
Comment: Several commenters commended CMS and supported our
proposal to revise the current regulations that would allow a rural
hospital redesignated as urban as a result of the changes to CBSAs that
were effective on October 1, 2004, to retain any adjustment that it
received as a rural hospital.
Response: We appreciate the commenters' support of our proposal.
Accordingly, in this final rule, we are adopting the proposal as
final without modification.

[[Page 47457]]

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. As we proposed in the FY 2006 IPPS
proposed rule, we are providing that, effective with discharges
occurring on or after October 1, 2005, a different policy applies 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 final rule, we are correcting 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. In this
final rule, we are correcting 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

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
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

[[Page 47458]]

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, in the FY 2006 IPPS proposed
rule, we proposed 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 policy, 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.
Comment: Two commenters supported the proposed change but did not
comment in further detail on it.
Response: We appreciate the commenters' views and have taken them
into consideration in developing the final rule.
Comment: One commenter recommended that the final rule be revised
to state that the inclusion of rural health clinics affiliated with
hospitals having 50 or more beds in Sec. 413.65(a)(1)(ii) is effective
for cost reporting periods beginning on or after October 1, 2005.
Response: Although rural health clinics affiliated with hospitals
having 50 or more beds were not previously specifically listed in Sec.
413.65(a)(1)(ii), it has been CMS' general policy that determinations
under Sec. 413.65 are not made for facilities or organizations if the
outcome of the determination would not have any effect on the amount of
Medicare payment or on the scope of benefits or liability of Medicare
beneficiaries. Under this general policy, we believe that such
determinations have historically not been made for such clinics, and,
therefore, we view this revision to Sec. 413.65 (a)(1)(ii) as a
clarification of existing policy and not as the announcement of a new
policy for which an effective date must be specified. Therefore we have
not made any changes to Sec. 413.65 (a)(1)(ii) based on this comment.
The general effective date for this final rule is October 1, 2005.
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

[[Page 47459]]

offsite NICUs are housed typically are 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 a 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, in the
FY 2006 IPPS proposed rule, we solicited specific public comment on the
following question:
Is the problem as described above actually occurring and,
if so, in what locations? We were 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.
Comment: One commenter stated that it is aware of only one hospital
in its State that is in the situation described above. Another
commenter echoed the same comment and stated that it is not aware of
any other children's hospital with off-campus NICU services in host
hospitals more than 35 miles from the main campus of the children's
hospital. Another commenter indicated that it is aware of only one
hospital in the country that is in the situation described above.
Response: We appreciate the information provided by these
commenters and have taken it into account in developing the final rule
set forth below.
We also asked those who believed 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
solicited specific comments were:
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.
Comment: Two commenters stated that this option, that of providing
a more generous mileage allowance for NICUs for which provider-based
status is sought, would not fully account for the appropriate provision
of crucial services in underserved areas. Two other commenters noted
that a mileage allowance of 50 miles would not accommodate both current
and proposed off-campus NICUs. Thus, these commenters recommended that
this option not be adopted.
Response: We understand and have considered the concerns of these
commenters. However, for the reasons set forth below, we are adopting
as final an approach under which a NICU seeking provider-based status
that is unable to meet existing location criteria can be located up to
100 miles from the main provider, as long as it meets certain other
requirements described in detail below.
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.)
Comment: Several commenters supported this option, stating that it
would be the most effective in ensuring access to crucial services in
underserved areas.
Response: We understand and have considered the views of these
commenters. However, we believe this final rule is not the appropriate
vehicle for such a change to the national Medicaid regulations. As
stated earlier and for the reasons set forth below, we are adopting as
final the approach proposed for public comment as Option 1, with some
modification.
A change in an individual State's Medicaid plans that
would provide enhanced financial incentives for community hospitals to
establish NICUs, possibly in collaboration with children's hospitals.
Comment: Two commenters expressed disapproval of this option,
stating that a change in State Medicaid plans would be too difficult
for individual hospitals to achieve. Two other commenters noted that
discussions with State Medicaid officials have indicated that changing
the State Medicaid plan is not a feasible option in that State.
Response: We understand the concerns of these commenters and, after
further review of this option, have decided not to adopt it in this
final rule.
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.)
Comment: Two commenters expressed disapproval of this option,
stating that it would be unrealistic to expect 6 to 8 bed facilities to
operate as separate hospitals because they would then not have the
support of a full-service children's hospital. Two other commenters
noted that operating these NICUs as separately certified hospitals
located within the community hospitals would result in a reduced level
of Medicaid DSH funding to the main

[[Page 47460]]

hospital under Medicaid rules in that State.
Response: We understand the concerns of these commenters and, after
further review of this option, have decided not to adopt it in this
final rule.
We also solicited suggestions for specific options other than those
listed above but did not receive any specific recommendations regarding
alternative approaches to the NICU issue.
After consideration of the comments received on the four options we
offered for comment, we have decided to adopt Option 1, but to modify
it by specifically requiring a NICU that is seeking provider-based
status but is unable to meet existing location criteria to qualify for
provider-based status only if the facility or organization meets all of
the following requirements:
The facility or organization meets the criteria for
identifying intensive care type units as set forth in the Medicare
reasonable cost reimbursement regulations at Sec. 413.53(d), and as
further explained in section 2202.7 II.A. of the Medicare Provider
Reimbursement Manual (CMS Pub. 15-1). Generally, these criteria state
that an intensive care type unit must--

--Be located in a hospital;
--Be physically and identifiably separate from general routine patient
care areas;
--Have specific written policies that include criteria for admission
to, and discharge from, the unit;
--Have registered nursing care available on a continuous 24-hour basis
with at least one registered nurse present in the unit at all times;
--Maintain a minimum nurse-patient ratio of one nurse to two patients
per patient day; and
--Be equipped with, or have available for immediate use, life-saving
equipment needed to treat the critically ill patients for which the
unit is designed.

The facility or organization accepts only patients who are
newborn infants who require intensive care on an inpatient basis.
The hospital that is the potential main provider meets the
criteria in Sec. 412.23(d) for reimbursement under Medicare as a
children's hospital.
The hospital in which the facility or organization is
physically located is in a rural area as defined in Sec.
412.64(b)(1)(ii)(C).
The facility or organization is located within a 100-mile
radius of the children's hospital that is the potential main provider.
The facility or organization is located at least 35 miles
from the nearest other NICU.
The facility or organization meets all other requirements
for provider-based status under Sec. 413.65.
We took several factors into account in adopting these final rules.
By requiring compliance with existing Medicare requirements for
intensive care-type units, we can ensure that only qualified NICUs are
considered under this new provision, while at the same time not
imposing any added burden on existing NICUs. The rural location
requirement is consistent with the description of these facilities as
being located in rural areas. The enhanced mileage allowance (100
miles) takes into account the comments of those who stated that a 50-
mile standard would be overly restrictive, but nevertheless establishes
a clear location standard for the NICUs to meet. We believe the 100-
mile criterion will sufficiently address the two currently operating
remote NICUs that commenters identified. The complementary requirement
for a minimum separation of at least 35 miles should help to ensure
that hospitals in which the remote NICUs are located are not currently
adequately served by another NICU. The requirement that the facility or
organization accept only patients who are newborn infants who require
intensive care on an inpatient basis will ensure that facilities or
organizations are able to take advantage of the more generous mileage
allowance only if they are dedicated to the care of neonates.
These criteria are set forth in new Sec. 413.65(e)(3)(v) of this
final rule.
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 proposed 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.
Comment: One commenter suggested that the text of paragraph (a)(2)
be revised to state that the change described above is effective with
respect to determinations made on or after October 1, 2005.
Response: The general effective date for this final rule is October
1, 2005. Therefore, the commenter is correct in understanding that this
change will apply to determinations made on or after that date, and
this policy will be communicated to all CMS staff involved in provider-
based determinations. However, we believe it could be confusing to
readers if we were to specifically revise the definition of ``provider-
based entity'' in Sec. 413.65(a)(2) to specify an effective date for
this change since the word ``name'' will no longer appear in the
definition. Therefore, we are not making any changes in the final rule
based on this comment.
We received no other comments on this proposed technical revision,
and after consideration of the comment summarized above, we are
adopting the revision as final without change in this final rule.
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
proposed to revise paragraph (b)(3)(ii) by removing the reference to
compliance with requirements in paragraph (f) for joint ventures. We
also proposed 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.

[[Page 47461]]

We did not receive any comments on this proposed revision and are
adopting it without change in this final rule.
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 proposed 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 also proposed, for purposes of 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).
We did not receive any comments on this proposed revision and are
adopting it without change in this final rule.
d. Additional requirements applicable to off-campus facilities or
organizations--Location. We proposed 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 proposed to correct this error
by redesignating existing paragraph (e)(3)(ii)(C) as paragraph
(e)(3)(iv). We also proposed 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 proposed 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 also proposed 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.
Comment: Regarding our proposal to revise the opening sentence of
paragraph (e)(3) of Sec. 413.65 for clarity, one commenter stated that
our proposed language did not clarify whether a facility or
organization not located on the campus of the prospective main provider
is required to meet all of 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 as well as the requirements in
paragraph (e)(3)(vi) of Sec. 413.65 or only any one of the
requirements in paragraphs (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 as well as the requirements in paragraph (e)(3)(vi). The
commenter requested that we clarify that a facility or organization
that is located within a 35-mile radius of the campus of the
prospective main provider is not also required to meet the requirement
in proposed paragraphs (e)(3)(ii), (e)(3)(iii), (e)(3)(iv), or, in the
case of an RHC, paragraph (e)(3)(v).
Response: The commenter's understanding of this requirement is
correct: a facility or organization that meets the 35-mile requirement
in proposed paragraph (e)(3)(i) would not also be required to meet the
criteria in proposed paragraphs (e)(3)(ii), (e)(3)(iii), (e)(3)(iv),
or, in the case of an RHC, paragraph (e)(3)(v). Because we did not
receive other comments expressing concern about the meaning of this
paragraph, we have not included any further revision of it in this
final rule. However, we understand the commenter's concern and will
issue clarifying instructions or educational materials in the future if
there is evidence of misunderstanding of this paragraph.
After consideration of all of the comments received on these
proposed revisions, we are adopting them with only two changes in this
final rule. Because we are adding a new paragraph (e)(3)(v) to Sec.
413.65 (see section V.J.3. of this preamble) that sets forth new
provider-based requirements for NICUs located in rural areas, we are
redesignating certain provisions of paragraph (e)(3) and are making
appropriate changes in the references to proposed paragraphs (e)(3)(v),
(e)(3)(vi), and (e)(3)(vii) to accommodate this addition. In addition,
to provide a reference to the definition of ``rural'' applicable to
Federal fiscal years 2005 and subsequent fiscal year for purposes of
paragraph (e)(3), in Sec. 413.65(e)(3)(v) (redesignated by this final
rule as section 413.65(e)(3)(vi)), we are removing the reference to
Sec. 412.62(f)(1)(iii) and replacing it with a reference to Sec.
412.64(b)(1)(ii)(C). We are also making a technical, clarifying change
to paragraph (e)(3)(i) of Sec. 413.65 by replacing the reference to
section 1886(e)(5)(F)(i)(II) of the Act with section
1886(d)(5)(F)(i)(II) of the Act, which is the statutory basis for Sec.
412.106(c)(2). Additionally, for consistency with the language of
section 404(b)(2)(B) of Pub. L. 106-554, we are making a clarifying
change in paragraph (e)(3)(ii) by revising the phrase ``and is
described in Sec. 412.106(c)(2) of this chapter'' to read ``or is
described in Sec. 412.106(c)(2) of this chapter''.
e. Paragraph (g)--Obligations of hospital outpatient departments
and hospital-based entities. We proposed 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 proposed to reorganize the subsequent paragraphs of that
section for clarity.
Comment: Two commenters expressed approval of this proposal,
stating that it would improve general understanding of the provider-
based requirements for off-campus facilities and organizations.
Response: We appreciate the support of the commenters and have
taken it into account in developing this final rule.
After consideration of all comments received on this proposed
revision, we are adopting it without change in this final rule.

K. Rural Community Hospital Demonstration Program

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;

[[Page 47462]]

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, as we
proposed in the FY 2006 IPPS proposed rule, we are adjusting national
inpatient PPS rates by an amount sufficient to account for the added
costs of this demonstration. In other words, we apply budget neutrality
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, the
estimated adjusted amount is $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 payment rate adjustment
that will be required to ensure the budget neutrality of the
demonstration in section II.A.4. of the Addendum to this final 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.
We did not receive any public comments on the Rural Community
Hospital Demonstration Program discussed in the proposed rule.

L. Definition of a Hospital in Connection With Specialty Hospitals

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
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, it has come to our attention that some entities that
describe themselves as surgical or orthopedic specialty hospitals may
be primarily engaged in furnishing services to outpatients, and thus
might not meet the definition of a hospital as contained in section
1861(e) of the Act. Therefore, if we were to determine that a facility
is not primarily engaged in inpatient care at the time it seeks
certification to participate in the Medicare program as a hospital, its
application for a provider agreement would be denied. Further, if we
were to determine that a specialty hospital operating under an existing
Medicare provider agreement 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 the whole hospital exception.

[[Page 47463]]

We received several comments concerning our observation in the FY
2006 IPPS proposed rule that some specialty hospitals may not meet the
definition of a ``hospital'' contained in section 1861(e) of the Act.
As we stated earlier, an institution must be ``primarily engaged'' in
furnishing services to inpatients in order to be a ``hospital'' for
purposes of participating in Medicare. We noted in the proposed rule
that some specialty hospitals may be primarily engaged in furnishing
care to outpatients. At least one commenter was under the impression
that we were proposing to make changes in the regulations in the FY
2006 IPPS proposed rule to address the ``primarily engaged''
requirement of the statute. In fact, that was not our intention. Over
the next several months, we plan to review our procedures for enrolling
specialty hospitals in Medicare. During this review, we will examine
whether specialty hospitals meet the definition of a ``hospital''
contained in section 1861(e) of the Act. Following such review, we may
issue proposed rulemaking for comment concerning the definition of a
``hospital'' or other conditions of participation.

VI. PPS for Capital-Related Costs

In the FY 2006 IPPS proposed rule, we did not propose any changes
in the policies governing the determination of the payment rates for
inpatient 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 inpatient
capital-related costs and the methodology used to determine capital-
related payments to hospitals. A discussion of the rates and factors
for FY 2006 (determined under our established methodology) can be found
in section III. of the Addendum of this final 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 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 threshold 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 exception
payment for extraordinary circumstances in Sec. 412.348(f) can be
found in the FY 2005 IPPS final rule (69 FR 49185 and 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

[[Page 47464]]

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 capital PPS Puerto
Rico specific rate and 25 percent of the 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 capital PPS Puerto Rico rate and
50 percent of the capital PPS 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 capital PPS Puerto Rico rate and 75 percent of the
capital PPS Federal rate for discharges occurring on or after October
1, 2004.

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

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
Historically, hospitals and units excluded from the PPS received
payment for inpatient hospital services they furnished on the basis of
reasonable costs, subject to a rate-of-increase ceiling. An annual per
discharge limit (the target amount as defined in Sec. 413.40(a)) was
set for each hospital or hospital unit based on the hospital's own cost
experience in its base year. The target amount was multiplied by the
Medicare discharges and applied as an aggregate upper limit (the
ceiling as defined in Sec. 413.40(a)) on total inpatient operating
costs for a hospital's cost reporting period. Prior to October 1, 1997,
these payment provisions applied consistently to all categories of
excluded providers (rehabilitation hospitals and units, psychiatric
hospitals and units, long term care hospitals, children's hospitals,
and cancer hospitals excluded from the IPPS). Payment for children's
hospitals and cancer hospitals that are excluded from the IPPS
continues to be subject to the rate-of-increase limits based on the
hospital's own historical cost experience. (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.)
For the other three classes of excluded providers, rehabilitation
hospitals and units, psychiatric hospitals and units, and LTCHs,
payment provisions changed significantly for cost reporting periods
beginning on or after October 1, 1997.
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 FY 2001, the hospital-specific
target amount is the net allowable cost in a base period increased by
the applicable update factor multiplied by 1.25.)
In addition, a new method of determining the payment amount for
``new'' excluded providers was established at Sec. 1886(b)(7) of the
Act. The law was applicable for three classes of excluded providers,
rehabilitation hospitals and units, psychiatric hospitals and units,
and LTCHs, with a first cost reporting period beginning on or after
October 1, 1997. These ``new'' excluded providers would be paid the
lesser of their net inpatient operating costs per case or 110 percent
of the national median of target amounts for providers in its class, as
adjusted for differences in wage levels and updated to the first cost
reporting period in which the hospital receives payment, as implemented
in the regulations at Sec. 413.40(f)(2)(ii). For providers in one of
the aforementioned classes of excluded providers that were not paid as
such prior to October 1, 1997, a hospital specific target amount based
on the hospital's own cost experience was no longer involved in the
payment process.
We have received questions regarding the determination of a target
amount for FY 2003 for certain existing hospitals and hospital units
excluded from the IPPS, and 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,

[[Page 47465]]

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, as we proposed in the May 4, 2005 proposed rule,
we are making 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.
Comment: Two commenters submitted a comment regarding the proposed
clarification of policy concerning the determination of a hospital's
target amount as described in Sec. 413.(c)(4)(iii) for the cost
reporting period beginning on or after October 1, 2002. One of the
commenters, in submitting two scenarios, asked CMS to affirm his
understanding of the proposed clarification regarding the calculation
of the target amount for cost reporting periods beginning on or after
October 1, 2002. The first scenario involved a psychiatric unit that
existed prior to FY 1998 (the first year of the 75th percentile
limitation), and therefore, was subject to the provisions in Sec.
413.40(c)(4)(iii) where the target amount is limited by the 75th
percentile cap. The provider was paid the capped amount in FY 2002, and
the fiscal intermediary used this capped amount, increasing it by the
update factor to arrive at the provider's target amount for FY 2003.
However, the commenter believed that the correct target amount for FY
2003 should be the hospital specific target amount, as determined in
the base year and updated.
The second scenario involved a psychiatric unit that was
established in FY 1999. In this case, as stated in the comment, the
fiscal intermediary used the ``capped rate trended forward with the
update factors as specified by CMS'' as the target amount for each
year, including years subsequent to FY 2002. Based on the proposed
clarification, the commenter believes that the higher hospital-specific
target rate should be used for those cost reporting periods beginning
in FY 2003 instead of the capped amount.
The second commenter stated that while there was a clarification of
policy regarding the effective period for the 75th percentile cap on
target amounts, CMS should also clarify that if a provider's target
amount was limited to the capped amount in FY 2002, it is that capped
amount that is updated for FY 2003.
Response: In order for us to clarify the applicability of the
provisions of Sec. 413.40(c)(4)(iii), we noted in the proposed rule
that this subsection applied only for cost reporting periods beginning
on or after October 1, 1997 through September 30, 2002, for psychiatric
hospitals and units, rehabilitation hospitals and units, and long term
hospitals. During this time period, payment to existing (in operation
prior to FY 1998) providers was limited by the 75th percentile cap,
i.e., the provider would be paid 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,
updated by the applicable market basket percentage. As we pointed out
in the proposed rule, we had previously clarified how the target amount
for FY 2003 was to be determined. In the FY 2003 final rule (67 FR
50103), we stated 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.'' The
provisions of Sec. 413.40(c)(4)(iii) are for a specific period of time
and the provider's target amount for FY 2003 is determined by updating
the target amount for FY 2002 (the target amount from the previous
period).
The intent of our proposal to clarify the language in Sec.
413.40(c)(4(iii) was to emphasize that because Sec. 413.40(c)(4)(iii)
was no longer applicable for cost reporting periods beginning on or
after October 1, 2002, the target amount for FY 2003 is determined
according to Sec. 413.40(c)(4)(ii) which states that ``Subject to the
provisions of paragraph (c)(4)(iii), 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 paragraph
(c)(5)(ii) of this section apply.'' Therefore, if a provider was paid
the cap amount in FY 2002, the target amount for FY 2003 would be the
cap amount paid in FY 2002, updated to FY 2003 (that is, the target
amount from the previous year increased by the applicable update
factor).
The commenter who submitted the two examples showing how the target
amount for FY 2003 should be determined misinterpreted the point of our
proposed clarification. That is, in the first example, the commenter
believed that because the 75th percentile cap provision had expired
with FY 2002, that the FY 2003 target amount should be the hospital
specific target amount (as determined in its base year), updated. This
is incorrect. Once the 75th percentile cap provision in paragraph
(c)(4)(iii) of Sec. 413.40 expired, the target amount is then
determined based on Sec. 413.40(c)(4)(ii) which states that, ``* * *
Subject to the provisions of 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 *
* *'' Thus, under the requirements of Sec. 413.40(c)(4)(ii), in this
instance, the previous cost reporting period's target amount would be
the capped amount increased by the applicable update factor to arrive
at the target amount for FY 2003.
In the commenter's second example, the provider was established in
FY 1999, thus, making it a ``new'' provider and therefore, subject to
payment in accordance with Sec. 413.40(f)(2)(ii) and not Sec.
413.40(c)(4)(iii), which is the subject of our clarification. Section
413.40(f)(2)(ii) of the regulations state that, `` For cost reporting
periods beginning on or after October 1, 1997, the amount of payment
for a new psychiatric hospital or unit, a new rehabilitation hospital
or unit, or a new LTCH that was not paid as an excluded hospital prior
to October 1, 1997, is the lower of the hospital's net inpatient
operating costs per case or 110 percent of the national median of the
target amounts for the class of excluded hospitals and units
(psychiatric, rehabilitation, or long-term care), as adjusted for
differences in wage levels and updated to the first cost reporting
period in which the hospital receives payment.'' This provision further
states that the second cost reporting period for such providers is
subject to the same target amount as in the first cost reporting
period, that is, the first year payment amount is not updated for
purposes of determining the payment amount for the second cost
reporting period. With respect to the third 12-month cost reporting
period for these new providers, the regulations at Sec.
413.40(c)(4)(v) specify that the target amount is the payment amount
from the second cost reporting period (the payment amount determined
under Sec. 413.40(f)(2)(ii)(A)), updated to the third cost reporting
period. Thus, the commenter is incorrect that a hospital-specific
target amount in a base year

[[Page 47466]]

should be used for cost reporting periods beginning in FY 2003 instead
of the ``capped amount.''
We point out that, with the implementation of a payment limit for
``new providers,'' a hospital-specific target amount (base year cost
per discharge updated) is not calculated. This is because, under the
new provider limit, the amount of payment for the first two cost
reporting periods (if less than a new provider's inpatient operating
costs) is based on the 110 percent of the national median provision in
Sec. 413.40(f)(2)(ii). The second cost reporting period is subject to
the same target amount as the first cost reporting period. For a new
provider's third 12-month cost reporting period, the payment amount in
the second cost reporting period is updated. We also note that, unlike
Sec. 413.40(c)(4)(iii) with the 75th percentile cap provision, the
regulation for new providers at Sec. 413.40(f)(2)(ii) is not time
limited. While it has the same effective date as the 75th percentile
cap provision (cost reporting periods beginning on or after October 1,
1997), it remains effective for cost reporting periods beyond FY 2002
to the extent a provider's payment or part of the payment is based on
reasonable cost.
As we stated in the proposed rule, ``* * * 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.'' We believe that this more than adequately responds to the
second commenter's concerns with regard to the determination of the
target amount for FY 2003 and thereafter.
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, not
paid as excluded hospitals prior to October 1, 1997), but were paid as
LTCHs 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 under Sec. 413.40(f)(2)(ii) 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 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 had the IPF PPS not been implemented. However,
under Sec. 412.426(c), 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. (See
section VII.A.5. of the preamble of this final 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 of new inpatient psychiatric facilities 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) and had their first cost reporting period
beginning 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 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. As stated above, IPFs with a first
cost reporting period beginning on or after January 1, 2005, are paid
100 percent of the Federal per diem payment amount; they are not
subject to the payment amount limitation in accordance with Sec.
412.426(c). 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, are 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 (Sec.
413.40(f)(2)(ii)) do not apply to those LTCHs or IPFs that have their
first cost reporting period beginning on or after the date that the
particular class of hospitals implemented their respective PPS, or for
new IRFs that are paid under the IRF PPS. Therefore, for the reasons
noted above, we are discontinuing the publication of Tables 4G and 4H
(Pre-Reclassified Wage Index for Urban and

[[Page 47467]]

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 unit (referred to in the statute as rehabilitation
facilities (IRFs)) 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 IRFs 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
inpatient 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 IRFs, 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 adjusted 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 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 whose first cost reporting periods began before January 1, 2005,
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, all IPFs will be paid 100 percent of the Federal per diem
payment amount.
6. Report of Adjustment (Exceptions) Payments
Section 4419(b) of Pub. L. 105-33 requires the Secretary to publish
annually in the Federal Register a report describing the total amount
of adjustment payments made to excluded hospitals and units, by reason
of section 1886(b)(4) of the Act, during the previous fiscal year.
The process of requesting, adjudicating, and awarding an adjustment
payment is likely to occur over a 2-year period or longer. First,
generally, an excluded hospital or excluded unit of a hospital must
file its cost report for a fiscal year with its fiscal intermediary
within 5 months after the close of its cost reporting period in
accordance with Sec. 413.24(f)(2). The fiscal intermediary then
reviews the cost report and issues a Notice of Program Reimbursement
(NPR) within approximately 2 months after the filing of the cost
report. If the hospital's operating costs are in excess of the ceiling,
the hospital may file a request for an adjustment payment within 180
days from the date of the NPR. The fiscal intermediary, or CMS,
depending on the type of adjustment requested, then reviews the request
and determines if an adjustment payment is warranted. This
determination is often not made until more than 6 months after the date
the request is filed. However, in an attempt to provide interested
parties with data on the most recent adjustments for which we do have
data, we are publishing data on adjustment payments that were processed
by the fiscal intermediary or CMS during FY 2004.
The table below includes the most recent data available from the
fiscal intermediaries and CMS on adjustment payments that were
adjudicated during FY 2004. As indicated above, the adjustments made
during FY 2004 only pertain to cost reporting periods ending in years
prior to FY 2003. Total adjustment payments awarded to excluded
hospitals and units during FY 2004 are $5,896,215. The table depicts
for each class of hospitals, in the aggregate, the number of adjustment
requests adjudicated, the excess operating cost over ceiling, and the
amount of the adjustment payments.

----------------------------------------------------------------------------------------------------------------
Excess cost over Adjustment
Class of hospital Number ceiling payments
----------------------------------------------------------------------------------------------------------------
Rehabilitation.......................................... 3 $825,008 $129,529
Psychiatric............................................. 11 7,491,268 2,628,817

[[Page 47468]]

Long-Term Care.......................................... 3 3,348,078 2,570,034
Children's.............................................. 1 99,942 58,825
Cancer .............. .................. ..................
Religious Nonmedical Health Care Institution............ 13 1,317,098 509,010
----------------------------------------------------------------------------------------------------------------

B. Critical Access Hospitals (CAHs)

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.
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 currently at Sec. 485.610
further define ``rural area'' for purposes of being a CAH. Under the
current regulations at 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 Sec. 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 Sec. 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 Sec. 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.
Prior to the issuance of the FY 2006 IPPS proposed rule, we
received comments that suggested 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, as we
discussed in the proposed rule, we proposed to clarify our policy with
respect to facilities located in Lugar counties. The FY 2005 IPPS final
rule already contained provisions allowing 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, in the proposed rule we stated our belief 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, it is
appropriate for the CAH to be allowed a reasonable opportunity to
reclassify to rural status. Thus, in the proposed rule, we stated that
we would clarify our policy 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, were to be given the same reclassification opportunity under
Sec. 412.103. In other words, we proposed to revise Sec.
485.610(b)(3) to allow CAHs in counties that were designated as Lugar
counties effective October 1, 2004, to remain in compliance with the
conditions of participation at Sec. 485.610(b)(2) through a
reclassification under Sec. 412.103. In addition, consistent with the
clarification of the policy, we proposed 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).
Comment: Several commenters supported our proposal to permit CAHs
in newly designated Lugar counties to reclassify to be considered
``rural'' under the regulations at Sec. 412.103.
Response: We appreciate the commenters' support and kept their
views in mind in finalizing the proposed policy change in this final
rule.
Comment: Several commenters disagreed with our proposed policy
because they believed that the rules under which a facility can
reclassify under Sec. 412.103 do not sufficiently protect all
facilities. They stated, for instance, that while rural referral
centers, SCHs, and CAHs receive special consideration for purposes of
reclassification, MDHs do not.
Response: We believe that addressing the reclassification
regulations at Sec. 412.103 in the context of the commenter's
statements is outside of the scope of our proposed rule change. This is
especially true for section 1886(d) hospitals, such as MDHs, which are
subject to the statutory provisions for Lugar status under section
1886(d)(8)(B) of the Act. Our proposal dealt only with CAHs and did not
include any proposal

[[Page 47469]]

to change the way in which other facilities, such as subsection 1886(d)
hospitals, are treated. Consequently, we are not making any change to
the final rule based on this comment.
Comment: Several commenters believed that the process to reclassify
under Sec. 412.103 is burdensome and unnecessary because, in their
view, the Secretary has the authority to allow a facility to opt out of
the reclassification under section 1886(d)(5)(I)(i) of the Act.
As an alternative to our proposal, the commenters suggested that
CMS allow hospitals that are disadvantaged by the Lugar
reclassification to waive or reject the reclassification. One of the
commenters suggested that waiver of Lugar status be allowed during a
limited time period. In support of their recommendation, the commenters
stated that CMS currently allows hospitals to waive other geographic
reclassifications during a defined period. Several commenters pointed
out that the Lugar provision was intended to help many rural hospitals
and not disadvantage the few facilities that were more benefited by
participating in a rural facility program.
Response: While we understand that Lugar designation affects
hospitals as well as CAHs, we do not believe it is within the scope of
our proposed rule to address changes in the way CMS treats hospitals in
Lugar counties. Therefore, we considered this comment and are
responding to it only insofar as it relates to CAHs in Lugar counties.
We considered the commenters' concerns that reclassification under
Sec. 412.103 is unnecessarily burdensome. In light of the stated
concerns, we revisited the statutory requirements under sections
1820(c)(2)(B)(i) and 1886(d)(8)(B) of the Act and the regulatory
requirements of Sec. 485.610. Section 1886(d)(8)(B) of the Act defines
the conditions under which a county is considered ``Lugar.'' The
statute specifically states that ``(f)or purposes of this subsection,
the Secretary shall treat a hospital located in a rural county adjacent
to one or more urban areas as being located in (a) urban metropolitan
statistical area. * * * '' CAHs do not fall under subsection 1886(d) of
the Act. In addition, section 1820(c)(2)(B)(i) of the Act permits a
facility to qualify for designation as a CAH only if it is located in a
rural area as defined in section 1886(d)(2)(D) of the Act or in an area
being treated as rural under section 1886(d)(8)(E) of the Act. Because
section 1820(c)(2)(B)(i) of the Act does not include any reference to
the Lugar provision (section 1886(d)(8)(B) of the Act), we do not
believe that the statute requires CMS to treat a facility as being in
an urban area for purposes of CAH participation because it is in a
Lugar county.
While CAHs are not subsection 1886(d) hospitals, they are subject
to the regulations at Sec. 485.610, which reference the definitions of
``rural'' and ``urban'' at Sec. 412.63(b) (for FYs 1985 through 2004).
(For FYs 2005 and subsequent fiscal years, the implementing regulations
are at Sec. 412.64(b).) The regulations at Sec. 412.63(b)(3) and
Sec. 412.64(b)(3) specify that a hospital in a Lugar county is urban
in accordance with section 1886(d)(8)(B) of the Act. Accordingly, under
the current regulations at Sec. 485.610, CAHs in a Lugar county are
considered under such regulations to be in an urban area. We believe
these regulations maintained consistency throughout the program, and
that it was permissible and appropriate to apply Lugar status (and,
hence, urban status) to all facilities in those counties, including
CAHs.
However, in light of the major revisions caused by the new OMB
areas, our review of the statute, and in consideration of the
commenters' concerns that the process for reclassification may create
an unnecessary burden, we have concluded that it is appropriate in this
final rule to amend the regulations at Sec. 485.610(b)(1)(i) to remove
all references to a facility being recognized as urban under the
regulations implementing the Lugar provision (Sec. 412.63(b)(3) for
FYs 1984 through 2004 and Sec. 412.64(b)(3) for FY 2005 and subsequent
fiscal years). The effect of this change is that, beginning in FY 2006,
facilities in Lugar counties will be considered, for purposes of CAH
participation, to be located in rural areas. In other words, the Lugar
reclassifications under section 1886(d)(8)(B) of the Act will not be
considered in determining whether a hospital is rural for purposes of
section 1820 of the Act. As a result, CAHs will not need to submit an
application for reclassification under Sec. 412.103 to remain in
compliance with the conditions of participation at Sec. 485.610. We
believe this change will achieve the result of our original proposal
without increasing the administrative burden for CAHs or the Medicare
program. We emphasize that this change will be effective only for
purposes of CAH participation and will not otherwise affect the status
of hospitals or CAHs in Lugar counties. In addition, section 1886(d)
hospitals in Lugar counties will be considered to be in a rural area
for purposes of applying for CAH status.
Accordingly, in light of the above, in this final rule, we are not
adopting the proposed revisions to Sec. 412.103(a)(4) and Sec.
485.610(b)(1)(ii) that were included in the proposed rule. Instead, we
are amending the regulations at Sec. 485.610(b)(1) to remove paragraph
(b)(1)(ii), which references a facility being recognized as urban under
the regulations implementing the Lugar provision (Sec. 412.63(b)(3)
for FYs 1984 through 2004. (As noted earlier, implementing regulations
for the Lugar provisions are set forth at Sec. 412.64(b)(3) for FY
2005 and subsequent fiscal years.)
In addition, as a technical conforming change, we are revising
paragraph (b)(1)(i) of Sec. 485.610 by removing the reference to Sec.
412.62(f), which relates to FYs 1984 through 2004, and replacing it
with a reference to Sec. 412.64(b), excluding paragraph (b)(3), which
relates to FY 2005 and subsequent fiscal years.
3. 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 situation
where the CAH is no longer the same facility due to relocation,
cessation of business, or a substitute facility. Currently, CMS
Regional

[[Page 47470]]

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, in the
FY 2006 IPPS proposed rule, we proposed 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 proposed that 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 indicated
that 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 proposed 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, as noted previously,
the language of section 1820(c)(2)(i) of the Act allowed a State to
exempt the mileage requirement and designate such 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,
was 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 the FY 2006 IPPS proposed rule, we proposed to amend the
regulations at Sec. 485.610 to set forth the criteria by which those
relocated CAHs designated as necessary providers that embarked on a
replacement facility project before the

[[Page 47471]]

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 proposed 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 proposed to use the specified
relocation criteria as the initial step to determine continuing
necessary provider status. Specifically, in the proposed rule, we
proposed 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 offsite 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 was 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 solicited 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 proposed to revise Sec. 485.610 of the regulations
by adding a new paragraph (d) to incorporate this proposal.
Specifically, under the proposed new paragraph (d) we specified 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. We
proposed that a 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 also proposed 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.
We received approximately 150 timely pieces of correspondence
commenting on the proposed policy change regarding CAHs with a
necessary provider designation being able to relocate and maintain
their necessary provider designation.
Comment: Most commenters opposed the proposed date restrictions
that would require a CAH to have initiated relocation plans prior to
December 8, 2003, and to notify the CMS Regional Office by January 1,
2006 of plans to relocate their facility.
Response: We have carefully considered the commenters' concerns
regarding the proposed date requirement. Many commenters stated that
the proposed date restrictions would force CAHs to continue to operate
in outdated, inefficient facilities which could potentially put
patients' safety at risk or to lose their necessary provider
designation. As a result of our review and in light of the compelling
argument presented by the commenters, we have decided not to adopt as
final the date requirement as proposed. Under this final rule, we are
allowing a necessary provider CAH to replace its facility at any time
and maintain its necessary provider designation, provided it complies
with the 75-percent criteria specified at Sec. 485.610(d)(1).
Comment: Many commenters opposed the proposed distance restriction
of 250 yards to qualify as a replacement facility. They stated that the
250 yards is arbitrary and will impede the progress

[[Page 47472]]

of health care. The commenters suggested that CMS should consider
distances that ranged from 500 yards to 5 miles that would qualify a
new CAH facility as a replacement facility and, therefore, be
considered to be serving the same service area.
Many commenters agreed with the proposed 75-percent criteria (75
percent of the same service area, same services, and same staff) as a
way to ensure that a necessary provider CAH will continue to provide
access to care in its community. However, one commenter opposed the 75-
percent criteria, stating that it is not reasonable and that necessary
provider CAHs should be allowed to relocate based on the needs of the
community.
Others commenters suggested that if a CAH moves further than 5
miles, then an approach similar to the 75-percent test could be used to
ensure that a facility is serving the same population. One commenter
suggested that a necessary provider CAH be allowed to relocate within 2
miles of the current location or within 5 miles of the current
location, provided that the nearest hospital is more than 15 miles
away.
Several CAHs cited issues of being land-locked and poor beneficiary
access as examples of why it is not feasible to replace their facility
on or adjacent to their current location. Several commenters
highlighted the fact that being able to modernize their facilities in a
new location will allow them to expand their services and gain a
competitive edge with larger full service hospitals.
Response: After carefully considering the comments received, we
have decided to modify proposed paragraph (d)(1) to state that a
necessary provider CAH can relocate its facility and begin providing
services at a new location, provided the necessary provider will be
essentially the same facility in its new location. To help ensure that
the facility is the same, we will require the relocated necessary
provider CAH to provide at least 75 percent of its current services to
75 percent of the same service area with 75 percent of its current
staff in its new location. This change effectively replaces the need to
distinguish between replacement and relocated necessary provider CAHs.
All new necessary provider CAH facilities that will be constructed
after January 1, 2006, will be considered relocated facilities.
Based on our review of comments, we have determined that a mileage
requirement would not effectively ensure access to care. Therefore, in
this final rule, we are modifying paragraph (d)(1) as proposed to
delete all distance restrictions to state that a necessary provider CAH
can relocate its facility and provide services at a new location if the
necessary provider is essentially the same facility in the new
location.
Comment: A few commenters asked CMS to explain how the necessary
provider CAH would demonstrate that it meets the 75-percent criteria.
Response: We will develop guidelines for the CMS Regional Offices
and State agencies to utilize when evaluating compliance with the 75-
percent criteria. One example could be to have the CAHs self attest
that they meet the 75-percent criteria in all areas. CMS could follow
up the attestation with an audit based on claims data. These data would
identify the services that the CAH provides and their service area. CMS
could conduct an audit at the end of the year when CMS settles the cost
report (which also identifies the service area and services provided).
To address the employee criterion, the CAH can provide a list of
employees before and after the move. These are some examples of how CMS
may evaluate compliance with the criteria and do not represent a final
decision as to how the 75-percent criteria will be administered.
Currently, the CMS Regional Offices make the decision for continued
certification following relocation of a certified facility on a case-
by-case basis. We have not changed this policy. The criteria used to
qualify a CAH as a necessary provider were established by each State in
its MRHFP. The State, in its MRHFP, defined those CAHs that provide
necessary services to a particular patient community. The State
agencies and Regional Offices will closely monitor each necessary
provider CAH that relocates to ensure that it will continue to provide
services based on the criteria that qualified the CAH to be designated
as a necessary provider.
The intent of the CAH program is to keep hospital-level services in
rural communities, thereby ensuring access to care. We are revising the
regulation to allow a necessary provider CAH to relocate its facility
and to continue to ensure access to care in the community for which it
was designated as a necessary provider. The intent of this policy
change is not to improve the competitive edge of necessary provider
CAHs with full service hospitals. CMS will monitor closely the
effectiveness of this policy change on the CAHs and full service
hospitals and, if necessary, will revisit this issue through future
rulemaking.
Comment: A few commenters suggested that a CAH should be considered
as a relocated facility if it constructs a new facility within the city
or town limits.
Response: We do not believe that the use of city or town limits
should be a criterion for determining if a necessary provider CAH has
relocated its facility. We have heard from several CAHs that have
special circumstances (landlocked, adjacent to a mountain, etc.) and,
thus, would find it difficult to relocate within the town or city
limits. We believe that the 75-percent criteria set forth in proposed
paragraphs (d)(1) will better help to ensure that CAHs appropriately
relocate their facilities.
Comment: A few commenters stated that flexibility in measuring
demographics for a CAH should be allowed due to expected changes in the
needs of the community.
Response: We believe that the three 75-percent criteria
requirements will assist in ensuring continued access to care in the
community for which the CAH was originally designated as a necessary
provider. We also believe that it is not the responsibility of CMS to
project future changes in demographics for a necessary provider CAH. We
do believe that we are responsible for ensuring access to care under
the current conditions for which necessary provider CAHs were granted
their designations.
Comment: Several commenters suggested requiring a CAH to satisfy
only three of five criteria for relocating. The commenters stated that,
in addition to the staff, services and population measures, CMS should
consider adding a needs assessment and cost comparison. The commenters
further stated that if a CAH can show through a needs assessment that a
change in services provided would be appropriate, the CAH should not
have to comply with the requirement to provide 75 percent of the same
services.
Response: We do not believe that it is necessary to add other
requirements such as a needs assessment and a cost comparison to the
criteria. We would expect a CAH, as part of its normal business
practice, to compare the cost of building a new facility with
renovating its current facility before making the decision to relocate.
We continue to believe that the 75-percent rule for the services
provided, staff, and service area allows sufficient flexibility to
ensure continued access to care in the communities that are served by
the necessary provider CAHs.
Comment: Several commenters suggested that we rescind the proposal
and allow necessary provider CAHs to relocate as needed to meet the
needs of their communities.

[[Page 47473]]

Response: We believe the revised policy does not interfere with any
CAH's ability to serve the needs of its community. We further believe
that it is prudent to establish consistent guidelines whereby necessary
provider CAHs can continue to provide care to their service area and
not violate the intent of the CAH program. We also believe that, by
maintaining the percentage criteria, CAHs will be able to relocate
appropriately and continue to serve their communities.
Comment: Several commenters chose to raise issues that are beyond
the scope of the proposed rule concerning the CAH necessary provider
policy.
Response: In this final rule, we are not summarizing or responding
to those comments. However, we will review the comments and consider
whether to take other actions, such as revising or clarifying CMS
program operating instructions or procedures.
In this final rule, we are adopting the proposed new Sec.
485.610(d), with modifications. We are removing the proposed
distinction between a replacement and relocation of a necessary
provider CAH. We are also eliminating the proposed distance requirement
for replacing a facility. As a result, all CAHs that construct a new
facility will be considered to have relocated and may be able to
maintain the necessary provider designation if they meet the
requirements of Sec. 485.610(d)(l). In addition, we are eliminating
the proposed date restriction.

VIII. Payment for Blood Clotting Factor Administered to Hemophilia
Inpatients

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
certain Medicare Part B drugs, 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
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. In accordance with the current regulations at Subpart K
of Part 414, effective January 1, 2005, blood clotting factor under
Medicare Part B is paid based on the lesser of 106 percent of ASP (that
is, ASP+ 6 percent) or the actual charge.
To ensure consistency in payment for Medicare Part A and Medicare
Part B drugs, in the FY 2006 IPPS proposed rule we proposed 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 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 proposed to apply under the IPPS for FY 2006
are specified in section V. of the Addendum to this final rule.
Comment: One commenter supported the proposal to pay for blood
clotting factors consistently under Medicare Part A and Part B in FY
2006. The commenter pointed out that clotting factors are described in
terms of International Units (IUs), and that one of the blood clotting
factors is dosed in micrograms rather than IUs. The commenter stated
that, under Medicare Part B, for the purpose of providing the $0.14 per
unit furnishing fee, a single unit is equal to one microgram. In order
to ensure consistency in payments for blood clotting factors, the
commenter requested that CMS designate one microgram as one unit for
the purpose of payment under the ASP methodology and for providing the
furnishing fee to hospital inpatient providers.
Response: In the Medicare Claims Processing Manual (Pub. 100-4),
Chapter 3, section 20.7.3, we instruct the fiscal intermediaries to
report HCPCS code Q0187 (Factors viia recombinant) which is dosed 1.2
micrograms, based on one billing unit per 1.2 mg; that is, one billing
unit per single dose.
In this final rule, we are adopting as final for FY 2006 that
fiscal intermediaries make payment for blood clotting factor using ASP+
6 percent and make payment for the furnishing at $0.14 per individual
unit (I.U.) that is currently used for Medicare Part B drugs. This
furnishing fee will be updated each calendar year in accordance with
Sec. 410.63.

IX. MedPAC Recommendations

We are required by section 1886(e)(4)(B) of the Act to respond to
MedPAC's IPPS recommendations in our annual IPPS rules. 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 in MedPAC March 2005 Reports to Congress

1. Update Factor
MedPAC's Recommendation 2A-1 in the Report to Congress on Medicare
Payment Policy concerning the update factor for inpatient hospital
operating costs and for hospitals and distinct-part hospital units
excluded from the IPPS is discussed in Appendix B to this final rule.
2. Quality Incentive Payment Policy
Recommendation 4A in the Report to Congress on Medicare Payment
Policy: The Congress should establish a quality incentive payment
policy for hospitals in Medicare.
In the FY 2006 IPPS proposed rule, we indicated that 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.
We did not receive any public comments on this recommendation.

[[Page 47474]]

3. Refinement of DRGs Based on Severity of Illness
Section 2A of the Report to Congress on Medicare Payment Policy
(page 64) and Recommendation 1 in the Report to Congress on Physician-
Owned Specialty Hospitals: 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 the FY 2006 IPPS proposed rule (70 FR 23454), we stated that we
expected to make changes to the DRGs to better reflect severity of
illness. We indicated that it was our plan to conduct a comprehensive
review of the complications and comorbidities (CC) list as well as of
the possibility of using the All Patient Refined (APR) DRGs for
Medicare for FY 2007. The comprehensive review of the CC list is
discussed in section II.B.12.b. of this preamble. We did not propose to
adopt APR-DRGs for FY 2006 because it would represent a significant
undertaking that could have a substantial effect on all hospitals.
There was insufficient time to adopt a change of this magnitude through
notice and comment rulemaking between the release of the MedPAC reports
in March 2005 and the publication of the FY 2006 IPPS proposed rule for
us to analyze fully a change of this magnitude. Nevertheless, we
indicated that we planned to further consider all of MedPAC's
recommendations.
As we indicated in section II.B.5.a. of this preamble, in response
to the proposed rule, we received a comment noting that section 507(c)
of Pub. L. 108-173 required MedPAC to conduct a study to determine how
the DRG system should be updated to better reflect the cost of
delivering care in a hospital setting. The commenter noted that MedPAC
reported that the ``cardiac surgery DRGs have high relative
profitability ratios.'' While the commenter noted that it may take time
to conduct and complete a thorough evaluation of the MedPAC payment
recommendations for all DRGs, the commenter strongly encouraged CMS to
revise the cardiac DRGs through patient severity refinement as part of
the IPPS final rule effective for FY 2006.
As a result of this comment, we performed an extensive review of
the cardiovascular DRGs in MDC 5 (Diseases and Disorders of the
Circulatory System), particularly those DRGs that are commonly billed
by specialty hospitals. To begin our analysis, we considered whether
the approach that is currently used for paired DRGs 121 and 122
(Circulatory Disorders With AMI With and Without Major Complication
Discharged Alive, respectively) and paired DRGs 124 and 125
(Circulatory Disorders Except AMI With Cardiac Catheterization With and
Without Complex Diagnosis, respectively) would have applicability to
other DRGs in MDC 5. Currently, DRGs 121 and 122 are split based on
whether the patient is diagnosed with a ``cardiovascular
complication.'' DRGs 124 and 125 are split based on whether the patient
has a ``complex diagnosis.'' There is some overlap between the lists of
cardiovascular complications and complex diagnoses. The lists are used
to segregate patients into DRGs that use greater resources. Because the
hospital industry is familiar with the major complication and complex
diagnosis lists used within the cardiovascular DRGs, we began our
analysis with these two overlapping lists.
These two lists were originally developed for the current DRG
system because they contained conditions that could have an impact on
the resources needed to treat a cardiovascular patient. Many of them
are cardiovascular diagnoses and, therefore, would be classified to MDC
5. However, we have determined that some of the diagnoses are not
cardiovascular, but would still have an impact on a cardiovascular
patient. The conditions that are not cardiovascular diagnoses would not
be assigned to MDC 5 if they were the principal diagnosis. An example
would be code 430 (Subarachnoid hemorrhage). If code 430 were the
principal diagnosis, the condition would be assigned to MDC 1 (Diseases
and Disorders of the Nervous System). However, we have determined that
this condition, if present as a secondary diagnosis, would be a major
complication for a patient with a principal diagnosis of AMI included
in DRG 121. For a case to be assigned to either DRG 121 or DRG 124, the
cardiovascular complication or complex diagnosis can be present as
either a principal diagnosis or a secondary diagnosis. We retained this
logic for our approach to identifying more severe cases in our focused
review of the cardiovascular DRGs.
Our clinical advisors reviewed the conditions on the two
overlapping lists and identified conditions that they believed would
lead to a more complicated patient stay requiring greater resource use.
We are referring to these conditions as ``major cardiovascular
conditions (MCVs).'' They could be present as either a principal
diagnosis or a secondary diagnosis and, as shown below, lead to greater
resource consumption. The complete list of MCVs is shown below.
Most of the conditions on the MCV list are cardiovascular diagnoses
assigned to MDC 5 when present as a principal diagnosis. In the chart
below, a code that is labeled ``PS'' could be present as either a
principal diagnosis or a secondary diagnosis to be assigned to an MCV
DRG (new DRGs 547, 549, 551, 553, 555, and 557 identified later in this
discussion). If only a ``P'' is shown, the diagnosis would only assign
the patient to an MCV DRG when present as a principal diagnosis.
Similarly, if only an ``S'' is shown, the diagnosis would only assign a
patient to an MCV DRG when present as a secondary diagnosis. Diagnosis
codes with only an ``S'' shown are noncardiovascular conditions that,
if present as a principal diagnosis, would assign a patient to a
noncardiovascular DRG. For example, code 415.19 (Pulmonary embolism and
infarction) is shown with only an ``S'' on the chart because if it were
present as the principal diagnosis, the case would not be assigned to a
cardiovascular DRG in MDC 5. Therefore, code 415.19 could only be
considered an MCV if it were listed as a secondary diagnosis. The
principal diagnosis must be a cardiovascular condition that assigns the
case to one of the new MCV or non-MCV DRGs (547 through 558). The case
would be classified to an MCV DRG if code 415.19 was present as a
secondary diagnosis.
Using the MCV list, we tested our assumption that these conditions
described a more severe set of cardiovascular surgery patients. We
grouped all the cardiovascular surgery patients within MDC 5 based on
the presence or absence of an MCV condition. We found that this split
was predictive of significantly increased resource use for nine
surgical cardiovascular DRGs. By splitting these surgical DRGs based on
the presence or absence of an MCV condition, we identified subgroups of
patients with average charges that were 28 to 45 percent higher than
average charges for those cases without an MCV condition. We did not
find that the MCV approach could explain patient severity and resource
use among the cardiovascular medical DRGs or surgical DRGs other than
the nine shown below. The other surgical DRGs within MDC 5 did not
clearly identify more severe cases using this methodology. Applying the
MCV

[[Page 47475]]

list to the other surgical cardiovascular DRGs did not provide a
sufficient difference in average charges or the distribution of cases
between the MCV and non-MCV patients to justify adopting this approach.
The chart below illustrates our findings.
We made one minor revision to this overall approach. Our clinical
advisors identified five diagnoses on the MCV list which they believe
would be the reason for admission for the surgical procedure.
Therefore, these five diagnoses should not be counted as an MCV for
specific surgical DRGs. For instance, a complete atrioventricular block
(code 426.0) would be the reason a patient would receive a pacemaker.
This patient is currently assigned to DRG 115 (Permanent Cardiac
Pacemaker Implant With AMI/HF/Shock or AICD Lead or Generator
Procedure) or DRG 116 (Other Permanent Cardiac Pacemaker Implant).
Because the patient's heart block is the reason for the pacemaker
insertion, our clinical advisors advised that code 426.0 should not
count as an MCV for our analysis of the pacemaker implant DRGs.
Therefore, code 426.0 will not count as an MCV for current DRGs 115 and
116.
The complete list of conditions that will not count as an MCV for
current DRGs 115 and 116 because they are the reason for the pacemaker
implant are:
426.0, Atrioventricular block, complete
426.53, Bilateral bundle branch block
426.54, Trifascicular block
Our clinical advisors identified two codes on the MCV condition
list that would be the reason for the cardiovascular surgery for cases
currently assigned to DRGs 107 (Coronary Bypass with Cardiac
Catheterization), 109 Coronary Bypass Without Cardiac Catheterization),
516 (Percutaneous Cardiovascular Procedures With AMI), 526
(Percutaneous Cardiovascular Procedure With Drug-Eluting Stent With
AMI), and 527 (Percutaneous Cardiovascular Procedure With Drug-Eluting
Stent Without AMI). These two conditions are:
411.1, Intermediate coronary syndrome (unstable angina)
411.81, Coronary occlusion without myocardical infarction
Making this minor revision to the MCV list greatly increased the
predictive value of this methodology for the relevant cardiovascular
DRGs. The following chart illustrates the current DRGs that are being
revised and the new DRGs being created based on the presence or absence
of an MCV.
Current DRGs 107, 109, and 478 are being split based on the
presence or absence of an MCV. For instance, cases currently assigned
to DRG 107 that have an MCV diagnosis will be assigned to new DRG 547
(Coronary Bypass With Cardiac Catheterization With MCV Diagnosis).
Cases in current DRG 107 that do not have an MCV will be assigned to
new DRG 548 (Coronary Bypass With Cardiac Catheterization Without MCV
Diagnosis). We are deleting DRG 107. Similarly, we are deleting DRGs
109 and 478 and assigning their cases to new DRG pairs 549 (Coronary
Bypass Without Cardiac Catheterization With MCV Diagnosis) and 550
(Coronary Bypass Without Cardiac Catheterization Without MCV Diagnosis)
and 553 (Other Vascular Procedures With CC With MCV Diagnosis) and 554
(Other Vascular Procedures With CC Without MCV Diagnosis),
respectively.
The following three DRG pairs are already divided based on the
presence of specific diagnoses such as AMI, heart failure, or shock
that are on the MCV list: DRG 115 (Permanent Cardiac Pacemaker Implant
With AMI, Heart Failure, and Shock) and 116 (Other Permanent Cardiac
Pacemaker Implant), DRGs 516 (Percutaneous Cardiovascular Procedures
With AMI) and 517 (Percutaneous Cardiovascular Procedures With Non-
Drug-Eluting Stent Without AMI), and DRGs 526 (Percutaneous
Cardiovascular Procedures With Drug-Eluting Stent With AMI) and 527
(Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without
AMI). Rather than further subdivide these DRGs, we are expanding the
DRGs that include AMI, heart failure, and shock to encompass all of the
other conditions on the MCV list. Thus, DRGs 115 and 116 are being
replaced by new DRGs 551 (Permanent Cardiac Pacemaker Implant With MCV
Diagnosis or AICD Lead or Generator) and 552 (Other Permanent Cardiac
Pacemaker Implant Without MCV Diagnosis). DRGs 516 and 517 are being
replaced by new DRGs 555 (Percutaneous Cardiovascular Procedures With
MCV Diagnosis) and 556 (Percutaneous Cardiovascular Procedures With
Nondrug-Eluting Stent Without MCV Diagnosis). DRGs 526 and 527 are
being replaced by new DRGs 557 (Percutaneous Cardiovascular Procedure
With Drug-Eluting Stent With MCV Diagnosis) and 558 (Percutaneous
Cardiovascular Procedure With Drug-Eluting Stent Without MCV
Diagnosis). The left side of the chart shows the 9 existing DRGs and
their relevant statistics. These 9 DRGs are being deleted and replaced
by the 12 new DRGs on the right side.
BILLING CODE 4120-01-P

[[Page 47476]]

[GRAPHIC] [TIFF OMITTED] TR12AU05.003

As can be seen from this chart, 6 of these 12 new DRGs better
identify subgroups of significantly more severely ill patients who use
greater hospital resources than was possible under the previous DRGs,
while the remaining 6 DRGs better account for the less severely ill
patients who use fewer hospital resources. For instance, current DRG

[[Page 47477]]

107 has average standardized charges of $82,398. DRG 107 has been
replaced by new DRGs 547 and 548 with average standardized charges of
$92,542 and $71,906, respectively. These two new DRGs have a difference
of $20,635, or 28.7 percent, in average standardized charges. The chart
illustrates that other pairs of new DRGs show differences in average
standardized charges of 30.0 to 47.7 percent. Thus, we believe these
new DRGs are an improvement over the existing DRG structure because
they better recognize a patient's severity of illness and, accordingly,
permit us to make higher payments for more severely ill patients who
require more resources while lowering our payments for less severely
ill and less resource-intensive patients.
The complete list of MCVs is shown below:

----------------------------------------------------------------------------------------------------------------
DRGs 547, 548, 549, 550,
MCV code number MCV code titles P-Principal, DRGs 551 and 552 553, 554, 555, 556, 557,
S-Secondary diagnosis and 558
----------------------------------------------------------------------------------------------------------------
398.91................. Rheumatic Heart Failure PS PS
(Congestive).
402.01................. Hypertensive Heart Disease, PS PS
Malignant, With Congestive
Heart Failure.
402.11................. Hypertensive Heart Disease, PS PS
Benign, With Congestive
Heart Failure.
402.91................. Hypertensive Heart Disease, PS PS
With Congestive Heart
Failure, Unspecified Benign
or Malignant.
404.01................. Malignant Hypertensive Heart PS PS
and Renal Disease, With
Congestive Heart Failure.
404.03................. Malignant Hypertensive Heart PS PS
and Renal Disease, With
Congestive Heart Failure
and Renal Failure.
404.11................. Benign Hypertensive Heart PS PS
and Renal Disease, With
Congestive Heart Failure.
404.13................. Benign Hypertensive Heart PS PS
and Renal Disease, With
Congestive Heart Failure
and Renal Failure.
404.91................. Hypertensive Heart and Renal PS PS
Disease, Unspecified Benign
or Malignant, With
Congestive Heart Failure.
404.93................. Hypertensive Heart & Renal PS PS
Disease, Unspecified Benign
or Malignant, W/ Congestive
Heart Failure & Renal
Failure.
410.01................. Acute Myocardial Infarction, PS PS
Anterolateral Wall, Initial
Episode of Care.
410.11................. Acute Myocardial Infarction, PS PS
Anterior Wall, Initial
Episode of Care.
410.21................. Acute Myocardial Infarction, PS PS
Inferolateral Wall, Initial
Episode of Care.
410.31................. Acute Myocardial Infarction, PS PS
Inferoposterior Wall,
Initial Episode of Care.
410.41................. Acute Myocardial Infarction, PS PS
Inferior Wall, Initial
Episode of Care.
410.51................. Acute Myocardial Infarction, PS PS
Lateral Wall, Initial
Episode of Care.
410.61................. True Posterior Wall PS PS
Infarction, Initial Episode
of Care.
410.71................. Subendocardial Infarction, PS PS
Initial Episode of Care.
410.81................. Acute Myocardial Infarction, PS PS
Other Specified Site,
Initial Episode of Care.
410.91................. Acute Myocardial Infarction, PS PS
Unspecified Site, Initial
Episode of Care.
411.0.................. Postmyocardial Infarction PS PS
Syndrome.
411.1.................. Intermediate Coronary PS Code does not count.
Syndrome (Unstable Angina).
411.81................. Coronary Occlusion Without PS Code does not count.
Myocardial Infarction.
414.10................. Heart (Wall) Aneurysm....... PS PS
414.11................. Aneurysm of Coronary Vessel. PS PS
414.12................. Dissection of Coronary PS PS
Artery.
414.19................. Aneurysm of Heart........... PS PS
415.0.................. Acute Cor Pulmonale......... PS PS
415.11................. Iatrogenic Pulmonary S S
Embolism and Infarction.
415.19................. Pulmonary Embolism and S S
Infarction.
420.0.................. Acute Pericarditis In PS PS
Diseases Classified
Elsewhere.
420.90................. Acute Pericarditis, PS PS
Unspecified.
420.91................. Acute Idiopathic PS PS
Pericarditis.
420.99................. Acute Pericarditis.......... PS PS
421.0.................. Acute/Subacute Bacterial PS PS
Endocarditis.
421.1.................. Acute/Subacute Infective PS PS
Endocarditis In Diseases
Classified Elsewhere.
421.9.................. Acute Endocarditis, PS PS
Unspecified.
422.92................. Septic Myocarditis.......... PS PS
423.0.................. Hemopericardium............. PS PS
424.90................. Endocarditis, Valve PS PS
Unspecified, Unspecified
Cause.
426.0.................. Atrioventricular Block, Code does not count PS
Complete.
426.53................. Bilateral Bundle Branch Code does not count PS
Block.
426.54................. Trifascicular Block......... Code does not count PS
427.1.................. Paroxysmal Ventricular PS PS
Tachycardia.
427.41................. Ventricular Fibrillation.... PS PS
427.5.................. Cardiac Arrest.............. PS PS
428.0.................. Congestive Heart Failure.... PS PS
428.1.................. Left Heart Failure.......... PS PS
428.20................. Unspecified Systolic Heart PS PS
Failure.
428.21................. Acute Systolic Heart Failure PS PS
428.22................. Chronic Systolic Heart PS PS
Failure.
428.23................. Acute on Chronic Systolic PS PS
Heart Failure.

[[Page 47478]]

428.30................. Unspecified Diastolic Heart PS PS
Failure.
428.31................. Acute Diastolic Heart PS PS
Failure.
428.32................. Chronic Diastolic Heart PS PS
Failure.
428.33................. Acute on Chronic Diastolic PS PS
Heart Failure.
428.40................. Unspecified Combined PS PS
Systolic and Diastolic
Heart Failure.
428.41................. Acute Combined Systolic and PS PS
Diastolic Heart Failure.
428.42................. Chronic Combined Systolic PS PS
and Diastolic Heart Failure.
428.43................. Acute on Chronic Combined PS PS
Systolic and Diastolic
Heart Failure.
428.9.................. Heart Failure, Unspecified.. PS PS
429.5.................. Chordae Tendineae Rupture... PS PS
429.6.................. Papillary Muscle Rupture.... PS PS
429.71................. Acquired Cardiac Septal PS PS
Defect.
429.79................. Other Certain Sequelae of PS PS
Myocardial Infarction, Not
Elsewhere Classified.
429.81................. Papillary Muscle Disorder... PS PS
430.................... Subarachnoid Hemorrhage..... S S
431.................... Intracerebral Hemorrhage.... S S
432.0.................. Nontraumatic Extradural S S
Hemorrhage.
432.1.................. Subdural Hemorrhage......... S S
432.9.................. Unspecified Intracranial S S
Hemorrhage.
433.01................. Occlusion and Stenosis of S S
Basilar Artery With
Cerebral Infarction.
433.11................. Occlusion and Stenosis of S S
Carotid Artery With
Cerebral Infarction.
433.21................. Occlusion and Stenosis of S S
Vertebral Artery With
Cerebral Infarction.
433.31................. Occlusion and Stenosis of S S
Multiple and Bilateral
Precerebral Arteries With
Cerebral Infarction.
433.81................. Occlusion and Stenosis of S S
Precerebral Artery With
Cerebral Infarction.
433.91................. Occlusion and Stenosis of S S
Unspecified Precerebral
Artery With Cerebral
Infarction.
434.00................. Cerebral Thrombosis Without S S
Cerebral Infarction.
434.01................. Cerebral Thrombosis With S S
Cerebral Infarction.
434.10................. Cerebral Embolism Without S S
Cerebral Infarction.
434.11................. Cerebral Embolism With S S
Cerebral Infarction.
434.90................. Unspecified Cerebral Artery S S
Occlusion Without Cerebral
Infarction.
434.91................. Unspecified Cerebral Artery S S
Occlusion With Cerebral
Infarction.
436.................... Acute, But Ill-Defined, S S
Cerebrovascular Disease.
441.00................. Dissection of Aorta, PS PS
Unspecified Site.
441.01................. Dissection of Aorta, PS PS
Thoracic.
441.02................. Dissection of Aorta, PS PS
Abdominal.
441.03................. Dissection of Aorta, PS PS
Thoracoabdominal.
441.1.................. Thoracic Aneurysm, Ruptured. PS PS
441.3.................. Abdominal Aneurysm, Ruptured PS PS
441.5.................. Aortic Aneurysm of PS PS
Unspecified Site, Ruptured.
441.6.................. Thoracoabdominal Aneurysm, PS PS
Ruptured.
443.22................. Dissection of Iliac Artery.. PS PS
443.29................. Dissection of Other Artery.. PS PS
444.0.................. Embolism or Thrombosis of PS PS
Abdominal Aorta.
444.1.................. Embolism or Thrombosis of PS PS
Thoracic Aorta.
445.81................. Atheroembolism of Kidney.... S S
453.2.................. Embolism and Thrombosis of PS PS
Vena Cava.
785.50................. Shock, Unspecified.......... PS PS
785.51................. Cardiogenic Shock........... PS PS
861.02................. Laceration of Heart Without PS PS
Penetration of Heart
Chambers or Open Wound Into
Thorax.
861.03................. Laceration of Heart With PS PS
Penetration of Heart
Chambers, Without Open
Wound Into Thorax.
861.10................. Unspecified Injury of Heart PS PS
With Open Wound Into Thorax.
861.11................. Contusion of Heart With Open PS PS
Wound Into Thorax.
861.12................. Laceration of Heart Without PS PS
Penetration of Heart
Chambers With Open Wound
Into Thorax.
861.13................. Laceration of Heart With PS PS
Penetration of Heart
Chambers, and Open Wound
Into Thorax.
862.9.................. Multiple/Unspecified S S
Intrathoracic Organ Injury
With Open Wound Into Cavity.
996.61................. Infection and Inflammatory PS PS
Reaction Due To Cardiac
Device/Implant/Graft.
996.62................. Infection and Inflammatory PS PS
Reaction Due To Other
Vascular Device/Implant/
Graft.
996.72................. Complication Due To Other PS PS
Cardiac Device/Implant/
Graft.
996.83................. Complications of PS PS
Transplanted Heart.
----------------------------------------------------------------------------------------------------------------

In this final rule, we are implementing new DRGs 547 through 558 as
described above for FY 2006. However, we emphasize that the refinements
to the DRGs described above are being taken as an interim step to
better recognize severity in the DRG system for FY 2006 until we can
complete a more comprehensive analysis of the APR-DRG system and the CC
list as part of a complete analysis of the MedPAC recommendations that
we plan to perform over the next year.
4. APR-DRGs
In the FY 2006 IPPS proposed rule, we indicated that we were 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.

[[Page 47479]]

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, such a far-reaching structural change to the
current DRG system could have substantial effects across all hospitals.
Therefore, we believe we must thoroughly analyze the options and their
impacts on the various types of hospitals before making any proposal to
replace the current DRG system. In addition, as noted above, we
indicated our concern 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, before making a change of this
magnitude, we must consider how to mitigate the risk of paying
significantly more under an alternative DRG system, while measuring the
benefit for Medicare beneficiaries.
We received the following comments in response to the FY 2006 IPPS
proposed rule:
Comment: A number of commenters supported our proposal to consider
the APR-DRGs as an alternate DRG system in response to the MedPAC
recommendation. Seventeen commenters also agreed with the concerns we
identified in the proposed rule regarding the potential impact and
unpredictable effect a change of this magnitude could have upon a
hospital's reimbursement. One commenter recommended that CMS not
implement any of the MedPAC recommendations administratively and that
CMS discourage Congress from requiring such implementation in statute.
This commenter indicated that if CMS and Congress are interested in
pursuing these ideas, they should first conduct a full-scale fiscal
impact analysis. The commenter stated that its own internal analysis,
completed using data from the FY 2002 MedPAR file and the Hospital Cost
Reporting Information System (HCRIS), of the APR-DRGs and hospital-
specific relative values showed that these changes alone would
redistribute $1 billion in Medicare payments. According to the
commenter, hospitals that would experience a disproportionate share of
the losses from these changes would be rural hospitals, public
hospitals, and major teaching hospitals.
Response: We appreciate the commenters' support of our proposal. We
agree that the process to determine whether an APR-DRG system would be
an improvement over our current DRG system will require a thorough and
extensive evaluation. As discussed in the proposed rule, we will
thoroughly study MedPAC's recommendations over the course of the next
year and consider proposing changes for FY 2007 if our analysis
suggests that adopting MedPAC's recommendations would lead to
improvements in the DRG system. We are currently in the process of
engaging a contractor experienced in Medicare payment issues to conduct
a comprehensive review of the MedPAC recommendations. We note that any
fundamental changes to our DRG classification system in order to better
recognize severity; to use cost-based weights; or to adopt hospital-
specific relative weights could have implications for other payment
adjustments that are part of the IPPS (for example, the indirect
medical education and disproportionate share adjustments). The contract
we expect to award shortly will include tasks to study both the MedPAC
recommendations and their implications for these other payment
adjustments.
Comment: MedPAC responded to our concern that adopting an
alternative payment system might improve payment accuracy but could
also substantially alter the distribution of payments among hospitals.
MedPAC indicated that the potential redistribution of payments among
hospitals provides strong evidence that the current payment system is
distorted. Therefore, MedPAC believes its payment recommendations
should be adopted quickly. In addition, MedPAC indicated that our
concern about the impact of their suggested changes upon the current
payment system should not prevent us from taking steps toward improving
the DRG system.
Response: MedPAC believes that the potential redistribution of
payments resulting from improvements to the DRG system should not deter
us from making changes that are designed to increase the accuracy of
the DRG system. We agree. Given the potential for significant
redistribution in payments, our discussion of the MedPAC
recommendations in the proposed rule was simply intended to indicate
that the changes MedPAC is recommending are significant and should be
extensively studied before we make any broad, fundamental changes to
the current Medicare DRG system. As shown above, we are replacing 9
cardiovascular DRGs with 12 new DRGs that account for nearly 700,000
cases as an interim step to better recognize severity of illness in the
DRG system until we can complete a comprehensive analysis of MedPAC's
recommendations.
Comment: MedPAC also addressed our concern that significantly
expanding the number of DRGs could lead to changes in hospitals' case-
mix reporting that may cause inappropriate increases in Medicare
payments. According to MedPAC's comment, the Secretary has authority to
make a prospective adjustment to the national base payment amounts to
offset expected increases in payments resulting from changes in
hospitals' case-mix reporting. MedPAC suggested that CMS use
reabstracted medical records collected from Medicare's quality
assurance program to carry out this policy. It also suggested that CMS
exclude nonspecific secondary diagnoses from more highly valued
severity DRGs; issue guidance to hospitals about appropriate coding
practices; monitor case-mix changes for individual hospitals; and
select hospitals for review and audit of medical records and claims.
Response: We agree that the law provides the Secretary with
authority to make a prospective adjustment to the national base payment
rate to offset expected increases in payments resulting from changes in
hospital case-mix. We also appreciate MedPAC's suggestions for using
reabstracted data from Medicare's quality data reporting process and
are interested in learning more from MedPAC about how the data can be
used for this purpose.
5. DRG Relative Weights
In the FY 2006 proposed rule, 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 noted 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

[[Page 47480]]

accounting systems, and because cost information is not available until
a year or more after claims information. In addition, the application
of a single, uniform cost-to-charge ratio 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 overestimates 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 the accuracy of inpatient
payments would be improved by adopting this method is not obvious.
In the proposed rule, we indicated that we would closely analyze
the impact of a change from the current charge-based DRG weights to
cost-based DRG weights. We noted that such a change is complex and
would require further analysis. With this in mind, we indicated that we
would consider the following issues in performing this analysis:
The effect of using cost-to-charge ratio data, which are
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; \12\
---------------------------------------------------------------------------

\12\ Cost Accounting for Health Care Organizations, Technical
Report Series, I-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 the 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 of a DRG when the hospital is
responsible for 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 adoption of an improved
severity adjustment and the use of charges adjusted to estimated cost
through the application of 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. Therefore, the charges of one or a few hospitals
could 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.
Comment: MedPAC responded that cost-based weights would better
track the true relative costliness of DRGs than charge-based weights.
MedPAC explained that hospital charge markups are highly varied both
among and within hospitals. These differences will result in varying
amounts of distortion in charge-based relative weights. While MedPAC
agreed that there would be some level of distortion in cost-based
weights because they are based in part on hospital charges, it
indicated that the substantial difference in markups across departments
are removed when cost-based weights are calculated while in charge-
based weights they are included.
MedPAC noted that CMS had correctly observed that cost data are not
as timely as charge data and, therefore, cost-based weights may trail
changes in costliness compared to charge-based weights. In response,
MedPAC commented that under its methodology, CMS would recalibrate the
weights using cost estimates only periodically and would calculate the
relationship between cost-based and charge-based weights and adjust the
weights to account for the relationship between cost-based and charge-
based weights in intervening years, which would mitigate the timeliness
problem of using cost-based weights.
With respect to hospital-specific relative weights, MedPAC
commented on our point that data from a 1993 RAND study showed that
this method could undervalue high-cost DRGs and overvalue low-cost
DRGs, a phenomenon known as ``compression.'' MedPAC indicated that the
conclusions from the RAND study may no longer apply today. It indicated
that the compression may not have resulted from the methodology itself
but instead from the pattern of cross-subsidies in charge markups by
hospitals that performed the majority of cardiac surgeries. MedPAC
indicated that charge markups were much smaller 15 years ago than they
are today and cardiac surgeries are currently performed by more
hospitals than they were at the time of the RAND study. Thus, MedPAC
believed the hospital-specific relative value method is a more
effective way of removing the effects on the weights of the differences
in the level of costs or charges among hospitals. MedPAC also stated
that CMS' method of standardizing hospital

[[Page 47481]]

charges could also be causing distortions in the relative weights, in
particular because MedPAC believes that the IME and DSH adjustments are
poorly related to the cost impact on hospitals of providing medical
education and treating low-income patients.
Response: We will consider these comments in our analysis of cost-
based weights and hospital-specific DRGs. As we have indicated above,
these issues are among those that we have engaged a contractor to
assist us in analyzing.
6. High-Cost Outliers
Recommendation 2 in the Report to Congress on Physician-Owned
Specialty Hospitals: 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.
In the FY 2006 IPPS proposed rule, we noted that, 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 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. In the proposed rule, we indicated
that we expect to further analyze these ideas as we consider the other
changes recommended by MedPAC and solicited public comments on this
issue.
We received the following comments in response to the FY 2006 IPPS
proposed rule.
Comment: One commenter disagreed with MedPAC's proposal to exclude
outliers from the computation of the DRG weights because this would
exacerbate the problem of overestimating the outlier threshold,
resulting in underpayments of outliers in a given fiscal year.
Response: We appreciate these comments and will take them into
consideration as we conduct further analysis of MedPAC's
recommendations.
Comment: MedPAC clarified its earlier recommendation in its
comments on the proposed rule. MedPAC explained that, rather than
finance outlier payments through a single 5.1 percent adjustment to the
standardized amount that is required under current law, it meant to
recommend that outlier payments in each DRG be financed out of
aggregate payments in the DRG. MedPAC believes that the current policy
makes DRGs with a high prevalence of outliers more profitable for two
reasons: (1) These DRGs receive more in outlier payments than the 5.1
percent that is removed from the national standardized amount; and (2)
the relative weights for these DRGs are overvalued because their values
are influenced by the high standardized charges for outlier cases
included in the relative weight calculation. MedPAC's recommendation
would require a change in law because the current law requires that the
Secretary reduce the standardized amount by 5 to 6 percent for cases
paid as cost outliers. MedPAC further noted that, under its
recommendation, outlier payments in each DRG would be financed out of
the aggregate payments in the DRG which would reduce the distortion in
the relative weights that comes from including the outlier cases in the
calculation of the weight and would correct the differences in
profitability that stem from using a uniform outlier offset for all
cases. MedPAC added that its recommendation would help make relative
profitability more uniform across all DRGs.
Response: We appreciate MedPAC clarifying and providing more detail
on its outlier recommendation. Now that we better understand the
recommendation, it is clear that the part of MedPAC's proposal that
would replace the 5.1 percent offset to the standardized amount would
require a change in the law. While CMS does have broad authority to
determine how the DRG relative weights are calculated, we are required
by law to reduce the standardized amount by not less than 5 percent or
more than 6 percent to account for the additional payments made to
outlier cases. However, as explained above, MedPAC found DRGs with a
high prevalence of outliers are overvalued both because they receive
more in outlier payments than is removed from the national standardized
amount and the relative weights of these DRGs are influenced by the
high standardized charges that are included in the relative weight
calculation. We believe this latter factor can be addressed without a
change in law. As we indicated in the proposed rule, the law provides
broad discretion to the Secretary to consider all factors that change
the relative use of hospital resources in calculating the DRG relative
weights. Thus, even in the absence of a change in law, we expect to
consider changes that would reduce or eliminate the effect of high-cost
outliers on the DRG relative weights for FY 2007.
Finally, we believe that the recommendations made by MedPAC, or
some variants of them, have significant promise to improve the accuracy
of rates in the IPPS. We agree with MedPAC that these possible
refinements to our payment methodology should be explored, 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 all 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 such an extent that Medicare payments no longer
provide a significant impetus for the further development of specialty
hospitals.
Recommendation 3 of the Report to Congress on Physician-Owned
Specialty Hospitals: The Congress and the Secretary should implement
the case-mix measurement and outlier policies over a transitional
period.
In the FY 2006 IPPS proposed rule, we stated that, before proposing
any fundamental changes to the DRGs system, 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 did note that, in the event we replace 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

[[Page 47482]]

and legal implications of such a transition or any other major change
to the DRGs could be significant.
We received the following comments in response to the FY 2006 IPPS
proposed rule.
Comment: One commenter supported refinements to the DRGs that
better capture cost variations among Medicare patients but expressed
concern about the redistributive impact such a change would have on
Medicare reimbursement to hospitals. The commenter recommended that CMS
evaluate DRG case-mix severity outside of budget neutrality. The
commenter also recommended that CMS make these changes over a
transition period of at least 6 years. Many other commenters suggested
that CMS implement any changes over a transition period in order to
mitigate the financial impact on hospitals. Other commenters also urged
CMS to proceed slowly and deliberately with extensive research as a
foundation for any proposed changes. MedPAC noted it would continue to
work with CMS to develop ways to mitigate the complexity and burden of
a transition methodology.
Response: Section 1886(d)(4) of the Act gives the Secretary broad
discretion to develop DRG classifications and weighting factors.
However, it also requires that adjustments to the classification or
weighting factors cannot change aggregate payments under the IPPS.
Thus, while the Secretary has authority to adopt DRGs that better
recognize severity of illness under current law, the law does not allow
us to adopt these changes outside of budget neutrality. As noted above,
before proposing any changes to the DRGs, we would need to model the
impact of any specific proposal and assess our authority under the
statute to determine whether any changes should be implemented
immediately or over a period of time. We appreciate MedPAC's efforts in
working with CMS and note that we will take all of the comments into
consideration as we conduct further analysis of MedPAC's
recommendations.
Comment: MedPAC commented that it was pleased that CMS shares its
views on improving payment accuracy within the IPPS. However, MedPAC
was concerned that CMS may not be doing enough to address the
distortions within the IPPS pointed out by MedPAC. The commission
explained that the list of analyses CMS included in response to
MedPAC's recommendation is long and broad, raising the risk that some
analysis may not be complete by FY 2007.
Response: We are currently engaging a contractor experienced in
Medicare payment issues to assist in CMS's comprehensive review of the
MedPAC recommendations. We also have made significant progress in our
review of the CC list. As a result, we are optimistic that these
analyses will be completed during the next year.

B. Other MedPAC Recommendations

MedPAC also made the following recommendations that we addressed in
the Secretary's Report to Congress on Specialty Hospitals. This report
is available on our Web site at: http://www.cms.hhs.gov/media/press/files/052005/RTC-StudyofPhysOwnedSpecHosp.pdf.
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.
We received no comments in response to our discussion of these
recommendations in the FY 2006 proposed rule. We note, however, that in
section V.L. of the preamble to this final rule, we address comments
relating to the definition of a hospital in connection with specialty
hospitals.

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. In the FY 2006 IPPS
proposed rule, we published a list of data files that are available for
purchase from CMS or that may be downloaded from the internet without
charge (70 FR 23456 through 23459).

B. Collection of Information Requirements

Under the Paperwork Reduction Act of 1995 (PRA), we are required to
provide 30-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.
In the FY 2006 IPPS proposed rule (70 FR 23459), we solicited
public comments on each of these issues for the information collection
requirements discussed below. A summary of any public comments we
received and our responses follow each requirement.
The following information collection requirements included in this
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, in order to qualify for
the full annual market basket update, 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 these 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

[[Page 47483]]

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 the FY 2006 IPPS proposed rule, we proposed
additional validation criteria to ensure that the quality data being
sent to CMS are accurate (70 FR 23424 through 23426). These validation
criteria are finalized in this final rule. 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 5 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.
A summary of the public comments that we received and our responses
on the quality data submission requirement are included under section
V.B. of this preamble.

Section 413.65 Requirements for a Determination That a Facility or an
Organization Has Provider-Based Status

We proposed under Sec. 413.65(b)(3)(i) to require 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 Sec. 413.65(d) 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 Sec. 413.65(g). We also proposed
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 Sec. 413.65(f).
We proposed under Sec. 413.65(b)(3)(ii) to provide 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 paragraphs (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 Sec. 413.65(g). If the facility is operated
under a management contract, the potential main provider must also
attest that the facility meets the requirements of Sec. 413.65(h).
We proposed to clarify the regulations under Sec. 413.65(e)(3)
which require 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) greater than 11.75
percent and is described in Sec. 412.106(c)(2) 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
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 Sec. 413.65(e)(3)(iii)(A) or
(e)(3)(iii)(B); or (iv) if the facility or organization is unable to
meet the criteria in Sec. 413.65(e)(3)(iii)(A) or Sec.
413.65(e)(3)(iii)(B) because it was not in operation during all of the
12-month period described in Sec. 413.65(e)(3)(iii), be located in a
zip code area included among those that, during all of the 12-month
period described in Sec. 413.65(e)(3)(iii), accounted for at least 75
percent of the patients served by the main provider; or (v) the
facility or organization meets the requirements applicable to neonatal
intensive care units in Sec. 413(e)(3)(v); or (vi) in the case of an
RHC (A) the hospital is 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 is located in a rural area; and (vii) the
hospital is 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 Sec. 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 the FY 2006 IPPS proposed rule, we proposed under proposed Sec.
485.610(d)(2)(ii) that, in order to be considered a relocation, a CAH
would be required to provide documentation demonstrating that its plans
to rebuild in a relocated area were undertaken prior to December 8,
2003. This requirement would have imposed an information collection
requirement if it were finalized. However, after consideration of the
public comments received, we have deleted this provision, and hence the
information collection requirement, from the final regulation in this
final rule.
We have submitted a copy of this rule to OMB for its review of the
information collection requirements described above. The information
collection and recording requirement of Sec. 412.64(d)(2) are not
effective until they are approved by OMB. If you comment on these
information collection and recordkeeping requirements, please mail
copies directly to the following:

Centers for Medicare & Medicaid Services, Office of Strategic
Operations and Regulatory Affairs, Regulations Development and

[[Page 47484]]

Issuances Group, Attn: Jim Wickliffe, CMS-1500-F Room C5-13-28, 7500
Security Boulevard, Baltimore, MD 21244-1850; and
Office of Information and Regulatory Affairs, Office of Management and
Budget, Room 10235, New Executive Office Building, Washington, DC
20503, Attn: Christopher Martin, CMS Desk Officer, CMS-1500-F,
[email protected]. Fax (202) 395-6974.

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.

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

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

0
A. Part 405 is amended as follows:
0
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]

0
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

0
B. Part 412 is amended as follows:
0
1. The authority citation for Part 412 continues to read as follows:

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

Sec. 412.1 [Amended]

0
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]

0
3. In Sec. 412.2--
0
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''.
0
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.''
0
4. Section 412.4 is amended by--
0
a. Revising the introductory text of paragraph (d)(1).
0
b. Revising paragraph (d)(1)(v).
0
c. Adding a new paragraph (d)(3).
0
d. Revising the introductory text of paragraph (f)(2).
0
e. Adding a new paragraph (f)(5).
The revision and additions read as follows:

Sec. 412.4 Discharges and transfers.

* * * * *
(d) Qualifying DRGs. (1) For a fiscal year prior to FY 2006, for
purposes of paragraph (c) of this section, and subject to the
provisions of paragraph (d)(2) of this section, the qualifying DRGs
must meet the following criteria for both of the 2 most recent years
for which data are available:
* * * * *
(v) To initially qualify, the DRG must meet the criteria specified
in paragraphs (d)(1)(i) through (d)(1)(iv) of this section and must
have a decline in the geometric mean length of stay for the DRG during
the most recent 5 years of at least 7 percent. Once a DRG initially
qualifies, the DRG is subject to the criteria specified in paragraphs
(d)(1)(i) through (d)(1)(iv) of this section for each subsequent fiscal
year.
* * * * *
(3) For fiscal years beginning with FY 2006, for purposes of
paragraph (c) of this section--
(i) The qualifying DRGs must meet the following criteria using data
from the March 2005 update of the FY 2004 MedPAR file and Version 23.0
of the DRG Definitions Manual (FY 2006):
(A) The DRG has at least 2,050 total postacute care transfer cases;
(B) At least 5.5 percent of the cases in the DRG are discharged to
postacute care prior to the geometric mean length of stay for the DRG;
(C) The DRG must have a geometric mean length of stay greater than
3 days;
(D) The DRG is paired with a DRG based on the presence or absence
of a comorbidity or complication or major cardiovascular condition
that, it meets the criteria specified in paragraphs (d)(3)(i)(A) and
(d)(3)(ii)(B) of this section.
(ii) If a DRG did not exist in Version 23.0 of the DRG Definitions
Manual or a DRG included in Version 23.0 of the DRG Definitions Manual
is revised, the DRG will be a qualifying DRG if it meets the following
criteria based on the version of the DRG Definitions Manual in use when
the new or revised DRG first becomes effective, using the most recent
complete year of MedPAR data:
(A) The total number of discharges to postacute care in the DRG
must equal or exceed the 55th percentile for all DRGs;
(B) The proportion of short-stay discharges to postacute care to
total discharges in the DRG exceeds the 55th percentile for all DRGs;
and
(C) The DRG is paired with a DRG based on the presence or absence
of a comorbidity or a complication or major cardiovascular condition
that meets the criteria specified under paragraph (d)(3)(ii)(A) and
(d)(3)(ii)(B) of this section.
* * * * *
(f) Payment for transfers.
* * * * *
(2) Special rule for DRGs 209, 210, and 211 for fiscal years prior
to FY 2006. For fiscal years prior to FY 2006, a hospital that
transfers an inpatient under the circumstances described in paragraph
(c) of this section and the transfer is assigned to DRGs 209, 210, or
211 is paid as follows:
* * * * *
(5) Special rule for DRGs meeting specific criteria. For discharges
occurring on or after October 1, 2005, a hospital that transfers an
inpatient under the circumstances described in paragraph (c) of this
section is paid

[[Page 47485]]

using the provisions of paragraph (f)(2)(i) and (f)(2)(ii) of this
section if the transfer case is assigned to one of the DRGs meeting the
following criteria:
(i) The DRG meets the criteria specified in paragraph (d)(3)(i) or
(d)(3)(iii) of this section;
(ii) The average charges of the 1-day discharge cases in the DRG
must be at least 50 percent of the average charges for all cases in the
DRG; and
(iii) The geometric mean length of stay for the DRG is greater than
4 days; and
(iv) If a DRG is a paired with a DRG based on the presence or
absence of a comorbidity or complication or a major cardiovascular
complication that meets the criteria specified in paragraph (f)(5)(i)
through (f)(5)(iii) of this section, that DRG will also be paid under
the provisions of paragraph (f)(2)(i) and (f)(2)(ii) of this section.

0
5. Section 412.64 is amended by--
0
a. Adding a new paragraph (b)(5).
0
b. Revising paragraph (i)(3)(iv).
0
c. Revising paragraph (k)(2).
The addition and revision reads as follows:

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

* * * * *
(b) Geographic classifications. * * *
(5) For hospitals that consist of two or more separately located
inpatient hospital facilities, the national adjusted prospective
payment rate is based on the geographic location of the hospital
facility at which the discharge occurred.
* * * * *
(i) Adjusting the wage index to account for commuting patterns of
hospital employees. * * *
(3) Process for determining the adjustment.
* * * * *
(iv) A hospital in a qualifying county that receives a wage index
adjustment under this paragraph (i) is not eligible for
reclassification under subpart L of this part or section 1886(d)(8) of
the Act.
* * * * *
(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.
* * * * *

0
6. 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.

0
7. 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.

0
8. Section 412.77 is amended by--
0
a. Revising paragraph (a)(1).
0
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.

0
9. 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.
* * * * *

0
10. Section 412.92 is amended by--
0
a. In paragraph (a) introductory text, removing the reference ``Sec.
412.83(b)'' and adding in its place the reference ``Sec. 412.64''.
0
b Revising paragraph (d)(1)(i).
0
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.
* * * * *

0
11. Section 412.96 is amended by--
0
a. Revising paragraph (b)(1) introductory text.
0
b. Revising paragraph (c) introductory text.
0
c. In paragraph (c)(1) introductory text, removing the reference
``paragraph (g)'' and adding in its place the reference ``paragraph
(h)''.
0
d. In paragraph (c)(2)(i), removing the reference ``paragraph (h)'' and
adding in its place the reference ``paragraph (i)''.

[[Page 47486]]

0
e. Revising paragraph (g)(1).
0
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)''.
0
g. In paragraph (h)(2), removing the reference ``(g)(1)'' and adding in
its place the reference ``(h)(1)''.
0
h. Removing paragraph (h)(4).
0
i. In paragraph (i)(2), removing the reference ``(h)(1)'' and adding in
its place the reference ``(i)(1)''.
0
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 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.
* * * * *

0
12. Section 412.103 is amended by revising paragraph (a)(1) 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.
* * * * *

0
13. Section 412.105 is amended by--
0
a. Adding a new paragraph (f)(1)(iv)(D).
0
b. Adding a new paragraph (f)(1)(xiii).
0
c. Adding a new paragraph (f)(1)(xiv).
0
d. Adding a new paragraph (f)(1)(xv).
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 paid under Part 413 of this chapter
as a hospital excluded from the hospital inpatient prospective payment
system and that subsequently becomes subject to the hospital inpatient
prospective payment system, the limit on the total number of FTE
residents for payment purposes is determined based on the data from the
hospital's most recent cost reporting period ending on or before
December 31, 1996.
(xiv) In the case of a merger of a hospital that is excluded from
the hospital inpatient prospective payment system and an acute care
hospital subject to the hospital inpatient prospective payment system,
if the surviving hospital is a hospital subject to the hospital
inpatient prospective payment system and no hospital unit that is
excluded from the hospital inpatient prospective payment system is
created as a result of the merger, the surviving hospital's number of
FTE residents for payment purposes is equal to the sum of the FTE
resident count of the hospital that is subject to the hospital
inpatient prospective payment system as determined under paragraph
(f)(1)(ii)(B) of this section and the limit on the total number of FTE
residents for the excluded hospital as determined under paragraph
(f)(1)(xiii) of this section.
(xv) Effective for discharges occurring on or after October 1,
2005, an urban hospital that reclassifies to a rural area under Sec.
412.103 for fewer than 10 continuous years 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.
* * * * *

0
14. 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).
* * * * *

0
15. 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]

0
16. In Sec. 412.113--
0
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.
0
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]

0
17. In Sec. 412.115--
0
a. In paragraph (a), the reference ``Sec. 413.80'' is removed and the
reference ``Sec. 413.89'' is added in its place.
0
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.''

0
18. Section 412.230 is amended by--
0
a. Revising paragraph (a)(5)(iv)
0
b. Redesignating paragraph (d)(2)(iii) as paragraph (d)(2)(iv).

[[Page 47487]]

0
c. Adding new paragraph (d)(2)(iii).
The revision and additions read as follows:

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

(a) General. * * *
(5) Limitations on redesignations. * * *
(iv) An urban hospital that has been granted redesignation as rural
under Sec. 412.103 cannot receive an additional reclassification by
the MGCRB based on this acquired rural status for a year in which such
redesignation is in effect.
* * * * *
(d) Use of urban or other rural area's wage index.-- * * *
(2) Appropriate wage data. * * *
(iii) For applications submitted for reclassifications effective in
FYs 2006 through 2008, a campus of a multicampus hospital may seek
reclassification to a CBSA in which another campus(es) is located. If
the campus is seeking reclassification to a CBSA in which another
campus(es) is located, as part of its reclassification request, the
requesting entity may submit the composite wage data for the entire
multicampus hospital as its hospital-specific data.
* * * * *

0
19. Section 412.234 is amended by--
0
a. Revising paragraph (a)(3)(ii).
0
b. Adding a new paragraph (a)(3)(iii).
0
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) * * *
(ii) For fiscal year 2006, hospitals located in counties that are
in the same Combined Statistical Area (CSA) (under the MSA definitions
announced by the OMB on June 6, 2003) as the urban area to which they
seek redesignation; 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 designation
qualify as meeting the proximity requirements for reclassification to
the urban area to which they seek redesignation.
(iii) For Federal fiscal year 2007 and thereafter, hospitals
located in counties that are in the same Combined 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]

0
20. 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.

0
21. 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]

0
22. In Sec. 412.521--
0
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.
0
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

0
C. Part 413 is amended as follows:
0
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]

0
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.

0
3. Section 413.40 is amended by--
0
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''.
0
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.
* * * * *

0
4. Section 413.65 is amended by--
0
a. Reprinting the introductory text of paragraph (a)(1)(ii) and adding
a new paragraph (a)(1)(ii)(L).
0
b. Revising the definition of ``Provider-based entity'' under paragraph
(a)(2).
0
c. Revising paragraphs (b)(3)(i) and (b)(3)(ii).
0
d. Revising paragraph (e)(1) introductory text, (e)(1)(i), (e)(1)(ii),
and (e)(1)(iii).
0
e. Revising paragraph (e)(3).
0
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

[[Page 47488]]

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 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.
(ii) The main provider and the facility or organization seeking
status as a department of the main provider, a remote location of a
hospital, or a satellite facility have the same governing body.
(iii) The facility or organization is operated under the same
organizational documents as the main provider. For example, the
facility or organization seeking provider-based status must be subject
to common bylaws and operating decisions of the governing body of the
main provider where it is based.
* * * * *
(3) Location. The facility or organization meets the requirements
in paragraph (e)(3)(i), (e)(3)(ii), (e)(3)(iii), (e)(3)(iv), (e)(3)(v),
or, in the case of an RHC, paragraph (e)(3)(vi) of this section, and
the requirements in paragraph (e)(3)(vii) 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 or is described in Sec. 412.106(c)(2) of this chapter
implementing section 1886(d)(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) The facility or organization meets all of the following
criteria:
(A) The facility or organization is seeking provider-based status
with respect to a hospital that meets the criteria in Sec. 412.23(d)
for reimbursement under Medicare as a children's hospital;
(B) The facility or organization meets the criteria for identifying
intensive care type units set forth in the Medicare reasonable cost
reimbursement regulations under Sec. 413.53(d).
(C) The facility or organization accepts only patients who are
newborn infants who require intensive care on an inpatient basis.
(D) The hospital in which the facility or organization is
physically located is in a rural area as defined in Sec.
412.64(b)(1)(ii)(C) of this chapter.
(E) The facility or organization is located within a 100-mile
radius of the children's hospital that is the potential main provider.
(F) The facility or organization is located at least 35 miles from
the nearest other neonatal intensive care unit.
(G) The facility or organization meets all other requirements for
provider-based status under this section.
(vi) 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
Sec. 412.64(b)(1)(ii)(C) of this subchapter.
(vii) 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

[[Page 47489]]

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.
* * * * *

0
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]

0
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.

0
7. Section 413.79 is amended by--
0
a. Revising paragraph (a)(10).
0
b. Revising the introductory text of paragraph (c)(2).
0
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''.
0
d. Adding a new paragraph (c)(6).
0
e. Revising paragraph (e)(1)(iv).
0
f. In the introductory text of paragraph (k), removing the reference
``(k)(6)'' and adding in its place the reference ``(k)(7)''.
0
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.

* * * * *
(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 portions of 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 redesignated 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]

0
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]

0
9. In Sec. 413.178--
0
a. In paragraph (a), the reference ``Sec. 413.80(b)'' is removed and
the reference ``Sec. 413.89(b)'' is added in its place.
0
b. In paragraph (b), the reference ``Sec. 413.80'' is removed and the
reference ``Sec. 413.89'' is added in its place.

[[Page 47490]]

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

0
D. Part 415 is amended as follows:
0
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]

0
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]

0
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]

0
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]

0
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]

0
6. In Sec. 415.152--
0
a. In paragraph (2) of the definition of ``Approved graduate medical
education program'', the reference ``Sec. 413.86(b)'' is removed and
the reference ``Sec. 413.75(b)'' is added in its place.
0
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]

0
7. In Sec. 415.160--
0
a. In paragraph (c)(2), the reference ``Sec. 413.86'' is removed and
the reference ``Sec. 413.78'' is added in its place.
0
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]

0
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]

0
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]

0
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]

0
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]

0
12. In Sec. 415.208--
0
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.
0
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

0
F. Part 419 is amended as follows:
0
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).

Sec. 419.2 [Amended]

0
2. In Sec. 419.2--
0
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.
0
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

0
G. Part 422 is amended as follows:
0
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]

0
2. In Sec. 422.214--
0
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.
0
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]

0
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

0
G. Part 485 is amended as follows:
0
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 1395hh.

0
2. Section 485.610 is amended by--
0
a. In paragraph (b)(1)(i), removing the reference ``Sec. 412.62(f)''
and adding in its place the reference ``Sec. 412.64(b), excluding
paragraph (b)(3).''
0
b. Removing paragraph (b)(1)(ii) and redesignating paragraph
(b)(1)(iii) as paragraph (b)(1)(ii).
0
c. Adding a new paragraph (d).
The revisions and additions read as follows:

Sec. 485.610 Condition of participation: Status and location.

* * * * *
(d) Standard: Relocation of CAHs with a necessary provider
designation. A CAH that has a necessary provider designation from the
State that was in effect prior to January 1, 2006, and relocates its
facility after January 1, 2006, can continue to meet the location
requirement of paragraph (c) of this section based on the necessary
provider designation only if the relocated facility meets the
requirements as specified in paragraph (d)(1) of this section.
(1) If a necessary provider CAH relocates its facility and begins
providing services in a new location, the CAH can continue to meet the
location requirement of paragraph (c) of this section based on the
necessary provider designation only if the CAH in its new location--
(i) Serves at least 75 percent of the same service area that it
served prior to its relocation;
(ii) Provides at least 75 percent of the same services that it
provided prior to the relocation; and
(iii) Is staffed by 75 percent of the same staff (including medical
staff, contracted staff, and employees) that were on staff at the
original location.
(2) If a CAH that has been designated as a necessary provider by
the State begins providing services at another location after January
1, 2006, and does not meet the requirements in paragraph (d)(1) of this
section, the action will be considered a cessation of business as
described in Sec. 489.52(b)(3).

[[Page 47491]]

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

Dated: July 26, 2005.
Mark B. McClellan,
Administrator, Centers for Medicare & Medicaid Services.
Dated: July 27, 2005.
Michael O. Leavitt,
Secretary.

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

Addendum--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

I. Summary and Background

In this Addendum, we are setting forth the amounts and factors
for determining prospective payment rates for Medicare hospital
inpatient operating costs and Medicare hospital inpatient capital-
related costs. We are also setting forth the 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
making changes in the determination of the prospective payment rates
for Medicare inpatient operating costs for FY 2006. The changes, to
be applied 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 changes for
determining the prospective payment rates for Medicare inpatient
capital-related costs for FY 2006. Section IV. of this Addendum sets
forth our 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 final rule are presented in section VI. of this
Addendum.

II. 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 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 3.7 percent for all areas (that is, the full
market basket percentage increase of 3.7 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 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 updating the labor-
related share to 69.7 percent for FY 2006, as discussed in section
IV.B.3. of the preamble to this final rule. We note that the revised
labor-related share for FY 2006 was determined to be 69.731 (the
same amount that we proposed in the FY 2006 IPPS proposed rule ), as
discussed in section IV of the preamble to this final rule. We used
our

[[Page 47492]]

previous methodology and rounded 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 final rule, we are also rebasing the
current labor-related share for the Puerto Rico-specific amounts for
FY 2006. At the time we issued the proposed rule, we had not
calculated a rebased Puerto Rico labor-related share. Therefore, the
proposed standardized amounts that appeared in Table 1C of the
Addendum of the proposed rule for providers with a wage index
greater than 1.0000 reflected the FY 2005 labor-related share for
the Puerto Rico-specific amounts of 71.3 percent for FY 2006.
However, we subsequently calculated a rebased labor-related share
for Puerto Rico for FY 2006 of 58.7 percent which was posted on the
CMS Web site the week of May 29, 2005. We are adopting this Puerto
Rico specific labor share of 58.7 in this final rule.
We are adjusting 62 percent of the national standardized amount
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 adjusting the national standardized amount by a labor-related
share of 69.7 percent. For hospitals in Puerto Rico, we are
adjusting 58.7 percent of the Puerto Rico specific standardized
amount for all hospitals whose wage indexes are less than or equal
to 1.0000 and 62 percent of the Puerto Rico specific standardized
amount for hospitals whose wage values are greater than 1.0000.

2. Computing the Average Standardized Amount

Section 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 final rule for a single
national standardized amount and a 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 updating 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 3.7 percent (compared to the proposed estimated forecast
of 3.2 percent). Thus, for FY 2006, the update to the average
standardized amount is 3.7 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
standardized amounts in Tables 1A through 1C 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)(4) of the Act to report to the Congress
our 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 final rule.

4. Other Adjustments to the Average Standardized Amount

As in the past, we are adjusting 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 adjusting 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 making a budget neutrality adjustment to
ensure that the requirement of section 1886(d)(4)(C)(iii) of the Act
is met.
Section 1886(d)(3)(E) of the Act requires us to update the
hospital wage index on an annual basis beginning October 1, 1993.
This provision also requires us to make any updates or adjustments
to the wage index in a manner that ensures that aggregate payments
to hospitals are not affected by the change in the wage index. For
FY 2006, we are continuing to adjust 10 percent of the wage index
factor for occupational mix. We describe the occupational mix
adjustment in section III.C. of the preamble to this final 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 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

[[Page 47493]]

2006, and FY 2007. Because we are in the second year of this 3-year
transition, we are adjusting 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 final 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 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 budget neutrality
adjustment factor equal to 1.002271. We also are adjusting the
Puerto Rico-specific standardized amount for the effect of DRG
reclassification and recalibration. We computed a budget neutrality
adjustment factor for the Puerto Rico-specific standardized amount
equal to 0.998993. These 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 final rule, we are
applying the same DRG reclassification and recalibration budget
neutrality factor of 0.998993 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 pre-
reclassified 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 transition budget neutrality adjustment of 0.998859.

b. Reclassified Hospitals--Budget Neutrality Adjustment

Section 1886(d)(8)(B) of the Act provides that, effective with
discharges occurring on or after October 1, 1988, certain rural
hospitals are deemed urban. In addition, section 1886(d)(10) of the
Act provides for the reclassification of hospitals based on
determinations by the MGCRB. Under section 1886(d)(10) of the Act, a
hospital may be reclassified for purposes of the 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 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 applying an
adjustment factor of 0.992521 to ensure that the effects of this
reclassification are budget neutral.
The adjustment factor is applied to the standardized amount
after removing the effects of the FY 2005 budget neutrality
adjustment factor. We note that the 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 greater than the sum of the
prospective payment rate for the DRG, any IME and DSH payments, any
new technology add-on payments, and the ``outlier threshold'' or
``fixed loss'' amount (a dollar amount by which the costs of a case
must exceed payments in order to qualify for outlier payment). We
refer to the sum of the prospective payment rate for the DRG, any
IME and DSH payments, any new technology add-on payments, and the
outlier threshold as the outlier ``fixed-loss cost threshold.'' To
determine whether the costs of a case exceed the fixed-loss cost
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 fixed-loss cost
threshold. The marginal cost factor for FY 2006 is 80 percent--the
same marginal cost factor we have used since FY 1995 (59 FR 45367).
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 amount 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. FY 2006 outlier fixed-loss cost threshold. For FY 2006, as we
proposed, we are using a refined methodology to calculate the
outlier 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 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
outlier 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
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
proposing to use 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 the IPPS final rule for FY2005 (69 FR 49275), in response to
the many comments we received on the proposed FY 2005 methodology,
we revised 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

[[Page 47494]]

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 used this 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 an outlier fixed-loss cost 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.
In the FY 2006 IPPS proposed rule, we proposed to use a refined
methodology to calculate the outlier threshold that would take into
account the lower inflation in hospital charges that is occurring as
a result of the outlier final rule (68 FR 34505, June 9, 2003),
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 FY 2006 outlier threshold, we proposed to simulate
payments by applying FY 2006 rates and policies using cases from the
FY 2004 MedPAR files. Therefore, in order to determine the FY 2006
outlier threshold, we proposed to inflate the charges on the MedPAR
claims by 2 years, from FY 2004 to FY 2006.
However, we did not propose 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 atypically high rate of
hospital charge inflation during FYs 2002 and 2003. Instead, we
proposed to use more recent data that reflected the rate-of-change
in hospital charges under the new outlier policy. However, we stated
we would continue to consider other methodologies in the future when
calculating the outlier threshold once we had 2 complete years of
charge data under the new outlier policy.
Specifically, we proposed to establish the FY 2006 outlier
threshold as follows: Using the latest data available, we proposed
to calculate 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). This
rate-of-change was 8.65 percent (1.0865) or 18.04 percent (1.1804)
over 2 years. As we have done in the past, in establishing the FY
2006 outlier threshold, we proposed to use, hospital cost-to-charge
ratios from the most recent Provider-Specific File, which, at the
time of the proposed rule was the December 2004 update, in
establishing the 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 proposed an outlier fixed-loss cost
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.
For this final rule, we determined the FY 2006 outlier threshold
using the methodology proposed in the proposed rule, but using
updated data. We determined a charge inflation factor based on the
first six months of FY 2005 relative to same period for FY 2004. The
new outlier policy was in effect for this entire period, so we
believe these charge inflation data will project charge inflation
more accurately than the data that were available when we
established the outlier thresholds for FYs 2004 and 2005. For this
final rule, we had hospital charge information for two full 6-month
periods (October 1, 2003 through March 31, 2004 and October 1, 2004
through March 31, 2005) that span only two fiscal years (FY 2004 and
FY 2005) and fully incorporate implementation of the new outlier
policy. Using data from this period, we determined a charge
inflation factor of 14.94 percent, which is substantially lower than
the charge inflation factor of 18.04 percent in the proposed rule.
We used updated cost-to-charge ratios from the March 2005 update of
the Provider Specific File. This file includes cost-to-charge ratios
taken from the most recent tentatively settled cost reports of
hospitals.
Using this methodology, for FY 2006, we are establishing an
outlier fixed-loss cost threshold equal to the prospective payment
rate for the DRG, plus any IME and DSH payments, and any add on
payment for new technology, plus $23,600.
Comment: A number of commenters opposed the proposed increase in
the outlier threshold because outlier payments over the last several
years have been less than the 5.1 percent removed from the
standardized amounts. These commenters requested an explanation of
why CMS proposed to increase the outlier threshold for FY 2006 when
actual outlier payments are projected to be below 5.1 percent for FY
2004 and FY 2005 and result in a savings to Medicare of $1.4 billion
and $600 million for each of these respective years.
Several commenters suggested an alternative to the methodology
we proposed using. These commenters indicated that in addition to
inflating charges from FY 2004 to FY 2006, CMS similarly should
adjust cost-to-charge ratios that will be used to calculate the FY
2006 outlier threshold. Using cost report data from the March 31,
2005 update to HCRIS, the commenters calculated an aggregate annual
rate of increase in cost per discharge from 2001-2003 of 6.57
percent. Taken together with the 8.65 percent increase in charges
calculated by CMS in the proposed rule, the commenter projected a
decline in cost-to-charge ratios and estimated an outlier threshold
of $24,050 for FY 2006.
These commenters indicated that, if CMS had applied the
commenters' methodology to calculate the outlier thresholds for FY
2004 and FY 2005 outlier payments would have been much closer to 5.1
percent of total IPPS payments. These and other commenters also
estimated what the outlier threshold for the past three fiscal years
would have been if CMS had used a methodology of inflating costs
instead charges. The commenters argued that using a cost inflation
methodology would have resulted in total outlier payment being much
closer to 5.1 percent of total IPPS payments. These commenters noted
that CMS set the outlier threshold using cost inflation from FY 1994
to FY 2002. Using data from the March 31, 2005 HCRIS update and
using a cost inflation methodology, the commenter projected an
outlier threshold of $22,250. The commenters recommended that CMS
either return to using cost inflation or adopt a methodology that
takes into account the decline in cost-to-charge ratios as well as
increases in charges when calculating the outlier threshold.
According to the commenters these methodologies have proven to be
more accurate in predicting outlier payments than the ones used by
CMS.
Some commenters recommended that CMS consider making mid-year
adjustments to the outlier threshold if it appears that outlier
payments are going to be less than 95 or more than 105 percent of
the 5.1 percent of total IPPS payments. One commenter recommended
that CMS analyze the practicality and effects of making change to
the outlier threshold similar to the market basket update forecast
error adjustment. Another commenter suggested that CMS recalculate
the outlier threshold that would have been necessary in FY 2005 for
outlier payments to be 5.1 percent of total IPPS payments and use
that amount as the outlier threshold for FY 2006.
Response: We appreciate the alternative methodologies suggested
by the commenters and have considered them carefully. However, as
explained above, we determined the FY 2006 outlier threshold using
the methodology we had proposed in the proposed rule.
While our current estimates are that actual outlier payments
were less than 5.1 percent of total IPPS payments for both FYs 2004
and 2005, we believe that there are special circumstances that
applied in these years that made it especially difficult to project
the increase in Medicare charges when calculating the outlier
threshold. To calculate the outlier threshold for FY 2004 we used an
inflation factor of 26.8 percent based on a 2-year average of the
rate-of-change in charges from FY 2000 to FY 2002. This high rate of
charge inflation coincided with a period when Medicare payments for
outliers were substantially in excess of the outlier thresholds for
those years (7.7 percent for FY 2001 and 7.8 percent for FY 2002).
The actual rate of charge inflation subsided significantly in FY
2004 after we made significant changes to our outlier policy (68 FR
34494, June 9, 2003). We believe that hospitals changed their
charging practices as a result of the changes. Thus, the projected
rate of charge inflation used to set the outlier threshold in the
IPPS rule for FY 2004 was substantially in excess of the actual rate
of charge inflation during FY 2004
Similarly, it was also difficult to project charge inflation in
setting the FY 2005 outlier

[[Page 47495]]

threshold using FY 2003 MedPAR data. The effective date of the
outlier final rule was August 8, 2003, almost 2 months before the
end of FY 2003. Thus, most of the FY 2003 MedPAR data reflected
charges from discharges occurring prior to the effective date of the
changes to our outlier policy and other data reflected charges from
after the effective date of the changes. In addition, we used data
from the first half of FY 2003 to measure the rate of charge
inflation, so all of these data reflected charges from discharges
that occurred prior to the effective date of the changes in our
outlier policy.
Therefore, we believe that the charge inflation used for setting
both the FY 2004 and FY 2005 cost thresholds was atypical because of
the significant growth in hospital charges in the years preceding
the change to our outlier policy as well as the instability in
hospital charging practices that followed the adoption of our new
outlier policy.
We also carefully analyzed the comments suggesting that we also
adjust the cost-to-charge ratios that are used in setting the
outlier thresholds. We believe it is necessary to inflate the
charges from the FY 2004 MedPAR file to project charge levels for FY
2006, but we do not believe it is also necessary to adjust the cost-
to-charge ratios from the March 2005 Provider-Specific File. The FY
2004 MedPAR charge data include charges for dates of service through
August 31, 2003. Although these data are the most recent case-
specific charge information we have available for a complete fiscal
year, the FY 2004 MedPAR charge data are over 2 years old. We likely
would greatly underestimate FY 2006 outlier payments if we did not
inflate the MedPAR charge data.
On the other hand, the cost-to-charge ratios from the March 2005
Provider-Specific File reflect much more recent hospital-specific
data than the case-specific data in the FY 2005 MedPAR file. The
March 2005 Provider-Specific File includes the cost-to-charge ratios
from hospitals' most recent tentatively-settled cost report. In many
cases, for part of FY 2006, fiscal intermediaries will determine
actual outlier payment amounts using the same cost-to-charge ratios
that are in the March 2005 Provider-Specific File. Fiscal
intermediaries will begin using an updated cost-to-charge ratio to
calculate the outlier payments for a hospital only after a more
recent cost report of the hospital has been tentatively settled. We
note that the cost-to-charge ratios that we are using from the March
2005 Provider-Specific File are approximately 3 percent lower on
average than the cost-to-charge ratios from the December 2004
Provider-Specific File that we used in setting the proposed rule
outlier threshold.
In addition, we continue to believe that using charge inflation,
rather than cost inflation, will more likely result in an outlier
threshold that leads to outlier payments equaling 5.1 percent of
total IPPS payments. Our current methodology of estimating outlier
payments more closely captures how actual outlier payment amounts
are calculated. Fiscal intermediaries approximate the costs of a
case by applying the hospital's cost-to-charge ratio to the total
covered charges for the case. Similarly, under the charge inflation
methodology we used to simulate FY 2006 outlier payments, we applied
the most recent provider-specific cost-to-charge ratios we had
available (which, as explained above, in some cases will be the same
cost-to-charge ratios fiscal intermediaries will use to calculate
actual outlier payments during FY 2006) to case-specific FY 2004
MedPAR charge data that had been inflated to approximate current
hospital charge levels.
If we estimated FY 2006 outlier payments using the cost
inflation methodology we employed from FY 1994 to FY 2002, we would
apply historical cost-to-charge ratios from FY 2004 to FY 2004
MedPAR data and then inflate the simulated FY 2004 costs using a
cost inflation factor. As a commenter pointed out, this methodology
would not include an adjustment for the time lag between the
historical FY 2004 cost-to-charge ratios and the cost-to-charge
ratios fiscal intermediaries will use to calculate actual outlier
payments in FY 2006. Because our charge inflation methodology
simulates outlier payments using much more recent cost-to-charge
ratios, we believe that our charge inflation methodology is
preferable to the cost inflation methodology suggested by the
commenters. We note that, as hospital charging practices stabilize
and we gain more experience forecasting charge inflation, we expect
it will become easier to forecast outlier payments.
As we did in establishing the FY 2005 outlier threshold (69 FR
49278), in our projection of FY 2006 outlier payments we did not
make an adjustment for 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 that cost-to-charge ratios
accurately measure hospital costs and, therefore, are more
indicative 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.
We also do not believe that a mid-year adjustment is consistent
with the goals of the IPPS. We have responded to similar comments a
number of times, including the final rules for FY 1993 (57 FR
39784), FY 1994 (58 FR 46347), FY 1995 (59 FR 45408), FY 1996 (60 FR
45856), and FY 1997 (61 FR 46299).
The mid-year adjustments contemplated by the commenters would be
extremely difficult or impracticable (if not impossible) to
administer. Hospital bill data with respect to a given fiscal year
continue to be added to the MedPAR file some time after the end of
the fiscal year. (We update the MedPAR file for 2 full years after
the end of the respective fiscal year.) Therefore, precise figures
on actual outlier payments for a given fiscal year cannot be
determined until well after that fiscal year ends. As a result, we
do not believe we would have sufficient data in time to make a
meaningful mid-year adjustment to the outlier threshold. We do
publish estimates of ``actual'' outlier payments for recent fiscal
years, but those estimates are based on available bills (and
sometimes based on simulations using bills for a previous year,
adjusted for estimates of inflation).
With respect to the commenter's suggestion that we analyze the
practicality and effects of a forecast error adjustment, it is not
clear how a forecast error adjustment would function in the outlier
context. However, we note that our outlier policy is intended to
reimburse hospitals for treating extraordinarily costly cases and,
under the statute, outlier payments are intended to approximate the
marginal cost of providing care above the outlier fixed-loss cost
threshold. Any adjustment to the outlier threshold or standardized
amount in a given year to account for ``overpayments'' or
``underpayments'' of outliers in other years would result in us
making outlier payments that were not directly related to the actual
cost of furnishing care in extraordinarily costly cases.
In addition, consistent with the policy and statutory
interpretation we have maintained since the inception of the IPPS,
we do not make retroactive adjustments to outlier payments to ensure
that total outlier payments in a past year are equal to 5.1 percent
of total DRG payments. In short, we believe our outlier policies are
consistent with the statute and the goals of the prospective payment
system.
We finally note that CMS plans on issuing instructions to fiscal
intermediaries in the near future that update the policies in the
July 3, 2003 program memorandum (A-03-058) and detail the specifics
of reconciling outlier payments and other policies related to
outliers.
ii. Other changes concerning outliers. As stated in the FY 1994
final rule (58 FR 46348, September 1, 1993), 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 thresholds for FY 2006 will result in outlier
payments equal to 5.1 percent of operating DRG payments and 4.85
percent of capital payments based on the Federal rate.
In accordance with section 1886(d)(3)(B) of the Act, we reduced
the FY 2006 standardized amount by the same percentage to account
for the projected proportion of payments paid to outliers.
The outlier adjustment factors that will be applied to the
standardized amount for FY 2006 are as follows:

[[Page 47496]]

----------------------------------------------------------------------------------------------------------------
Operating standardized amounts Capital Federal rate
----------------------------------------------------------------------------------------------------------------
National...................... 0.948990 0.951511
Puerto Rico................... 0.974897 0.973755
----------------------------------------------------------------------------------------------------------------

We are applying 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 outlier fixed-loss cost threshold.
The outlier final rule (68 FR 34494, June 9, 2003) eliminated
the application of the statewide average cost-to-charge ratios 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 1.254 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 (412.84(i)(3) of our regulations), we are still using
statewide average cost-to-charge ratios to determine whether a
hospital qualifies for outlier payments.\13\ Table 8A in section VI.
of this Addendum contains the statewide average operating cost-to-
charge ratios for urban hospitals and for rural hospitals for which
the fiscal intermediary is unable to compute a hospital-specific
cost-to-charge ratio within the above range. Effective for
discharges occurring on or after October 1, 2005, these statewide
average ratios will 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 comparable statewide average capital cost-to-
charge ratios. Again, the cost-to-charge ratios in Tables 8A and 8B
will 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.
---------------------------------------------------------------------------

\13\ 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 3.52 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 that went into
effect on August 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 4.1 percent of actual total DRG payments, 1
percentage point lower than the 5.1 percent we projected in setting
the 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 final 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 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
0.999865.
In order to achieve budget neutrality, we are adjusting national
IPPS rates by an amount sufficient to account for the added costs of
this demonstration. In other words, we are applying 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. 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
applying 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
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. For hospitals in Puerto Rico the labor-
related share of the standardized amount is 58.7 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 final
rule (reflecting the Secretary's current estimate of the proportion
of costs that are attributable to wages and wage-related costs), we
are setting the labor-related share of the standardized amount at
69.7 percent for hospitals whose wage indexes are greater than
1.0000. For hospitals in Puerto Rico the labor-related share of the
standardized amount is 62 percent for all hospitals whose wage
indexes are greater than 1.0000. In addition, Tables 1A and 1B
include standardized amounts reflecting the full 3.7 percent update
for FY 2006, and 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 standardized amounts for Puerto Rico
for FY 2006, reflecting the different labor-related shares that
apply, that is, 58.7 percent or 62 percent.)
The following table illustrates the changes from the FY 2005
national average standardized amount. The first column shows the
changes from the FY 2005

[[Page 47497]]

standardized amounts for hospitals that satisfy the quality data
submission requirement for receiving the full update (3.7 percent).
The second column shows the changes for hospitals receiving the
reduced update (3.3 percent). The first row of the table shows the
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.

Comparison of FY 2005 Standardized Amounts to FY 2006 Single Standardized Amount With Full Update and Reduced
Update
----------------------------------------------------------------------------------------------------------------
Full update (3.7 percent) Reduced update (3.3 percent)
----------------------------------------------------------------------------------------------------------------
FY 2005 Base Rate, after removing Labor: $3,373.02..................... Labor: $3,373.02
reclassification budget Nonlabor: $1,466.32.................. Nonlabor: $1,466.32
neutrality, demonstration budget
neutrality, wage index transition
budget neutrality factors and
outlier offset (based on the labor
and nonlabor market share
percentage for FY 2006).
FY 2006 Update Factor.............. 1.037................................ 1.033
FY 2006 DRG Recalibrations and Wage 1.002271............................. 1.002271
Index Budget Neutrality Factor.
FY 2006 Reclassification Budget 0.992521............................. 0.992521
Neutrality Factor.
Adjusted for Blend of FY 2005 DRG Labor: $3,479.54..................... Labor: $3,466.12
Recalibration and Wage Index Nonlabor: $1,512.63.................. Nonlabor: $1,506.79
Budget Neutrality Factors.
FY 2006 Outlier Factor............. 0.94899.............................. 0.94899
FY 2006 Labor Market Wage Index 0.998859............................. 0.998859
Transition Budget Neutrality
Factor.
Rural Demonstration Budget 0.999865............................. 0.999865
Neutrality Factor.
Rate for FY 2006 (after multiplying Labor: $2,933.52..................... Labor: $2,922.20
FY 2005 base rate by above Nonlabor: $1,797.95.................. Nonlabor: $1,791.02
factors) where the wage index is
less than or equal to 1.0000.
Rate for FY 2006 (after multiplying Labor: $3,297.84..................... Labor: $3,285.12
FY 2005 base rate by above Nonlabor: $1,433.63.................. Nonlabor: $1,482.10
factors) where the wage index is
greater than 1.0000.
----------------------------------------------------------------------------------------------------------------

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 specific standardized
amount is 58.7 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.)

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

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

1. Adjustment for Area Wage Levels

Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require
that we make an adjustment to the labor-related portion of the
national and Puerto Rico prospective payment rates, respectively, to
account for area differences in hospital wage levels. This
adjustment is made by multiplying the labor-related portion of the
adjusted standardized amounts by the appropriate wage index for the
area in which the hospital is located. In section III. of the
preamble to this final rule, we discuss the data and methodology for
the FY 2006 wage index. The 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 adjusting 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.

Table of Cost-of-Living Adjustment Factors, Alaska and Hawaii Hospitals
------------------------------------------------------------------------
Cost of living
Area Adjustment
factor
------------------------------------------------------------------------
Alaska--All areas..................................... 1.25
Hawaii:
County of Honolulu.................................. 1.25
County of Hawaii.................................... 1.165
County of Kauai..................................... 1.2325
County of Maui...................................... 1.2375
County of Kalawao................................... 1.2375
------------------------------------------------------------------------
(The above factors are based on data obtained from the U.S. Office of
Personnel Management.)

C. DRG Relative Weights

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

D. Calculation of Prospective Payment Rates for FY 2006

General Formula for Calculation of Prospective Payment Rates for FY
2006

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

[[Page 47498]]

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.
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 FY 1984 IPPS interim
final rule (September 1, 1983, 48 FR 39772); the April 20, 1990
final rule with comment (55 FR 15150); the FY 1991 IPPS final rule
(September 4, 1990, 55 FR 35994); and the FY 2001 IPPS final rule
(August 1, 2000, 65 FR 47082). In addition, for both SCHs and MDHs,
the hospital-specific rate is adjusted by the budget neutrality
adjustment factor (that is, by the recalibration budget neutrality
factor of 0.998993) as discussed in section V.C.2. of the preamble
to this final rule. The resulting rate is used in determining the
payment rate an SCH or MDH will 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 increasing the hospital-specific rates by 3.7 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 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. Changes to Payment Rates for Acute Care Hospital Inpatient
Capital-Related Costs for FY 2006

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 using to
determine the capital Federal rate for FY 2006, which will 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

[[Page 47499]]

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 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 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 FY
2006 capital Federal rate. In particular, we explain why the FY 2006
capital Federal rate will increase approximately 1.0 percent
compared to the FY 2005 capital Federal rate. We also estimate
aggregate capital payments will increase by 0.6 percent during this
same period. This increase is due to several factors, including the
update to the capital Federal rate (discussed in section III.A.1.a.
of this Addendum) and a projected increase in outlier payments. We
are projecting a slight increase in capital outlier payments as a
result of the decrease in the outlier thresholds (as discussed in
section II.A.4.c. this Addendum). Thus, we are projecting that
capital PPS payments will increase slightly 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 increase 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 update factor for FY 2006 under that framework
is 0.8 percent based on the best data available at this time. The
update factor is based on a projected 0.8 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 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 final 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 will
also equal 1.0 percent in FY 2006. The net adjustment for change in
case-mix is the difference between the projected increase in case-
mix and the projected total increase in case-mix. Therefore, the net
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

[[Page 47500]]

reclassification and recalibration as part of our update for FY
2006. We estimate that FY 2004 DRG reclassification and
recalibration will result in a 0.0 percent change in the case-mix
when compared with the case-mix index that would have resulted if we
had not made the reclassification and recalibration changes to the
DRGs. Therefore, we are making a 0.0 percent adjustment for DRG
reclassification and recalibration in the update for FY 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 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 making a 0.0 percent
adjustment for forecast error in the update for FY 2006.
Under the capital IPPS update framework, we also make an
adjustment for changes in intensity. We calculate this adjustment
using the same methodology and data that were used in the framework
used in the past under the operating IPPS. 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. Accordingly, in the FY 2006 IPPS proposed
rule (70 FR 23476), we proposed a 0.0 percent adjustment for
intensity for FY 2006. As we explained in that same proposed rule,
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 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. Therefore, in this final
rule, we are establishing a 0.0 percent adjustment for intensity for
FY 2006.
Above we described the basis of the components used to develop
the 0.8 percent capital update factor for FY 2006 as shown in the
table below.

CMS FY 2006 Update Factor to the Capital Federal Rate
------------------------------------------------------------------------

------------------------------------------------------------------------
Capital Input Price Index....................................... 0.8
Intensity....................................................... 0.0
Case-Mix Adjustment Factors:
Real Across DRG Change........................................ 1.0
Projected Case-Mix Change..................................... -1.0
-------
Subtotal.................................................... 0.0
Effect of FY 2004 Reclassification and Recalibration............ 0.0
Forecast Error Correction....................................... 0.0
-------
Total Update................................................ 0.8
------------------------------------------------------------------------

b. Comparison of CMS and MedPAC Update Recommendation

As we discussed in the FY 2006 IPPS proposed rule (70 FR 23477),
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

[[Page 47501]]

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. 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 will
equal 4.85 percent for inpatient capital-related payments based on
the Federal rate in FY 2006. Therefore, we are applying an outlier
adjustment factor of 0.9515 to the capital Federal rate. Thus, the
percentage of capital outlier payments to total capital standard
payments for FY 2006 will be lower 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 FY 2006 outlier adjustment
of 0.9515 is a 0.09 percent change from the FY 2005 outlier
adjustment of 0.9506. The net change in the outlier adjustment to
the capital Federal rate for FY 2006 is 1.0009 (0.9515/0.9506).
Thus, the outlier adjustment increases the FY 2006 capital Federal
rate by 0.09 percent compared with the FY 2005 outlier adjustment.

3. 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 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 FY 2006 relative weights and the 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 applying an incremental budget neutrality adjustment of
1.0019 for FY 2006 to the weighted average of the previous
cumulative FY 2005 adjustments of 0.9912 (yielding an adjustment of
0.9931) through FY 2006 (calculations done on unrounded numbers).
For the Puerto Rico GAF, we are applying an incremental budget
neutrality adjustment of 1.0076 for FY 2006 to the previous
cumulative FY 2005 adjustment of 0.9895, yielding a cumulative
adjustment of 0.9970 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 FY 2006 DRG relative weights and the FY 2006 GAF. The
incremental adjustment for DRG classifications and changes in
relative weights is 0.9989 both nationally and for Puerto Rico. The
cumulative adjustments for DRG classifications and changes in
relative weights and for changes in the GAF through FY 2005 are
0.9920 nationally and 9.9959 for Puerto Rico. The following table
summarizes the adjustment factors for each fiscal year:
BILLING CODE 4120-01-P

[[Page 47502]]

[GRAPHIC] [TIFF OMITTED] TR12AU05.004

The methodology used to determine the 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

[[Page 47503]]

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 establishing a GAF/
DRG budget neutrality factor of 1.0008. The GAF/DRG budget
neutrality factors are built permanently into the capital rates;
that is, they are applied cumulatively in determining the capital
Federal rate. This follows from the requirement that estimated
aggregate payments each year be no more or less than they would have
been in the absence of the annual DRG reclassification and
recalibration and changes in the GAF. The incremental change in the
adjustment from the average from FY 2005 to FY 2006 is 1.0008. The
cumulative change in the capital Federal rate due to this adjustment
is 0.9920 (the product of the incremental factors for FYs 1993
though 2005 and the incremental factor of 1.0008 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 cumulative adjustment of 0.9920 for FY 2006.)
This 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. 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 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 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 adjustment based on actual
cost experience. Using data from cost reports ending in FY 2004 from
the March 2005 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
offsetting the capital Federal rate by 0.03 percent for special
exceptions payments for FY 2006. Therefore, the 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 will
equal 0.03 percent of aggregate payments based on the FY 2006
capital Federal rate. Therefore, we are applying an exceptions
payment adjustment factor of 0.9997 to the capital Federal rate for
FY 2006. The 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 net change in the exceptions adjustment factor
used in determining the FY 2006 capital Federal rate is 1.0001
(0.9997/0.9996).

5. 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 final rule, we
are establishing a capital Federal rate of $420.65 for FY 2006. The
capital Federal rate for FY 2006 was calculated as follows:
The FY 2006 update factor is 1.0080; that is, the
update is 0.8 percent.
The 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 1.0008.
The FY 2006 outlier adjustment factor is 0.95150.
The FY 2006 (special) exceptions payment adjustment
factor is 0.9997.
Because the capital Federal rate has already been adjusted for
differences in case-mix, wages, cost-of-living, indirect medical
education costs, and payments to hospitals serving a
disproportionate share of low-income patients, we are making no
additional adjustments in the capital standard Federal rate for
these factors, other than the budget neutrality factor for changes
in the DRG relative weights and the GAF.
We are providing a chart that shows how each of the factors and
adjustments for FY 2006 affected the computation of the FY 2006
capital Federal rate in comparison to the average FY 2005 capital
Federal rate. The FY 2006 update factor has the effect of increasing
the capital Federal rate by 0.80 percent compared to the average FY
2005 Federal rate. The GAF/DRG budget neutrality factor has the
effect of increasing the capital Federal rate by 0.8 percent. The FY
2006 outlier adjustment factor has the effect of increasing the
capital Federal rate by 0.09 percent compared to the average FY 2005
capital Federal rate, and the 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 changes
is to increase the capital Federal rate by 0.99 percent compared to
the average FY 2005 capital Federal rate.

Comparison of Factors and Adjustments: FY 2005 Capital Federal Rate and FY 2006 Capital Federal Rate
----------------------------------------------------------------------------------------------------------------
FY 2005 FY 2006 Change Percent change
----------------------------------------------------------------------------------------------------------------
Update factor1.................................. 1.0070 1.0080 1.0080 0.80
GAF/DRG Adjustment Factor1...................... 1.0004 1.0008 1.0008 0.08
Outlier Adjustment Factor2...................... 0.9506 0.9515 1.0009 0.09

[[Page 47504]]

Exceptions Adjustment Factor2................... 0.9996 0.9997 0.0001 0.01
Capital Federal Rate3........................... $416.53 $420.65 1.0099 0.99
----------------------------------------------------------------------------------------------------------------
1The update factor and the GAF/DRG budget neutrality factors are built permanently into the capital rates. Thus,
for example, the incremental change from FY 2005 to FY 2006 resulting from the application of the 1.0008 GAF/
DRG budget neutrality factor for FY 2006 is 1.0008. 2The outlier reduction factor and the exceptions
adjustment factor are not built permanently into the capital rates; that is, these factors are not applied
cumulatively in determining the capital rates. Thus, for example, the net change resulting from the
application of the FY 2006 outlier adjustment factor is 0.9515/0.9506, or 1.0009. 3The percent change in
factors may not sum due to rounding.

We are also providing a chart that shows how the final FY 2006
capital Federal rate differs from the proposed FY 2006 capital
Federal rate presented in the FY 2006 IPPS proposed rule (70 FR
23480).

Comparison of Factors and Adjustments: Proposed FY 2006 Capital Federal Rate and Final FY 2006 Capital Federal
Rate
----------------------------------------------------------------------------------------------------------------
Proposed FY Percent
2006 Final FY 2006 Change Change
----------------------------------------------------------------------------------------------------------------
Update factor................................... 1.0070 1.0080 1.0010 0.10
GAF/DRG Adjustment Factor....................... 1.0019 1.0008 0.9989 -0.11
Outlier Adjustment Factor....................... 0.9497 0.9515 1.0019 0.19
Exceptions Adjustment Factor.................... 0.9997 0.9997 0.0000 0.00
Capital Federal Rate............................ $419.90 $420.65 1.0018 0.18
----------------------------------------------------------------------------------------------------------------

6. 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 final 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 GAF budget
neutrality factor is 1.0076, while the DRG adjustment is 0.9989, for
a combined cumulative adjustment of 0.9959.
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 making to the factors used to determine the capital
rate, the FY 2006 special capital rate for Puerto Rico is $201.93.

B. Calculation of 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 capital Federal rate
was determined by making adjustments as follows:
For outliers, by dividing the capital standard Federal
rate by the outlier reduction factor for that fiscal year; and
For the payment adjustments applicable to the hospital,
by multiplying the hospital's GAF, disproportionate share adjustment
factor, and IME adjustment factor, when appropriate.
For purposes of calculating payments for each discharge during
FY 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 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 $23,600.
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

[[Page 47505]]

combined Medicare and Medicaid inpatient utilization of at least 70
percent. Under Sec. 412.348(g)(8), the amount of a special
exceptions payment is determined by comparing the cumulative
payments made to the hospital under the capital PPS to the
cumulative minimum payment level. This amount is offset by: (1) Any
amount by which a hospital's cumulative capital payments exceed its
cumulative minimum payment levels applicable under the regular
exceptions process for cost reporting periods beginning during which
the hospital has been subject to the capital PPS; and (2) any amount
by which a hospital's current year operating and capital payments
(excluding 75 percent of operating DSH payments) exceed its
operating and capital costs. Under Sec. 412.348(g)(6), the minimum
payment level is 70 percent for all eligible hospitals.
During the transition period, new hospitals (as defined under
Sec. 412.300) were exempt from the capital PPS for their first 2
years of operation and were paid 85 percent of their reasonable
costs during that period. Effective with the third year of operation
through the remainder of the transition period, under Sec.
412.324(b), we paid the 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 rebasing to FY 2002 in section IV. of the preamble of this final
rule.)

2. Forecast of the CIPI for FY 2006

Based on the latest forecast by Global Insight, Inc. (second
quarter of 2005), we are forecasting the CIPI to increase 0.8
percent in FY 2006. This reflects a projected 1.4 percent increase
in vintage-weighted depreciation prices (building and fixed
equipment, and movable equipment) and a 3.3 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 0.8 percent
increase for the CIPI as a whole in FY 2006.

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

A. Payments to Existing Excluded Hospitals and Units

As discussed in section VII. of the preamble of this final rule,
in accordance with section 1886(b)(3)(H)(i) of the Act and effective
for cost reporting periods beginning on or after October 1, 2002,
payments to existing psychiatric hospitals and units, rehabilitation
hospitals and units, and long-term care hospitals (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 was set for each hospital. 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. LTCHs and IPFs
that have part of their payments based on reasonable costs also have
the reasonable cost portion subject to the rate of increase limits
in Sec. 413.40.
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 existing 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. New IPFs are paid based on 100
percent of the Federal per diem payment amount (Sec. 412.426). 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.

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 adjusted 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
under Sec. 413.40(f)(2)(ii)

[[Page 47506]]

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
payment limitation is also no longer applicable to new
rehabilitation hospitals and units because they are paid 100 percent
of the adjusted 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 reasonable cost-based payment amount
TEFRA. 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 discontinuing
the publication of 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

As discussed in section VIII. of the preamble to this final
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, as we proposed in the FY 2006 IPPS proposed rule, we are
providing that, for FY 2006, the fiscal intermediaries make payment
for blood clotting factor using 106 percent of ASP (that is ASP+ 6
percent) 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.

[[Page 47507]]

VI. Tables

This section contains the tables referred to throughout the
preamble to this final 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 Labore 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 Wage Indexes for Federal Fiscal
Year 2006; 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 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, 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 March 2005 GROUPER V22.0]
Table 7B--Medicare Prospective Payment System Selected Percentile
Lengths of Stay [FY 2004 MedPAR Update March 2005 GROUPER V23.0]
Table 8A--Statewide Average Operating Cost-to-Charge Ratios--July
2005
Table 8B--Statewide Average Capital Cost-to-Charge Ratios--July 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(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)--July
2005
Table 11--FY 2006 LTC-DRGs, Relative Weights, Geometric Average
Length of Stay, and 5/6ths of the Geometric Average Length of Stay

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 (3.7 percent) Reduced update (3.3 percent)
------------------------------------------------------------------------
Labor-related Nonlabor-related Labor-related Nonlabor-related
------------------------------------------------------------------------
$3,297.84 $1,433.63 $3,285.12 $1,428.10
------------------------------------------------------------------------

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 (3.7 percent) Reduced update (3.3 percent)
------------------------------------------------------------------------
Labor-related Nonlabor-related Labor-related Nonlabor-related
------------------------------------------------------------------------
$2,933.52 $1,797.95 $2,922.20 $1,791.02
------------------------------------------------------------------------

Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
Rates if wage index greater than 1 Rates if wage index less than or equal to 1
------------------------------------------------------------------------------------------
Labor Nonlabor Labor Nonlabor
----------------------------------------------------------------------------------------------------------------
National $3,297.84 $1,433.63 $2,933.52 $1,797.95
Puerto Rico $1,402.46 $859.57 $1,327.81 $934.22
----------------------------------------------------------------------------------------------------------------

Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
Rate
------------------------------------------------------------------------
National................................................ $420.65
Puerto Rico............................................. $201.93
------------------------------------------------------------------------

[[Page 47508]]

Table 2.--Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2004; Hospital Wage Indexes
for Federal Fiscal Year 2006; Hospital Average Hourly Wages 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 FY 2006 Average Average Average hourly wage
Provider No. index \3\ wage index hourly wage hourly wage hourly wage ** (3
FY 2004 FY 2005 FY 2006 \1\ years)
----------------------------------------------------------------------------------------------------------------
010001............................ 1.4738 0.7757 $19.4061 $20.6563 $21.6546 $20.5970
010004............................ *** * $22.2674 $22.7585 * $22.4801
010005 \h\........................ 1.1467 0.9379 $19.6063 $20.4937 $22.4906 $20.9007
010006............................ 1.4559 0.8297 $19.0976 $21.0241 $23.4823 $21.1655
010007............................ 1.0885 0.7463 $17.5462 $16.8811 $18.2430 $17.5458
010008............................ 1.0025 0.8300 $19.6573 $23.8333 $20.4591 $21.3782
010009............................ 0.9852 0.8601 $20.4309 $21.6422 $23.2229 $21.7690
010010 \h\........................ 1.0269 0.9379 $19.2644 $22.3021 $21.4974 $21.0618
010011............................ 1.5830 0.8959 $25.8231 $24.8166 $27.4850 $26.0626
010012............................ 1.2324 0.9089 $20.0896 $21.7622 $22.7020 $21.5233
010015............................ 0.9730 0.7463 $18.8890 $20.4732 $21.5111 $20.4315
010016............................ 1.3312 0.8959 $21.7918 $23.0414 $25.1502 $23.3217
010018............................ 1.2538 0.8959 $19.2071 $20.5888 $22.2990 $20.6865
010019............................ 1.2330 0.8297 $18.9177 $20.1336 $22.0906 $20.4039
010021 \h\........................ 1.2024 0.7757 $17.7596 $20.7108 $18.6785 $19.0123
010022............................ 0.9447 0.9405 $22.2267 $25.8797 $24.5670 $24.2502
010023............................ 1.8563 0.8630 $20.4901 $23.7791 $27.6174 $23.7666
010024............................ 1.6214 0.8630 $18.5942 $20.0067 $20.7265 $19.7702
010025............................ 1.3289 0.8394 $19.3649 $19.8561 $21.2674 $20.1430
010027............................ 0.7679 0.7463 $14.0975 $14.9585 $15.3704 $14.7992
010029............................ 1.5563 0.8394 $20.9868 $21.6724 $22.6976 $21.8061
010031............................ *** * $21.0176 $20.9463 * $20.9818
010032............................ 0.8874 0.7463 $16.4713 $18.5073 $19.1555 $18.1219
010033............................ 2.0404 0.8959 $24.5088 $25.5165 $26.3784 $25.4860
010034............................ 0.9689 0.8630 $14.9333 $17.1625 $16.9686 $16.3417
010035............................ 1.2590 0.8959 $21.6182 $23.1319 $22.2870 $22.3532
010036............................ 1.1539 0.7463 $19.2501 $20.5125 $22.9747 $20.9446
010038............................ 1.3348 0.7779 $18.6578 $20.3935 $21.4509 $20.2189
010039............................ 1.6434 0.9120 $23.0339 $23.4151 $25.8820 $24.1525
010040............................ 1.4704 0.7966 $20.7779 $21.6708 $22.8851 $21.7864
010043............................ 1.0652 0.8959 $19.9012 $19.5422 $22.5945 $20.7320
010044............................ 1.0535 0.8959 $25.8560 $23.0220 $21.4036 $23.2608
010045............................ 1.0943 0.8959 $22.7713 $20.5658 $19.8803 $20.8779
010046............................ 1.4623 0.7966 $19.6754 $20.8935 $21.6965 $20.8067
010047............................ 0.8851 0.7618 $16.1695 $19.5937 $21.0604 $18.8438
010049............................ 1.0914 0.7463 $16.2973 $17.7801 $20.2413 $18.1494
010050............................ 1.0423 0.8959 $20.7398 $21.5625 $22.1584 $21.5077
010051............................ 0.9034 0.8648 $14.3006 $14.7053 $15.2208 $14.7351
010052............................ 0.8752 0.7463 $11.9019 $21.3673 $16.4959 $15.4174
010053............................ 1.0186 0.7463 $17.3238 $17.4160 $19.0108 $17.9166
010054............................ 1.0675 0.8601 $20.6382 $23.1894 $22.5554 $22.1149
010055............................ 1.5040 0.7757 $18.9664 $19.1847 $22.3800 $20.1389
010056............................ 1.5304 0.8959 $21.1104 $22.7183 $23.7144 $22.5773
010058............................ 0.8812 0.8959 $17.7800 $20.3182 $18.5537 $18.9295
010059............................ 1.0579 0.8509 $20.5534 $23.6963 $21.3237 $21.8874
010061............................ 0.9745 0.7969 $17.0447 $20.5683 $21.9370 $19.8088
010062............................ 1.0751 0.7757 $17.1786 $18.1323 $18.3435 $17.8796
010064............................ 1.7028 0.8959 $22.2280 $25.4345 $26.1110 $24.2542
010065............................ 1.4305 0.8300 $17.2698 $20.0108 $21.3785 $19.6007
010066............................ 0.8403 0.7463 $14.8696 $17.0935 $17.6152 $16.5083
010068............................ 1.2166 0.8959 $18.3308 $17.5690 $19.0789 $18.3440
010069............................ 1.0532 0.7463 $17.0957 $19.6317 $21.3608 $19.4027
010072............................ 1.1497 0.7717 $18.8807 $21.5419 $21.8169 $20.7331
010073............................ 0.9378 0.7463 $14.9826 $16.4043 $16.4168 $15.9303
010078............................ 1.3765 0.7779 $20.1447 $21.0633 $21.6857 $20.9549
010079............................ 1.1745 0.9120 $20.7401 $20.4254 $21.8199 $21.0143
010083 \h\........................ 1.2054 0.8081 $19.8524 $20.2166 $22.3041 $20.7945
010084............................ 1.5407 0.8959 $21.6522 $22.5219 $24.7127 $22.9810
010085............................ 1.2286 0.8601 $22.5282 $23.7007 $24.4710 $23.5499
010086............................ 1.0940 0.7463 $18.0122 $19.4332 $18.6081 $18.6721
010087............................ 1.9263 0.7898 $19.7620 $21.6226 $22.5225 $21.2536
010089............................ 1.2383 0.8959 $19.5783 $22.2508 $22.8448 $21.5236
010090............................ 1.6654 0.7898 $20.0287 $21.4322 $23.6948 $21.7237
010091............................ 0.9268 0.7463 $17.4672 $19.4222 $18.6912 $18.5367
010092............................ 1.5091 0.8648 $19.9351 $22.0709 $24.4592 $22.1357
010095............................ 0.8679 0.8648 $12.5243 $13.4426 $13.9326 $13.3037
010097............................ 0.7797 0.8630 $15.1593 $17.1735 $16.7548 $16.2912

[[Page 47509]]

010098............................ 1.1057 0.7463 $15.1629 $19.6717 $14.3076 $16.0844
010099............................ 0.9928 0.7463 $16.3307 $18.1849 $18.7909 $17.7973
010100 \h\........................ 1.6620 0.8081 $19.8146 $20.0027 $21.2915 $20.4113
010101............................ 1.1183 0.7717 $19.0718 $21.0085 $21.6593 $20.5878
010102............................ 0.9035 0.7463 $16.4637 $19.9196 $21.0903 $19.1526
010103............................ 1.8583 0.8959 $22.5709 $24.2201 $26.1163 $24.2529
010104............................ 1.7367 0.8959 $20.9391 $24.1929 $24.7394 $23.1972
010108............................ 1.0869 0.8630 $20.7787 $23.7803 $28.4624 $24.2639
010109............................ 0.9573 0.7914 $18.2235 $21.7128 $21.6194 $20.4648
010110............................ 0.7413 0.7463 $16.0015 $19.2706 $17.5957 $17.7893
010112............................ 0.9711 0.7463 $17.9243 $17.2963 $16.8902 $17.3960
010113............................ 1.6497 0.7898 $19.4106 $20.4181 $21.4121 $20.4357
010114............................ 1.3236 0.8959 $20.1763 $21.5319 $22.3752 $21.3396
010115............................ 0.8303 0.7556 $15.7872 $17.5985 $21.7478 $17.8278
010118............................ 1.2532 0.8300 $19.5302 $18.8560 $19.7673 $19.4467
010119............................ *** * $20.5245 $21.8215 * $21.1743
010120............................ 0.9549 0.7898 $19.4368 $20.5855 $20.9450 $20.3424
010121............................ *** * $17.1640 $17.0329 $24.0867 $18.5589
010125............................ 1.0390 0.7463 $16.8622 $16.8419 $18.4114 $17.3762
010126............................ 1.1100 0.8300 $19.9647 $23.1856 $23.1381 $22.1149
010128............................ 0.8402 0.7463 $14.7646 $17.9354 $21.4201 $18.0579
010129 \h\........................ 0.9911 0.8019 $16.4905 $18.7821 $21.3555 $19.1436
010130............................ 0.9505 0.8959 $18.7190 $18.4944 $23.2488 $20.0658
010131............................ 1.3400 0.9120 $22.9969 $24.2197 $25.7837 $24.4029
010134............................ *** * $17.7717 * * $17.7717
010137............................ 1.2752 0.8959 $28.9402 $29.7665 $24.7366 $27.6545
010138............................ 0.6239 0.7463 $14.2025 $13.5082 $13.8475 $13.8713
010139............................ 1.5213 0.8959 $22.8390 $24.9410 $25.3014 $24.4108
010143............................ 1.1690 0.8959 $20.5639 $22.1312 $22.0215 $21.5734
010144............................ 1.5618 0.7898 $19.1497 $20.6425 $20.8209 $20.2306
010145............................ 1.2807 0.8648 $22.1394 $23.1976 $24.9531 $23.4608
010146............................ 1.0363 0.7779 $21.3083 $19.9944 $20.8917 $20.7213
010148............................ 0.8816 0.7463 $17.6829 $18.5309 $20.5589 $19.0324
010149............................ 1.3313 0.8630 $21.0086 $3.1593 $26.5854 $23.4663
010150............................ 1.0526 0.8394 $21.2360 $20.6738 $21.6377 $21.1783
010152............................ 1.2065 0.7898 $21.6038 $22.1626 $22.6202 $22.1446
010157............................ 1.1281 0.8297 $19.6977 $21.3574 $24.3560 $21.7462
010158............................ 1.0829 0.8509 $18.5464 $22.4440 $24.3531 $21.6528
010161............................ *** * * $27.5119 * $27.5119
010162............................ 1.8283 0.8959 * * * *
010163............................ 1.2761 0.7757 * * * *
010164............................ 1.0870 0.7717 * * * *
010165............................ 1.7531 0.9120 * * * *
020001............................ 1.6984 1.1965 $30.1452 $31.6091 $32.8120 $31.6051
020004............................ 1.1704 1.1965 $27.3516 $29.9926 $32.0966 $29.8229
020005............................ 0.9519 * $32.7936 * * $32.7936
020006............................ 1.2203 1.1965 $31.2673 $33.4210 $36.0540 $33.6428
020008............................ 1.2317 1.2828 $33.4543 $34.5856 $35.9236 $34.6652
020010............................ *** * $20.7929 * * $20.7929
020012............................ 1.3442 1.1965 $27.9955 $29.3419 $31.8995 $29.8198
020013............................ *** * $30.6423 * * $30.6423
020014............................ 1.0326 1.1965 $29.6805 $32.1233 $32.0893 $31.3377
020017............................ 1.9353 1.1965 $30.3017 $32.9281 $33.5852 $32.3606
020018............................ 0.9338 1.1965 * * * *
020019............................ 0.8198 1.9343 * * * *
020020............................ 0.8449 * * * * *
020021............................ 0.9569 * * * * *
020024............................ 1.1394 1.1965 $28.0930 $27.9799 $33.0644 $29.9221
020026............................ 1.5552 1.9343 * * * *
020027............................ 0.9166 1.9343 * * * *
030001............................ 1.3883 1.0129 $25.7513 $27.7572 $29.9840 $27.8499
030002............................ 2.0946 1.0129 $25.6038 $27.9628 $29.0519 $27.5075
030003............................ *** * $22.1436 * * $22.1436
030004............................ 0.8735 * * * * *
030006............................ 1.6926 0.9027 $23.2881 $24.0169 $25.8872 $24.4719
030007............................ 1.3598 1.1382 $26.1551 $26.9442 $29.6174 $27.6578
030009............................ 0.8941 0.9027 $19.9131 $21.4065 $22.3992 $21.1294

[[Page 47510]]

030010............................ 1.3563 0.9027 $20.7204 $22.8647 $24.8275 $22.8055
030011............................ 1.4714 0.9027 $21.0028 $22.8422 $25.1361 $23.0075
030012............................ 1.3007 0.9422 $24.2366 $25.5205 $26.3859 $25.4550
030013............................ 1.3461 0.9179 $21.9766 $23.5229 $25.7050 $23.8047
030014............................ 1.4729 1.0129 $23.3663 $25.1189 $25.6259 $24.7232
030016............................ 1.2676 1.0129 $24.3380 $27.1583 $26.7003 $26.0910
030017............................ 2.0460 1.0129 $21.8792 $24.4055 $26.2452 $24.0378
030018............................ 1.2271 1.0129 $24.9216 $24.4308 $28.9476 $25.9371
030019............................ 1.3599 1.0129 $23.2973 $28.4917 $27.3156 $26.2053
030022............................ 1.5548 1.0129 $24.9941 $25.1461 $26.4404 $25.5437
030023............................ 1.6260 1.2082 $28.6627 $28.4112 $33.8333 $30.2808
030024............................ 2.0251 1.0129 $26.7641 $28.3470 $31.6658 $28.9293
030027............................ 0.9336 0.9007 $19.4583 $21.0527 $20.4031 $20.3074
030030............................ 1.6760 1.0129 $25.2425 $24.6005 $30.2712 $26.5838
030033............................ 1.2098 1.1382 $26.3814 $26.6009 $26.6531 $26.5511
030036............................ 1.3281 1.0129 $24.9432 $26.5708 $30.3521 $27.3868
030037............................ 2.2386 1.0129 $23.0542 $30.3907 $28.6453 $27.0409
030038............................ 1.6056 1.0129 $25.2632 $26.5178 $29.5509 $27.6724
030040............................ 0.9548 0.9007 $21.2717 $22.5130 $24.8145 $22.8703
030043............................ 1.3515 0.9007 $23.5172 $26.0825 $24.7932 $24.8113
030044............................ 0.9107 * $21.9503 $19.5714 * $20.6512
030055 \h\........................ 1.3655 1.1404 $22.8612 $23.1837 $24.5202 $23.5684
030059............................ *** * * $24.7676 * $24.7676
030060............................ 1.1098 0.9007 $21.7685 $22.3551 $24.3523 $22.7950
030061............................ 1.6175 1.0129 $22.9706 $23.4722 $25.5529 $24.0363
030062............................ 1.1767 0.9007 $21.1639 $21.9849 $23.8068 $22.3433
030064............................ 1.9148 0.9027 $22.8009 $24.6732 $25.4922 $24.2954
030065............................ 1.5739 1.0129 $24.6064 $25.6738 $27.1646 $25.8836
030067............................ 1.0119 0.9007 $18.4003 $19.1332 $20.4376 $19.2370
030068............................ 1.1175 0.9007 $19.7097 $19.7030 $20.8846 $20.1346
030069 \h\........................ 1.3479 1.1404 $24.5432 $25.6243 $26.3518 $25.5167
030071............................ 0.9121 1.4448 * * * *
030073............................ 1.0619 1.4448 * * * *
030074............................ 1.3283 1.4448 * * * *
030077............................ 0.8892 1.4448 * * * *
030078............................ 1.2973 1.4448 * * * *
030080............................ 1.5280 0.9027 $22.8953 $24.3573 $25.2077 $24.1500
030083............................ 1.3085 1.0129 $24.3273 $24.9269 $27.5353 $25.6343
030084............................ 0.9817 1.4448 * * * *
030085............................ 1.5277 0.9027 $21.8196 $23.2070 $24.5792 $23.3008
030087............................ 1.5910 1.0129 $25.6351 $26.3878 $26.6594 $26.2197
030088............................ 1.3843 1.0129 $23.5761 $23.2478 $26.6796 $24.5472
030089............................ 1.5441 1.0129 $24.5055 $26.2166 $27.1835 $26.0965
030092............................ 1.3900 1.0129 $24.0515 $25.4127 $27.3203 $25.7452
030093............................ 1.2317 1.0129 $23.2485 $23.5623 $25.8955 $24.3686
030094............................ 1.3602 1.0129 $24.5992 $26.9985 $29.5948 $27.0516
030099............................ 0.9027 0.9007 $20.3310 $26.7996 $26.3236 $24.0344
030100............................ 2.0028 0.9027 $27.6299 * $29.0691 $28.4177
030101 \h\........................ 1.4076 1.1404 $23.7661 $25.0077 $26.1927 $25.0150
030102............................ 2.5592 1.0129 $27.9419 * $29.0942 $28.5553
030103............................ 1.6685 1.0129 $29.1105 $28.2832 $30.1994 $29.2117
030104............................ *** * $34.6028 * * $34.6028
030105............................ 2.4472 1.0129 * $27.6900 $31.3094 $29.8084
030106............................ 1.5550 1.0129 * $30.4791 $34.7222 $32.1177
030107............................ 2.2261 1.0129 * * * *
030108............................ 1.9023 1.0129 * * * *
030109............................ 2.1680 1.0129 * * * *
030110............................ 1.0957 1.0129 * * * *
030111............................ 0.8225 0.9027 * * * *
030112............................ 1.8096 1.0129 * * * *
040001............................ 1.0611 0.8707 $18.7141 $23.1475 $23.7718 $21.8056
040002............................ 1.1352 0.7493 $18.0776 $19.3429 $20.1384 $19.2037
040003............................ 1.0582 * $16.3918 $18.5000 * $17.3854
040004............................ 1.5440 0.8707 $21.2335 $23.3504 $25.0286 $23.2843
040007............................ 1.6746 0.8759 $23.3992 $23.4565 $25.7142 $24.1728
040010............................ 1.3668 0.8707 $20.7114 $22.0984 $23.0274 $21.9856
040011............................ 1.0105 0.7493 $18.8346 $19.0319 $20.3970 $19.4802

[[Page 47511]]

040014............................ 1.3837 0.8558 $22.4970 $24.0846 $25.3451 $23.9535
040015............................ 1.0508 0.7493 $18.8513 $18.0793 $19.2831 $18.7435
040016............................ 1.7065 0.8759 $21.2198 $22.7219 $22.1228 $22.0244
040017............................ 1.0997 0.8242 $17.7545 $19.4365 $21.9875 $19.7066
040018............................ 0.9918 0.8247 $22.0408 $23.8515 $23.6044 $23.2404
040019............................ 1.1532 0.9148 $21.1711 $21.5316 $23.7328 $22.1722
040020............................ 1.5108 0.9148 $18.6419 $20.9136 $21.6603 $20.4199
040021............................ 1.2519 0.8759 $23.5620 $24.7771 $25.6917 $24.7363
040022............................ 1.6253 0.8707 $21.4194 $23.7462 $25.4052 $23.5017
040024............................ 1.0583 * $17.5750 $20.1101 * $18.8371
040026............................ 1.5143 0.9020 $22.7699 $24.3053 $25.4072 $24.2169
040027............................ 1.3588 0.8242 $19.3388 $19.9348 $21.1412 $20.1077
040029............................ 1.5605 0.8759 $22.1882 $22.8770 $24.0704 $23.0869
040032............................ 0.9574 * $16.2781 $18.5171 * $17.4291
040035............................ 0.9191 * $11.8237 $13.4265 * $12.6475
040036............................ 1.5893 0.8759 $21.6742 $24.2851 $26.3226 $24.0976
040039............................ 1.3470 0.7784 $15.9673 $17.7976 $19.5998 $17.8170
040041............................ 1.1930 0.8558 $20.4646 $22.0188 $22.1531 $21.5535
040042............................ 1.3638 0.9402 $16.2285 $18.9550 $19.9627 $18.3286
040045............................ 0.9454 0.7493 $19.5572 $18.7952 $17.2280 $18.4644
040047............................ 1.0852 0.7919 $21.6323 $21.5334 $21.9163 $21.6924
040050............................ 1.0870 0.7493 $15.1428 $15.4782 $16.3930 $15.6589
040051............................ 0.9253 0.7493 $17.6964 $18.8943 $19.1401 $18.6103
040053............................ 1.0125 0.7493 $19.2586 $20.8153 $20.7824 $20.2863
040054............................ 1.0370 0.7493 $16.5573 $16.7370 $18.2684 $17.1740
040055............................ 1.5720 0.8247 $19.7336 $22.2237 $23.3156 $21.7960
040062............................ 1.5986 0.8247 $21.9336 $21.6403 $23.3083 $22.3231
040066............................ 1.0416 * $21.7766 $23.4616 * $22.6592
040067............................ 1.0257 0.7493 $16.0516 $15.1441 $16.8799 $16.0038
040069............................ 1.0526 0.9148 $20.5968 $21.7607 $24.4662 $22.2668
040071............................ 1.5315 0.8733 $19.4324 $22.9350 $24.3824 $22.1870
040072............................ 1.0802 0.8558 $19.3079 $20.8269 $19.9009 $19.9951
040074............................ 1.2035 0.8759 $22.0800 $22.6147 $25.2423 $23.2187
040075............................ 0.9612 0.7493 $15.7875 $16.2583 $18.3254 $16.7901
040076............................ 1.0330 0.8842 $23.5947 $21.0442 $20.6272 $21.6458
040077............................ 0.9696 0.7493 $16.7832 $18.3261 $18.2082 $17.7537
040078............................ 1.5651 0.9020 $21.4854 $24.4589 $24.5378 $23.4806
040080............................ 0.9900 0.7784 $18.4470 $21.3483 $22.3392 $20.6867
040081............................ 0.8227 0.7493 $13.2797 $13.7148 $15.1081 $14.0348
040084............................ 1.0802 0.8759 $20.1163 $22.6441 $24.7225 $22.5619
040085............................ 1.0020 0.7493 $15.5811 $18.0756 $29.8444 $19.6100
040088............................ 1.3134 0.8758 $20.0032 $21.2974 $22.6183 $21.3215
040091............................ 1.1579 0.8285 $20.6688 $23.0252 $23.1320 $22.2743
040100............................ 1.3499 0.8558 $17.8889 $19.3560 $20.0460 $19.1639
040105............................ 1.0187 0.7493 $15.4697 $15.8171 $18.2182 $16.4079
040107............................ 0.7355 * $17.6695 * * $17.6695
040109............................ 1.0950 0.7493 $17.1706 $18.8624 $22.8801 $19.5134
040114............................ 1.7269 0.8759 $21.6849 $23.5628 $24.8992 $23.4046
040118............................ 1.4172 0.7960 $21.7913 $24.2547 $24.7363 $23.6447
040119............................ 1.4440 0.8558 $19.9013 $20.1631 $21.0103 $20.3637
040126............................ 0.8734 0.7493 $13.3832 $12.5944 $14.0701 $13.3074
040132............................ *** * $29.2343 $36.5525 $28.1390 $31.3524
040134............................ 2.4871 0.8759 $24.4646 * $27.3412 $25.9794
040137............................ 1.2240 0.8759 $24.7813 $23.4672 $25.2907 $24.5263
040138............................ 1.2558 0.8707 $22.3523 $23.3615 $25.7513 $23.9295
040140............................ *** * * $25.1224 * $25.1224
040141............................ 0.7865 0.8707 * * $24.0901 $24.0901
040142............................ 1.2881 0.9020 * * $27.9695 $27.9695
040144............................ 1.8281 0.8247 * * * *
040145............................ 1.6490 0.7960 * * * *
040146............................ 1.5160 0.8707 * * * *
050002............................ 1.3838 1.5463 $30.9729 $31.9709 $34.1948 $32.4064
050006............................ 1.6406 1.1897 $25.4604 $27.6176 $30.5373 $27.9248
050007............................ 1.4970 1.4974 $34.1406 $37.5804 $38.7033 $36.8959
050008............................ 1.3604 1.5000 $32.4067 $36.9371 $39.1539 $36.3445
050009............................ 1.8013 1.3972 $30.2740 $35.5384 $39.6393 $35.2947
050013............................ 2.0861 1.3972 $29.8401 $31.7637 $31.9837 $31.2570

[[Page 47512]]

050014............................ 1.1355 1.2949 $27.7646 $29.5726 $33.0373 $30.2311
050015............................ 1.2876 1.1042 $27.5652 $30.1398 $30.7940 $29.4852
050016............................ 1.2303 1.1449 $25.5508 $25.5735 $26.2162 $25.7788
050017............................ 1.9469 1.2949 $28.4911 $30.5863 $36.6593 $31.9215
050018............................ 1.1836 1.1793 $17.9621 $20.3179 $22.3472 $20.1629
050022............................ 1.5996 1.1296 $28.1312 $28.2773 $29.8632 $28.8610
050024............................ 1.1356 1.1406 $25.1425 $26.9378 $27.5587 $26.6747
050025............................ 1.8361 1.1406 $29.8262 $31.7242 $36.1622 $32.6605
050026............................ 1.5525 1.1406 $24.2564 $26.6406 $28.3027 $26.5474
050028............................ 1.2414 1.1042 $18.7866 $21.5448 $26.6160 $21.9931
050029............................ *** * $30.2538 $34.3934 * $31.9320
050030............................ 1.2356 1.1042 $21.9251 $22.9148 $24.9707 $23.2719
050032............................ *** * $28.8046 * * $28.8046
050036............................ 1.6046 1.1042 $25.3885 $27.4915 $32.7929 $28.6943
050038............................ 1.4838 1.5088 $36.1619 $35.0441 $38.7527 $36.6692
050039............................ 1.6104 1.1042 $26.8993 $29.8179 $31.6734 $29.4369
050040............................ 1.2146 1.1793 $30.7426 $31.8983 $34.3279 $32.3366
050042............................ 1.3842 1.1897 $27.6765 $29.8062 $33.9415 $30.4516
050043............................ 1.6433 1.5463 $37.3217 $39.6054 $43.1589 $40.0134
050045............................ 1.2820 1.1042 $22.1691 $22.7051 $23.8408 $22.8906
050046............................ 1.2229 1.1769 $25.5490 $25.2786 $25.6875 $25.5104
050047............................ 1.7071 1.5000 $34.4427 $39.3993 $40.9874 $38.4201
050054............................ 1.1951 1.1296 $21.3495 $27.1437 $24.1262 $24.0051
050055............................ 1.2558 1.5000 $36.1182 $36.9386 $37.5879 $36.9364
050056............................ 1.3730 1.1793 $27.1458 $29.4829 $27.9330 $28.1647
050057............................ 1.6271 1.1042 $24.2759 $26.2099 $29.4351 $26.6650
050058............................ 1.5543 1.1793 $25.9389 $27.3584 $33.8215 $29.0264
050060............................ 1.5154 1.1042 $22.9491 $26.5515 $27.3282 $25.6824
050061............................ 0.8661 1.1681 $25.3042 * $32.2172 $28.5425
050063............................ 1.3437 1.1793 $28.6093 $32.0515 $33.3039 $31.3845
050065............................ 1.7814 1.1687 $28.8369 $33.8223 $34.0280 $32.3405
050067............................ 1.2547 1.1960 $27.8867 $29.6982 $31.9597 $29.7844
050068............................ *** * $21.9031 * * $21.9031
050069............................ 1.6333 1.1687 $27.2744 $28.6752 $31.2172 $29.0770
050070............................ 1.3101 1.4974 $39.5178 $40.5645 $45.3382 $41.9509
050071............................ 1.3143 1.5463 $40.1344 $41.1036 $44.9464 $42.2000
050072............................ 1.3841 1.5463 $39.2529 $40.8108 $44.2651 $41.6223
050073............................ 1.3621 1.5463 $38.6763 $41.3430 $45.9765 $42.1975
050075............................ 1.2741 1.5463 $40.2265 $43.7101 $47.2356 $44.0053
050076............................ 2.0222 1.5463 $40.8075 $43.0845 $46.4990 $43.5903
050077............................ 1.6862 1.1406 $27.1234 $29.6264 $32.0245 $29.6181
050078............................ 1.3018 1.1793 $24.1091 $25.6814 $31.1425 $26.6955
050079............................ 1.4490 1.5463 $38.8981 $42.7385 $47.8597 $43.4884
050082............................ 1.6915 1.1769 $27.5022 $28.9139 $37.7783 $31.5037
050084............................ 1.5652 1.1884 $26.0607 $28.2664 $33.0179 $29.0525
050088............................ *** * $27.1103 $26.4093 $25.7385 $26.4472
050089............................ 1.4042 1.1687 $24.7857 $29.4884 $33.5323 $29.3416
050090............................ 1.2979 1.4740 $27.4193 $31.1774 $32.9584 $30.4520
050091............................ 1.1111 1.1793 $29.2522 $30.1534 $30.8560 $30.1209
050093............................ 1.5182 1.1042 $29.2642 $31.1083 $33.4119 $31.3614
050095............................ 1.9620 1.5463 * * * *
050096............................ 1.3470 1.1793 $23.0525 $24.2277 $24.6680 $23.9648
050097............................ *** * $24.6726 $26.6788 * $25.5991
050099............................ 1.5364 1.1687 $27.1282 $28.7711 $31.0437 $29.0188
050100............................ 1.7257 1.1406 $25.6798 $28.0303 $29.6949 $27.8627
050101............................ 1.3034 1.5194 $32.9866 $35.4655 $40.3195 $36.3932
050102............................ 1.3335 1.1296 $25.5763 $24.9381 $29.1364 $26.2832
050103............................ 1.5518 1.1793 $27.8079 $28.7375 $34.2529 $30.2688
050104............................ 1.4289 1.1793 $26.1592 $29.1240 $29.7326 $28.3301
050107............................ 1.3995 1.1681 $22.6900 $27.6002 $33.1358 $27.7768
050108............................ 1.9705 1.2949 $28.5244 $31.4271 $35.5711 $32.0693
050110............................ 1.2808 1.1681 $21.9297 $20.0769 $26.1453 $22.5312
050111............................ 1.2956 1.1793 $23.7715 $26.6345 $28.1588 $26.1803
050112............................ 1.5575 1.1793 $31.9797 $34.0258 $36.8026 $34.4310
050113............................ 1.2863 1.4974 $32.6932 $34.2851 $33.8064 $33.6092
050114............................ 1.4206 1.1793 $28.1938 $29.2858 $31.1294 $29.5973
050115............................ 1.4425 1.1406 $24.1481 $27.5207 $30.9288 $27.6106

[[Page 47513]]

050116............................ 1.5310 1.1793 $28.2924 $28.8193 $34.5110 $30.5901
050117............................ 1.2695 1.1575 $24.7555 $28.2227 $32.4414 $28.3268
050118............................ 1.1749 1.1960 $28.9358 $33.0650 $35.4044 $32.6634
050121............................ 1.3421 1.1042 $25.0858 $25.5962 $27.9537 $26.3210
050122............................ 1.5329 1.1884 $29.1534 $29.7629 $34.2416 $31.1709
050124............................ 1.2574 1.1793 $23.0843 $26.7065 $28.0288 $25.9680
050125............................ 1.3697 1.5088 $35.6573 $40.9218 $41.7020 $39.5040
050126............................ 1.4092 1.1793 $27.7126 $29.6203 $29.3360 $28.8881
050127............................ 1.3547 1.2949 $21.8719 $23.6208 $26.1222 $23.7516
050128............................ 1.5401 1.1406 $28.7668 $28.3278 $31.0662 $29.4553
050129............................ 1.7891 1.1687 $25.2780 $27.8488 $32.2680 $28.7272
050131............................ 1.3037 1.4974 $37.7845 $38.6834 $40.5321 $39.0707
050132............................ 1.4510 1.1793 $27.8805 $29.4317 $35.1544 $30.7495
050133............................ 1.5036 1.1212 $25.1948 $27.6030 $31.3530 $28.2112
050135............................ 1.0272 1.1793 * $24.9415 $24.3927 $24.6796
050136............................ 1.2278 1.4740 $31.6146 $35.2834 $37.4560 $34.8123
050137............................ 1.3314 1.1793 $35.0503 $36.5409 $38.4827 $36.7225
050138............................ 1.9543 1.1793 $43.0858 $43.8671 $46.9557 $44.6742
050139............................ 1.3297 1.1793 $33.8749 $35.1013 $37.6217 $35.5604
050140............................ 1.3938 1.1687 $36.1708 $37.5473 $39.6269 $37.8550
050144............................ 1.4278 1.1793 $30.3679 $32.4042 $33.5109 $32.1636
050145............................ 1.3157 1.4126 $37.5722 $39.5676 $42.3134 $39.8846
050146............................ 1.6530 * * * * *
050148............................ 1.1183 1.1042 $17.3908 $24.7063 $27.3005 $22.6027
050149............................ 1.4274 1.1793 $28.0500 $30.1596 $33.2270 $30.4737
050150............................ 1.1828 1.2949 $26.7728 $31.5333 $31.7560 $29.9321
050152............................ 1.4073 1.5000 $34.5694 $40.3464 $43.6487 $39.6060
050153............................ 1.5356 1.5088 $34.5870 $40.4446 $43.3190 $39.3912
050155............................ 0.9853 1.1793 $21.2068 $21.8829 $21.8550 $21.6128
050158............................ 1.2548 1.1793 $30.6598 $33.6400 $35.1326 $33.3121
050159............................ 1.3195 1.1769 $27.4051 $30.8069 $31.3199 $29.8120
050167............................ 1.3716 1.1884 $23.2022 $25.9850 $28.5179 $25.9911
050168............................ 1.6387 1.1687 $27.5313 $30.8036 $33.2506 $30.5684
050169............................ 1.4440 1.1793 $25.6896 $26.2864 $27.4644 $26.5104
050170............................ *** * $29.4075 * * $29.4075
050172............................ 1.2976 1.1042 $24.5849 $27.1497 $28.5604 $26.7638
050173............................ 1.2683 1.1687 $27.7070 $27.6097 $30.3582 $28.5541
050174............................ 1.6685 1.4740 $33.5204 $36.3117 $40.1747 $36.7717
050175............................ 1.3257 1.1793 $26.9627 $31.5615 $30.5733 $29.6977
050177............................ 1.2560 1.1769 $23.1575 $24.7531 $25.1442 $24.3743
050179............................ 1.2062 1.1960 $23.0583 $25.8072 $27.1155 $25.4092
050180............................ 1.5936 1.5463 $36.9905 $40.8101 $40.2504 $39.4196
050186............................ *** * $27.6638 * * $27.6638
050188............................ 1.3728 1.5088 $34.1503 $39.3507 $39.5110 $37.7827
050189............................ 0.9950 1.4126 $32.3513 $20.0709 $29.1280 $26.2226
050191............................ 1.4576 1.1793 $28.1689 * $34.2091 $31.2052
050192............................ 0.9922 1.1042 $19.5327 $21.2448 $27.0424 $22.7189
050193............................ 1.2105 1.1687 $24.6307 $30.7341 $29.6421 $28.4881
050194............................ 1.3143 1.5144 $28.1413 $38.6750 $40.9096 $35.6972
050195............................ 1.5288 1.5463 $42.1735 $43.9696 $48.4358 $44.9294
050196............................ 1.0813 1.1042 $20.7257 $25.2168 $32.1933 $25.8088
050197............................ 1.9485 1.4974 * $40.8832 $48.9052 $44.8389
050204............................ 1.4278 1.1793 $24.9458 $25.2512 $28.6423 $26.2829
050205............................ 1.2423 1.1793 $25.2841 $28.0504 $27.8611 $27.0700
050207............................ 1.2722 1.1042 $25.1863 $27.0216 $29.5215 $27.2272
050211............................ 1.2769 1.5463 $34.3396 $38.3319 $41.2166 $37.8840
050214............................ *** * $22.4773 $24.4785 $23.9972 $23.6229
050215............................ 1.6360 1.5088 $36.6063 $41.6886 $43.7985 $40.7257
050217............................ 1.1523 * $22.2055 $23.6286 * $22.9187
050219............................ 1.1203 1.1793 $21.8649 $22.9226 $22.4065 $22.4391
050222............................ 1.6451 1.1406 $25.2922 $26.3882 $29.1094 $27.0242
050224............................ 1.7382 1.1687 $26.2108 $26.7916 $29.3143 $27.4653
050225............................ 1.5374 1.1042 $25.0219 $29.5184 $29.9656 $28.1785
050226............................ 1.6099 1.1687 $26.0826 $29.2259 $30.5867 $28.6690
050228............................ 1.3576 1.5463 $38.6751 $40.1362 $42.4226 $40.4482
050230............................ 1.3869 1.1687 $30.0380 $34.1417 $32.9555 $32.4641
050231............................ 1.6526 1.1793 $27.8896 $30.1298 $30.9607 $29.7082

[[Page 47514]]

050232............................ 1.4450 1.1449 $25.3439 $24.4383 $27.4099 $25.6865
050234............................ 1.1731 1.1406 $24.0754 $29.2421 $29.6560 $27.4243
050235............................ 1.5444 1.1793 $27.2838 $27.8965 $29.2979 $28.1654
050236............................ 1.3994 1.1769 $27.0687 $28.1969 $32.1647 $29.0012
050238............................ 1.4564 1.1793 $26.0312 $29.1481 $31.1764 $28.8569
050239............................ 1.5849 1.1793 $27.0866 $28.2327 $31.0963 $28.8857
050240............................ 1.6565 1.1793 $32.8542 $35.2284 $35.5735 $34.6528
050242............................ 1.3410 1.5144 $34.4412 $39.7629 $44.3130 $39.6054
050243............................ 1.6534 1.1296 $28.5626 $31.8153 $31.4883 $30.6830
050245............................ 1.3548 1.1687 $25.7585 $27.0949 $28.6527 $27.2127
050248............................ 1.0461 1.4126 $29.1192 $31.6240 $35.3864 $32.0261
050251............................ 1.0047 1.1042 $24.4552 $26.5021 $27.2675 $26.0899
050253............................ *** * $23.9246 $22.2450 $24.0044 $23.3808
050254............................ 1.2205 1.2949 $23.3358 $24.1512 $27.0041 $24.9056
050256............................ 1.5793 1.1793 $26.8618 $28.4728 $29.8194 $28.4077
050257............................ 1.0004 1.1042 $17.4909 $20.8367 $21.3216 $19.7770
050261............................ 1.3301 1.1042 $21.4693 $25.3005 $27.3234 $24.7145
050262............................ 2.1454 1.1793 $33.0425 $36.1162 $44.0256 $37.8981
050264............................ 1.3258 1.5463 $37.4742 $41.3478 $41.1211 $39.9496
050267............................ *** * $26.6558 $26.7060 * $26.6806
050270............................ 1.3557 1.1406 $27.9871 $30.0540 $32.4812 $30.2697
050272............................ 1.3855 1.1687 $24.0921 $25.9103 $27.1989 $25.7666
050276............................ 1.1976 1.5463 $34.7422 $41.2251 $39.3778 $38.5361
050277............................ 1.0670 1.1793 $35.6323 $35.8246 $32.5213 $34.3014
050278............................ 1.5957 1.1793 $26.0331 $28.0351 $29.9244 $28.0988
050279............................ 1.2401 1.1687 $23.5145 $25.5299 $27.6573 $25.5685
050280............................ 1.6713 1.2195 $28.5504 $30.6723 $35.2030 $31.5494
050281............................ 1.5109 1.1793 $25.7832 $26.2623 $27.3824 $26.5030
050283............................ 1.5342 1.5463 $35.1831 $38.5600 $43.0638 $39.0754
050286............................ *** * $19.7352 $19.4973 * $19.6057
050289............................ 1.5684 1.4974 $34.9645 $38.6875 $41.1774 $38.2497
050290............................ 1.6298 1.1793 $31.9510 $32.6388 $34.5482 $33.0758
050291............................ 1.8266 1.4740 $28.3451 $29.6162 $35.3653 $31.1027
050292............................ 1.0060 1.1296 $27.6114 $27.0775 $26.8879 $27.1685
050295............................ 1.5315 1.1042 $25.4332 $31.5960 $36.1950 $30.7774
050296............................ 1.1543 1.5088 $33.5948 $34.9952 $39.0061 $36.0343
050298............................ 1.1432 1.1687 $26.1707 $25.8232 $27.7416 $26.6026
050299............................ 1.2359 1.1793 $26.9870 $27.7535 $31.5435 $28.9060
050300............................ 1.5896 1.1687 $26.3182 $28.3862 $30.7148 $28.5022
050301............................ 1.2259 1.1042 $25.7167 $28.5769 $31.9995 $28.7858
050305............................ 1.4554 1.5463 $38.7597 $40.9978 $44.8630 $41.5654
050308............................ 1.4708 1.5088 $31.6790 $38.0564 $43.0691 $37.5162
050309............................ 1.3967 1.2949 $25.5367 $28.9181 $34.4145 $29.9035
050312............................ 1.4897 1.2195 $28.2557 $32.6846 $33.9022 $31.7615
050313............................ 1.2490 1.1884 $25.3372 $27.5321 $31.8003 $28.5358
050315............................ 1.3108 1.1042 $23.6638 $26.1224 $28.5933 $26.1591
050320............................ 1.2329 1.5463 $31.4570 $36.3252 $40.2352 $36.0082
050324............................ 1.9659 1.1406 $28.4931 $30.9958 $32.9792 $30.9355
050325............................ 1.1941 1.1218 $26.6325 $30.2280 $30.6117 $29.1581
050327............................ 1.6830 1.1687 $33.0549 $29.8327 $33.0087 $31.8986
050329............................ 1.2877 1.1296 $26.6341 $26.8021 $26.2120 $26.5339
050331............................ 1.1730 1.4740 $21.5193 $20.9847 $20.2692 $20.9637
050333............................ 1.0827 1.1042 $15.6929 $15.3119 $23.4009 $17.5306
050334............................ 1.7039 1.4126 $37.2336 $38.7635 $40.7467 $38.9455
050335............................ 1.4400 1.1218 $24.9274 $27.4046 $28.9403 $27.1683
050336............................ 1.1812 1.1884 $23.2687 $25.3062 $28.5659 $25.7519
050342............................ 1.2397 1.1042 $23.0282 $24.7654 $26.8507 $24.9581
050348............................ 1.7148 1.1687 $28.9864 $33.2676 $37.7898 $33.4975
050349............................ 0.9544 1.1042 $15.6043 $16.9251 $17.4791 $16.6299
050350............................ 1.3733 1.1793 $27.2573 $29.4262 $31.1833 $29.2715
050351............................ 1.5221 1.1793 $27.4042 $29.3082 $30.8661 $29.2314
050352............................ 1.2426 1.2949 $32.6572 $24.2931 $33.9362 $30.0053
050353............................ 1.5760 1.1793 $25.4309 $26.6332 $31.8291 $27.9376
050355............................ *** * * $11.2498 * $11.2498
050357............................ 1.4534 1.1681 $25.2126 $26.7265 $32.3095 $27.5322
050359............................ 1.1458 1.1042 $22.9175 $23.6030 $25.7739 $24.1671
050360............................ 1.4790 1.4974 $35.9032 $38.8658 $37.0769 $37.3332

[[Page 47515]]

050366............................ 1.2339 1.1042 $23.4696 $25.7692 $31.1854 $26.8679
050367............................ 1.4231 1.5194 $32.6760 $34.4959 $38.7727 $35.6827
050369............................ 1.4460 1.1793 $28.0909 $27.1327 $29.5697 $28.2751
050373............................ 1.5312 1.1793 $30.7301 $32.2315 $31.9271 $31.6344
050376............................ 1.4749 1.1793 $30.3530 $30.7562 $32.9393 $31.3430
050377............................ *** * $14.3892 $20.2484 * $16.9896
050378............................ 1.0130 1.1793 $30.4937 $33.9087 $34.2417 $32.8674
050379............................ *** * $27.5151 $31.7645 $32.9575 $30.5157
050380............................ 1.5551 1.5088 $35.8014 $39.1098 $42.0782 $38.9514
050382............................ 1.4416 1.1793 $26.8950 $26.0927 $29.4323 $27.5053
050385............................ 1.3604 1.4740 * $25.5735 $34.5184 $29.9098
050390............................ 1.2081 1.1296 $25.7881 $28.7761 $26.0066 $26.7871
050391............................ 1.3574 1.1793 $20.2887 $21.3012 $18.1004 $19.7304
050392............................ 1.0336 * $21.8139 $22.7209 * $22.2790
050393............................ 1.3444 1.1793 $26.4918 $28.2369 $30.0661 $28.2139
050394............................ 1.5114 1.1769 $25.1869 $26.0074 $27.5061 $26.2967
050396............................ 1.5986 1.1681 $28.4161 $30.5470 $33.5699 $30.9065
050397............................ 0.8430 1.1042 $24.7279 $27.4716 $28.1640 $26.7356
050407............................ 1.2038 1.5000 $33.2894 $35.6035 $37.9066 $35.6609
050410............................ 0.9582 1.1042 $19.8436 $19.4995 $21.3814 $20.2094
050411............................ 1.4367 1.1793 $35.5207 $37.3817 $37.8064 $36.9551
050414............................ 1.3118 1.2949 $28.2381 $28.8561 $34.6672 $30.6054
050417............................ 1.3035 1.1042 $24.5360 $25.2930 $29.5031 $26.5285
050419............................ 1.3417 1.1897 $26.4357 $28.4471 $33.3125 $29.3954
050420............................ 1.1580 1.1793 $26.7537 $26.1838 $24.9401 $25.8686
050423............................ 0.9647 1.1296 $26.5188 $28.5944 $30.6416 $28.6936
050424............................ 1.9964 1.1406 $27.5273 $29.9133 $31.0730 $29.4697
050425............................ 1.3918 1.2949 $37.7347 $38.5317 $42.4177 $39.7789
050426............................ 1.3428 1.1687 $30.9610 $30.0077 $30.6899 $30.5313
050430............................ 0.9530 1.1042 $31.5170 $24.6684 $25.0607 $26.4412
050432............................ 1.5243 1.1793 $28.1105 $30.3547 $30.8030 $29.8170
050433............................ 0.9295 1.1042 $14.3846 $20.7565 $23.0806 $19.1896
050434............................ 1.1531 1.1042 * $25.9506 $26.1621 $26.0550
050435............................ 1.1069 1.1406 $22.6618 $32.2183 $28.0306 $27.3138
050438............................ 1.5308 1.1793 $26.5535 $26.4668 $27.2662 $26.7804
050441............................ 1.9818 1.5088 $36.6680 $38.2823 $42.9765 $39.2937
050444............................ 1.3397 1.1575 $23.5299 $27.6971 $30.5504 $27.3177
050447............................ 0.9222 1.1406 $25.7274 $21.8552 $25.2573 $24.1974
050448............................ 1.1545 1.1042 $26.6967 $25.0983 $27.9759 $26.6380
050454............................ 1.8872 1.5000 $34.4813 $36.8383 $43.5311 $38.4458
050455............................ 1.6960 1.1042 $24.1694 $24.5314 $22.7235 $23.7347
050456............................ 1.2406 1.1793 $23.7594 $22.1675 $22.5630 $22.8117
050457............................ 1.6228 1.5000 $37.4570 $40.2725 $45.5829 $41.0011
050464............................ 1.6633 1.1960 $31.4768 $37.1342 $37.3692 $35.4838
050468............................ 1.4897 1.1793 $17.8128 $29.4280 $29.5448 $24.3346
050469............................ 1.1011 1.1042 $25.7995 $27.3281 $28.9079 $27.4122
050470............................ 1.1024 1.1042 $21.6981 $18.4689 $24.6755 $21.6205
050471............................ 1.7973 1.1793 $32.3570 $34.5484 $34.5211 $33.8184
050476............................ 1.3677 1.1299 $26.0482 $30.9974 $34.6585 $30.3567
050477............................ 1.5014 1.1793 $32.1676 $34.6400 $34.6995 $33.8960
050478............................ 0.9911 1.1681 $28.3894 $30.9865 $33.3998 $30.9361
050481............................ 1.4449 1.1793 $30.3890 $31.9177 $33.7446 $32.0928
050485............................ 1.6093 1.1793 $27.1437 $28.8459 $31.4233 $29.1407
050488............................ 1.3372 1.5463 $37.2438 $40.5313 $42.9904 $40.3037
050491............................ *** * $29.2987 $30.6461 $32.1379 $30.5664
050492............................ 1.4155 1.1042 $23.7384 $27.4933 $27.1540 $26.2639
050494............................ 1.3645 1.3467 $30.8706 $35.1457 $35.9909 $33.9880
050496............................ 1.7942 1.5463 $35.7115 $38.2871 $42.2672 $38.6931
050497............................ *** * $14.4481 $15.9501 * $15.1581
050498............................ 1.2896 1.2949 $28.2196 $28.2667 $33.0298 $29.9964
050502............................ 1.7506 1.1793 $28.0102 $28.7200 $29.5615 $28.8118
050503............................ 1.4553 1.1406 $26.7924 $29.2001 $31.6418 $29.3049
050506............................ 1.7275 1.1449 $30.4731 $32.4509 $36.0164 $33.1455
050510............................ 1.2221 1.5463 $39.6005 $44.3883 $47.5510 $44.1129
050512............................ 1.3790 1.5463 $39.0767 $41.8921 $46.9233 $42.8915
050515............................ 1.3588 1.1406 $36.3131 $37.4251 $38.9978 $37.6365
050516............................ 1.4661 1.2949 $30.0985 $29.4936 $36.2772 $31.8725

[[Page 47516]]

050517............................ 1.0856 1.1687 $23.4131 $23.6034 $23.9007 $23.6377
050522............................ *** * $38.9157 * * $38.9157
050523............................ 1.2555 1.5463 $33.8053 $34.7491 $35.5452 $34.7574
050526............................ 1.2399 1.1687 $29.0004 $29.9495 $31.3744 $30.1287
050528............................ 1.1417 1.1042 $23.9177 $28.6273 $29.6838 $27.7337
050531............................ 1.1058 1.1793 $22.7311 $25.0157 $26.9420 $24.9597
050534............................ 1.2857 1.1296 $26.7941 $29.7546 $29.8603 $28.8863
050535............................ 1.3768 1.1687 $29.7904 $32.3646 $32.3723 $31.6438
050537............................ 1.3916 1.2949 $25.1291 $27.4196 $31.3844 $28.1091
050539............................ 1.2510 * $25.3328 $28.0586 $29.8242 $27.8112
050541............................ 1.6070 1.5463 $41.1980 $43.7765 $46.1121 $43.8355
050542............................ 1.1241 * $21.2846 * * $21.2846
050543............................ 0.7293 1.1687 $24.0334 $25.7161 $26.1103 $25.3298
050545............................ 0.7134 1.1793 $33.4322 $42.9451 $30.5554 $35.4562
050546............................ 0.7307 1.1042 $42.8052 $52.7180 $30.2329 $41.5266
050547............................ 0.8543 1.4740 $40.6483 $45.1842 $33.2205 $39.9154
050548............................ 0.7266 1.1687 $32.3944 $37.1314 $30.3775 $33.5849
050549............................ 1.5502 1.3467 $31.8525 $33.8288 $34.9818 $33.6342
050550............................ 1.4030 1.1687 $29.0938 $31.1918 $30.2302 $30.2108
050551............................ 1.3078 1.1687 $28.6834 $31.6782 $31.6165 $30.7425
050552............................ 1.1266 1.1793 $24.9755 $26.8274 $27.1744 $26.5471
050557............................ 1.5569 1.1960 $25.8719 $28.3111 $31.8048 $28.8575
050559............................ *** * $25.3299 $26.9662 * $26.0948
050561............................ 1.2622 1.1793 $35.9611 $37.5863 $38.8651 $37.5449
050567............................ 1.5993 1.1687 $27.8475 $30.1167 $32.9829 $30.4114
050568............................ 1.2479 1.1104 $20.8324 $22.5008 $24.4061 $22.5795
050569............................ 1.3416 1.3467 $27.7955 $30.4874 $33.0259 $30.5066
050570............................ 1.5225 1.1687 $29.9470 $32.6896 $34.0171 $32.2949
050571............................ 1.3109 1.1793 $29.1716 $32.1656 $33.6156 $31.7338
050573............................ 1.7313 1.1296 $27.2328 $30.5249 $34.1991 $30.6886
050575............................ 1.2700 1.1793 $23.1358 $23.2447 $25.2513 $23.9658
050577............................ 1.2292 1.1793 $26.4806 $28.7060 $30.8841 $28.7176
050578............................ 1.7728 1.1793 $30.4934 $31.5953 $33.8825 $31.9512
050579............................ 1.4467 1.1793 $34.9794 $40.2740 $39.4976 $38.3190
050580............................ 1.2914 1.1687 $27.2431 $29.4337 $31.6256 $29.3950
050581............................ 1.4899 1.1793 $28.9696 $32.0823 $32.1801 $31.1581
050583............................ 1.5944 1.1406 $30.0427 $33.5209 $33.3697 $32.3610
050584............................ 1.3233 1.1687 $24.5544 $24.5757 $24.8180 $24.6565
050585............................ 1.1560 1.1687 $26.0595 $27.2982 $22.7121 $24.9986
050586............................ 1.1733 1.1687 $25.7172 $25.3551 $27.4173 $26.0841
050588............................ 1.3510 1.1793 $30.5453 $32.3603 $32.8212 $31.9715
050589............................ 1.2707 1.1687 $27.9845 $30.6273 $30.9547 $29.9199
050590............................ 1.2858 1.2949 $27.0620 $31.5987 $32.2142 $30.2046
050591............................ 1.1589 1.1793 $28.6151 $28.5915 $28.8549 $28.6959
050592............................ 1.1853 1.1687 $25.9545 $32.5000 $24.4542 $27.4073
050594............................ 2.0368 1.1687 $30.8028 $34.6747 $34.7946 $33.5328
050597............................ 1.2589 1.1793 $24.5542 $25.4868 $27.5691 $25.8776
050598............................ *** * $24.6875 * * $24.6875
050599............................ 1.8974 1.2949 $27.7684 $30.8420 $38.1975 $32.3121
050601............................ 1.5294 1.1793 $32.3033 $35.0325 $34.7409 $34.0841
050603............................ 1.4068 1.1687 $25.0996 $28.6982 $30.2464 $28.0787
050604............................ 1.2727 1.5088 $42.0018 $45.4433 $49.9429 $45.9484
050608............................ 1.4179 1.1042 $20.7955 $22.1999 $23.3630 $22.1922
050609............................ 1.3791 1.1687 $37.4563 $38.4561 $41.1797 $39.1280
050613............................ 0.8939 1.4974 * * * *
050615............................ 1.3236 1.1793 $29.4323 $32.8786 $33.2909 $31.8903
050616............................ 1.3870 1.1769 $23.1748 $28.5636 $36.9017 $29.6253
050618............................ 1.0253 1.1042 $22.3481 $25.4500 $27.4539 $25.0614
050623............................ *** * $29.9553 $29.6550 $32.0627 $30.4768
050624............................ 1.2788 1.1793 $23.3492 $28.1941 $32.2907 $27.6796
050625............................ 1.7550 1.1793 $30.8013 $33.5137 $36.3631 $33.6260
050630............................ *** * $27.7051 $28.0726 $30.9410 $28.9666
050633............................ 1.2323 1.1449 $30.2883 $33.4771 $35.3734 $33.1070
050636............................ 1.3270 1.1406 $23.2573 $27.2360 $30.5156 $27.0926
050641............................ 1.2310 1.1793 $21.5030 $20.4720 $21.4612 $21.1520
050644............................ 0.9036 1.1793 $28.4054 $25.6614 $27.6547 $27.1915
050660............................ 1.4561 * * * * *

[[Page 47517]]

050662............................ 0.7908 1.5088 $40.9242 $47.5065 $32.6362 $40.4932
050663............................ 1.0382 1.1793 $22.9161 $25.1493 $25.7747 $24.4728
050667............................ 0.9090 1.3972 $31.4906 $25.9250 $26.3937 $27.9100
050668............................ 1.0144 1.5463 $55.9594 * $31.8065 $41.1707
050674............................ 1.3172 1.2949 $36.8871 $38.4454 $42.6866 $39.5960
050677............................ 1.4866 1.1793 $36.2702 $37.3389 $38.7984 $37.5511
050678............................ 1.2681 1.1687 $27.1337 $29.1159 $30.7220 $29.1295
050680............................ 1.2141 1.5194 $32.7065 $35.6614 $38.3946 $35.9028
050681............................ 1.5453 1.1793 * * * *
050682............................ 0.8883 1.1042 $23.0984 $21.7264 $21.7791 $22.0865
050684............................ 1.1340 1.1296 $23.7443 $25.2575 $26.4234 $25.2119
050686............................ 1.3399 1.1296 $37.3033 $38.5595 $40.9486 $39.0574
050688............................ 1.2165 1.5088 $36.5555 $41.3305 $41.9325 $39.9230
050689............................ 1.5667 1.5463 $37.5449 $40.3815 $42.2018 $40.1932
050690............................ 1.2618 1.4740 $41.1385 $43.9228 $47.2769 $44.3743
050693............................ 1.2877 1.1687 $32.6638 $34.8040 $35.0621 $34.2547
050694............................ 1.2058 1.1296 $25.8298 $26.7041 $28.9544 $27.1978
050695............................ 1.1260 1.1884 $27.8742 $30.1226 $35.6549 $31.4872
050696............................ 2.0831 1.1793 $29.9410 $36.9314 $35.9220 $34.4812
050697............................ 1.0591 1.2195 $18.6962 $19.2603 $25.1984 $20.8006
050699............................ *** * $26.0909 $25.6818 $26.8210 $26.1958
050701............................ 1.2963 1.1296 $28.4650 $29.6896 $29.6253 $29.3536
050704............................ 1.0586 1.1793 $24.6072 $24.6609 $25.3488 $24.8998
050707............................ 1.3365 1.4974 $27.7366 $32.4877 $34.0550 $31.4563
050708............................ 1.6893 1.1042 $22.1606 $21.2163 $22.5034 $21.9751
050709............................ 1.2235 1.1687 $22.7897 $21.9079 $25.6119 $23.3937
050710............................ 1.3958 1.1042 $33.7204 $34.8311 $39.9858 $36.4647
050713............................ 1.1982 1.1793 $19.0071 $20.7448 $20.2803 $19.9969
050714............................ 1.3705 1.5144 $30.3263 $32.4491 $33.6676 $32.2064
050717............................ 1.0677 1.1793 $33.0719 $34.5519 $38.0796 $35.2375
050718............................ 1.0244 1.1296 $21.7835 $15.4037 $21.4996 $18.9377
050719............................ *** * $22.0998 * * $22.0998
050720............................ 0.9271 1.1687 $26.1941 $24.8117 $30.0812 $27.1452
050722............................ 0.9675 1.1406 * * * *
050723............................ 1.2891 1.1793 $33.0797 $34.9814 $35.0119 $34.4384
050724............................ 2.1500 1.1042 $23.7567 * $34.4267 $28.5323
050725............................ 1.0001 1.1793 $20.6592 $22.0946 $21.7816 $21.6358
050726............................ 1.6871 1.1960 $25.8742 $27.0928 $27.8433 $27.0367
050727............................ 1.3105 1.1793 * $23.7179 $24.3026 $24.0102
050728............................ 1.3521 1.4740 * $31.4768 $36.0820 $33.6891
050729............................ 1.4726 1.1793 * * $34.2580 $34.2580
050730............................ 1.2831 1.1793 * * $51.5425 $51.5425
050731............................ 1.7945 1.1194 * * * *
050732............................ 2.6180 1.1042 * * * *
050733............................ 1.4289 1.2195 * * * *
050734............................ 1.5908 1.1793 * * * *
060001............................ 1.5846 1.0507 $23.1548 $24.9410 $26.8470 $25.0779
060003............................ 1.4167 1.0507 $23.0807 $24.7856 $24.2224 $24.0730
060004............................ 1.2436 1.0699 $25.0037 $28.0656 $29.9649 $27.8289
060006............................ 1.3607 0.9369 $21.8609 $22.7493 $24.5704 $23.0964
060007............................ 1.0268 * $21.4244 $21.4792 * $21.4535
060008............................ 1.1218 0.9369 $19.8803 $21.8037 $23.3859 $21.7601
060009............................ 1.4811 1.0699 $24.7920 $27.0511 $28.7645 $26.9116
060010............................ 1.7203 1.0136 $25.8475 $27.2290 $28.9850 $27.4402
060011............................ 1.4799 1.0699 $25.8919 $26.1958 $27.2833 $26.4630
060012............................ 1.5002 0.9369 $22.6374 $24.1557 $26.2469 $24.3434
060013............................ 1.3908 0.9369 $23.3954 $24.9708 $24.5994 $24.0758
060014............................ 1.7944 1.0699 $27.0326 $29.6744 $31.2588 $29.2315
060015............................ 1.7610 1.0699 $27.6338 $30.1158 $30.4533 $29.4109
060016............................ 1.1757 0.9369 $22.9300 $23.9655 $25.6527 $24.2479
060018............................ 1.2207 0.9369 $21.0581 $23.6620 $25.7628 $23.4747
060020............................ 1.6221 0.9369 $20.9025 $22.2052 $22.6748 $21.9753
060022............................ 1.6261 0.9447 $24.7928 $25.7832 $26.5238 $25.7483
060023............................ 1.6527 0.9581 $24.3749 $26.7285 $27.7644 $26.3625
060024............................ 1.7646 1.0699 $25.2409 $28.7231 $29.0130 $27.7028
060027............................ 1.5906 1.0507 $25.1480 $26.6348 $28.0909 $26.7085
060028............................ 1.4101 1.0699 $27.1303 $27.9686 $30.0448 $28.4352

[[Page 47518]]

060029............................ *** * $19.7379 * * $19.7379
060030............................ 1.3890 1.0136 $22.8309 $26.0011 $26.6251 $25.3046
060031............................ 1.5600 0.9447 $23.8781 $25.6207 $26.3650 $25.3306
060032............................ 1.5456 1.0699 $27.1783 $28.2234 $30.4247 $28.6396
060033............................ 0.9940 * $16.7266 * * $16.7266
060034............................ 1.6440 1.0699 $26.1602 $28.4604 $29.8445 $28.2231
060036............................ 1.1229 0.9369 $19.4144 $20.4635 $20.7131 $20.1878
060041............................ 0.9282 0.9369 $20.8746 $22.7123 $23.4978 $22.3670
060043............................ 0.9500 0.9369 $19.1085 $20.0939 $18.7896 $19.3418
060044............................ 1.1611 1.0507 $25.6112 $25.2471 $25.0360 $25.3737
060049............................ 1.2730 1.0136 $25.3425 $26.8089 $29.0598 $27.1748
060050............................ 1.1992 * $20.4386 $21.9108 * $21.1679
060054............................ 1.4317 0.9581 $21.1281 $23.5803 $22.3490 $22.3633
060057............................ 1.0678 * $24.3982 $26.9891 * $25.7472
060064............................ 1.4920 1.0699 $29.1806 $30.0963 $31.3105 $30.2470
060065............................ 1.3196 1.0699 $29.2377 $28.5282 $31.1987 $29.6323
060070............................ *** * $22.6894 * * $22.6894
060071............................ 1.1349 0.9369 $20.1385 $20.2706 $25.7248 $22.1931
060075............................ 1.2191 1.1697 $27.7835 $30.7835 $32.7563 $30.4907
060076............................ 1.2865 0.9369 $23.6266 $25.5406 $26.8236 $25.4496
060096............................ 1.4740 1.0507 $26.4167 $27.4085 $30.0602 $27.9908
060100............................ 1.7163 1.0699 $28.0561 $29.7690 $32.1537 $30.0220
060103............................ 1.1819 1.0507 $26.6863 $28.8063 $30.3002 $28.6961
060104............................ 1.3833 1.0699 $26.7683 $30.8625 $32.0889 $29.9703
060107............................ 1.3856 1.0699 * $26.8267 $26.1883 $26.4984
060108............................ *** * $19.0011 * * $19.0011
060110............................ *** * $29.8561 * * $29.8561
060111............................ *** * * $31.2571 * $31.2571
060112............................ 1.5129 1.0699 * * * *
060113............................ 1.2985 1.0699 * * * *
060114............................ 1.1972 1.0699 * * * *
070001............................ 1.6462 1.2739 $29.9592 $32.2718 $34.0302 $32.0467
070002............................ 1.8219 1.1726 $28.1101 $29.0663 $31.1530 $29.4722
070003............................ 1.0941 1.1726 $29.8684 $31.3716 $32.4197 $31.2543
070004............................ 1.1910 1.1726 $25.7207 $27.3004 $29.2544 $27.3780
070005............................ 1.3868 1.2739 $29.8173 $29.3265 $32.1668 $30.4848
070006 \2\........................ 1.3201 1.3194 $33.3814 $33.9310 $36.8469 $34.7695
070007............................ 1.2960 1.1726 $29.0336 $30.3648 $31.7125 $30.4064
070008............................ 1.2616 1.1726 $24.3907 $24.9176 $26.4806 $25.2986
070009............................ 1.2064 1.1726 $25.6072 $28.8649 $30.2706 $28.2076
070010............................ 1.8394 1.3194 $30.4192 $33.1535 $32.5798 $32.0648
070011............................ 1.3775 1.1726 $24.9457 $27.5391 $29.9105 $27.3901
070012............................ 1.1898 1.1726 $34.9099 $40.3337 $44.1424 $39.6372
070015............................ 1.4436 1.3194 $30.0614 $30.9728 $33.4595 $31.5141
070016............................ 1.3613 1.2739 $29.7505 $29.6662 $31.0903 $30.2000
070017............................ 1.3930 1.2739 $29.2978 $30.3951 $31.7223 $30.4949
070018 \2\........................ 1.3416 1.3194 $33.8654 $35.7189 $37.6081 $35.8796
070019............................ 1.2639 1.2739 $27.9838 $29.6290 $31.8148 $29.8448
070020............................ 1.3495 1.1799 $28.4084 $29.9507 $31.0935 $29.8423
070021............................ 1.2785 1.1726 $30.3254 $31.4397 $33.2357 $31.7179
070022............................ 1.7912 1.2739 $29.7376 $32.3625 $35.4120 $32.5068
070024............................ 1.3856 1.1726 $28.3460 $31.0243 $32.0430 $30.5001
070025............................ 1.8602 1.1726 $28.3017 $29.2540 $30.9938 $29.5451
070027............................ 1.3063 1.1726 $36.9700 $27.3487 $31.8018 $31.4568
070028............................ 1.6215 1.3194 $28.2078 $29.5653 $31.5036 $29.7843
070029............................ 1.2918 1.1726 $25.8107 $26.3871 $27.7213 $26.6692
070031............................ 1.2501 1.2739 $25.5880 $27.2359 $28.9190 $27.3126
070033............................ 1.2736 1.3194 $34.3904 $35.5355 $37.1929 $35.7524
070034 \2\........................ 1.3886 1.3194 $32.8074 $35.6831 $36.3899 $34.9826
070035............................ 1.3067 1.1726 $26.1693 $27.1816 $27.5585 $26.9760
070036............................ 1.6645 1.2913 $35.0701 $34.0555 $36.1610 $35.1155
070038............................ 1.1829 1.1910 * $31.1133 $25.7516 $26.9407
070039............................ 0.9507 1.2739 $32.6059 $35.0164 $31.2269 $32.9340
080001............................ 1.6806 1.0579 $28.0859 $30.2463 $30.0242 $29.4815
080002............................ *** * $23.7309 $26.4192 $27.7932 $25.9827
080003............................ 1.5960 1.0579 $24.8199 $27.1131 $29.2266 $26.9651
080004............................ 1.3844 1.0325 $24.2251 $26.0092 $27.4921 $25.9420

[[Page 47519]]

080006............................ 1.2825 0.9579 $23.6838 $24.4204 $25.6160 $24.5955
080007............................ 1.4048 1.0279 $23.4964 $24.6485 $27.0074 $25.0565
090001............................ 1.7144 1.0928 $29.5432 $31.3552 $35.0413 $32.0128
090002............................ *** * $23.5158 $29.6780 * $25.5760
090003............................ 1.2860 1.0928 $22.7014 $27.0514 $29.2660 $26.1789
090004............................ 1.9621 1.0928 $28.7417 $29.9785 $32.2021 $30.4513
090005............................ 1.3773 1.0928 $28.6142 $30.2504 $30.7728 $29.9417
090006............................ 1.4103 1.0928 $23.7241 $25.9086 $29.5590 $26.3083
090007............................ *** * $25.8430 $30.1419 * $27.7359
090008............................ 1.4931 1.0928 $19.3212 $29.6744 $29.1059 $25.7761
090011............................ 2.0232 1.0928 $31.7710 $32.4412 $34.0693 $32.7262
100001............................ 1.6183 0.9294 $22.6150 $25.2381 $24.4060 $24.0790
100002............................ 1.3562 1.0051 $22.5982 $22.1269 $25.3389 $23.3729
100004............................ 0.9452 0.8584 $15.6306 $16.2637 $16.5974 $16.2012
100006............................ 1.6269 0.9450 $23.3745 $26.2372 $26.3789 $25.3884
100007............................ 1.6462 0.9450 $24.3305 $25.4333 $26.5378 $25.5049
100008............................ 1.6518 0.9747 $22.7706 $25.7377 $27.4314 $25.4374
100009............................ 1.4445 0.9747 $24.7811 $24.4666 $25.9381 $25.0983
100010............................ *** * $25.5614 $26.9486 * $26.2759
100012............................ 1.6553 0.9323 $24.2602 $24.5762 $26.3788 $25.1063
100014............................ 1.3001 0.9416 $21.7566 $22.3054 $24.5862 $22.8508
100015............................ 1.3184 0.9328 $22.1272 $22.5781 $24.6038 $23.0946
100017............................ 1.5242 0.9416 $21.1905 $22.9545 $26.1580 $23.5300
100018............................ 1.6293 1.0114 $24.1885 $27.8582 $28.1481 $26.7680
100019............................ 1.6455 0.9830 $24.2888 $25.5566 $27.6179 $25.9118
100020............................ 1.3148 0.9747 $23.5303 $23.6106 $23.9414 $23.7036
100022............................ 1.7585 1.0497 $27.9072 $29.0519 $29.9345 $29.0212
100023............................ 1.4527 0.9450 $21.8111 $21.4015 $23.0074 $22.0889
100024............................ 1.2489 0.9747 $24.4070 $27.6476 $30.2395 $27.3189
100025............................ 1.6924 0.8584 $21.2568 $21.1174 $22.1580 $21.5429
100026............................ 1.6201 0.8584 $20.1602 $21.3533 $21.4703 $20.9953
100027............................ 1.1975 0.8584 $23.8982 $12.0314 $16.1223 $16.3797
100028............................ 1.3007 0.9830 $21.8879 $23.7818 $26.8661 $24.1693
100029............................ 1.1782 0.9747 $24.6814 $26.9307 $27.5844 $26.4439
100030............................ 1.2924 0.9450 $21.8567 $22.4887 $24.0943 $22.9211
100032............................ 1.7231 0.9328 $21.6415 $23.0174 $25.2450 $23.3565
100034............................ 1.8273 0.9747 $23.1111 $24.4064 $25.9415 $24.5360
100035............................ 1.5876 0.9634 $22.6349 $25.3590 $26.9407 $24.9239
100038............................ 1.8898 1.0497 $25.7948 $27.4422 $29.8583 $27.7714
100039............................ 1.4212 1.0497 $23.8060 $26.6016 $28.4627 $26.3398
100040............................ 1.6882 0.9294 $22.4679 $23.5372 $23.6443 $23.2382
100043............................ 1.2798 0.9328 $21.7738 $22.8963 $25.2273 $23.3549
100044............................ 1.4261 1.0151 $23.9952 $26.3208 $28.3596 $26.2570
100045............................ 1.3178 0.9450 $25.2285 $23.0520 $26.9641 $25.0756
100046............................ 1.2409 0.9328 $24.2746 $26.6169 $26.3673 $25.8723
100047............................ 1.7017 0.9286 $24.3522 $24.4212 $25.0404 $24.6186
100048............................ 0.9446 0.8584 $17.5533 $18.3767 $18.8771 $18.2575
100049............................ 1.2006 0.8925 $21.8679 $22.9532 $22.9810 $22.6230
100050............................ 1.1817 0.9747 $20.0405 $20.6893 $19.8713 $20.2035
100051............................ 1.3167 0.9450 $20.0231 $22.3311 $23.1940 $22.0077
100052............................ 1.3612 0.8925 $20.5916 $20.9078 $22.3920 $21.3174
100053............................ 1.2414 0.9747 $23.7837 $27.3383 $27.3224 $26.2170
100054............................ 1.2242 0.8868 $22.0352 $25.7279 $28.0512 $25.3241
100055............................ 1.3567 0.9328 $19.6350 $22.1051 $23.5332 $21.7040
100056............................ *** * $25.9245 $25.7945 * $25.8574
100057............................ 1.4902 0.9450 $24.6417 $22.6038 $25.3897 $24.1823
100061............................ 1.5568 0.9747 $26.1273 $26.7673 $29.2565 $27.4077
100062............................ 1.7188 0.9006 $24.9807 $24.1413 $25.2340 $24.7789
100063............................ 1.2226 0.9328 $21.5620 $21.5566 $24.7026 $22.5862
100067............................ 1.4372 0.9328 $23.8892 $23.9333 $26.1213 $24.6500
100068............................ 1.7322 0.9416 $23.7840 $24.9025 $25.9202 $25.2289
100069............................ 1.3222 0.9328 $19.6037 $22.4386 $24.7442 $22.2985
100070............................ 1.6777 0.9634 $23.5524 $23.7746 $24.8883 $24.0603
100071............................ 1.2323 0.9328 $21.7675 $23.4176 $24.9682 $23.4234
100072............................ 1.3707 0.9416 $23.5362 $24.2934 $26.0459 $24.7023
100073............................ 1.6999 1.0497 $23.5843 $25.3685 $30.3358 $26.4443
100075............................ 1.4873 0.9328 $22.3890 $23.3503 $25.1691 $23.6907

[[Page 47520]]

100076............................ 1.2488 0.9747 $19.6444 $21.0777 $21.9483 $20.8673
100077............................ 1.4270 0.9286 $22.3755 $24.3478 $26.0347 $24.2410
100079............................ 1.6927 * * * * *
100080............................ 1.7700 1.0051 $22.8704 $26.3596 $27.0126 $25.4415
100081............................ 1.0416 0.8584 $16.8087 $16.9168 $15.6662 $16.4022
100084............................ 1.8066 0.9450 $24.1122 $25.4140 $26.3393 $25.2629
100086............................ 1.2304 1.0497 $25.2375 $26.4817 $28.2641 $26.6950
100087............................ 1.8903 0.9634 $26.5915 $25.9909 $27.1531 $26.5891
100088............................ 1.6794 0.9294 $23.6270 $24.8729 $25.9182 $24.8465
100090............................ 1.4786 0.9294 $22.5894 $24.0501 $24.2422 $23.6608
100092............................ 1.5155 0.9830 $25.4630 $26.0856 $28.4789 $26.7319
100093............................ 1.7097 0.8584 $20.2949 $21.1547 $21.3524 $20.9431
100098............................ 1.1058 * $20.0639 $21.2505 * $20.6613
100099............................ 1.0234 0.8925 $18.5287 $20.4328 $21.3036 $20.1035
100102............................ 1.0598 0.8709 $21.6772 $22.8850 $23.8596 $22.8413
100103............................ 0.9719 * $20.3633 $21.7494 * $21.0705
100105............................ 1.3731 0.9448 $24.5464 $24.9503 $26.8091 $25.4381
100106............................ 0.9559 0.8584 $20.3417 $20.2882 $24.0389 $21.6406
100107............................ 1.1536 0.9323 $23.3789 $24.4484 $26.1337 $24.6951
100108............................ 0.7740 0.8584 $14.8039 $16.3757 $22.0750 $17.7359
100109............................ 1.2577 0.9450 $23.0779 $23.8836 $24.9951 $24.0208
100110............................ 1.5362 0.9450 $24.4533 $28.3699 $29.1494 $27.5406
100113............................ 1.9395 0.9375 $24.3614 $25.0067 $26.3806 $25.2830
100114............................ 1.3730 0.9747 $25.3699 $27.7413 $29.2195 $27.4364
100117............................ 1.2013 0.9294 $23.9134 $26.0451 $26.4536 $25.5634
100118............................ 1.3382 0.9294 $24.1104 $23.6669 $28.0569 $25.5448
100121............................ 1.0774 0.8925 $23.1100 $24.0937 $24.8579 $24.0497
100122............................ 1.2284 0.8868 $24.1820 $21.2597 $23.4751 $22.8811
100124............................ 1.1728 0.8584 $24.3048 $21.6483 $22.7023 $22.7933
100125............................ 1.1907 0.9747 $22.4185 $25.3532 $26.7452 $24.9756
100126............................ 1.4150 0.9328 $21.7977 $23.2996 $24.4515 $23.2342
100127............................ 1.6611 0.9328 $21.0153 $21.3223 $24.4485 $22.2652
100128............................ 2.1526 0.9328 $24.4104 $25.6763 $29.4979 $26.6451
100130............................ 1.2025 1.0051 $20.2478 $22.8324 $24.2046 $22.4252
100131............................ 1.2751 0.9747 $25.4811 $25.8316 $29.2462 $26.9103
100132............................ 1.2231 0.9328 $21.1538 $23.0428 $24.3293 $22.8670
100134............................ 0.9566 0.8584 $18.3391 $19.5337 $20.9244 $19.6271
100135............................ 1.6045 0.8703 $20.4915 $22.3071 $24.0024 $22.2526
100137............................ 1.1709 0.8925 $20.4007 $23.3692 $25.1974 $23.1447
100139............................ 0.8583 0.9375 $18.2204 $14.5046 $17.5489 $16.8211
100140............................ 1.1864 0.9294 $22.5124 $24.8165 $26.4720 $24.7189
100142............................ 1.2277 0.8584 $20.0689 $20.7219 $22.9577 $21.2432
100147............................ *** * $17.1045 * * $17.1045
100150............................ 1.4017 0.9747 $22.9194 $25.7122 $26.1990 $24.9706
100151............................ 1.7883 0.9294 $26.6470 $26.1848 $28.1322 $27.0891
100154............................ 1.5421 0.9747 $23.0820 $26.3703 $27.6127 $25.8181
100156............................ 1.1045 0.8709 $20.6928 $22.2757 $26.7092 $23.2451
100157............................ 1.5973 0.9328 $23.1045 $25.9133 $27.3851 $25.4671
100160............................ 1.1995 0.8584 $23.4877 $27.2019 $26.9851 $25.9544
100161............................ 1.5798 0.9450 $24.6268 $28.3607 $28.8077 $27.4143
100162............................ *** * $23.8001 * * $23.8001
100166............................ 1.4927 0.9634 $23.7419 $24.4251 $27.9618 $25.2885
100167............................ 1.3172 1.0497 $26.4517 $26.8584 $30.3694 $27.8827
100168............................ 1.3915 1.0051 $24.6276 $26.0864 $27.1292 $25.9577
100169............................ *** * $23.4575 * * $23.4575
100172............................ 1.2906 0.9747 $17.6051 $18.4651 $18.2735 $18.1344
100173............................ 1.7474 0.9328 $19.7190 $22.4866 $24.8721 $22.4023
100175............................ 1.0032 0.8815 $21.0474 $22.0666 $23.5455 $22.2224
100176............................ 1.9043 1.0151 $26.8740 $29.8326 $31.2694 $29.3692
100177............................ 1.3333 0.9830 $24.5078 $25.3973 $26.6781 $25.6089
100179............................ 1.7758 0.9294 $24.1801 $26.6537 $29.5619 $26.9037
100180............................ 1.3821 0.9328 $24.9433 $26.3299 $27.1804 $26.1924
100181............................ 1.1077 0.9747 $18.1320 $19.5022 $21.8540 $19.8108
100183............................ 1.1819 0.9747 $24.4575 $26.7893 $27.4951 $26.3276
100187............................ 1.2915 0.9747 $23.4760 $26.1394 $27.3653 $25.7401
100189............................ 1.3226 1.0497 $26.6846 $26.5763 $28.4136 $27.3048
100191............................ 1.3178 0.9328 $24.1911 $24.3553 $26.6340 $25.0785

[[Page 47521]]

100200............................ 1.3861 1.0497 $24.8120 $28.0926 $29.8963 $27.6635
100204............................ 1.5308 0.9375 $22.2613 $24.4697 $25.7537 $24.2423
100206............................ 1.3026 0.9328 $22.8782 $23.0340 $25.2196 $23.7228
100208............................ *** * $24.1482 $24.9854 * $24.5807
100209............................ 1.3649 0.9747 $23.8502 $25.0778 $26.6246 $25.2683
100210............................ 1.5495 1.0497 $26.0933 $28.6449 $28.9486 $27.9114
100211............................ 1.1990 0.9328 $24.3243 * $24.7095 $24.5352
100212............................ 1.4656 0.9006 $22.6584 $24.2669 $24.7566 $23.9351
100213............................ 1.6219 0.9634 $24.4467 $25.1893 $27.1936 $25.6138
100217............................ 1.1882 1.0151 $24.0291 $25.2635 $25.2907 $24.8791
100220............................ 1.6567 0.9323 $24.9733 $25.0154 $26.0905 $25.3692
100223............................ 1.5971 0.8868 $21.2434 $23.4556 $24.7015 $23.2004
100224............................ 1.2332 1.0497 $23.0804 $23.3593 $24.8077 $23.7932
100225............................ 1.2993 1.0497 $23.9971 $27.9473 $28.4316 $26.8326
100226............................ 1.2785 0.9294 $23.8701 $27.8003 $29.3317 $27.1288
100228............................ 1.3238 1.0497 $26.2593 $27.2873 $29.8952 $28.0013
100229............................ *** * $21.0038 * * $21.0038
100230............................ 1.3172 1.0497 $25.0518 $26.3690 $28.1703 $26.6050
100231............................ 1.6896 0.8584 $23.5418 $24.6994 $25.5175 $24.6455
100232 \h\........................ 1.2414 0.9722 $21.8105 $23.9405 $24.9322 $23.5285
100234............................ 1.3194 1.0051 $24.9141 $25.2574 $26.3601 $25.5144
100236............................ 1.3721 0.9286 $23.9781 $25.9282 $26.6585 $25.5663
100237............................ 1.9760 1.0497 $26.7664 $25.6112 $31.3543 $27.7849
100238............................ 1.5274 0.9328 $24.6513 $27.1748 $28.4302 $26.8154
100239............................ 1.2798 0.9634 $25.0509 $26.9668 $27.7592 $26.6605
100240............................ 0.8844 0.9747 $23.0650 $23.4830 $25.3265 $24.0024
100242............................ 1.3721 0.8584 $20.4681 $21.5130 $24.0990 $22.0856
100243............................ 1.5526 0.9328 $23.2812 $25.2987 $26.1131 $24.9766
100244............................ 1.3600 0.9323 $23.4876 $24.1515 $25.2584 $24.3502
100246............................ 1.6200 1.0151 $26.7630 $27.6382 $28.9894 $27.8151
100248............................ 1.5168 0.9328 $23.8742 $25.9170 $27.7797 $25.9263
100249............................ 1.2673 0.8946 $21.3942 $23.4021 $23.2084 $22.6697
100252............................ 1.2047 1.0151 $22.6475 $24.9860 $25.8540 $24.5257
100253............................ 1.3828 1.0051 $23.6939 $24.4051 $25.7121 $24.6472
100254............................ 1.5903 0.8703 $23.2794 $25.0192 $25.7338 $24.6995
100255............................ 1.2022 0.9328 $22.9793 $22.2341 $24.4808 $23.2508
100256............................ 2.0016 0.9328 $24.1969 $26.0629 $28.8856 $26.4333
100258............................ 1.4996 1.0051 $24.5699 $31.8772 $31.2482 $29.0443
100259............................ 1.2301 0.9328 $24.1148 $24.9404 $26.0175 $25.0705
100260............................ 1.3611 1.0151 $23.5164 $25.2630 $27.5188 $25.5518
100262............................ *** * $23.8006 $26.3954 * $25.1412
100264............................ 1.2614 0.9328 $22.4800 $25.0250 $25.5489 $24.4115
100265............................ 1.2982 0.9328 $21.0688 $23.4758 $24.1454 $23.0219
100266............................ 1.4044 0.8584 $21.5258 $22.6614 $23.2340 $22.5196
100267............................ 1.2892 0.9634 $23.3760 $26.5059 $27.3768 $25.7444
100268............................ 1.1552 1.0051 $26.0297 $29.8289 $29.2898 $28.4053
100269............................ 1.3013 1.0051 $24.9002 $25.3228 $26.7450 $25.7303
100271............................ 2.2234 * * * * *
100275............................ 1.2960 1.0051 $23.1419 $24.3059 $26.0361 $24.5544
100276............................ 1.2393 1.0497 $25.4557 $27.2589 $30.0576 $27.6322
100277............................ 1.3788 0.9747 $25.2985 $47.3905 $16.5427 $24.0477
100279............................ 1.2480 0.9323 $24.8484 $25.4909 $26.8606 $25.7747
100281............................ 1.2803 1.0497 $25.3382 $27.0864 $28.6660 $27.1929
100284............................ 1.0961 0.9747 $22.3046 $22.5927 $23.8170 $22.9628
100286............................ 1.5763 1.0114 * $27.1051 $29.4284 $28.3288
100287............................ 1.3767 1.0051 * $28.2229 $28.3427 $28.2858
100288............................ 1.5086 1.0051 * $37.4785 $33.8141 $35.4781
100289............................ 1.8008 1.0497 * $28.4504 $29.2915 $28.8970
100290............................ 1.1344 0.9166 * * $23.5080 $23.5080
100291............................ 1.2572 0.9830 * * * *
100292............................ 1.2330 0.8584 * * * *
100294............................ 2.6620 0.9450 * * * *
100295............................ 2.0078 0.9747 * * * *
100296............................ 1.3342 0.9747 * * * *
100297............................ 1.9333 0.8584 * * * *
100298............................ 0.6963 0.8703 * * * *
100299............................ 1.3082 0.9634 * * * *

[[Page 47522]]

110001............................ 1.2397 0.9782 $24.0561 $25.1164 $25.3102 $24.8284
110002............................ 1.2464 0.9782 $20.4502 $21.8616 $25.3897 $22.5380
110003............................ 1.3086 0.9294 $19.7061 $20.0968 $21.4002 $20.4029
110004............................ 1.2230 0.9089 $21.8791 $22.7929 $23.9911 $22.8563
110005............................ 1.1638 0.9782 $23.6146 $22.3645 $22.9000 $22.9401
110006............................ 1.4890 0.9826 $23.8762 $25.0719 $28.6090 $25.8225
110007............................ 1.6071 0.8634 $28.2025 $30.7430 $23.8729 $27.0966
110008............................ 1.3988 0.9782 $22.6308 $23.4662 $27.1711 $24.4777
110010............................ 2.1369 0.9782 $27.2029 $28.7690 $29.7142 $28.5850
110011............................ 1.1924 0.9782 $23.2149 $25.4620 $26.0899 $24.9213
110015............................ 1.1494 0.9782 $23.2280 $25.5661 $26.6610 $25.2080
110016............................ 1.1984 0.7679 $18.8228 $18.8376 $21.7610 $19.7802
110018............................ 1.1923 0.9782 $24.7007 $25.6485 $28.2431 $26.2640
110020............................ 1.2822 0.9782 $23.3004 $24.8735 $26.8501 $25.0177
110023............................ 1.3719 0.9782 $23.5673 $25.3746 $27.3029 $25.5307
110024............................ 1.3944 0.9464 $22.1471 $23.8091 $25.7205 $23.8901
110025............................ 1.4489 0.9294 $29.0965 $31.5253 $26.1311 $28.6493
110026............................ 1.1044 0.7679 $19.3201 $20.5740 $21.2826 $20.4005
110027............................ 1.0675 0.8066 $19.8351 $19.2323 $20.2175 $19.7328
110028............................ 1.7446 0.9751 $25.9474 $25.1836 $28.1619 $26.4128
110029............................ 1.6684 0.9782 $22.7981 $25.2335 $24.8893 $24.3542
110030............................ 1.2123 0.9782 $22.2341 $25.0842 $26.4770 $24.7162
110031............................ 1.2695 0.9782 $22.8695 $24.1711 $24.7874 $23.9912
110032............................ 1.1708 0.7679 $18.0744 $20.7211 $21.9407 $20.2437
110033............................ 1.4050 0.9782 $24.1447 $25.2326 $28.3210 $25.8930
110034............................ 1.7124 0.9751 $24.0791 $24.4141 $26.9986 $25.1766
110035............................ 1.5056 0.9782 $24.2581 $25.7562 $27.4583 $25.9197
110036............................ 1.8079 0.9464 $24.4788 $25.4854 $26.8789 $25.6507
110038............................ 1.5737 0.8385 $20.1710 $20.5880 $21.2138 $20.6802
110039............................ 1.4151 0.9751 $17.0608 $19.4032 $24.7248 $20.0879
110040............................ 1.1196 0.9782 $17.3095 $18.8744 $19.7509 $18.6568
110041............................ 1.2605 0.9694 $20.8080 $21.5402 $23.4074 $21.9417
110042............................ 1.1045 0.9782 $25.5588 $26.8321 $28.6873 $27.1121
110043............................ 1.7587 0.9464 $22.7589 $25.2788 $26.6323 $24.8956
110044............................ 1.1685 0.7679 $19.2562 $19.6940 $20.9654 $19.9819
110045............................ 1.1544 0.9782 $19.7746 $21.3922 $24.9821 $22.1119
110046............................ 1.1621 0.9782 $21.6201 $24.0022 $23.8292 $23.2190
110049............................ 0.9856 * $18.9096 $19.8706 * $19.4074
110050............................ 1.1084 0.9067 * $25.6020 $26.1320 $25.8647
110051............................ 1.1338 0.7679 $17.6816 $19.0995 $19.4276 $18.7634
110054............................ 1.4998 0.9782 $20.5387 $22.2250 $25.7085 $22.7254
110056............................ 0.9527 * $21.7608 $23.0080 * $22.3710
110059............................ 1.0870 0.7679 $19.9802 $18.7097 $20.5565 $19.6943
110061............................ *** * $18.6696 * * $18.6696
110063............................ 1.1145 * $19.4401 $20.3760 * $19.9198
110064............................ 1.5138 0.8562 $21.7636 $23.8739 $24.2739 $23.3486
110069............................ 1.2779 0.9078 $21.0518 $22.3006 $24.1669 $22.5324
110071............................ 0.9789 0.7679 $15.2336 $13.3731 $18.0224 $15.4555
110073............................ 1.0915 0.7679 $15.2711 $16.3610 $18.6336 $16.6863
110074............................ 1.5001 0.9826 $24.4094 $27.5836 $27.1207 $26.3724
110075............................ 1.2651 0.9300 $20.4634 $20.9973 $22.0935 $21.2149
110076............................ 1.4712 0.9782 $23.8211 $25.2424 $26.3506 $25.1774
110078............................ 2.0531 0.9782 $28.2149 $27.8627 $29.5779 $28.5704
110079............................ 1.4257 0.9782 $22.8017 $24.5255 $23.1024 $23.4646
110080............................ 1.2797 0.9782 $24.1958 $21.5482 $22.3213 $22.5788
110082............................ 1.9279 0.9782 $27.2931 $28.9731 $29.8366 $28.7072
110083............................ 1.9347 0.9782 $24.6460 $26.2604 $27.8245 $26.3029
110086............................ 1.4411 0.7679 $18.8751 $20.8557 $21.1509 $20.2673
110087............................ 1.4167 0.9782 $25.7908 $26.2872 $28.0471 $26.7332
110089............................ 1.1500 0.7679 $20.6757 $21.2013 $21.9509 $21.2887
110091............................ 1.2959 0.9782 $24.3354 $26.3857 $26.5523 $25.8218
110092............................ 1.0183 0.7679 $16.9116 $18.7397 $18.5527 $18.0853
110095............................ 1.4222 0.8701 $20.1024 $21.8709 $23.4846 $21.8636
110096............................ 0.9833 * $18.5513 $19.4498 * $19.0000
110100............................ 0.9748 0.7679 $15.1316 $16.5833 $16.5600 $16.0845
110101............................ 1.0811 0.7679 $13.3943 $14.4630 $16.4270 $14.7428
110104............................ 1.0702 0.7679 $17.9805 $19.5575 $18.7951 $18.8040

[[Page 47523]]

110105............................ 1.3296 0.7679 $19.2156 $20.6270 $21.1077 $20.3365
110107............................ 1.8825 0.9475 $21.8167 $26.0763 $26.2526 $24.6977
110109............................ 1.0145 0.7679 $18.7397 $20.4726 $21.4280 $20.2690
110111............................ 1.1472 0.9751 $20.9535 $20.5577 $29.2190 $22.9282
110112............................ 0.9453 0.7679 $20.4565 $21.0612 $24.2463 $21.7104
110113............................ 1.0690 0.9751 $18.0770 $16.7641 $19.1753 $18.0155
110115............................ 1.7318 0.9782 $26.3274 $29.8699 $32.0197 $29.3454
110118............................ *** * $17.7344 * * $17.7344
110120............................ *** * $20.3098 * * $20.3098
110121............................ 1.0471 0.7679 $19.5230 $21.2534 $21.6637 $20.8173
110122............................ 1.5383 0.8864 $20.4184 $22.0210 $23.7589 $22.1314
110124............................ 1.0894 0.8107 $19.7004 $20.9334 $22.7058 $21.1178
110125............................ 1.2347 0.9078 $19.8695 $22.1458 $22.4238 $21.5044
110128............................ 1.2275 0.9300 $28.4943 $23.2576 $24.4596 $24.9779
110129............................ 1.5326 0.8562 $21.8204 $22.4202 $23.3631 $22.5595
110130............................ 0.9572 0.7679 $17.5272 $17.6529 $18.7549 $18.0115
110132............................ 1.0434 0.7679 $17.2924 $18.9927 $19.2307 $18.5224
110135............................ 1.2819 0.7679 $18.5125 $20.0057 $20.4411 $19.6750
110136............................ 1.0906 0.7940 $21.1235 $22.7715 $15.8573 $19.9782
110142............................ 0.9682 0.7679 $16.3359 $17.3328 $18.1980 $17.2921
110143............................ 1.3817 0.9782 $24.3898 $25.4932 $27.7055 $25.9154
110146............................ 1.0617 0.7679 $17.2250 $19.9221 $23.9067 $20.1122
110149............................ 1.3423 0.9782 $25.3619 $24.7686 $27.1477 $25.8232
110150............................ 1.2819 0.9078 $22.7366 $23.8157 $22.6624 $23.0726
110153............................ 1.1438 0.9078 $21.5300 $22.8660 $24.5368 $22.9872
110155............................ *** * $16.1785 * * $16.1785
110161............................ 1.5043 0.9782 $26.4200 $27.4435 $29.3201 $27.7967
110163............................ 1.4067 0.8634 $21.9411 $25.5461 $26.0764 $24.4314
110164............................ 1.5286 0.9475 $23.7801 $26.4450 $27.0600 $25.7931
110165............................ 1.4137 0.9782 $23.4071 $24.3897 $26.8378 $24.9170
110166............................ *** * $23.6665 $25.2264 $26.8070 $25.1758
110168............................ 1.8519 0.9782 $23.3426 $24.6321 $27.0022 $25.0628
110169............................ *** * $24.7083 * * $24.7083
110171............................ *** * $32.6386 * * $32.6386
110172............................ 1.2169 0.9782 $25.2396 $27.0240 $29.1703 $27.1002
110177............................ 1.6728 0.9751 $24.0700 $25.0129 $26.7504 $25.3590
110179............................ *** * $26.0365 $26.1173 $26.0759 $26.0760
110183............................ 1.2387 0.9782 $26.4248 $27.6020 $29.6133 $28.0105
110184............................ 1.2066 0.9782 $24.3379 $25.5420 $26.5240 $25.5354
110186............................ 1.3917 0.8562 $21.1176 $23.2348 $25.0299 $23.1796
110187............................ 1.2286 0.9782 $23.2571 $22.5730 $24.2933 $23.3967
110188............................ *** * $24.4785 * * $24.4785
110189............................ 1.0968 0.9782 $21.4255 $23.9404 $26.7653 $24.1143
110190............................ 1.0217 0.7861 $21.9008 $19.1054 $14.2517 $17.7557
110191............................ 1.3090 0.9782 $24.0572 $25.8409 $26.8277 $25.5872
110192............................ 1.3254 0.9782 $24.3823 $25.7406 $26.7852 $25.7103
110193............................ 1.4091 0.9782 $25.1779 $27.8223 $27.3341 $26.8213
110194............................ 0.9413 0.7679 $16.8075 $16.3148 $18.4776 $17.2529
110198............................ 1.4037 0.9782 $28.0634 $30.8014 $31.7748 $30.3084
110200............................ 1.8513 0.8562 $20.1816 $21.2177 $22.3249 $21.2486
110201............................ 1.4094 0.9475 $24.1171 $27.0388 $28.2232 $26.3653
110203............................ 0.9953 0.9782 $30.2609 $25.8951 $26.8768 $27.4232
110205............................ 1.0813 0.9782 $23.1969 $20.6150 $19.7409 $21.0203
110209............................ 0.5664 0.7679 $17.4145 $19.1000 $19.0450 $18.5793
110212............................ 1.0529 0.8864 $18.7651 $20.9365 $40.5120 $27.9394
110215............................ 1.2763 0.9782 $22.5679 $23.9657 $25.7886 $24.2458
110218............................ *** * * $26.1073 * $26.1073
110219............................ 1.4347 0.9782 * $27.1880 $27.0362 $27.1115
110220............................ 1.3633 0.8562 * * * *
110221............................ 2.1187 0.9782 * * * *
110222............................ 2.6522 0.9751 * * * *
110223............................ 1.2880 0.9782 * * * *
110224............................ 1.3977 0.9475 * * * *
110225............................ 1.1917 0.9782 * * * *
120001............................ 1.7844 1.1213 $30.0871 $31.7108 $34.7715 $32.1848
120002............................ 1.2199 1.0587 $24.2715 $26.9900 $29.9913 $27.2572
120004............................ 1.2647 1.1213 $26.8010 $28.3569 $28.6527 $27.9367

[[Page 47524]]

120005............................ 1.3002 1.0587 $23.0113 $26.9053 $29.3405 $26.3828
120006............................ 1.2367 1.1213 $28.1562 $29.6751 $31.2285 $29.7168
120007............................ 1.6704 1.1213 $27.8497 $28.7964 $30.4247 $29.0434
120010............................ 1.6900 1.1213 $25.4050 $27.1265 $30.1659 $27.2823
120011............................ 1.4781 1.1213 $30.9308 $31.7447 $34.1643 $32.3199
120014............................ 1.2116 1.0587 $25.3682 $28.0786 $28.6416 $27.3772
120016............................ 1.5918 1.0587 $39.1173 $52.1034 $19.6034 $33.6763
120019............................ 1.1922 1.0587 $24.4036 $28.9661 $30.3809 $27.8836
120022............................ 1.8675 1.1213 $22.4951 $24.7875 $26.6100 $24.7024
120024............................ 0.8789 1.0587 * * * *
120025............................ *** * $40.2473 $48.7148 $30.2358 $39.7283
120026............................ 1.2789 1.1213 $26.3653 $28.5048 $30.3293 $28.4200
120027............................ 1.2385 1.1213 $24.9464 $26.4630 $28.6717 $26.5704
120028............................ 1.2824 1.1213 $29.5070 $31.3195 $30.3794 $30.4272
120029............................ 1.9790 1.1213 * * * *
130002............................ 1.3652 0.9039 $20.1143 $21.6626 $23.6078 $21.8876
130003............................ 1.3678 1.0095 $23.9403 $25.4904 $27.6345 $25.7287
130005............................ *** * $24.4844 $25.2550 $25.7523 $25.1326
130006............................ 1.7997 0.9039 $22.8567 $24.3982 $25.3221 $24.2894
130007............................ 1.7373 0.9039 $22.8475 $24.8764 $24.9562 $24.2827
130011............................ 1.2278 * $23.1120 $22.9336 * $23.0196
130013............................ 1.2951 0.9039 $23.5316 $26.3118 $27.9209 $25.9669
130014............................ 1.1868 0.9039 $21.6495 $23.4789 $24.3884 $23.2115
130018............................ 1.5966 0.9394 $22.2249 $23.9798 $26.4125 $24.2860
130021............................ *** * $18.0006 $18.9400 $16.1658 $17.7607
130022............................ 1.1928 * $21.5602 * * $21.5602
130024............................ 1.1376 0.8964 $22.1610 $21.7853 $23.3347 $22.4344
130025............................ 1.2091 0.8689 $18.7814 $19.7066 $20.1452 $19.5513
130026............................ 1.1154 * $24.4976 $25.4020 * $24.9502
130028............................ 1.3724 0.9394 $21.1492 $25.2938 $26.3443 $24.2492
130036............................ *** * $18.5921 $16.7907 * $17.6689
130045............................ *** * $19.0270 * * $19.0270
130049............................ 1.4577 1.0711 $23.7212 $24.5841 $26.9749 $25.1364
130060............................ *** * $24.6773 $26.7516 * $25.7861
130062............................ *** * $24.0494 $16.7951 $20.6642 $20.3051
130063............................ 1.4722 0.9039 $18.8782 $20.9502 $22.5904 $20.7967
130065............................ 1.8387 0.8689 * * * *
130066............................ 1.9247 0.9982 * * * *
130067............................ 0.6317 0.8689 * * * *
140001............................ 1.0975 0.8279 $20.0247 $21.4779 $22.3170 $21.3141
140002............................ 1.2742 0.8958 $23.0207 $24.4908 $24.6954 $24.0687
140003............................ 1.0219 * $19.2097 $22.6230 * $20.9305
140005............................ *** * $13.2365 * * $13.2365
140007............................ 1.3190 1.0787 $25.1836 $26.7943 $28.3482 $26.7800
140008............................ 1.5155 1.0787 $26.3287 $27.2211 $28.5297 $27.3790
140010............................ 1.4537 1.0787 $29.0224 $31.5774 $35.1024 $32.1200
140011............................ 1.1584 0.8279 $19.0903 $20.6338 $22.4091 $20.7429
140012............................ 1.2419 1.0646 $24.4070 $24.3675 $28.6564 $25.7920
140013............................ 1.4287 0.8845 $19.9800 $22.6022 $23.3065 $21.9604
140015............................ 1.3914 0.8958 $21.4328 $22.2266 $23.0600 $22.2778
140016............................ 1.0254 0.8279 $16.3417 $17.1372 $18.1242 $17.2195
140018............................ 1.4356 1.0787 $24.3285 $27.3334 $27.7548 $26.4350
140019............................ 0.9686 0.8279 $17.4206 $18.4554 $18.9228 $18.2432
140024............................ 1.0049 * $15.6616 $16.9672 $17.5249 $16.7192
140026............................ 1.1678 0.8625 $20.4084 $21.6847 $23.0470 $21.6994
140027............................ 1.1697 * $20.9855 $22.6208 * $21.8225
140029............................ 1.5538 1.0787 $25.0485 $27.7304 $28.6565 $27.2604
140030............................ 1.7218 1.0787 $26.5733 $28.7623 $29.7771 $28.4275
140032............................ 1.1810 0.8958 $20.6273 $22.8157 $24.0574 $22.5257
140033............................ 1.2358 1.0581 $23.4279 $26.1553 $25.6068 $25.0497
140034............................ 1.2428 0.8958 $20.9635 $22.1003 $23.0034 $21.9987
140037............................ 0.8642 * $15.5578 * * $15.5578
140040............................ 1.2197 0.8743 $19.2160 $20.0269 $22.2969 $20.4819
140043............................ 1.2416 0.9664 $23.3751 $26.0330 $26.7996 $25.3939
140045............................ 1.0450 * $18.9587 $21.0042 $20.6548 $20.2345
140046............................ 1.4795 0.8958 $21.7969 $22.5022 $23.2127 $22.5567
140048............................ 1.2945 1.0787 $25.9122 $27.0874 $28.2222 $27.0819

[[Page 47525]]

140049............................ 1.5948 1.0787 $21.9546 $26.6533 $27.4009 $25.3465
140051............................ 1.5185 1.0787 $24.2472 $27.9935 $27.7901 $26.6740
140052............................ 1.2078 0.8958 $21.8161 $22.2588 $23.5662 $22.5560
140053............................ 1.8710 0.8787 $22.6099 $23.5477 $24.8455 $23.6468
140054............................ 1.4602 1.0787 $35.5659 $31.7265 $31.8564 $32.8769
140058............................ 1.2598 0.8958 $20.5089 $22.1269 $22.8423 $21.8133
140059............................ 1.0851 0.8958 $19.9777 $22.7121 $22.4651 $21.7552
140061............................ 0.9901 0.8958 $22.7515 $30.9925 $20.8063 $24.6734
140062............................ 1.2163 1.0787 $30.7005 $31.2359 $34.7704 $32.2360
140063............................ 1.3737 1.0787 $30.5430 $26.5584 $27.8306 $28.2367
140064............................ 1.1693 0.8743 $20.6505 $21.7470 $22.0407 $21.4911
140065............................ 1.3953 1.0787 $26.3521 $26.1904 $29.4678 $27.3858
140066............................ 1.1355 0.8958 $18.0915 $20.4353 $21.9771 $20.1053
140067............................ 1.8342 0.8845 $21.9579 $23.5906 $25.3986 $23.6801
140068............................ 1.2364 1.0787 $24.1316 $25.8963 $27.3956 $25.8156
140070............................ *** * $25.2960 * * $25.2960
140075............................ 1.3361 1.0787 $26.5350 $26.9257 $27.9325 $27.1256
140077............................ 0.9621 0.8958 $18.0487 $19.0922 $19.1363 $18.7657
140079............................ *** * $25.7090 $29.3040 * $27.5634
140080............................ 1.4435 1.0787 $24.4056 $26.0109 $23.2575 $24.4826
140082............................ 1.4014 1.0787 $25.0474 $26.8077 $25.6645 $25.8332
140083............................ 1.0694 1.0787 $23.2822 $24.6491 $26.2972 $24.7955
140084............................ 1.2159 1.0581 $25.4818 $27.6819 $29.2515 $27.5306
140088............................ 1.8214 1.0787 $28.4219 $31.0364 $32.4978 $30.6729
140089............................ 1.1983 0.8279 $20.7632 $22.1227 $23.3401 $22.0452
140090............................ *** * $35.0300 * * $35.0300
140091............................ 1.7746 0.9582 $23.7560 $26.1075 $26.8518 $25.6285
140093............................ 1.1579 0.9262 $21.5376 $22.1540 $25.3127 $22.9099
140094............................ 1.0608 1.0787 $24.2166 $25.3678 $27.9273 $25.8494
140095............................ 1.2411 1.0787 $24.7706 $29.9746 $27.6799 $27.5947
140100............................ 1.2328 1.0581 $27.1868 $32.8743 $37.0819 $32.5610
140101............................ 1.1378 1.0787 $24.6106 $25.4784 $28.5365 $26.3107
140102............................ 1.0470 * $19.8678 $21.2278 * $20.5493
140103............................ 1.3191 1.0787 $21.2404 $21.7512 $23.3258 $22.1297
140105............................ 1.2587 1.0787 $27.3323 $26.3054 $27.4531 $27.0018
140109............................ 1.1459 0.8279 $16.4261 $17.8103 $19.5675 $17.9602
140110............................ 1.0552 1.0646 $21.9880 $25.6561 $27.9844 $25.2166
140113............................ 1.5847 0.9582 $25.6621 $23.5337 $26.7969 $25.2477
140114............................ 1.4787 1.0787 $24.1926 $25.7968 $28.3014 $26.1695
140115............................ 1.1789 1.0787 $25.3410 $26.3677 $25.1498 $25.6313
140116............................ 1.2924 1.0787 $26.8924 $30.5166 $31.9902 $29.9696
140117............................ 1.5169 1.0787 $23.3531 $25.6314 $26.8802 $25.3065
140118............................ 1.7320 1.0787 $26.7350 $27.7392 $29.7570 $28.1023
140119............................ 1.7467 1.0787 $31.3486 $33.6302 $36.1419 $33.6518
140120............................ 1.2682 0.8845 $20.3237 $22.5795 $22.7375 $21.8812
140121............................ 1.6616 * $17.6019 * * $17.6019
140122............................ 1.4446 1.0787 $26.8595 $26.4991 $28.4188 $27.2710
140124............................ 1.2587 1.0787 $30.9648 $35.2798 $36.1327 $34.0784
140125............................ 1.2383 0.8958 $19.5359 $20.7189 $20.4014 $20.2151
140127............................ 1.5857 0.9074 $21.3102 $22.8172 $24.1658 $22.7988
140129............................ *** * $21.6495 * * $21.6495
140130............................ 1.2726 1.0581 $25.7324 $26.3518 $29.5247 $27.3008
140132............................ *** * $23.0595 * * $23.0595
140133............................ 1.2932 1.0787 $24.0458 $26.1599 $28.0339 $25.9998
140135............................ 1.4186 0.8279 $19.7919 $21.2104 $22.3264 $21.1811
140137............................ 1.0401 0.8958 $21.6017 $20.5053 $21.4700 $21.1955
140140............................ 1.0197 * $19.1636 $21.4710 * $20.3063
140141............................ 1.0211 * $20.3706 $23.0515 $21.7871 $21.7302
140143............................ 1.1551 0.8743 $22.0009 $23.8255 $26.2954 $24.0154
140144............................ 0.9634 * $26.9258 $27.8046 * $27.3474
140145............................ 1.1271 0.8958 $19.6429 $21.6168 $23.4608 $21.6090
140147............................ 1.1178 0.8279 $18.2692 $19.5896 $19.8541 $19.2467
140148............................ 1.7094 0.8787 $21.5777 $23.0022 $24.7031 $23.0546
140150............................ 1.6139 1.0787 $32.9291 $33.9013 $35.2711 $34.0702
140151............................ 0.8241 1.0787 $21.5167 $22.4842 $23.4879 $22.5018
140152............................ 1.2404 1.0787 $28.5468 $29.6882 $27.6086 $28.6011
140155............................ 1.2756 1.0765 $25.2034 $27.6610 $28.9724 $27.2937

[[Page 47526]]

140158............................ 1.4203 1.0787 $22.5638 $23.8542 $27.0986 $24.2703
140160............................ 1.2385 0.9664 $20.9986 $22.7002 $24.5373 $22.7502
140161............................ 1.1279 1.0646 $22.2191 $24.1071 $23.1647 $23.1691
140162............................ 1.6229 0.9074 $22.6426 $26.0312 $27.4472 $25.4182
140164............................ 1.7657 0.8958 $19.7774 $22.0424 $23.7457 $21.8696
140165............................ 1.0651 * $17.0666 $15.9312 $16.6304 $16.5175
140166............................ 1.1824 0.8279 $20.7849 $21.7776 $23.1005 $21.8859
140167............................ 1.0499 0.8279 $19.5959 $19.7610 $22.8911 $20.7477
140168............................ 1.1726 * $18.7504 $20.0225 * $19.4021
140170............................ 0.9358 * $17.0665 $17.1608 * $17.1147
140171............................ *** * $17.3214 * * $17.3214
140172............................ 1.3752 1.0787 $27.3372 $27.1121 $29.8568 $28.4878
140174............................ 1.4729 1.0787 $23.6893 $24.7011 $27.8131 $25.3970
140176............................ 1.2141 1.0787 $25.6824 $28.9378 $31.3490 $28.8390
140177............................ 0.9529 1.0787 $20.8526 $19.3328 $22.5610 $20.9656
140179............................ 1.3721 1.0787 $24.1539 $26.3200 $27.6376 $26.0525
140180............................ 1.2667 1.0787 $25.4022 $27.4366 $28.3629 $27.0710
140181............................ 1.2082 1.0787 $23.7308 $23.6034 $25.0100 $24.1182
140182............................ 1.5193 1.0787 $32.1969 $28.0337 $28.2211 $28.8901
140184............................ 1.2187 0.8279 $20.6499 $20.1279 $21.1802 $20.6885
140185............................ 1.4330 0.8958 $20.0903 $22.0222 $23.8531 $22.0093
140186............................ 1.5107 1.0765 $26.0970 $28.1977 $30.6951 $28.4624
140187............................ 1.5026 0.8958 $20.5829 $22.0674 $23.2892 $21.9710
140189............................ 1.1505 0.9262 $22.5875 $25.6954 $23.7198 $24.0159
140190............................ 1.0728 * $17.9193 $18.8530 $19.8297 $18.8585
140191............................ 1.3122 1.0787 $24.5446 $25.2817 $25.8678 $25.2409
140193............................ 0.9701 * $20.5958 $22.9443 * $21.7731
140197............................ 1.3542 1.0787 $19.2980 $21.8060 $23.0684 $21.2577
140199............................ 1.0548 0.8279 $19.7888 $21.3464 $22.0315 $21.0597
140200............................ 1.4946 1.0787 $24.1358 $24.9217 $26.3379 $25.1308
140202............................ 1.5604 1.0581 $26.2460 $27.4336 $29.7870 $27.9702
140203............................ 1.0839 * $26.5789 $28.2212 * $27.4338
140205............................ 0.5759 1.0128 $25.1010 * * $25.1010
140206............................ 1.1417 1.0787 $24.7616 $27.5481 $30.6561 $27.6301
140207............................ 1.4242 1.0787 $23.3197 $25.7331 $24.1048 $24.4812
140208............................ 1.6608 1.0787 $27.4671 $27.6586 $29.4708 $28.2131
140209............................ 1.5477 0.8845 $22.0813 $23.3886 $24.5376 $23.3577
140210............................ 1.0896 0.8279 $15.5339 $16.6729 $19.2639 $17.1406
140211............................ 1.3172 1.0787 $25.8556 $29.5114 $29.7054 $28.4947
140213............................ 1.1697 1.0787 $27.4607 $29.1649 $30.2945 $29.0178
140215............................ *** * $18.6962 $22.3097 * $20.4262
140217............................ 1.4497 1.0787 $24.7146 $29.3711 $31.5324 $28.5274
140223............................ 1.4386 1.0787 $27.4355 $29.2540 $30.4923 $29.0769
140224............................ 1.3999 1.0787 $27.1725 $29.0350 $28.2177 $28.1560
140228............................ 1.5463 0.9965 $22.9899 $25.0074 $25.6419 $24.5738
140231............................ 1.4877 1.0787 $25.5536 $28.3545 $30.6410 $28.2754
140233............................ 1.5789 1.0646 $24.7103 $27.3379 $28.6305 $26.9841
140234............................ 1.0500 0.8743 $20.8676 $23.2604 $23.6928 $22.6766
140239............................ 1.5620 0.9965 $23.9205 $24.2112 $29.0092 $25.6976
140240............................ 1.4134 1.0787 $25.0325 $27.2654 $28.7310 $26.9902
140242............................ 1.4982 1.0787 $28.8686 $30.4005 $32.0522 $30.5576
140245............................ 0.9917 * $15.2537 $16.0772 * $15.6642
140246............................ *** * $16.1305 * * $16.1305
140250............................ 1.2339 1.0787 $25.5501 $27.4628 $28.5971 $27.2294
140251............................ 1.2951 1.0787 $24.8256 $26.7266 $27.1687 $26.2377
140252............................ 1.4213 1.0787 $28.3479 $30.2656 $33.3351 $30.8078
140258............................ 1.5301 1.0787 $27.5741 $27.9478 $30.2639 $28.6430
140271............................ 0.8940 * $17.5174 $18.8535 * $18.2163
140275............................ 1.2853 0.8709 $23.1871 $25.2824 $26.1473 $24.8583
140276............................ 1.8142 1.0787 $25.3222 $27.5936 $29.8325 $27.5408
140280............................ 1.4671 0.8709 $21.7004 $21.9302 $23.4447 $22.3667
140281............................ 1.7032 1.0787 $27.9115 $29.2602 $30.4838 $29.2416
140285............................ *** * * $17.7824 $20.7576 $19.1679
140286............................ 1.1142 1.0787 $25.5805 $28.4378 $29.1543 $27.7906
140288............................ 1.5423 1.0787 $26.3572 $26.9581 $29.3988 $27.5648
140289............................ 1.3270 0.8958 $20.7506 $22.3274 $22.6211 $21.9308
140290............................ 1.3299 1.0787 $29.9098 $28.6926 $31.7341 $30.1371

[[Page 47527]]

140291............................ 1.2633 1.0646 $27.6675 $28.2338 $29.8958 $28.6610
140292............................ 1.1590 1.0787 $26.4077 $26.1781 $27.6285 $26.7692
140294............................ 1.1328 0.8279 $21.7473 $22.6123 $23.4504 $22.6034
140300............................ 1.2322 1.0787 $30.5172 $33.3983 $34.8568 $32.8808
140301............................ 1.1673 1.0787 * * $31.7073 $31.7073
140303............................ 2.1093 1.0787 * * * *
150001............................ 1.1882 0.9912 $25.4897 $27.1021 $29.6844 $27.4774
150002............................ 1.4225 1.0646 $22.3327 $23.3804 $25.0063 $23.5866
150003............................ 1.6821 0.8721 $21.0944 $23.3196 $25.3458 $23.2610
150004............................ 1.5573 1.0646 $23.6169 $24.8884 $26.8458 $25.1066
150005............................ 1.2087 0.9912 $23.8818 $25.4443 $27.2369 $25.6152
150006............................ 1.3215 0.9775 $23.1779 $24.8976 $26.4061 $24.8616
150007............................ 1.3254 0.9546 $22.1098 $23.5841 $26.6073 $24.2353
150008............................ 1.4227 1.0646 $23.8916 $23.6953 $26.6928 $24.7814
150009............................ 1.3828 0.9254 $19.4763 $20.4993 $22.2147 $20.7473
150010............................ 1.3579 0.9546 $22.5445 $23.9740 $26.8524 $24.4792
150011............................ 1.1670 0.9766 $22.1559 $23.2249 $24.3490 $23.2593
150012............................ 1.5500 0.9775 $23.1644 $22.9314 $27.3029 $24.2924
150013............................ 0.9904 * $19.8564 $19.7689 $21.8465 $20.4949
150014............................ 1.3341 0.9912 $24.3754 $26.5785 * $25.4309
150015............................ 1.3287 1.0646 $23.1616 $24.3015 $26.2434 $24.6064
150017............................ 1.8334 0.9787 $22.7979 $23.7180 $25.2342 $23.9446
150018............................ 1.6441 0.9606 $24.6138 $24.7048 $26.3289 $25.2344
150019............................ 1.0496 * $17.3170 * * $17.3170
150020............................ 1.1215 * $18.4689 * * $18.4689
150021............................ 1.7451 0.9787 $24.3658 $27.8168 $29.6967 $27.2581
150022............................ 1.0786 0.8875 $22.2973 $22.8035 $22.6773 $22.6089
150023............................ 1.5291 0.8626 $20.6926 $23.1253 $23.7159 $22.4697
150024............................ 1.4380 0.9912 $21.7593 $24.7879 $27.1589 $24.7582
150026............................ 1.2837 0.9606 $23.2169 $23.7185 $28.1127 $25.1166
150027............................ 1.0264 0.9912 $21.5766 $21.2855 $17.4862 $19.9164
150029............................ 1.4385 0.9775 $25.2067 $23.4103 $26.9680 $25.0754
150030............................ 1.2127 0.9766 $23.0196 $24.4361 $26.9533 $24.8565
150031............................ 1.0638 * $18.9180 * * $18.9180
150033............................ 1.7015 0.9912 $24.1701 $25.8851 $27.9995 $26.0913
150034............................ 1.5097 1.0646 $22.8812 $23.9388 $26.0465 $24.3610
150035............................ 1.4639 0.9473 $23.5468 $26.0952 $26.6620 $25.4702
150037............................ 1.3136 0.9912 $24.4997 $27.7009 $28.5451 $26.8949
150038............................ 1.1135 0.9912 $21.6608 $24.4188 $28.8054 $24.9650
150042............................ 1.4015 0.8626 $23.7838 $21.9917 $23.0102 $22.8781
150044............................ 1.3418 0.9254 $20.5156 $23.1200 $23.7065 $22.4683
150045 \h\........................ 1.0611 1.0203 $23.0361 $24.2899 $25.2225 $24.2205
150046............................ 1.4435 0.8626 $20.3453 $21.0417 $21.9369 $21.1254
150047............................ 1.7099 0.9787 $24.8786 $24.5455 $25.8349 $25.1035
150048............................ 1.3290 0.9595 $22.5181 $24.5864 $27.1817 $24.7509
150049............................ 1.1302 0.8626 $18.4942 $20.2178 $22.3370 $20.2342
150051............................ 1.5723 0.8626 $21.4009 $22.6866 $23.7061 $22.5941
150052 \h\........................ 1.0456 0.9254 $19.1070 $19.6073 $20.6339 $19.7871
150056............................ 1.8501 0.9912 $24.7841 $27.6754 $28.2842 $26.9368
150057............................ 1.9981 0.9912 $28.0884 $22.7804 $24.8605 $24.9551
150058............................ 1.5717 0.9775 $24.9479 $26.9753 $27.5341 $26.5322
150059............................ 1.5913 0.9912 $25.6738 $27.0792 $28.5715 $27.1975
150060............................ 1.0914 * $19.8990 $23.2409 $24.8544 $22.6276
150061............................ 1.1149 0.8626 $19.2826 $21.3640 $22.2822 $20.9919
150062............................ 1.1174 0.8779 $22.9214 $23.5550 $24.6088 $23.7293
150063............................ *** * $24.4091 $19.0377 * $21.8339
150064............................ 1.1816 0.8626 $21.2512 $21.6370 $23.7707 $22.2400
150065............................ 1.2407 0.9766 $23.0636 $24.4451 $25.9461 $24.5094
150067............................ 1.0394 * $21.4374 * * $21.4374
150069............................ 1.2003 0.9595 $23.8353 $25.3445 $25.2655 $24.8300
150070............................ 0.9449 * $20.7413 $22.6260 * $21.7117
150072............................ 1.2044 0.8626 $18.5447 $20.3191 $20.5111 $19.8274
150073............................ *** * $14.8287 * * $14.8287
150074............................ 1.4325 0.9912 $22.9598 $24.4374 $25.2586 $24.2433
150075............................ 1.0887 0.9787 $20.1119 $24.2085 $24.0745 $22.8038
150076............................ 1.2419 0.9775 $25.4519 $24.1434 $28.1874 $25.9085
150078............................ 0.9482 * $20.1259 $21.2476 * $20.7180

[[Page 47528]]

150079............................ 1.0979 0.9254 $19.3860 $20.6486 $21.4067 $20.5165
150082............................ 1.7386 0.8727 $21.0651 $22.2054 $25.5860 $22.9776
150084............................ 1.8008 0.9912 $27.8354 $28.7722 $29.3905 $28.6939
150086............................ 1.2204 0.9595 $21.5815 $22.4471 $23.9404 $22.7151
150088............................ 1.2877 0.9766 $22.2627 $23.0998 $23.6253 $23.0168
150089............................ 1.4776 0.8943 $21.6806 $22.6545 $25.0449 $23.0977
150090............................ 1.5045 1.0646 $24.9021 $24.6758 $26.2899 $25.3163
150091 \h\........................ 1.0899 1.0360 $26.4248 $27.8087 $30.6209 $28.2762
150096............................ 0.9793 * $19.7975 $21.9091 * $20.8347
150097............................ 1.0695 0.9912 $22.4564 $24.4179 $25.0367 $24.0346
150100............................ 1.7186 0.8727 $21.2980 $22.2687 $24.3530 $22.6387
150101............................ 1.0362 0.9787 $26.1271 $27.9745 $29.1657 $27.6430
150102............................ 1.1050 0.9390 $21.3313 $22.6870 $24.5923 $22.8112
150104............................ 1.0587 0.9912 $21.0799 $21.8172 $25.5871 $22.8454
150106 \h\........................ 1.0532 0.9787 $19.1976 $20.9955 $20.9387 $20.4063
150109............................ 1.4302 0.8721 $23.4642 $24.3786 $23.5865 $23.8124
150112............................ 1.4431 0.9766 $23.5151 $24.7455 $26.5643 $24.9478
150113............................ 1.2063 0.9766 $21.2412 $23.0450 $24.8760 $23.1460
150115............................ 1.3456 0.8626 $20.3863 $20.5215 $19.3411 $20.0486
150122............................ 1.1236 0.8825 $22.2752 $24.2471 $26.0173 $24.2508
150123............................ *** * $15.5997 $15.3050 * $15.4580
150124............................ 1.1255 0.8626 $17.9063 $18.8218 $21.3933 $19.4269
150125............................ 1.5069 1.0646 $23.1464 $24.3872 $26.7666 $24.8140
150126............................ 1.4223 1.0646 $24.1917 $25.5585 $26.9887 $25.6255
150128............................ 1.3965 0.9912 $20.9869 $23.1660 $26.4976 $23.5710
150129............................ 1.2019 0.9912 $34.3166 $35.4311 $29.9099 $32.9368
150130............................ 1.0268 * $18.5578 $21.5678 $21.7399 $20.5294
150132............................ 1.4086 1.0646 $22.2707 $24.2559 $25.6257 $24.1021
150133............................ 1.2666 0.9787 $21.8807 $21.8839 $22.7293 $22.1682
150134............................ 1.1176 0.9254 $20.7680 $22.1085 $23.8526 $22.2228
150136............................ *** * $25.8467 $25.7004 $26.2703 $25.9403
150146............................ 1.0225 0.9787 $25.1827 $26.1168 $29.3383 $26.7878
150147............................ 1.1926 1.0646 * $32.3336 $22.8456 $26.0420
150148............................ *** * $26.2188 $27.2081 * $26.7661
150149............................ 0.9715 0.8727 * $23.8554 $23.6361 $23.7419
150150............................ 1.2769 0.9787 * $26.5138 $25.5331 $26.0172
150151............................ *** * * * $38.1446 $38.1446
150152............................ *** * * * $44.7143 $44.7143
150153............................ 2.4699 0.9912 * * * *
150154............................ 2.5955 0.9912 * * * *
150156............................ 1.8815 0.9390 * * * *
150157............................ 1.6131 0.9912 * * * *
160001............................ 1.2088 0.9272 $22.8426 $23.8657 $25.1220 $23.9155
160002............................ *** * $19.9607 * * $19.9607
160003............................ 0.9701 * $17.5050 $19.0037 * $18.2436
160005............................ 1.1966 0.8553 $20.3313 $21.1745 $21.8950 $21.1337
160008............................ 1.0690 0.8553 $17.9463 $19.8066 $20.7200 $19.4883
160013............................ 1.2076 0.8771 $21.0541 $23.0163 $23.7163 $22.5118
160014............................ 0.9968 * $18.3097 $19.2447 $20.5882 $19.3912
160016............................ 1.5950 0.9430 $21.8400 $21.2785 $23.3619 $22.1755
160020............................ 1.0680 0.8553 $16.6092 $19.0043 $19.5554 $18.4145
160024............................ 1.5950 0.9668 $22.4256 $24.2385 $26.2392 $24.3248
160026............................ 0.9887 0.9272 $22.8967 $24.2045 $24.7424 $23.9779
160028............................ 1.3174 0.9546 $25.1998 $26.0052 $26.2948 $25.8671
160029............................ 1.6190 0.9741 $23.7268 $24.9493 $27.9277 $25.5651
160030............................ 1.2758 0.9577 $23.3687 $24.9920 $26.7068 $25.0247
160031............................ 0.9697 0.8553 $17.8994 $18.5281 $19.7368 $18.7354
160032............................ 1.0590 0.8825 $20.5024 $22.3837 $23.4727 $22.1329
160033............................ 1.7424 0.8709 $22.2660 $23.4148 $24.6768 $23.4865
160034............................ 0.9421 0.8553 $19.0684 $19.4837 $19.3503 $19.3060
160039............................ 0.9342 0.8553 $19.8851 $20.9623 $22.1180 $20.9879
160040............................ 1.2439 0.8813 $20.0567 $21.8187 $23.9053 $21.9454
160043............................ *** * $15.5765 * * $15.5765
160044............................ 1.1315 * $19.0956 $19.5635 * $19.3281
160045............................ 1.6942 0.8813 $22.1285 $24.4957 $25.4153 $24.0445
160047............................ 1.3730 0.9546 $22.1550 $24.5000 $25.2072 $23.9813
160048............................ 1.0536 0.8553 $18.1174 $19.5701 $19.5832 $19.1110

[[Page 47529]]

160050............................ 1.1034 0.8553 $21.6247 $23.8830 $24.5403 $23.3364
160057............................ 1.2602 0.9556 $20.8345 $22.0472 $23.0937 $21.9969
160058............................ 1.8406 0.9741 $23.5663 $25.5244 $27.1646 $25.4595
160064............................ 1.6054 1.0218 $23.8367 $27.6301 $28.6139 $26.8350
160066............................ 1.0906 0.8553 $20.4609 $21.4631 $22.7709 $21.6117
160067............................ 1.3672 0.8813 $19.9422 $21.9418 $23.4060 $21.8952
160069............................ 1.4498 0.9005 $21.7197 $22.7514 $25.3402 $23.2842
160072............................ *** * $15.8236 * * $15.8236
160074............................ 1.0213 * $22.2988 $20.2418 * $21.1624
160076............................ 0.9957 * $20.1603 $20.9749 * $20.5825
160079............................ 1.5094 0.8813 $21.6562 $22.5299 $23.7234 $22.6640
160080............................ 1.3139 0.9664 $21.1713 $23.5721 $23.1837 $22.6302
160081............................ 1.1943 * $20.4415 $21.3614 $23.1930 $21.6437
160082............................ 1.7485 0.9668 $21.6230 $23.8181 $26.4398 $23.8972
160083............................ 1.6640 0.9668 $23.4670 $25.0617 $28.2193 $25.6738
160089............................ 1.2859 0.9430 $19.9688 $21.5693 $22.6551 $21.4092
160090............................ 0.9952 * $19.6767 $21.2753 * $20.4851
160091............................ 0.9580 * $16.1660 $18.0630 $17.9862 $17.3974
160092............................ 0.9609 * $20.4731 $22.0841 * $21.2805
160093............................ *** * $22.8553 * * $22.8553
160101............................ 1.1027 0.9668 $22.1741 $24.2309 $25.1000 $23.8100
160104............................ 1.3950 0.8709 $23.2832 $24.0075 $24.9134 $24.0516
160106............................ 1.1265 * $19.8905 $21.4912 * $20.6919
160107............................ 1.0451 * $19.5111 $21.3754 * $20.4402
160110............................ 1.6682 0.8813 $21.9299 $24.1762 $24.9434 $23.7256
160112............................ 1.2599 0.8553 $20.4038 $21.8901 $23.0672 $21.8008
160113............................ 0.9661 * $16.7574 $18.6599 * $17.7162
160114............................ 0.9810 * $19.1743 * * $19.1743
160115............................ 1.0985 * $17.6815 $19.5764 * $18.5763
160116............................ 1.0398 * $19.6923 $22.2019 * $20.9445
160117............................ 1.2805 0.9005 $22.3228 $23.4250 $25.0278 $23.6002
160118............................ 1.0326 0.8553 $16.9466 $18.3322 $19.7764 $18.4025
160122............................ 1.0846 0.8553 $21.2843 $22.9565 $22.5872 $22.2853
160124............................ 1.1237 0.8553 $21.2279 $22.7223 $23.1690 $22.3848
160126............................ 1.0433 0.8553 $20.0149 $20.3748 $19.8323 $20.0754
160131............................ 0.9408 * $18.0486 * * $18.0486
160140............................ 1.0209 * $22.1666 $22.5230 * $22.3471
160143............................ 1.0157 * $19.0623 * * $19.0623
160146............................ 1.4086 0.9365 $20.6638 $20.9583 $22.9897 $21.5377
160147............................ 1.2192 0.9430 $22.7993 $26.6577 $26.6438 $25.4406
160153............................ 1.6067 0.9365 $23.5212 $26.3671 $28.9881 $26.3386
170001............................ 1.1627 0.8076 $19.8149 $20.9837 $21.9131 $20.9143
170006............................ 1.2468 0.8450 $19.4488 $20.6460 $21.9019 $20.7240
170008............................ *** * $18.2352 * * $18.2352
170009............................ 1.0640 0.9463 $25.8246 $29.1979 $29.2588 $28.1227
170010............................ 1.2408 0.8569 $20.6294 $21.2131 $24.0008 $21.9435
170012............................ 1.6234 0.8977 $21.8587 $22.6869 $24.7392 $23.0750
170013............................ 1.6094 0.8977 $21.4954 $23.1159 $25.0419 $23.1862
170014............................ 0.9839 0.9463 $21.3416 $22.9772 $23.5960 $22.6522
170015............................ 1.0552 * $18.0485 $19.1902 $20.2367 $19.1620
170016............................ 1.6375 0.8912 $22.9479 $24.2336 $25.9482 $24.4090
170017............................ 1.1078 0.9168 $21.6323 $23.3030 $24.7771 $23.3226
170018............................ 0.8965 * $16.9169 $17.9497 * $17.4623
170019............................ 1.2271 0.8076 $18.7916 $20.3243 $22.0251 $20.4068
170020............................ 1.5762 0.8977 $20.6658 $22.2571 $23.1800 $22.0586
170022............................ 1.0981 0.9463 $21.1947 $22.9313 $22.2878 $22.1486
170023............................ 1.4687 0.8977 $21.6273 $23.2690 $23.9808 $22.9706
170024............................ *** * $16.1196 * * $16.1196
170025............................ *** * $19.2123 * * $19.2123
170026............................ *** * $17.0836 * * $17.0836
170027............................ 1.4017 0.8076 $20.7776 $21.4678 $22.5103 $21.6098
170033............................ 1.3937 0.8977 $20.0627 $20.0801 $20.7865 $20.2914
170034............................ 0.8608 * $18.1074 * * $18.1074
170039............................ 0.9591 0.9168 $18.4473 $20.1983 $21.5203 $20.0407
170040............................ 1.9183 0.9463 $24.5234 $27.1771 $28.2856 $26.8014
170041............................ 0.6109 * $13.9709 * * $13.9709
170049............................ 1.5134 0.9463 $22.9404 $24.1208 $24.7895 $23.9996

[[Page 47530]]

170052............................ 1.1936 0.8076 $15.8809 $17.3794 $18.5291 $17.3370
170054............................ 0.9997 * $18.5239 $17.5500 * $18.0250
170056............................ *** * $17.1872 * * $17.1872
170058............................ 1.0822 0.9463 $23.0648 $22.0398 $23.3398 $22.8013
170068............................ 1.2035 0.9156 $20.5512 $20.8771 $22.6087 $21.3531
170070............................ 1.0815 0.8076 $15.0539 $16.4767 $16.0162 $15.8428
170074............................ 1.2512 0.8076 $18.5446 $20.4936 $21.0565 $20.0516
170075............................ 0.8352 0.8076 $15.6809 $16.2047 $16.5444 $16.1586
170077............................ *** * $14.6377 * * $14.6377
170080............................ 0.9108 * $15.0079 * * $15.0079
170082............................ *** * $15.9973 * * $15.9973
170085............................ 0.9571 * $17.2585 $18.4867 * $17.8616
170086............................ 1.5689 0.8912 $22.1067 $22.7737 $24.0812 $23.0117
170090............................ 0.9555 * $16.3550 $15.9807 * $16.1812
170093............................ 0.8272 0.8076 $15.0307 $16.8710 $16.5553 $16.1514
170094............................ 0.9999 0.8076 $20.1253 $20.3678 $21.3887 $20.6420
170097............................ 0.8994 * $18.9865 $20.3391 * $19.6594
170098............................ 1.0088 0.8076 $18.6676 $20.0078 $20.1242 $19.5946
170099............................ 1.0382 * $15.8117 * * $15.8117
170101............................ *** * $17.9291 * * $17.9291
170103............................ 1.2477 0.9168 $20.1263 $21.4985 $22.8707 $21.5590
170104............................ 1.5175 0.9463 $23.6589 $26.1866 $26.9671 $25.6385
170105............................ 1.0793 0.8076 $18.3824 $19.6687 $21.4422 $19.8723
170109............................ 0.9870 0.9463 $20.7580 $22.7166 $23.2626 $22.2703
170110............................ 0.9756 0.8076 $16.5883 $21.8904 $22.9195 $20.4004
170113............................ 1.0265 * $19.9957 * * $19.9957
170114............................ 0.8632 0.8076 $17.4688 $18.1610 $18.9158 $18.1987
170116............................ 1.0105 * $20.8800 $23.1127 * $21.9980
170120............................ 1.2735 0.8450 $18.5895 $19.8723 $21.0499 $19.8632
170122............................ 1.6272 0.9168 $22.2681 $24.6532 $25.3981 $24.1333
170123............................ 1.6884 0.9168 $25.0073 $26.4676 $27.2239 $26.2255
170133............................ 1.0703 0.9463 $20.0593 $21.7748 $22.9309 $21.5574
170137............................ 1.2393 0.8076 $21.4394 $22.7676 $23.8863 $22.7099
170142............................ 1.3477 0.8776 $19.8269 $22.4095 $22.5778 $21.6027
170143............................ 1.1298 0.8076 $18.0308 $19.7643 $20.4459 $19.4072
170144............................ *** * $23.9180 $24.4259 $24.6260 $24.3634
170145............................ 1.0677 0.8076 $20.5143 $21.4472 $21.5756 $21.1869
170146............................ 1.5459 0.9463 $27.0312 $28.1965 $29.1358 $28.2094
170147............................ 1.2323 0.9168 $18.2480 $23.1610 $21.4753 $20.9339
170148............................ *** * $26.3491 * * $26.3491
170150............................ 1.1267 0.8076 $16.3724 $17.4916 $18.5744 $17.4967
170151............................ 1.0276 * $15.7242 * * $15.7242
170152............................ 1.0618 * * * * *
170166............................ 0.9449 0.8076 $17.8131 $18.5978 $19.2842 $18.5319
170171............................ *** * $14.7251 * * $14.7251
170175............................ 1.3487 0.8977 $22.5605 $23.6262 $23.9304 $23.3714
170176............................ 1.3432 0.9463 $25.5404 $24.2283 $26.2366 $25.2863
170180............................ *** * $25.0935 * $25.1366 $25.1166
170182............................ 1.4280 0.9463 $23.2115 $24.3820 $25.7443 $24.4497
170183............................ 1.9727 0.9168 $19.6919 $22.8633 $24.5539 $22.4468
170185............................ 1.3253 0.9463 $26.8307 $24.8478 $26.7797 $26.1506
170186............................ 2.9322 0.9168 $28.5602 $30.5157 $31.7896 $30.4381
170187............................ 1.1537 0.8076 $20.8289 $21.0780 $23.3702 $21.8354
170188............................ 2.0471 0.9463 $25.2504 $27.2225 $29.9751 $27.6756
170189............................ *** * $28.1996 * * $28.1996
170190............................ 1.0582 0.8076 * $22.4865 $22.8729 $22.6685
170191............................ 1.1279 0.8076 * $24.9599 $21.3069 $23.1771
170192............................ 2.0907 0.9168 * * $27.9704 $27.9704
170193............................ 1.2176 0.8076 * * $24.7430 $24.7430
170194............................ 1.7132 0.9463 * * $27.9904 $27.9904
170195............................ 2.2634 0.9463 * * * *
170196............................ 2.4484 0.9168 * * * *
180001............................ 1.2743 0.9595 $22.2674 $24.7647 $25.4217 $24.1342
180002............................ 1.0566 0.7780 $20.5135 $21.6843 $22.9727 $21.7424
180004............................ 1.1137 0.7780 $19.8552 $19.0834 $19.5437 $19.4871
180005............................ 1.1545 0.9110 $22.6704 $22.8871 $24.5561 $23.3888
180006............................ 0.9171 0.7780 $14.4066 $15.7136 $14.8011 $14.9439

[[Page 47531]]

180007............................ 1.4243 0.9051 $21.3545 $21.8724 $22.7606 $21.9873
180009............................ 1.6411 0.9473 $22.4450 $24.0971 $25.3837 $24.0052
180010............................ 1.9593 0.9051 $22.6846 $26.4116 $24.7256 $24.5688
180011............................ 1.3606 0.8732 $18.8056 $22.3183 $22.7364 $21.2726
180012............................ 1.5066 0.9254 $20.2758 $22.9096 $24.6642 $22.6125
180013............................ 1.4556 0.9450 $21.0512 $21.4728 $22.9512 $21.8902
180016............................ 1.3161 0.9254 $20.5203 $22.2148 $23.1832 $22.0005
180017............................ 1.2474 0.8278 $18.0329 $19.0694 $20.8630 $19.3296
180018............................ 1.3343 0.8732 $17.5670 $18.3314 $19.0992 $18.3166
180019............................ 1.1920 0.9595 $20.8416 $22.0379 $24.1342 $22.3292
180020............................ 1.0412 0.7780 $20.9964 $22.3477 $21.9494 $21.7537
180021............................ 1.0484 0.7780 $17.6331 $17.9346 $18.5966 $18.0522
180024............................ 1.1385 0.9254 $22.3922 $23.6826 $32.1824 $25.9352
180025............................ 1.0658 0.9254 $18.3306 $17.4781 $19.1543 $18.3232
180026............................ 1.1076 0.7780 $15.5354 $15.8431 $18.2120 $16.5328
180027............................ 1.2142 0.8084 $20.5017 $22.1072 $23.8763 $22.1722
180028............................ 0.9014 0.9110 $20.6324 $21.4766 $24.7968 $22.1418
180029............................ 1.2921 0.8087 $20.4262 $21.2110 $23.0536 $21.5776
180035............................ 1.5475 0.9595 $24.3874 $26.7702 $29.8438 $27.1206
180036............................ 1.1732 0.9473 $22.2389 $23.1636 $25.1154 $23.5250
180037............................ 1.2870 0.9254 $22.7893 $24.4451 $25.7361 $24.4985
180038............................ 1.3647 0.8797 $20.6888 $22.2750 $24.6348 $22.4970
180040............................ 2.1017 0.9254 $23.2341 $24.5590 $26.2125 $24.7248
180041............................ 1.0818 * $19.1325 $18.5483 * $18.8494
180043............................ 1.2068 0.7780 $20.6498 $18.8436 $19.0617 $19.4791
180044............................ 1.5212 0.9110 $21.8163 $21.6837 $23.0971 $22.1791
180045............................ 1.3293 0.9595 $22.1027 $24.5856 $25.8349 $24.1325
180046............................ 1.0574 0.9051 $23.1139 $24.7562 $27.2244 $25.0514
180047............................ 0.8551 0.7780 $17.8574 $20.4768 $21.8037 $20.0588
180048............................ 1.2811 0.9254 $20.0114 $22.3601 $21.6571 $21.3621
180049 \h\........................ 1.3932 0.9051 $18.5188 $19.4488 $23.3407 $20.4067
180050............................ 1.1398 0.7780 $19.9082 $21.7150 $22.6473 $21.3727
180051............................ 1.4278 0.8264 $18.8186 $19.2100 $21.3312 $19.7863
180053............................ 1.0413 0.7780 $17.6239 $18.6610 $19.1578 $18.5083
180054............................ 0.9767 * $19.1340 $19.0657 * $19.0979
180055 \h\........................ 1.1334 0.9051 $17.8704 $21.1989 $20.7237 $19.9661
180056............................ 1.0730 0.8727 $19.4072 $21.4695 $22.8910 $21.2490
180063............................ 1.1816 0.7780 $15.5078 $15.9185 $17.9741 $16.5674
180064............................ 1.2331 0.7780 $21.1067 $15.3819 $16.2638 $17.3349
180066............................ 1.0540 0.9450 $21.1884 $24.6359 $24.9543 $23.6588
180067............................ 1.9820 0.9051 $22.0056 $24.0551 $25.4080 $23.7960
180069............................ 1.0535 0.9110 $20.3982 $20.8797 $22.3674 $21.2166
180070............................ 1.1278 0.7780 $16.9892 $17.4266 $20.1308 $18.1917
180072............................ *** * $17.5411 * * $17.5411
180078............................ 1.0926 0.9110 $23.4616 $25.4196 $26.2636 $25.0479
180079............................ 1.1273 0.7780 $18.0472 $19.5783 $19.7791 $19.1405
180080............................ 1.3148 0.8732 $18.9582 $20.1651 $21.7380 $20.2813
180087............................ 1.1773 0.7780 $16.4726 $17.7758 $18.4331 $17.6017
180088............................ 1.5731 0.9254 $23.7217 $24.6053 $27.5767 $25.3642
180092............................ 1.1351 0.9051 $19.6790 $22.4864 $22.5679 $21.6047
180093............................ 1.4508 0.8499 $18.8469 $19.2748 $20.5422 $19.5520
180094............................ 0.9639 * $15.7640 * * $15.7640
180095............................ 1.0535 0.7780 $15.9881 $17.1354 $17.9677 $17.0401
180099............................ *** * $14.0115 * * $14.0115
180101............................ 1.1363 0.9051 $22.4094 $24.2242 $25.4796 $24.0981
180102............................ 1.5634 0.8084 $20.1885 $19.1136 $18.4388 $19.1595
180103............................ 2.2314 0.9051 $21.3867 $25.1577 $26.9407 $24.4722
180104............................ 1.6311 0.8084 $21.3866 $22.8911 $24.9441 $23.1113
180105............................ 0.8503 0.7780 $18.3521 $19.5364 $19.7615 $19.2381
180106............................ 0.9842 0.7780 $15.4937 $15.7851 $17.8020 $16.4485
180108............................ *** * $16.7327 * * $16.7327
180115............................ 0.9674 0.7780 $19.2396 $19.9316 $20.9831 $20.0578
180116............................ 1.2126 0.8279 $20.5453 $21.8698 $22.7353 $21.7465
180117............................ 0.9872 0.7780 $17.7885 $20.5952 $21.1854 $19.7909
180120............................ 0.7900 * $20.4507 * * $20.4507
180121............................ 0.9689 * $16.9881 * * $16.9881
180124............................ 1.3234 0.9450 $20.5369 $21.4270 $23.1917 $21.6877

[[Page 47532]]

180126............................ 1.0467 * $14.5644 $15.1776 * $14.8844
180127............................ 1.2802 0.9254 $20.0059 $21.4633 $23.4765 $21.6735
180128............................ 0.9517 0.8062 $19.8502 $20.5575 $20.8406 $20.4307
180129............................ *** * $14.1861 * * $14.1861
180130............................ 1.6476 0.9254 $23.4982 $24.8441 $26.0278 $24.8066
180132............................ 1.3469 0.8732 $19.9358 $22.2101 $23.7652 $21.9796
180134............................ 1.0734 0.7780 * $17.3449 $18.6779 $18.0324
180138............................ 1.2131 0.9254 $23.0996 $25.1789 $27.3400 $25.1767
180139............................ 1.0857 0.8732 $20.6287 $21.3797 $23.5363 $21.8425
180141............................ 1.7853 0.9254 $22.6722 $24.3140 $25.3042 $24.1450
180143............................ 1.5170 0.9051 $20.1309 $23.9125 $25.1613 $23.2370
180146............................ 1.9117 0.9595 * * * *
180147............................ 1.3564 0.8214 * * * *
180148............................ 1.6098 0.7780 * * * *
190001............................ 1.0919 0.8993 $20.4946 $19.5680 $19.7516 $19.8963
190002............................ 1.7582 0.8420 $20.7172 $21.7000 $22.0056 $21.4744
190003............................ 1.4846 0.8420 $20.7505 $21.8156 $23.4977 $22.0368
190004............................ 1.3144 0.7895 $20.5272 $22.1835 $23.3290 $21.9727
190005............................ 1.4478 0.8993 $20.0551 $20.7987 $22.3208 $21.0635
190006............................ 1.2800 0.8420 $18.8115 $19.4573 $22.2467 $20.1618
190007............................ 1.1307 0.7438 $17.9392 $18.7854 $19.7528 $18.8587
190008............................ 1.6652 0.7895 $20.3278 $21.4137 $24.0111 $21.9572
190009............................ 1.2108 0.8040 $17.5144 $18.8295 $19.8404 $18.6932
190010............................ 1.1459 0.7839 $18.1797 $19.9788 $21.6889 $19.9508
190011............................ 1.0389 0.8036 $15.4699 $18.1525 $19.7319 $17.7235
190013............................ 1.3473 0.7839 $18.7538 $19.6346 $20.8626 $19.7509
190014............................ 1.1833 0.7438 $17.0630 $17.4740 $22.4596 $18.7727
190015............................ 1.3085 0.8993 $20.6167 $22.1046 $22.8875 $21.9289
190017 \h\........................ 1.3500 0.8655 $18.3528 $18.6962 $21.5033 $19.4006
190018............................ *** * $19.2055 * * $19.2055
190019............................ 1.7107 0.8040 $20.8193 $23.0704 $23.7168 $22.5353
190020............................ 1.1470 0.8596 $18.5659 $19.8505 $21.6136 $19.9828
190025............................ 1.2413 0.7438 $19.9969 $20.4651 $20.8950 $20.4776
190026............................ 1.5333 0.8040 $19.9229 $21.3386 $22.5087 $21.3125
190027............................ 1.6874 0.7839 $19.4057 $21.2449 $21.2526 $20.6470
190034............................ 1.1882 0.7438 $16.8439 $17.5002 $19.6943 $18.0127
190036............................ 1.6697 0.8993 $23.3903 $23.7356 $24.8152 $23.9954
190037............................ 0.9569 0.7839 $15.6062 $16.7629 $18.6393 $17.0499
190039............................ 1.4777 0.8993 $20.4900 $23.3105 $25.6665 $23.2338
190040............................ 1.3328 0.8993 $22.9262 $23.8076 $26.7428 $24.3506
190041............................ 1.4983 0.8758 $21.9983 $23.9082 $24.6734 $23.4433
190043............................ 1.0016 0.7438 $15.7333 $16.8944 $17.3477 $16.6784
190044 \h\........................ 1.2408 0.8420 $17.7460 $19.5304 $19.5567 $18.9595
190045............................ 1.6136 0.8993 $22.8709 $24.0490 $25.3854 $24.1220
190046............................ 1.4259 0.8993 $21.1019 $22.2884 $24.2128 $22.4847
190048............................ 1.0721 0.7438 $18.1698 $18.6148 $19.6288 $18.7855
190049............................ 1.0285 * $19.3768 $20.1229 * $19.7625
190050............................ 1.0919 0.7438 $18.6663 $18.5287 $19.1076 $18.7685
190053............................ 1.1396 0.7438 $13.8037 $15.7258 $16.4968 $15.3819
190054............................ 1.3813 0.7545 $19.9370 $20.3525 $20.1108 $20.1339
190059............................ 0.8461 * $18.3334 $19.2396 * $18.7888
190060............................ 1.5045 0.7839 $20.2207 $22.2517 $23.6278 $22.0195
190064............................ 1.5825 0.8596 $21.1262 $21.5514 $23.3617 $22.0132
190065............................ 1.5073 0.8596 $20.3583 $23.0523 $23.7450 $22.3992
190077............................ 0.8561 0.8036 $17.0480 $18.4043 $18.8409 $18.0986
190078 \h\........................ 1.0179 0.8655 $19.8607 $21.5782 $21.3786 $20.9721
190079............................ 1.2698 0.8993 $20.5000 $21.8158 $21.2546 $21.1972
190081............................ 0.8933 0.7438 $11.4756 $14.9141 $15.6146 $13.9838
190083............................ 0.8765 * $18.4954 $19.2683 * $18.9013
190086............................ 1.2554 0.8758 $18.2005 $18.8306 $19.8823 $18.9783
190088 \h\........................ 1.0856 0.9463 $18.6738 $22.5045 $22.3480 $20.9939
190089............................ 0.9661 * $15.5151 $16.2961 * $15.9103
190090............................ 1.0976 0.7438 $19.0519 $20.0745 $20.2045 $19.8076
190095............................ *** * $16.9519 $8.7302 $18.0174 $17.8930
190098............................ 1.6297 0.8758 $20.7537 $23.0802 $24.6353 $22.7792
190099............................ 1.0348 0.8461 $23.1606 $21.1657 $20.4597 $21.4552
190102............................ 1.6431 0.8420 $22.0190 $23.4618 $25.2267 $23.6255

[[Page 47533]]

190106............................ 1.2127 0.8040 $20.3114 $21.5643 $21.7228 $21.2163
190109............................ 1.1477 0.7895 $16.6515 $17.4842 $18.6524 $17.5941
190110............................ 0.8711 * $16.5007 $19.0611 * $17.8105
190111............................ 1.5859 0.8758 $24.4380 $25.2370 $24.4998 $24.7275
190114............................ 1.0549 0.7438 $13.6101 $14.6258 $15.8031 $14.6821
190115............................ 1.2024 0.8758 $25.4984 $26.0272 $26.6295 $26.0395
190116............................ 1.2579 0.7438 $17.8297 $18.6074 $20.3844 $18.9443
190118............................ 0.9498 0.8758 $17.5060 $19.0200 $19.7025 $18.7558
190122............................ 1.1979 0.8596 $17.7811 $19.3131 $23.7082 $20.0706
190124............................ 1.5411 0.8993 $23.3859 $23.4862 $24.6675 $23.8477
190125............................ 1.6662 0.8036 $21.5692 $22.3976 $23.9649 $22.6514
190128............................ 1.0876 0.8596 $23.8786 $24.7842 $27.9136 $25.5637
190130............................ 0.9548 * $15.2678 $16.6910 * $15.9880
190131............................ 1.2145 0.8993 $21.3154 $22.5032 $25.1917 $22.9740
190133............................ 0.8962 0.7676 $13.4062 $14.3089 $13.6266 $13.7628
190135............................ 1.4655 0.8993 $24.4908 $26.9920 $26.8238 $26.1247
190140............................ 0.9978 0.7438 $15.4030 $17.0371 $17.6936 $16.7104
190144 \h\........................ 1.1534 0.9463 $21.3838 $21.1658 $21.7547 $21.4426
190145............................ 0.9515 0.7438 $17.4407 $17.3361 $18.9678 $17.9319
190146............................ 1.5597 0.8993 $22.1502 $23.7721 $26.1792 $24.0255
190147............................ *** * $16.3596 * * $16.3596
190148............................ 1.0428 * $19.3245 $20.8321 * $20.0526
190149............................ 0.9282 0.7438 $18.4197 $17.1671 $18.8819 $18.1219
190151............................ 1.0245 0.7438 $17.3402 $17.8741 $18.6293 $17.9597
190152............................ 1.3603 0.8993 $25.1136 $27.4708 $27.6099 $26.7879
190156............................ 0.8775 * $18.0528 $18.3702 * $18.2089
190158............................ 1.3827 0.8993 $23.2361 $26.2352 $26.3042 $25.4140
190160............................ 1.5036 0.8036 $19.8428 $20.0025 $21.6740 $20.5204
190161............................ 1.1051 0.7839 $16.5322 $17.8794 $19.1022 $17.8227
190162............................ *** * $20.7350 $22.1781 $25.0328 $22.6102
190164............................ 1.1752 0.8040 $20.2791 $21.4247 $22.8599 $21.6241
190167............................ 1.2233 0.7438 $17.2643 $17.8604 $24.3185 $19.7786
190175............................ 1.3694 0.8993 $22.7574 $24.6790 $27.1531 $25.0038
190176............................ 1.7655 0.8993 $25.2536 $25.8482 $25.6997 $25.6097
190177............................ 1.5808 0.8993 $22.3318 $25.4769 $27.4621 $25.2171
190182............................ 0.9407 0.8993 $23.6016 $25.0837 $28.4799 $25.6314
190183............................ 1.1930 0.7895 $17.1805 $18.3151 $19.8084 $18.4205
190184............................ 1.0092 0.7599 $20.6096 $21.3191 $23.9609 $21.8425
190185............................ 1.3487 0.8993 $29.7870 $24.4176 $24.7912 $25.8807
190190............................ 0.8782 0.7599 $16.2819 $14.0052 $16.1195 $15.4593
190191 \h\........................ 1.3706 0.8461 $21.9141 $22.3755 $23.5734 $22.6642
190196............................ 0.8702 0.8420 $20.7601 $21.9355 $24.7135 $22.5497
190197............................ 1.3549 0.8036 $21.6908 $22.9631 $24.3735 $23.0241
190199............................ 1.1734 0.8596 $19.7776 $18.5317 $14.1410 $17.3575
190200............................ 1.5774 0.8993 $24.1667 $26.4258 $27.5681 $25.9873
190201............................ 1.2956 0.7839 $21.4335 $22.5588 $24.5877 $22.9165
190202............................ 1.2769 0.8596 $22.4062 $21.8900 $24.7944 $23.0825
190203............................ 1.5054 0.8993 $24.9518 $26.9099 $26.8795 $26.2979
190204............................ 1.5090 0.8993 $26.1231 $28.8777 $28.3684 $27.8932
190205............................ 1.7338 0.8420 $20.2374 $21.7696 $24.4540 $22.1979
190206............................ 1.7022 0.8993 $24.2892 $26.9117 $26.0139 $25.7960
190207............................ *** * $21.5325 * * $21.5325
190208............................ 0.8593 0.7438 $23.0838 $24.8409 $24.2586 $24.0684
190218............................ 1.1871 0.8758 $21.6206 $23.9182 $25.0356 $23.6192
190236............................ 1.4525 0.8758 $24.4661 $23.8233 $23.6824 $23.9582
190240............................ 0.9826 * $15.4026 $13.9888 * $14.7116
190241............................ 1.2669 0.7895 $24.2462 $28.9620 $23.9700 $25.7012
190242............................ 1.1361 0.8596 $18.6672 $20.5937 $23.0072 $20.7608
190243............................ *** * * $30.6060 * $30.6060
190245............................ 2.2150 0.8036 * * $27.1786 $27.1786
190246............................ 1.5661 0.7599 * * * *
190249............................ 1.5255 0.8596 * * * *
190250............................ 2.4714 0.8993 * * * *
190251............................ 1.6216 0.8596 * * * *
190252............................ 0.9901 0.8596 * * * *
190253............................ 1.0434 0.8993 * * * *
190254............................ 1.4466 0.8596 * * * *

[[Page 47534]]

190255............................ 0.7772 0.8420 * * * *
190256............................ 1.0194 0.8993 * * * *
190257............................ 1.7195 0.7438 * * * *
190258............................ 1.5399 0.8758 * * * *
190259............................ 1.9052 0.8420 * * * *
190260............................ 1.5277 0.8993 * * * *
190261............................ 0.7151 0.8036 * * * *
190262............................ 1.2664 0.8993 * * * *
190263............................ 2.4990 0.8420 * * * *
200001............................ 1.2994 0.9975 $21.6050 $23.2210 $25.1145 $23.3710
200002............................ 1.1686 0.9874 $22.0700 $24.1446 $25.7478 $23.9468
200007............................ 1.0815 * $21.0603 $22.3920 * $21.7470
200008............................ 1.2589 1.0371 $25.1115 $25.1741 $27.4412 $25.9041
200009............................ 1.9763 1.0371 $24.9041 $28.1409 $31.1056 $28.0391
200012............................ 1.1397 0.8831 $21.8529 $24.1243 $25.7623 $23.9787
200013............................ 1.1054 0.9017 $22.8909 $23.9048 $24.4131 $23.7685
200018............................ 1.1830 0.8831 $21.1330 $24.3294 $23.6337 $23.0851
200019............................ 1.2935 1.0371 $23.1114 $24.0926 $25.1367 $24.1296
200020............................ 1.2570 1.0492 $27.0798 $28.7351 $31.7083 $29.2990
200021............................ 1.1914 1.0371 $24.9925 $25.1027 $24.5519 $24.8792
200024............................ 1.5273 0.9874 $22.9698 $24.6484 $26.0080 $24.6372
200025............................ 1.0698 1.0371 $22.9023 $24.3646 $26.0573 $24.4151
200026............................ 1.0477 * $19.7172 $21.9997 * $20.8927
200027............................ 1.2293 0.8831 $21.0156 $23.2912 $26.3118 $23.4478
200028............................ 1.0453 0.8831 $21.2180 $24.3061 $24.3271 $23.3297
200031............................ 1.3580 0.8831 $18.8262 $20.6202 $21.9489 $20.4626
200032............................ 1.2196 0.9297 $23.0487 $24.2221 $25.5227 $24.3050
200033............................ 1.8626 0.9975 $25.1723 $26.8727 $28.6479 $26.9328
200034............................ 1.3926 0.9874 $23.5415 $26.1150 $26.2926 $25.3574
200037............................ 1.1984 0.8831 $22.6534 $23.3490 $23.2333 $23.0870
200039............................ 1.2758 0.9874 $22.1333 $24.0474 $25.1196 $23.8217
200040............................ 1.2300 1.0371 $21.8528 $23.6791 $25.5405 $23.6763
200041............................ 1.1436 0.8831 $21.3816 $23.6797 $24.5532 $23.3316
200050............................ 1.2576 0.9975 $23.4391 $25.5233 $26.4992 $25.2144
200052............................ 1.0569 0.8831 $19.0535 $22.7763 $21.8726 $21.2769
200063............................ 1.1958 0.9874 $23.0135 $24.7235 $25.0167 $24.2686
200066............................ 1.2469 * $19.5890 $21.6354 * $20.6005
210001............................ 1.4251 0.9647 $22.6614 $26.3144 $27.7561 $25.5750
210002............................ 2.0200 0.9882 $25.6975 $25.2859 $26.4992 $25.8584
210003............................ 1.6590 1.0928 $23.0790 $32.3042 $29.8684 $28.0698
210004............................ 1.4471 1.1499 $29.4841 $29.4300 $34.2392 $31.0347
210005............................ 1.2974 1.1459 $24.7185 $27.1276 $28.7557 $26.8963
210006............................ 1.1056 0.9882 $24.7327 $25.6396 $25.4081 $25.2468
210007............................ 1.9113 0.9882 $27.5104 $28.4496 $30.2548 $28.7829
210008............................ 1.3194 0.9882 $24.6569 $26.3008 $25.2833 $25.4086
210009............................ 1.7719 0.9882 $23.4889 $24.6332 $26.2360 $24.8136
210010............................ *** * $23.7761 $24.5071 $25.7775 $24.7218
210011............................ 1.4035 0.9882 $22.3262 $24.8373 $27.5031 $24.9589
210012............................ 1.6057 0.9882 $25.2892 $25.7934 $27.4103 $26.2116
210013............................ 1.2739 0.9882 $23.0151 $23.9875 $25.1348 $24.0450
210015............................ 1.3351 0.9882 $23.8419 $25.8532 $28.2029 $25.9683
210016............................ 1.7872 1.1499 $27.2632 $28.6992 $32.2081 $29.4293
210017............................ 1.1676 0.9357 $19.0248 $21.3983 $23.2168 $21.2523
210018............................ 1.2269 1.1499 $25.3112 $27.5431 $29.1870 $27.3837
210019............................ 1.7512 0.9357 $23.5259 $24.9252 $26.1824 $24.9054
210022............................ 1.4046 1.1499 $27.6680 $30.1470 $33.8015 $30.5481
210023............................ 1.4601 1.0091 $26.7837 $29.0844 $30.4656 $28.8005
210024............................ 1.6921 0.9882 $24.8939 $27.1756 $29.5579 $27.2560
210025............................ 1.2415 0.9357 $22.8882 $23.8943 $26.0771 $24.3114
210027............................ 1.4867 0.9357 $19.3517 $23.9255 $26.0111 $22.9283
210028............................ 1.0874 0.9357 $22.4054 $24.1265 $25.9221 $24.1901
210029............................ 1.2477 0.9882 $26.2082 $31.2888 $27.9741 $28.3176
210030............................ 1.2689 0.9357 $20.7802 $27.5507 $29.5635 $25.7209
210032............................ 1.1442 1.0516 $20.3407 $25.7138 $26.1829 $23.9925
210033............................ 1.1745 0.9882 $25.0301 $26.6113 $29.0420 $26.9838
210034............................ 1.2975 0.9882 $22.8827 $26.3896 $28.4308 $25.7800
210035............................ 1.3293 1.0928 $21.6973 $24.5198 $26.1082 $24.1712

[[Page 47535]]

210037............................ 1.1871 0.9357 $23.5536 $24.1913 $27.0973 $24.9552
210038............................ 1.2500 0.9882 $26.5696 $28.3414 $29.5980 $28.1851
210039............................ 1.1125 1.0928 $24.0987 $25.8415 $27.6940 $25.8514
210040............................ 1.2688 0.9882 $25.4729 $28.3723 $29.3514 $27.8674
210043............................ 1.3169 1.0091 $22.2177 $24.3070 $27.5657 $24.7038
210044............................ 1.3613 0.9882 $23.8101 $24.8083 $28.8700 $25.7966
210045............................ 1.0532 0.9357 $11.8350 $15.0867 $15.6380 $14.3653
210048............................ 1.3276 1.0169 $24.4328 $25.0617 $28.4638 $26.0370
210049............................ 1.2425 0.9882 $24.7148 $25.9342 $26.9656 $25.9278
210051............................ 1.3323 1.0928 $25.7103 $27.3692 $29.2998 $27.5052
210054............................ 1.3523 1.0928 $27.3551 $24.6658 $26.2295 $26.0806
210055............................ 1.2162 1.0928 $27.4218 $28.0014 $29.9708 $28.5097
210056............................ 1.3306 0.9882 $23.5881 $26.6884 $28.6091 $26.3638
210057............................ 1.4047 1.1499 $27.3520 $29.2233 $32.2883 $29.7939
210058............................ 1.1672 0.9882 $22.0351 $24.8576 $29.7841 $25.5191
210060............................ 1.1733 1.0928 $25.8377 $28.7531 $28.5087 $27.8143
210061............................ 1.2516 0.9357 $22.5455 $24.1369 $23.6662 $23.5086
220001............................ 1.2205 1.1274 $25.8030 $27.3238 $29.0014 $27.3878
220002............................ 1.3882 1.1415 $26.3348 $28.9722 $30.3598 $28.5921
220003............................ 1.1608 1.1274 $18.8150 $20.5790 $22.0549 $20.5049
220006............................ 1.5147 1.1021 $27.1576 $29.5946 $30.8599 $29.3270
220008............................ 1.2538 1.0954 $25.6647 $27.1675 $30.1043 $27.7253
220010............................ 1.2902 1.1274 $24.5020 $27.4161 $29.7998 $27.3015
220011............................ 1.1378 1.1415 $32.2266 $32.6624 $34.4064 $33.2336
220012............................ 1.4927 1.2592 $32.0521 $32.9791 $35.7872 $33.6778
220015............................ 1.1862 1.0715 $25.0272 $25.5449 $28.3397 $26.3904
220016............................ 1.1279 1.0715 $25.7740 $26.8798 $28.0609 $26.8986
220017............................ 1.3293 1.1551 $28.9024 $28.8264 $29.7108 $29.1461
220019............................ 1.2167 1.1274 $21.6620 $22.2294 $23.2544 $22.3943
220020............................ 1.2576 1.0954 $23.5737 $24.2279 $26.5305 $24.8270
220024............................ 1.2616 1.0715 $24.1071 $25.5837 $27.3488 $25.6784
220025............................ 1.1054 1.1274 $23.2374 $24.5186 $23.0637 $23.5753
220028............................ 1.4583 1.1274 $31.4858 $31.3592 $32.0980 $31.6438
220029............................ 1.1257 1.1274 $27.4792 $28.1432 $28.6970 $28.1288
220030............................ 1.1225 1.0715 $20.0816 $23.6257 $24.4289 $22.7602
220031............................ 1.5516 1.1551 $30.8324 $32.2660 $34.8183 $32.6251
220033............................ 1.1970 1.1274 $25.4500 $26.8049 $28.2539 $26.9214
220035............................ 1.3982 1.1274 $26.8486 $27.5533 $28.6238 $27.6997
220036............................ 1.5239 1.1551 $28.2182 $29.6296 $31.5184 $29.8330
220041............................ *** * $28.8184 $29.7464 * $29.2230
220046............................ 1.3664 1.1274 $26.1955 $27.7726 $28.1396 $27.3951
220049............................ 1.1613 1.1415 $26.7688 $27.0464 $27.7517 $27.2011
220050............................ 1.1404 1.0715 $23.7326 $24.9945 $26.3768 $25.0718
220051............................ 1.2220 1.0715 $22.2965 $26.5575 $29.8380 $26.3369
220052............................ 1.1719 1.1551 $26.3043 $28.0925 $29.8577 $28.1429
220058............................ 1.0134 1.1274 $22.4885 $25.0598 $24.9642 $24.1665
220060............................ 1.1946 1.2303 $29.6960 $30.8242 $32.3362 $31.0565
220062............................ 0.5902 1.1274 $22.6598 $21.9489 $24.2779 $22.9699
220063............................ 1.2060 1.1415 $23.3704 $25.5840 $27.3967 $25.3936
220065............................ 1.2350 1.0715 $22.4143 $24.8737 $26.5513 $24.6535
220066............................ 1.3008 1.0715 $27.5575 $26.2561 $27.1317 $26.9786
220067............................ 1.1875 1.1551 $22.4968 $28.5220 $29.8911 $26.7470
220070............................ 1.1508 1.1415 $26.2697 $28.9100 $31.9283 $28.7436
220071............................ 1.8769 1.1551 $27.7773 $31.8322 $32.2936 $30.6814
220073............................ 1.2301 1.0954 $27.9309 $29.2399 $31.3566 $29.4912
220074............................ 1.3075 1.1551 $25.7840 $27.5763 $28.4930 $27.3187
220075............................ 1.4268 1.1551 $26.0527 $27.9503 $29.1588 $27.7387
220076............................ *** * $24.8040 $27.2534 $29.7507 $27.1315
220077............................ 1.7218 1.1075 $27.0946 $28.0935 $30.2684 $28.5352
220080............................ 1.2205 1.1274 $24.7399 $27.1578 $28.9835 $27.0784
220082............................ 1.2599 1.1415 $23.9542 $24.8060 $26.9841 $25.2609
220083............................ 1.1206 1.1551 $28.3533 $29.9001 $32.9143 $30.3719
220084............................ 1.2324 1.1415 $26.8596 $29.0505 $32.5711 $29.5958
220086............................ 1.7352 1.1551 $29.4911 $31.7482 $34.3667 $31.8192
220088............................ 1.8304 1.1551 $26.5849 $28.5711 $28.5462 $27.9606
220089............................ 1.2531 1.1415 $28.9252 $32.4409 $31.1708 $30.8836
220090............................ 1.2045 1.1274 $26.5552 $29.7945 $30.8685 $29.1558

[[Page 47536]]

220095............................ 1.1124 1.1274 $23.7629 $24.9871 $27.4273 $25.3894
220098............................ 1.1795 1.1415 $26.2287 $26.8538 $28.8314 $27.2888
220100............................ 1.2965 1.1551 $27.0265 $28.4848 $29.6912 $28.4369
220101............................ 1.3346 1.1415 $26.9992 $31.0834 $33.1690 $30.4912
220105............................ 1.2283 1.1415 $26.7570 $30.0892 $31.9421 $29.7099
220108............................ 1.2295 1.1551 $26.0166 $29.0804 $30.6252 $28.5516
220110............................ 2.0817 1.1551 $33.0445 $35.4242 $36.6084 $35.0926
220111............................ 1.2101 1.1551 $27.7395 $28.9092 $31.1850 $29.2950
220116............................ 2.0287 1.1551 $30.9871 $32.2337 $32.9988 $32.0845
220119............................ 1.1583 1.1551 $25.9789 $27.8372 $30.1056 $28.0781
220126............................ 1.1634 1.1551 $26.9853 $26.7660 $28.7805 $27.5408
220133............................ *** * $33.0819 $31.2981 $33.6003 $32.6683
220135............................ 1.3124 1.2592 $31.9159 $31.3246 $33.9866 $32.4440
220153............................ 1.0242 1.0715 * $18.9267 * $18.9267
220154............................ 0.9702 1.1551 $25.6069 $30.9009 $28.6462 $28.0721
220162............................ 1.3910 * * * * *
220163............................ 1.6274 1.1274 $29.9312 $30.5056 $33.6484 $31.2574
220171............................ 1.7493 1.1415 $27.2647 $28.9733 $30.4036 $28.9007
220174............................ 1.1913 1.1274 * $30.3356 $31.7572 $31.0464
230001............................ 1.1136 * $22.0875 $24.3660 * $23.2049
230002............................ 1.3022 1.0436 $23.7972 $27.0305 $29.1410 $26.7010
230003............................ 1.2080 1.0393 $22.4322 $25.2596 $26.1278 $24.6604
230004............................ 1.7070 1.0393 $23.0827 $25.5573 $26.7206 $25.1973
230005 \h\........................ 1.2383 1.0874 $20.3750 $22.1018 $24.1902 $22.4061
230006............................ 1.1371 0.9788 $22.0733 $22.7656 $23.8835 $22.9495
230013............................ 1.3752 1.0461 $20.4633 $22.7014 $23.7822 $22.3686
230015............................ 1.0463 0.9325 $21.7640 $23.4512 $24.6570 $23.3267
230017............................ 1.6296 1.0393 $26.1609 $27.3259 $29.5178 $27.7392
230019............................ 1.5743 1.0461 $24.7472 $27.6563 $28.4575 $26.9496
230020............................ 1.6919 1.0570 $25.8267 $26.8516 $29.2869 $27.3788
230021............................ 1.5257 0.9102 $22.0757 $23.4663 $24.9551 $23.5352
230022............................ 1.2333 1.0570 $22.2179 $22.2528 $23.3000 $22.6032
230024............................ 1.5606 1.0570 $24.7364 $27.6555 $30.0813 $27.3385
230027............................ 1.0877 0.9389 $21.2223 $22.5736 $23.5511 $22.4431
230029............................ 1.6623 1.0461 $26.7646 $27.9012 $29.0935 $27.9121
230030............................ 1.2630 0.8966 $19.9853 $20.9867 $22.3174 $21.1301
230031............................ 1.3895 0.9868 $22.1874 $23.2910 $25.4678 $23.7275
230032............................ *** * $23.8366 * * $23.8366
230034............................ 1.2255 0.8966 $18.5768 $20.9195 $26.7967 $22.0680
230035............................ 1.3094 0.9389 $18.0735 $20.9197 $21.2317 $19.9973
230036............................ 1.3643 1.0461 $25.9801 $26.5854 $28.3622 $26.9984
230037............................ 1.2368 1.0570 $24.4115 $24.7875 $26.2000 $25.1648
230038............................ 1.6919 1.0393 $23.4685 $25.2499 $26.3480 $25.2371
230040............................ 1.2081 0.9389 $21.8062 $21.9813 $24.2349 $22.7262
230041............................ 1.4920 0.9624 $24.2297 $25.2518 $26.1760 $25.1852
230042............................ 1.1974 0.8966 $21.8241 $24.3640 $26.2037 $24.1687
230046............................ 1.8655 1.0874 $28.2320 $29.2683 $30.3591 $29.3515
230047............................ 1.4049 1.0436 $24.3622 $26.2447 $28.1351 $26.3210
230053............................ 1.6133 1.0570 $26.1415 $28.3030 $29.8703 $28.0492
230054............................ 2.0488 0.9470 $23.0818 $24.0137 $24.9905 $24.0601
230055............................ 1.2763 0.8966 $20.9350 $23.7671 $25.4143 $23.4450
230058............................ 1.1537 0.8966 $22.4516 $21.9308 $24.0657 $22.7966
230059............................ 1.4459 1.0393 $21.2743 $23.1451 $25.5350 $23.3695
230060............................ 1.2928 0.8966 $22.3512 $24.5073 $25.5015 $24.1280
230065............................ *** * $26.3217 $27.9179 $28.4631 $27.5421
230066............................ 1.3207 1.0393 $23.9696 $25.8517 $27.4928 $25.8295
230069............................ 1.1955 1.0461 $26.0438 $27.6815 $29.5556 $27.8051
230070............................ 1.6029 0.9140 $22.8588 $25.1587 $24.2342 $24.0769
230071............................ 0.9724 1.0461 $23.6674 $24.7707 $26.3907 $24.9681
230072............................ 1.3973 1.0393 $22.9626 $24.1560 $24.4933 $23.9114
230075............................ 1.3516 0.9635 $22.6799 $24.1482 $27.6193 $24.8869
230077............................ 1.9571 1.0461 $29.2041 $27.3117 $27.6157 $27.9729
230078............................ 1.0412 0.8966 $20.5427 $21.9200 $23.9901 $22.2077
230080............................ 1.2788 0.8966 $20.2405 $21.2840 $21.2314 $20.9185
230081............................ 1.2023 0.8966 $20.4289 $20.6777 $23.0788 $21.3975
230082............................ 1.0277 0.8966 $21.3100 $23.1240 $22.2165 $22.1964
230085............................ 1.2412 1.0393 $24.2802 $22.2569 $22.7314 $23.1872

[[Page 47537]]

230086............................ 1.1486 * $27.8923 $20.8759 * $24.2011
230087............................ *** * $22.2688 * $16.9168 $19.0752
230089............................ 1.3664 1.0570 $23.3847 $23.9486 $28.7015 $25.3973
230092............................ 1.2812 0.9680 $22.3122 $24.3768 $26.3584 $24.3257
230093............................ 1.1695 0.9389 $25.1213 $24.5055 $26.4967 $25.3702
230095............................ 1.2598 0.8966 $19.1810 $19.2244 $21.3915 $19.9401
230096............................ 1.1759 1.0393 $26.7156 $26.7578 $28.7681 $27.4077
230097............................ 1.8168 1.0393 $22.9902 $25.2104 $26.5773 $24.9608
230099............................ 1.2146 1.0570 $23.5490 $25.0390 $26.4882 $25.0486
230100............................ 1.1053 0.8966 $19.8016 $20.4565 $21.8895 $20.6965
230101............................ 1.0939 0.8966 $22.3310 $23.1349 $24.3772 $23.3147
230103............................ 1.0133 0.9788 $19.4434 $18.4304 $21.6609 $19.7646
230104............................ 1.5419 1.0570 $27.4119 $27.8864 $30.5570 $28.5801
230105............................ 1.9466 0.9525 $23.9851 $24.6853 $27.2705 $25.3146
230106............................ 1.1233 1.0393 $23.1962 $24.1128 $24.3980 $23.9236
230108............................ 1.1591 0.8966 $19.9842 $22.4966 $18.4063 $20.1757
230110............................ 1.2615 0.8966 $21.5523 $22.7621 $28.7704 $24.4693
230117............................ 1.8928 1.0393 $28.1220 $29.6361 $29.4775 $29.0873
230118............................ 1.0682 0.8966 $22.2208 $21.4886 $22.3636 $22.0278
230119............................ 1.3259 1.0570 $25.3562 $29.2509 $30.2441 $27.9914
230120 \h\........................ 1.1166 1.0874 $22.7243 $21.7894 $24.1485 $22.9095
230121............................ 1.2558 0.9788 $22.3708 $23.4394 $24.5220 $23.4095
230124............................ 1.3249 * $22.0097 $23.0508 * $22.5308
230130............................ 1.7417 1.0461 $23.7854 $26.9907 $26.6076 $25.8001
230132............................ 1.4061 1.0644 $29.0292 $29.9106 $30.5318 $29.8191
230133............................ 1.4148 0.8966 $20.4801 $21.2273 $24.3175 $22.0722
230135............................ 1.1266 1.0570 $19.8290 $23.9000 $25.8406 $23.1673
230141............................ 1.6549 1.0644 $23.9885 $30.4643 $28.6326 $27.6090
230142............................ 1.2687 1.0436 $22.9036 $25.6044 $26.9433 $25.2019
230143............................ 1.2616 0.8966 $19.5446 $19.5387 $21.4083 $20.1494
230144............................ 2.1498 * $23.6959 * * $23.6959
230145............................ 1.1530 * $15.8192 $17.2181 * $16.5158
230146............................ 1.2683 1.0570 $21.3539 $24.3891 $26.3432 $24.1395
230149............................ 0.9481 * $20.8933 $21.4753 * $21.1778
230151............................ 1.3327 1.0461 $23.8527 $26.4669 $28.2243 $26.2186
230153............................ 1.1020 0.9788 $22.8584 $22.3404 $22.8644 $22.6896
230155............................ 1.0473 * $18.0743 $24.0404 * $20.6336
230156............................ 1.5973 1.0874 $27.7164 $29.4855 $31.1909 $29.5181
230165............................ 1.7254 1.0570 $25.9534 $27.3164 $28.9636 $27.4184
230167............................ 1.6214 0.9788 $24.7935 $26.6828 $27.4562 $26.3153
230169............................ *** * $24.9265 $27.1172 $31.8442 $27.6798
230171............................ 1.0689 * $19.9097 $22.0635 * $20.9931
230172............................ 1.2378 1.0393 $23.0023 $24.0236 $25.7402 $24.2756
230174............................ 1.3643 1.0393 $24.4671 $26.2770 $27.6920 $26.1839
230175............................ *** * $22.5964 * * $22.5964
230176............................ 1.2540 1.0570 $24.6675 $25.6777 $27.3605 $26.1023
230180............................ 1.0980 0.8966 $20.9832 $22.5454 $24.7358 $22.8206
230184............................ 1.2060 0.9680 $21.4031 $21.9346 $23.6707 $22.3438
230186............................ *** * $21.6147 $27.1126 $26.2282 $24.5338
230188............................ 0.9386 * $18.8076 * * $18.8076
230189............................ 1.0084 0.8966 $22.7783 $20.8605 $23.0099 $22.2035
230190............................ 1.0096 1.0393 $27.3430 $28.7365 $29.9604 $28.6717
230193............................ 1.2826 0.9868 $22.8916 $24.3181 $23.3565 $23.5189
230195............................ 1.4454 1.0436 $25.3285 $27.1266 $28.2892 $26.9865
230197............................ 1.5759 1.0644 $26.9840 $28.3439 $30.0367 $28.4836
230204............................ 1.3229 1.0436 $24.4095 $25.9871 $29.1466 $26.3875
230207............................ 1.3781 1.0461 $22.2848 $22.2854 $24.5201 $23.0106
230208............................ 1.2059 0.9389 $20.3171 $20.9420 $21.9651 $21.0908
230212............................ 1.0320 1.0874 $26.0656 $27.3686 $29.7980 $27.6833
230216............................ 1.5747 0.9868 $23.4262 $26.1468 $27.5230 $25.7787
230217............................ 1.2944 0.9788 $24.3650 $26.7929 $28.6075 $26.7623
230222 \h\........................ 1.3316 0.9368 $24.6101 $24.8925 $26.9724 $25.4947
230223............................ 1.2948 1.0461 $28.5549 $27.1503 $29.2853 $28.3304
230227............................ 1.5114 1.0436 $27.7510 $28.1105 $29.5798 $28.4993
230230............................ 1.5119 0.9788 $23.9568 $25.4471 $27.9607 $25.8281
230235............................ 1.0369 0.8966 $19.9118 $19.6046 $21.8777 $20.4653
230236............................ 1.4349 1.0393 $25.7463 $26.3988 $28.4754 $26.9289

[[Page 47538]]

230239............................ 1.2193 0.8966 $19.8370 $21.1643 $22.1040 $21.0930
230241............................ 1.1743 0.9868 $24.2063 $25.8671 $27.4890 $25.8668
230244............................ 1.3568 1.0436 $23.9004 $25.3817 $26.4326 $25.2154
230254............................ 1.3507 1.0461 $24.2594 $26.4431 $28.1216 $26.2901
230257............................ 1.0361 1.0436 $24.8069 $25.4086 $27.8197 $25.8794
230259............................ 1.2125 1.0874 $24.8598 $24.3067 $26.8677 $25.3750
230264............................ 2.0733 1.0436 $17.4847 $19.9992 $19.2398 $19.0176
230269............................ 1.3677 1.0461 $25.3367 $27.4732 $28.8187 $27.2692
230270............................ 1.2712 1.0570 $22.8842 $26.1113 $27.8488 $25.6802
230273............................ 1.4501 1.0570 $25.8466 $30.2209 $29.9307 $28.6762
230275............................ 0.4648 0.9140 $29.4180 $30.2244 $23.1095 $27.7059
230276............................ *** * $23.4928 * * $23.4928
230277............................ 1.3829 1.0461 $25.3378 $26.9231 $29.1973 $27.2248
230279............................ 0.5490 1.0461 $21.2467 $23.1636 $24.7673 $22.9663
230283............................ 0.8715 1.0436 $25.0038 $24.9272 $26.2622 $25.3910
230288............................ *** * $30.3422 * * $30.3422
230289............................ *** * * * $29.7720 $29.7720
230290............................ *** * * $29.4792 * $29.4792
230291............................ *** * * * $30.9655 $30.9655
230292............................ *** * * * $31.8943 $31.8943
230296............................ 1.9453 0.9788 * * * *
240001............................ 1.5150 1.1052 $28.2239 $29.9123 $31.5753 $29.9731
240002............................ 1.8323 1.0226 $24.7674 $26.9608 $28.9860 $26.9851
240004............................ 1.5506 1.1052 $26.8197 $27.8796 $30.8072 $28.5006
240006............................ 1.0563 1.1116 $29.5789 $30.2330 $30.1950 $30.0237
240007............................ 1.1570 * $21.4367 $23.7588 * $22.6144
240010............................ 2.0308 1.1116 $29.0955 $30.4139 $31.3733 $30.3196
240011............................ 1.0533 * $24.0364 $22.9561 * $23.3835
240013............................ 1.2714 1.0900 $27.3855 $28.7202 $28.3860 $28.1704
240014............................ 1.0255 1.1052 $26.5144 $28.3788 $29.8623 $28.2985
240016............................ 1.2643 0.9132 $25.2629 $24.9211 $26.7814 $25.7376
240017............................ 1.2581 0.9132 $21.6243 $23.3314 $24.4417 $23.1535
240018............................ 1.2280 1.0900 $27.3634 $27.9218 $25.6236 $26.6208
240019............................ 1.1515 1.0226 $25.1331 $27.5441 $28.6723 $27.1439
240020............................ 1.0854 1.1052 $24.7516 $28.1568 $31.2443 $28.0203
240021............................ 0.8740 1.0052 $23.9568 $23.7096 $27.1235 $24.8433
240022............................ 1.1089 0.9132 $23.4702 $23.7368 $25.2066 $24.1392
240025............................ 1.0799 * $21.2597 $27.8656 * $24.3444
240027............................ 0.9514 0.9132 $18.3340 $20.2531 $18.2481 $18.8765
240029............................ 1.0910 0.9132 $21.2342 $24.3017 $25.3568 $23.3870
240030............................ 1.3509 0.9775 $22.0200 $23.3753 $24.7154 $23.4178
240031............................ 0.9576 * $23.4389 $26.7242 $26.7778 $25.6303
240036............................ 1.6930 1.0900 $23.4857 $27.0821 $28.0812 $26.3323
240037............................ 1.0462 * $21.8392 $24.3986 * $23.1115
240038............................ 1.5325 1.1052 $28.9676 $29.8465 $31.0779 $30.0073
240040............................ 1.0971 1.0226 $21.3870 $26.3177 $27.4895 $24.8843
240043............................ 1.1474 0.9132 $19.5532 $20.7155 $21.8685 $20.7481
240044............................ 1.1223 1.0000 $22.7482 $24.3009 $22.0973 $22.9999
240045............................ 1.1155 * $25.9223 $26.1743 * $26.0530
240047............................ 1.5788 1.0226 $29.6184 $29.1211 $28.8288 $29.1562
240050............................ 1.0371 1.1052 $24.7589 $26.6687 $26.4854 $26.0710
240052............................ 1.2117 0.9132 $23.5898 $24.9870 $26.4256 $25.0236
240053............................ 1.4271 1.1052 $26.7122 $28.4733 $29.5315 $28.3118
240056............................ 1.2482 1.1052 $28.5169 $30.8619 $31.6623 $30.4153
240057............................ 1.8689 1.1052 $27.7600 $29.4870 $30.6258 $29.3431
240059............................ 1.0941 1.1052 $27.0517 $28.6340 $29.7916 $28.5358
240061............................ 1.7548 1.1116 $28.7372 $30.0031 $30.6383 $29.8381
240063............................ 1.5720 1.1052 $26.7960 $29.9603 $32.3487 $29.6692
240064............................ 1.2696 1.0226 $24.9928 $26.6996 $29.9662 $27.5790
240066............................ 1.3865 1.1052 $27.4066 $30.2716 $33.4532 $30.4657
240069............................ 1.1509 1.1116 $25.6943 $27.4990 $28.9496 $27.4534
240071............................ 1.1507 1.1116 $24.8036 $26.4780 $28.0585 $26.4808
240075............................ 1.2095 0.9775 $24.4084 $26.6607 $26.1956 $25.7681
240076............................ 1.1103 1.1052 $26.7112 $28.4519 $29.8562 $28.4067
240077............................ *** * $18.9735 * * $18.9735
240078............................ 1.6081 1.1052 $27.5066 $30.5339 $32.3235 $30.0485
240079............................ 0.9659 * $20.6644 $20.9220 * $20.8010

[[Page 47539]]

240080............................ 1.7263 1.1052 $27.8807 $29.6274 $31.6828 $29.7638
240083............................ 1.2421 0.9132 $24.4352 $25.0214 $26.6582 $25.4096
240084............................ 1.1324 1.0226 $23.9942 $24.7856 $26.8142 $25.2047
240087............................ 1.0337 * $20.1002 $24.8479 * $22.4032
240088............................ 1.2796 0.9775 $25.5587 $27.6323 $28.0825 $27.1245
240089............................ *** * $23.4028 * * $23.4028
240093............................ 1.3386 1.0900 $22.3968 $23.7785 $25.5805 $23.9303
240094............................ 1.0933 * $24.4166 $27.3974 * $25.9702
240097............................ *** * $34.2810 * * $34.2810
240100............................ 1.3081 0.9132 $24.7500 $25.3269 $27.6299 $25.9040
240101............................ 1.1448 0.9132 $24.3455 $26.6078 $25.5355 $25.5132
240103............................ 1.0756 0.9132 $20.2324 $22.5416 $22.7078 $21.8542
240104............................ 1.1434 1.1052 $27.4946 $30.1392 $31.4306 $29.9577
240106............................ 1.5040 1.1052 $25.5890 $27.5171 $29.3455 $27.5527
240107............................ 0.9266 * $24.5583 $25.5199 * $25.0405
240109............................ 0.9571 0.9132 $14.5892 $15.2076 $16.5051 $15.4279
240115............................ 1.6254 1.1052 $27.0312 $29.0261 $31.3869 $29.1786
240117............................ 1.1426 0.9132 $20.1436 $22.0463 $23.6230 $21.9434
240121............................ 0.9181 * $24.5455 * * $24.5455
240122............................ 0.9991 * $23.5331 * * $23.5331
240123............................ 1.0632 0.9132 $20.0721 $20.5755 $21.7500 $20.8397
240124............................ 0.9935 * $23.5139 $23.9297 * $23.7277
240127............................ *** * $19.3857 $24.4824 * $21.5460
240128............................ 1.0317 0.9132 $20.1960 $21.2638 $21.5791 $21.0226
240132............................ 1.2709 1.1052 $26.7063 $29.5310 $31.7139 $29.3306
240133............................ 1.1454 * $23.6068 $26.1836 * $24.8841
240135............................ *** * $17.8573 $16.1837 * $16.9824
240137............................ 1.2132 * $23.1752 $23.8666 * $23.5315
240139............................ 1.0823 * $22.4473 $23.7898 * $23.1612
240141............................ 1.0302 1.1052 $25.1597 $26.7173 $26.4016 $26.1666
240143............................ 0.8573 0.9132 $18.9442 $21.1180 $21.7416 $20.6376
240145............................ *** * $22.6063 * * $22.6063
240152............................ 0.9381 * $25.4031 $27.3445 $29.6196 $27.5602
240154............................ 1.0445 0.9270 $21.3809 $23.9643 * $22.6453
240162............................ 1.1550 0.9132 $20.4807 $22.3136 $22.2721 $21.7043
240166............................ 1.1188 0.9132 $21.5002 $23.4265 $25.7509 $23.5628
240179............................ 0.8477 * $19.8249 $20.8449 * $20.3419
240187............................ 1.2042 1.0900 $24.8879 $26.5129 $27.8811 $26.4667
240196............................ 0.7590 1.1052 $27.2901 $28.9380 $30.7719 $29.0287
240205............................ 0.9108 * * * * *
240206............................ 0.9071 1.4448 * * * *
240207............................ 1.2158 1.1052 $27.4330 $29.2395 $31.7665 $29.5904
240210............................ 1.2547 1.1052 $26.6545 $29.7227 $32.1564 $29.5372
240211............................ 0.9342 1.0900 $32.8801 $44.4214 $18.8503 $27.6876
240213............................ 1.3162 1.1052 $27.5104 $31.3974 $32.7532 $30.8794
250001............................ 1.8740 0.8304 $20.9338 $21.9176 $22.7827 $21.9287
250002............................ 0.8830 0.8603 $21.6643 $20.1310 $23.3845 $21.6434
250004............................ 1.8410 0.9148 $20.9295 $20.6828 $24.1065 $21.8737
250006............................ 1.0537 0.9148 $20.3061 $21.4038 $24.0191 $21.9290
250007............................ 1.2501 0.8913 $21.2226 $23.6933 $25.8710 $23.5817
250009............................ 1.2499 0.8790 $19.7610 $20.4329 $22.2323 $20.8522
250010............................ 0.9858 0.7688 $17.6204 $19.4130 $19.4403 $18.8097
250012............................ 0.9474 0.9402 $15.6117 $20.0493 $20.2921 $18.4571
250015............................ 1.0283 0.7688 $19.3794 $20.6931 $20.7555 $20.2702
250017............................ 1.0990 0.7688 $19.0436 $18.1013 $21.3950 $19.5260
250018............................ 0.9187 0.7688 $16.8783 $17.0689 $16.6294 $16.8678
250019............................ 1.5751 0.8913 $22.9085 $22.8358 $23.9741 $23.2493
250020............................ 0.9907 0.7688 $19.1877 $19.3390 $21.4019 $19.9847
250021............................ *** * $15.8485 $15.1242 $20.3559 $16.0142
250023............................ 0.8489 0.8603 $14.7355 $16.1820 $16.2418 $15.7024
250025............................ 1.0467 0.7688 $21.2651 $20.6892 $20.5258 $20.8816
250027............................ 0.9980 0.7688 $17.5937 $17.3313 $17.3481 $17.4314
250030............................ *** * $27.2140 * * $27.2140
250031............................ 1.3065 0.8174 $21.0894 $22.0850 $21.4326 $21.5380
250034............................ 1.5522 0.9148 $20.3681 $20.6752 $24.3189 $21.8100
250035............................ 0.8612 0.7688 $17.1071 $14.6149 $17.2045 $16.2933
250036............................ 1.0134 0.8156 $17.0469 $17.8313 $19.1975 $18.0476

[[Page 47540]]

250037............................ 0.8781 0.7688 $16.6347 $17.4463 $17.4012 $17.1789
250038............................ 0.9918 0.8304 $16.8610 $18.0209 $18.9050 $17.9032
250039............................ 0.9235 0.8304 $16.8729 $15.2939 $17.3155 $16.4505
250040............................ 1.4785 0.8603 $20.8178 $21.3451 $23.2285 $21.8161
250042............................ 1.2257 0.9148 $19.4367 $21.4117 $23.4135 $21.3957
250043............................ 1.0459 0.7688 $17.7554 $18.3322 $19.8098 $18.6971
250044............................ 1.0268 0.7688 $20.3711 $21.1198 $23.3862 $21.6199
250045............................ 1.0860 0.8955 $25.3236 $25.0863 $26.3831 $25.6144
250048............................ 1.5885 0.8304 $19.3635 $21.6547 $22.9765 $21.3756
250049............................ 0.8502 0.7688 $13.4396 $17.8154 $17.7005 $16.2411
250050............................ 1.1938 0.7688 $16.6723 $18.3170 $19.1467 $18.0183
250051............................ 0.8440 0.7688 $10.5027 $10.6908 $10.6095 $10.6008
250057............................ 1.1364 0.7688 $19.0571 $19.6789 $20.1900 $19.6573
250058............................ 1.2634 0.7688 $16.5565 $17.5160 $18.1704 $17.4280
250059............................ 0.9887 0.7688 $19.0733 $17.7270 $19.2977 $18.6884
250060............................ 0.7969 0.7688 $14.0155 $20.8115 $16.8247 $17.2475
250061............................ 0.8471 0.7688 $11.4573 $15.2515 $12.8174 $12.9127
250065............................ 0.8335 * $16.2010 $16.1984 * $16.1997
250066............................ 0.7772 * $16.1044 * * $16.1044
250067............................ 1.0575 0.7688 $20.0430 $20.1261 $21.6911 $20.6215
250068............................ 0.7710 * $16.3759 $16.9585 * $16.6506
250069............................ 1.5154 0.8648 $21.2224 $21.6617 $22.8162 $21.9460
250071............................ 0.8510 * $13.7056 $17.7149 * $15.4400
250072............................ 1.5086 0.8304 $20.7827 $22.9316 $24.6587 $22.7773
250077............................ 0.9511 0.7688 $14.0318 $14.2271 $14.7632 $14.3259
250078 \2\........................ 1.6194 0.8603 $17.5186 $18.6563 $20.9354 $19.1036
250079............................ 0.8399 0.8174 $21.3506 $27.2549 $38.0031 $29.5848
250081............................ 1.2491 0.8174 $20.4513 $21.3830 $24.7031 $21.9463
250082............................ 1.2880 0.8091 $19.5962 $20.5212 $19.6966 $19.9404
250083............................ 0.9197 * $19.5217 $19.9484 * $19.7505
250084............................ 1.1778 0.7688 $22.4632 $21.8001 $18.5775 $20.7280
250085............................ 0.9636 0.7688 $18.0473 $18.7367 $19.7007 $18.8283
250089............................ 1.0566 * $16.0203 * * $16.0203
250093............................ 1.2244 0.7688 $17.4413 $18.8001 $21.3237 $19.1985
250094............................ 1.5974 0.8603 $19.9619 $22.3312 $22.7312 $21.7001
250095............................ 1.0096 0.7688 $18.6616 $19.9553 $21.3511 $19.9748
250096............................ 1.0813 0.8304 $20.7246 $22.7458 $22.6298 $22.0767
250097............................ 1.4095 0.8461 $18.8399 $19.4534 $20.1687 $19.4858
250098............................ *** * $17.9561 * * $17.9561
250099............................ 1.2497 0.8174 $18.2504 $19.0333 $19.5797 $18.9671
250100............................ 1.4599 0.8648 $18.8877 $22.0328 $24.2209 $21.7570
250101............................ *** * * $21.2234 $19.3543 $20.1785
250102............................ 1.5659 0.8304 $21.3213 $22.5518 $24.2868 $22.7655
250104............................ 1.4476 0.8174 $20.5035 $21.4431 $22.6591 $21.5782
250105............................ 0.9055 0.7688 $17.0136 $17.9468 $18.1196 $17.6992
250107............................ 0.9099 0.7688 $16.7104 $16.5369 $17.8999 $17.0742
250112............................ 0.9532 0.7688 $16.8696 $19.6172 $21.2824 $19.4217
250117............................ 1.0427 0.8603 $18.8863 $19.9774 $23.3673 $20.6608
250119............................ *** * $17.1373 * * $17.1373
250120............................ 1.0523 0.7688 $22.9071 $22.7607 $23.4277 $23.0135
250122............................ 1.0743 0.8603 $19.7966 $23.7230 $24.5854 $22.7156
250123............................ 1.2646 0.8913 $22.2184 $22.0486 $24.5115 $22.9495
250124............................ 0.8452 0.8304 $15.6866 $15.4343 $17.2181 $16.1302
250125............................ 1.2941 0.8913 $25.3415 $26.8379 $27.7077 $26.6997
250126............................ 0.9445 0.9402 $20.1118 $20.4085 $21.7111 $20.7174
250127............................ 0.9410 1.4448 * * * *
250128............................ 0.8891 0.7688 $15.8352 $15.9344 $17.6269 $16.4363
250131............................ 0.8974 * $11.5396 * * $11.5396
250134............................ 0.6463 0.8304 $22.0310 $23.5608 $25.8368 $23.6784
250136............................ 0.9913 0.8304 $21.9977 $22.5832 $23.0637 $22.5479
250138............................ 1.2713 0.8304 $21.2490 $22.7902 $23.8861 $22.6997
250141............................ 1.5730 0.9402 $22.5187 $24.5772 $27.6158 $25.2301
250146............................ 0.8892 0.7688 $16.9341 $17.2328 $18.6486 $17.5743
250149............................ 0.9022 0.7688 $16.4228 $15.0367 $15.0641 $15.5315
250151............................ 0.7349 0.7688 $20.4581 $21.8697 $17.2205 $18.4362
250152............................ 1.5970 0.8304 * * $25.7837 $25.7837
250153............................ *** * * * $29.0461 $29.0461

[[Page 47541]]

250154............................ 0.9022 * * * * *
250156............................ 1.3430 0.7688 * * * *
250157............................ 1.6672 0.7688 * * * *
250158............................ 1.6049 0.7688 * * * *
250159............................ 0.8412 * * * * *
260001............................ 1.6402 0.8585 $22.6646 $25.3084 $25.9250 $24.6413
260002............................ *** * $24.6812 $27.2329 $26.4879 $26.0819
260003............................ 1.0295 * $16.5931 $17.6339 * $17.1135
260004............................ 0.9660 0.7919 $16.4423 $16.7742 $16.9421 $16.7356
260005............................ 1.4856 0.8958 $25.5927 $24.6142 $26.5773 $25.6220
260006............................ 1.4373 0.7919 $24.1078 $26.4948 $26.7587 $25.8174
260008............................ *** * $21.6256 $17.6040 $18.9522 $19.2926
260009............................ 1.1870 0.9463 $20.1679 $21.2729 $22.1816 $21.2122
260011............................ 1.3912 0.8388 $21.1625 $21.4409 $22.7061 $21.7937
260012............................ 1.0557 0.7919 $17.7854 $19.3389 $20.3061 $19.2632
260013............................ 1.0239 0.8585 $18.4857 $19.2065 $20.5007 $19.3903
260015............................ 1.0966 0.7919 $21.7581 $22.4450 $22.5409 $22.2644
260017............................ 1.3141 0.8958 $20.7837 $21.1359 $22.7022 $21.5787
260018............................ 1.0604 0.7919 $14.3278 $14.8425 $17.0434 $15.4340
260020............................ 1.7533 0.8958 $22.4709 $25.7898 $26.0407 $24.8648
260021............................ 1.3869 0.8958 $27.2478 $27.8332 $27.6330 $27.5756
260022............................ 1.2259 0.8553 $20.5417 $21.7707 $22.8085 $21.6784
260023............................ 1.2848 0.8958 $19.6324 $21.2519 $21.2077 $20.7002
260024............................ 1.1431 0.7919 $16.9968 $17.5351 $18.4829 $17.6819
260025............................ 1.2731 0.8958 $19.3535 $20.0901 $22.4645 $20.6596
260027............................ 1.6048 0.9463 $22.9973 $24.7605 $25.3348 $24.3810
260029............................ 1.1007 * $22.0390 $22.2892 * $22.1651
260031............................ *** * $24.3626 $24.2877 * $24.3260
260032............................ 1.8231 0.8958 $21.8830 $23.1125 $23.9478 $22.9995
260034............................ 0.9611 0.9463 $21.6108 $23.3034 $24.1143 $23.0518
260035............................ 0.9500 * $15.0468 $16.8502 $17.8741 $16.5641
260036............................ 0.9544 * $19.4559 $20.1324 $22.1912 $20.4830
260040............................ 1.6840 0.8242 $20.0422 $21.9452 $23.3566 $21.8297
260044............................ 0.9461 * $18.2413 $20.0686 * $19.1695
260047............................ 1.5080 0.8357 $22.4585 $22.6169 $24.4185 $23.1892
260048............................ 1.2627 0.9463 $26.6363 $25.8089 $24.3906 $25.5119
260050............................ 1.1649 0.7919 $20.8510 $20.6364 $23.6849 $21.9007
260052............................ 1.3280 0.8958 $21.1297 $22.5809 $24.5165 $22.8077
260053............................ 1.0499 0.8585 $18.9606 $20.0051 $21.6607 $20.2038
260057............................ 1.0425 0.9463 $15.8404 $16.4875 $19.3335 $17.1879
260059............................ 1.1923 0.7919 $17.2807 $18.6379 $19.7243 $18.6135
260061............................ 1.0980 0.7919 $18.7280 $19.6674 $21.5264 $19.9180
260062............................ 1.1962 0.9463 $25.2958 $26.0439 $26.4539 $25.9705
260063............................ 0.9748 * $21.1284 $22.0826 * $21.6180
260064............................ 1.3701 0.8357 $17.5188 $19.1587 $19.0543 $18.5908
260065............................ 1.7311 0.8242 $22.0058 $23.6969 $23.0015 $22.9155
260067............................ 0.9016 0.7919 $14.9792 $16.5364 $17.6256 $16.4270
260068............................ 1.7690 0.8357 $22.0951 $23.9340 $24.9504 $23.7077
260070............................ 0.9649 0.7919 $11.2251 $14.3881 $18.4779 $14.0836
260073............................ 1.0223 0.7919 $17.8185 $19.2744 $21.6214 $19.6354
260074............................ 1.1765 0.8357 $18.7639 $23.9301 $24.8654 $22.4254
260077............................ 1.6652 0.8958 $21.9947 $23.5466 $25.5782 $23.7347
260078............................ 1.2201 0.7919 $16.9217 $18.4017 $19.0802 $18.1811
260080............................ 0.9095 0.7919 $13.6815 $11.2817 $14.7774 $13.2210
260081............................ 1.4955 0.8958 $22.6627 $23.7447 $26.3969 $24.2793
260085............................ 1.5999 0.9463 $22.7394 $24.6046 $25.6302 $24.3659
260086............................ 0.8794 0.7919 $17.2048 $17.1202 $19.1702 $17.8711
260091............................ 1.5303 0.8958 $23.9975 $26.1149 $27.2407 $25.8446
260094............................ 1.6494 0.8242 $20.1043 $20.6805 $23.2544 $21.4540
260095............................ 1.3127 0.9463 $22.8156 $23.8671 $25.5668 $24.0702
260096............................ 1.4324 0.9463 $23.5009 $25.9932 $27.5592 $25.8492
260097............................ 1.1529 0.8344 $19.6203 $21.5077 $21.3957 $20.9049
260102............................ 0.8644 0.9463 $24.1041 $22.9283 $24.2368 $23.7509
260103............................ *** * $21.6192 $23.3175 * $22.4894
260104............................ 1.4718 0.8958 $22.4769 $24.0038 $26.2867 $24.3941
260105............................ 1.7289 0.8958 $24.6572 $28.4652 $28.8849 $27.3498
260107............................ 1.3256 0.9463 $23.1564 $24.2001 $26.7782 $24.6444

[[Page 47542]]

260108............................ 1.8415 0.8958 $22.7975 $24.0936 $24.9880 $23.9815
260110............................ 1.6342 0.8958 $22.0026 $22.2730 $23.7978 $22.7167
260113............................ 1.0891 0.8279 $16.3440 $19.2467 $20.9644 $18.7740
260115............................ 1.1612 0.8958 $20.4880 $21.7450 $21.9859 $21.4408
260116............................ 1.1354 0.8279 $16.9807 $17.2698 $18.5076 $17.6168
260119............................ 1.3457 0.7919 $18.7959 $22.1588 $24.9937 $22.8442
260120............................ *** * $18.7651 * * $18.7651
260122............................ 1.1399 0.9463 $16.1637 $17.3270 $20.8015 $18.1468
260123............................ 1.0022 * $17.7996 $16.1169 * $17.0002
260127............................ 0.9654 0.8077 $19.7946 $22.5328 $21.8534 $21.3553
260134............................ 1.1531 * $18.4511 $18.1531 * $18.2845
260137............................ 1.6787 0.8585 $20.7638 $21.3426 $22.7431 $21.6630
260138............................ 1.9152 0.9463 $25.6579 $27.8229 $28.5610 $27.3740
260141............................ 1.9311 0.8357 $21.0771 $21.1511 $22.4886 $21.5378
260142............................ 1.0558 0.7919 $18.6412 $19.6582 $20.3993 $19.6104
260147............................ 0.9412 0.7919 $16.1171 $17.2291 $18.5153 $17.2858
260159............................ *** * $23.1093 $26.8924 $23.7427 $24.4817
260160............................ 1.0924 0.7919 $18.8723 $19.4997 $21.0544 $19.7923
260162............................ 1.3775 0.8958 $22.5705 $24.1246 $25.1423 $23.9984
260163............................ 1.1555 0.7919 $18.1310 $19.2885 $20.1949 $19.2038
260164............................ 1.0699 0.7919 $16.9403 $19.5539 $19.7068 $18.6878
260166............................ 1.2047 0.9463 $22.8409 $25.5151 $27.0237 $25.1725
260172............................ 0.9118 * $17.1504 $18.1438 * $17.6539
260175............................ 1.1009 0.7919 $19.7939 $21.1257 $22.6171 $21.1462
260176............................ 1.5984 0.8958 $25.7802 $29.2184 $27.4244 $27.5317
260177............................ 1.2264 0.9463 $24.0550 $25.0724 $26.1178 $25.1274
260178............................ 1.7950 0.8357 $21.7704 $21.4781 $22.2251 $21.8190
260179............................ 1.5777 0.8958 $23.2824 $24.8541 $26.1419 $24.7933
260180............................ 1.5476 0.8958 $21.8585 $21.9679 $26.7461 $23.4659
260183............................ 1.6527 0.8958 $24.2330 $23.3924 $26.0418 $24.6030
260186............................ 1.6276 0.8357 $21.6620 $23.4317 $25.3148 $23.5713
260190............................ 1.1494 0.9463 $24.5014 $25.1653 $26.4505 $25.4095
260191............................ 1.3231 0.8958 $21.1331 $22.4369 $23.3856 $22.3648
260193............................ 1.2211 0.9463 $22.9556 $24.4705 $26.2979 $24.7042
260195............................ 1.2806 0.7919 $20.0889 $20.1327 $22.3958 $20.9711
260198............................ 1.1880 0.8958 $25.3390 $27.6116 $27.5996 $26.8633
260200............................ 1.2239 0.8958 $22.3913 $25.1134 $24.8624 $24.2536
260207............................ 1.0639 0.8242 $18.5247 $19.2467 $19.7294 $19.2332
260208............................ *** * $28.3158 * * $28.3158
260209............................ 1.0858 0.8381 * $21.8396 $23.2430 $22.5334
260210............................ 1.2315 0.8958 * * $25.3782 $25.3782
260211............................ 1.6081 0.9463 * * $33.9109 $33.9109
260213............................ 2.4615 0.9463 * * * *
270002 \2\........................ 1.2991 0.9526 $19.7588 $20.7620 $22.7322 $21.1317
270003............................ 1.3122 0.9065 $23.0396 $24.2823 $26.4843 $24.5714
270004............................ 1.6944 0.8846 $21.5577 $22.9081 $23.5454 $22.7035
270009............................ 1.3205 * $21.5655 * * $21.5655
270011............................ 0.9741 0.9065 $21.4031 $22.0710 $22.1394 $21.8739
270012 \2\........................ 1.4543 0.9526 $21.7634 $23.1697 $25.2873 $23.4084
270014............................ 1.8361 0.9526 $20.3456 $25.0650 $26.2025 $23.6425
270017............................ 1.2834 0.9526 $23.2320 $24.6186 $27.5483 $25.1665
270021............................ 1.0162 0.8846 $21.1624 $21.6758 $21.7056 $21.5330
270023............................ 1.5384 0.8846 $23.7486 $25.5525 $26.7576 $25.3555
270032............................ 1.0493 0.8846 $20.1801 $18.2377 $19.6212 $19.3552
270036............................ 0.8049 * $18.8785 $21.8255 $20.4242 $20.3944
270040............................ 1.1952 * $20.7240 * * $20.7240
270049............................ 1.7898 0.8846 $22.9524 $24.6556 $26.3996 $24.7520
270050............................ 1.0516 * $21.0901 $22.4195 * $21.7451
270051............................ 1.5696 0.9526 $22.2580 $26.4457 $26.6619 $25.1119
270057............................ 1.2393 0.8846 $21.9997 $22.6251 $24.2980 $23.0119
270060............................ 0.8910 0.8752 * $16.6592 $17.7564 $17.1813
270074............................ 0.8557 1.4448 * * * *
270075............................ 0.9239 * * * * *
270079............................ 0.8481 * * $21.6382 * $21.6382
270081............................ 1.0142 0.8752 $15.6833 $17.3174 $17.4862 $16.8348
270082............................ 1.0574 * $21.0150 $19.6173 * $20.3610
270084 \2\........................ 1.0107 * $19.6104 $22.2340 * $21.0235

[[Page 47543]]

270086............................ 1.1183 0.9065 * * * *
270087............................ 1.0295 0.8752 * * * *
280003............................ 1.8656 1.0187 $26.0937 $27.2844 $29.3921 $27.8614
280005............................ *** * $23.9753 * * $23.9753
280009............................ 1.8585 0.9656 $23.8046 $25.3162 $26.7678 $25.2627
280010............................ *** * $23.8325 $22.6516 * $23.2571
280013............................ 1.8094 0.9546 $23.4920 $24.5214 $26.1908 $24.7334
280020............................ 1.8480 1.0187 $23.4577 $25.7522 $26.5068 $25.3300
280021............................ 1.1450 0.8658 $21.5215 $22.2864 $22.0489 $21.9595
280023............................ 1.4143 0.9656 $19.6265 $22.7207 $22.3230 $21.6126
280030............................ 1.9539 0.9546 $29.2221 $32.5601 $30.7481 $30.8807
280032............................ 1.3432 0.9656 $21.5150 $22.6510 $23.6462 $22.6240
280040............................ 1.6893 0.9546 $23.6597 $25.2965 $26.9827 $25.3499
280047............................ 0.7859 * $19.5815 * * $19.5815
280054............................ 1.1577 0.8795 $23.1191 $22.4241 $23.5665 $23.0380
280057............................ 0.8226 0.9656 $22.5481 $23.6793 $20.4830 $22.0597
280060............................ 1.6274 0.9546 $23.1128 $25.2288 $26.2139 $24.9273
280061............................ 1.3744 0.9249 $21.2901 $23.9110 $24.9482 $23.4090
280065............................ 1.2862 0.9587 $23.8128 $27.9937 $26.0135 $25.9591
280077............................ 1.3374 0.9546 $22.7244 $24.0516 $25.5624 $24.1150
280081............................ 1.6432 0.9546 $24.3199 $25.1973 $26.0541 $25.2026
280085............................ *** * $21.8473 * * $21.8473
280105............................ 1.3057 0.9546 $25.1401 $25.0445 $26.7555 $25.7137
280108............................ 1.0428 0.8658 $20.9016 $22.5584 $23.2502 $22.2006
280111............................ 1.2161 0.8658 $20.7398 $22.1424 $23.4770 $22.1827
280117............................ 1.0657 0.8658 $20.5464 $22.0611 $24.1521 $22.2744
280118............................ 0.9223 * $19.3466 * * $19.3466
280119............................ 0.8238 1.4448 * * * *
280123............................ 0.9746 0.8795 $24.3539 $27.5207 * $25.8965
280125............................ 1.5209 0.8658 $20.0643 $21.8385 $21.7658 $21.2295
280126............................ *** * $33.8918 * * $33.8918
280127............................ 1.8510 1.0187 * * * *
280128............................ 3.3466 1.0187 * * * *
280129............................ 1.9562 0.9546 * * * *
280130............................ 1.2105 0.9546 * * * *
290001............................ 1.7842 1.0973 $25.9590 $27.3105 $31.1981 $28.2417
290002............................ 0.8744 0.9776 $16.8363 $16.8433 $18.3469 $17.3909
290003............................ 1.7886 1.1404 $27.4732 $27.1099 $28.1625 $27.5886
290005............................ 1.3920 1.1404 $24.6877 $27.1531 $27.6697 $26.5417
290006............................ 1.2847 1.0794 $24.2211 $26.3617 $27.9502 $26.1547
290007............................ 1.6569 1.1404 $35.1020 $35.4193 $37.5559 $36.0546
290008............................ 1.1784 1.1237 $27.0115 $26.4086 $27.9714 $27.1141
290009............................ 1.8755 1.0973 $26.9020 $27.6011 $29.8019 $28.1837
290010............................ 1.0905 1.1404 $25.4598 $23.8733 $23.9654 $24.4204
290012............................ 1.3505 1.1404 $25.8036 $27.2675 $31.0843 $28.0502
290016............................ 1.1558 * $22.5111 $25.1726 $26.1925 $24.6281
290019............................ 1.4095 1.0794 $25.1684 $27.2484 $28.6158 $27.0192
290020 \h\........................ 0.9713 1.1404 $24.2373 $21.3094 $21.6993 $22.1469
290021............................ 1.7615 1.1404 $26.2510 $28.3837 $33.2116 $29.2014
290022............................ 1.5354 1.1404 $27.5364 $29.8144 $29.4422 $28.9634
290027............................ 0.9199 0.9070 $13.5031 $17.8850 $15.1448 $15.3083
290032............................ 1.3774 1.0973 $27.5425 $29.4164 $31.7105 $29.6070
290039............................ 1.5330 1.1404 $28.7599 $29.6801 $31.2941 $30.0435
290041............................ 1.3550 1.1404 $28.6294 $30.1346 $33.9878 $31.0661
290042............................ 0.8016 1.1404 * * * *
290044............................ 0.8476 1.1404 * * * *
290045............................ 1.5027 1.1404 $26.5644 $26.9319 $30.9612 $28.4883
290046............................ 1.3462 1.1404 * * * *
290047............................ 1.2927 1.1404 * * * *
290048............................ 0.8479 * * * * *
290049............................ 1.2664 1.0245 * * * *
290050............................ 1.0634 * * * * *
300001............................ 1.5613 1.1561 $27.1312 $29.4130 $27.5032 $28.0073
300003............................ 2.0882 1.1561 $26.7859 $27.8059 $33.3560 $29.3633
300005............................ 1.4274 1.1561 $22.8163 $25.1869 $25.6699 $24.5947
300006............................ 1.1183 * $22.0187 $20.6787 $23.3200 $21.9532
300007............................ 1.2618 * $23.6919 $25.3125 * $24.5082

[[Page 47544]]

300010............................ 1.2996 * $24.6295 $26.9346 $27.5028 $26.4641
300011............................ 1.3151 1.1561 $25.0979 $27.3325 $28.4044 $26.9920
300012............................ 1.3958 1.1561 $26.3914 $28.4234 $30.5198 $28.4955
300013............................ 1.0792 * $21.3397 $23.1529 * $22.1888
300014............................ 1.2142 1.1561 $23.7144 $25.5059 $27.5151 $25.6846
300015............................ 1.0999 * $24.4869 $24.0620 * $24.2732
300016............................ *** * $18.9756 $24.5498 * $21.6922
300017............................ 1.2296 1.1922 $26.1104 $28.3959 $29.6957 $28.0967
300018............................ 1.4036 1.1561 $25.7851 $28.0308 $29.7209 $27.9654
300019............................ 1.2296 1.1561 $23.8076 $25.3845 $25.9656 $25.1005
300020............................ 1.2033 1.1561 $24.8189 $26.8402 $28.6723 $26.8622
300022............................ 1.1157 * $22.3918 $23.5948 * $23.0102
300023............................ 1.4320 1.1922 $24.9992 $25.4873 $28.6309 $26.4774
300024............................ 1.2361 * $22.4883 $23.9205 * $23.2005
300029............................ 1.7597 1.1922 $24.5772 $26.9484 $29.0806 $26.9920
300034............................ 2.0835 1.1561 $26.9093 $28.5375 $29.7484 $28.4471
310001............................ 1.7881 1.3194 $30.1786 $33.9360 $35.3612 $33.2483
310002............................ 1.8499 1.3194 $33.9058 $35.4567 $37.3461 $35.5944
310003............................ 1.2158 1.3194 $30.4234 $31.1040 $32.8935 $31.5180
310005............................ 1.3325 1.1879 $26.0227 $27.5690 $29.0084 $27.5943
310006............................ 1.2371 1.3194 $25.9000 $27.0436 $27.4545 $26.7958
310008............................ 1.3135 1.3194 $28.0970 $29.5857 $31.2579 $29.6725
310009............................ 1.2631 1.3194 $24.6353 $29.7760 $32.7384 $29.0885
310010............................ 1.2926 1.1319 $26.7889 $25.3139 $28.5852 $26.9172
310011............................ 1.2822 1.1342 $26.1586 $28.5241 $30.8612 $28.5543
310012............................ 1.6929 1.3194 $31.1705 $33.1622 $34.6882 $33.0545
310013............................ 1.3611 1.3194 $25.0951 $28.5016 $30.6248 $28.1586
310014............................ 1.8368 1.1227 $29.1931 $32.7222 $29.7204 $30.4762
310015............................ 1.8831 1.3194 $30.1767 $32.4980 $36.4776 $33.0707
310016............................ 1.3521 1.3194 $25.7368 $28.9788 $33.9862 $29.9150
310017............................ 1.3377 1.1879 $25.2636 $28.0930 $30.9233 $28.1646
310018............................ 1.1436 1.3194 $25.9108 $26.9399 $30.3381 $27.8107
310019............................ 1.6345 1.3194 $26.8663 $31.0524 $29.6592 $29.1388
310020............................ 1.6071 1.3194 $25.0147 $29.3392 $30.6722 $28.2107
310021............................ 1.6314 1.3194 $29.4003 $29.6308 $31.3410 $30.1313
310022............................ 1.2376 1.1227 $26.7487 $26.1914 $28.2024 $27.0808
310024............................ 1.3723 1.1879 $26.9499 $27.5278 $30.9171 $28.3714
310025............................ 1.2711 1.3194 $26.8719 $27.7960 $31.1274 $28.7415
310026............................ 1.2595 1.3194 $24.6697 $25.3970 $27.5171 $25.9064
310027............................ 1.3032 1.1879 $22.1935 $27.0982 $28.8314 $26.4162
310028............................ 1.2382 1.3194 $25.7246 $29.1101 $31.3849 $28.7946
310029............................ 1.8875 1.1227 $25.9606 $29.1439 $30.7707 $28.6905
310031............................ 3.0548 1.1290 $29.5581 $30.2345 $33.9685 $31.2972
310032............................ 1.3038 1.1227 $25.7088 $27.8754 $27.5232 $27.0476
310034............................ 1.3424 1.1290 $26.5224 $27.8517 $29.9162 $28.1036
310037............................ 1.3214 1.3194 $30.1264 $32.1471 $35.0329 $32.5209
310038............................ 1.9998 1.3194 $32.3865 $32.1977 $33.4822 $32.7188
310039............................ 1.2576 1.1640 $24.6045 $27.1054 $28.8292 $26.9337
310040............................ 1.3440 1.3194 $27.4041 $28.0068 $34.1113 $29.8744
310041............................ 1.2776 1.1290 $26.8145 $29.7335 $32.8085 $29.8863
310042............................ 1.1597 1.3194 $26.9695 $29.0207 $30.7358 $28.9101
310044............................ 1.3350 1.1319 $25.1618 $27.7752 $31.3206 $28.1678
310045............................ 1.5973 1.3194 $31.7376 $32.6359 $34.1060 $32.8838
310047............................ 1.3157 1.1600 $26.1353 $28.3415 $32.7880 $29.2740
310048............................ 1.3670 1.1879 $27.4050 $28.4715 $30.2025 $28.7345
310049............................ *** * $26.5332 $32.7666 $27.8564 $27.2897
310050............................ 1.2840 1.3194 $25.3772 $27.2276 $27.3033 $26.7397
310051............................ 1.3861 1.3194 $29.2386 $32.0113 $33.7168 $31.6981
310052............................ 1.3183 1.1290 $27.0324 $28.1498 $30.8036 $28.6341
310054............................ 1.2891 1.3194 $28.1880 $30.6905 $34.1860 $31.0476
310057............................ 1.3232 1.1227 $26.3903 $26.4606 $29.5221 $27.5782
310058............................ 1.1046 1.3194 $28.1753 $26.4816 $28.0815 $27.5746
310060............................ 1.2819 1.3194 $22.1914 $23.2146 $25.1575 $23.5782
310061............................ 1.2681 1.1227 $24.9678 $27.5400 $28.2129 $26.9521
310063............................ 1.3537 1.1879 $25.9868 $28.3457 $31.4884 $28.5345
310064............................ 1.5668 1.1600 $27.8388 $29.5979 $33.4440 $30.4173
310067............................ *** * $26.3624 $26.8068 * $26.5479

[[Page 47545]]

310069............................ 1.2704 1.1227 $25.7690 $27.9656 $28.1681 $27.3281
310070............................ 1.3710 1.3194 $30.1917 $32.1806 $33.2310 $31.9325
310072............................ *** * $25.3145 $26.3520 * $25.8709
310073............................ 1.7905 1.1290 $28.8791 $29.6611 $32.0329 $30.2191
310074............................ 1.3372 1.3194 $27.6789 $28.4361 $29.4834 $28.5348
310075............................ 1.2812 1.1290 $25.7726 $26.2479 $31.6870 $27.8786
310076............................ 1.6139 1.3194 $32.4533 $34.9428 $36.4280 $34.6292
310077............................ 1.6620 1.3194 $28.7352 $30.7465 $32.6644 $30.7450
310078............................ 1.2889 1.3194 $24.7753 $26.9589 $29.8014 $27.2209
310081............................ 1.2546 1.1227 $24.6083 $26.4259 $26.6136 $25.9041
310083............................ 1.3035 1.3194 $25.2465 $24.6563 $28.2392 $25.9836
310084............................ 1.2321 1.1290 $27.3680 $29.9437 $32.9001 $30.0920
310086............................ 1.2262 1.1227 $25.2751 $27.3601 $29.3058 $27.3522
310088............................ 1.1801 1.1600 $23.7846 $25.5274 $26.4966 $25.2810
310090............................ 1.2575 1.1879 $25.3640 $27.1661 $30.8941 $27.8574
310091............................ 1.1983 1.1227 $25.6405 $27.1115 $27.7204 $26.8559
310092............................ 1.3772 1.1319 $23.2226 $25.7071 $29.4999 $26.1525
310093............................ 1.1945 1.3194 $24.6942 $25.8727 $28.0401 $26.2654
310096............................ 2.1069 1.3194 $28.4705 $30.3675 $34.4275 $31.1262
310105............................ 1.2141 1.3194 $28.7333 $30.9968 $31.9769 $30.6308
310108............................ 1.3926 1.1640 $24.9090 $29.1548 $30.1002 $28.0512
310110............................ 1.2919 1.1319 $26.4175 $27.8707 $31.2164 $28.8347
310111............................ 1.2048 1.1290 $26.2496 $28.8692 $30.7475 $28.7020
310112............................ 1.2411 1.1290 $27.8796 $28.9928 $30.4192 $29.1502
310113............................ 1.2444 1.1290 $25.9143 $27.5203 $29.6079 $27.7501
310115............................ 1.2750 1.3194 $24.5413 $26.2803 $29.6020 $26.9083
310116............................ 1.2596 1.3194 $25.1189 $26.6287 $25.6976 $25.7970
310118............................ 1.2916 1.3194 $28.0517 $28.1238 $28.8797 $28.3510
310119............................ 1.8491 1.3194 $34.7468 $35.6786 $37.7876 $36.1340
310120............................ 1.1631 1.3194 $24.7078 $27.2010 $31.4110 $27.6263
310122............................ 2.3504 1.1290 * * * *
310123............................ 1.7519 1.2230 * * * *
310124............................ 1.6667 1.1640 * * * *
310125............................ 2.0879 1.1879 * * * *
320001............................ 1.4902 0.9686 $23.0290 $26.1962 $26.9434 $25.3673
320002............................ 1.3977 1.0897 $26.7332 $28.6963 $30.5158 $28.6521
320003............................ 1.1158 0.9269 $20.7939 $22.3911 $28.1402 $23.4549
320004............................ 1.2784 0.8640 $19.4799 $24.0362 $24.9481 $23.1709
320005............................ 1.4190 0.9548 $22.1677 $21.2164 $23.8264 $22.4376
320006............................ 1.3263 1.0152 $21.1222 $22.5615 $24.2812 $22.6734
320009............................ 1.5264 0.9686 $21.5870 $24.4237 $22.8293 $22.9608
320011............................ 1.1800 0.9082 $20.7714 $23.1539 $24.2279 $22.7686
320013............................ 1.1550 1.0152 $19.4487 $27.8671 $28.9276 $24.8284
320014............................ 1.1314 0.8640 $19.7656 $26.7112 $24.5310 $23.5594
320016............................ 1.1578 0.8640 $19.9326 $21.7001 $23.5040 $21.7285
320017............................ 1.2944 0.9686 $22.5460 $23.6861 $25.0286 $23.7296
320018............................ 1.4792 0.8703 $21.4650 $23.0915 $23.2360 $22.6002
320019............................ 1.5611 0.9686 $26.6900 $31.2250 $31.5192 $29.7045
320021............................ 1.6370 0.9686 $21.0913 $28.5620 $27.2357 $25.1851
320022............................ 1.1035 0.8640 $20.7919 $22.1492 $23.7160 $22.2284
320030............................ 1.0503 0.8640 $16.8696 $18.0990 $22.1971 $18.9458
320033............................ 1.1604 1.0152 $24.2703 $24.1185 $27.6393 $25.3263
320037............................ 1.1579 0.9686 $19.6466 $21.6080 $23.3999 $21.6108
320038............................ 1.2492 0.8640 $19.2962 $21.2181 $20.1533 $20.2270
320046............................ 1.1922 0.8640 $21.5915 $22.9114 $24.3534 $22.9610
320057............................ 0.8993 1.4448 * * * *
320058............................ 0.7493 1.4448 * * * *
320059............................ 1.0334 1.4448 * * * *
320060............................ 0.9956 1.4448 * * * *
320061............................ 1.0533 1.4448 * * * *
320062............................ 0.8317 1.4448 * * * *
320063............................ 1.2977 0.9584 $20.7804 $24.9141 $24.4696 $23.4155
320065............................ 1.1296 0.9584 $19.9012 $21.6189 $26.6603 $22.8070
320067............................ 0.8447 0.8640 $13.9459 $20.4431 $23.7745 $19.8406
320069............................ 1.0789 0.8640 $18.5375 $19.7296 $20.9167 $19.7352
320070............................ 0.9077 1.4448 * * * *
320074............................ 1.1720 0.9686 $28.3086 $35.5980 $22.2175 $28.2084

[[Page 47546]]

320079............................ 1.1219 0.9686 $21.9090 $23.8092 $25.2105 $23.6814
320083............................ 2.6265 0.9686 $20.6771 * $28.2114 $23.7546
320084............................ 1.1015 0.8640 * * $17.2511 $17.2511
320085............................ 1.6312 0.8703 * * $24.8752 $24.8752
330001............................ *** * $30.8509 $31.3735 $33.4718 $31.9148
330002............................ 1.4714 1.3194 $28.0882 $29.3459 $31.1924 $29.5603
330003............................ 1.2754 0.8607 $20.2744 $21.6506 $22.9945 $21.6443
330004............................ 1.2891 1.0677 $24.3703 $23.9959 $26.0445 $24.8414
330005............................ 1.6050 0.9503 $24.3578 $25.9287 $29.0124 $26.3013
330006............................ 1.3144 1.3194 $28.3904 $29.7509 $31.5370 $29.8730
330008............................ 1.1195 0.9503 $20.6816 $21.3269 $21.8198 $21.2850
330009............................ 1.3259 1.3194 $33.3605 $35.8367 $35.4986 $34.8796
330010............................ *** * $19.8211 $17.9178 $19.6920 $19.0804
330011............................ 1.3109 0.8580 $19.8035 $20.3641 $21.8008 $20.6687
330013............................ 2.1016 0.8607 $21.2063 $23.9070 $24.5162 $23.2224
330014............................ 1.3670 1.3194 $32.0824 $35.4053 $38.8123 $35.4565
330016............................ 0.9945 0.8217 $18.1603 $18.9388 $28.4392 $20.9735
330019............................ 1.3013 1.3194 $31.9042 $32.3413 $34.8266 $33.0470
330023 \2\........................ 1.5963 1.3194 $29.4538 $29.2669 $31.6208 $30.1574
330024............................ 1.7371 1.3194 $35.3598 $36.5648 $37.8398 $36.5683
330025............................ 1.0525 0.9503 $18.7663 $19.7561 $20.2775 $19.6152
330027............................ 1.4762 1.3194 $34.1281 $35.1325 $39.0717 $36.0189
330028............................ 1.4305 1.3194 $31.8452 $33.5312 $34.2709 $33.2330
330029............................ 0.4479 0.9503 $18.4354 $18.6623 $19.1589 $18.7332
330030............................ 1.2729 0.9123 $22.0574 $22.4368 $22.9937 $22.4866
330033............................ 1.2661 0.8217 $18.6316 $21.3762 $22.5681 $20.8260
330036............................ 1.1408 1.3194 $27.0970 $27.6813 $28.9409 $27.8674
330037............................ 1.0939 0.9123 $18.3557 $19.6385 $20.6904 $19.5992
330041............................ 1.1981 1.3194 $34.5461 $36.2481 $36.0286 $35.6239
330043............................ 1.3182 1.2739 $31.7873 $34.1039 $34.7480 $33.5850
330044............................ 1.2710 0.8378 $22.0465 $23.1450 $24.1907 $23.1415
330045............................ 1.3384 1.2739 $30.9046 $34.4956 $36.1893 $33.9234
330046............................ 1.4099 1.3194 $41.6759 $42.0900 $44.8494 $42.8629
330047 \h\........................ 1.2039 0.8607 $20.1646 $21.1244 $24.0678 $21.8925
330049............................ 1.3530 1.3194 $24.7766 $25.7022 $29.2904 $26.5366
330053............................ 1.0936 0.9123 $18.1728 $19.6807 $18.5290 $18.7942
330055............................ 1.6595 1.3194 $34.9709 $35.1393 $38.4839 $36.2207
330056............................ 1.4846 1.3194 $32.0982 $32.9295 $37.8444 $34.2883
330057............................ 1.7122 0.8607 $20.9282 $22.6519 $24.4680 $22.6890
330058............................ 1.3286 0.9123 $19.2916 $19.5520 $21.3727 $20.0924
330059............................ 1.5373 1.3194 $36.4176 $38.1019 $39.7386 $38.0767
330061............................ 1.2282 1.3194 $28.6725 $32.7427 $33.2848 $31.6301
330062............................ 1.2015 0.9195 $20.0222 $21.4270 $21.0464 $20.8258
330064............................ 1.1499 1.3194 $36.0976 $38.5719 $36.4276 $37.0304
330065............................ 1.0337 0.9503 $20.5958 $21.9192 $23.9128 $22.1517
330066............................ 1.3298 0.8607 $20.9990 $23.0916 $24.7941 $23.0025
330067 \2\........................ 1.4233 1.3194 $24.8927 $34.8416 $26.4243 $28.0084
330072............................ 1.4104 1.3194 $32.9665 $32.7905 $36.4336 $34.0607
330073............................ 1.1359 0.9123 $18.4162 $19.0781 $20.1490 $19.1772
330074............................ 1.3388 0.9123 $21.7299 $20.2874 $21.4274 $21.1093
330075............................ 1.1708 0.9589 $19.9781 $22.0240 $22.4188 $21.4854
330078............................ 1.4383 0.9503 $20.8379 $22.7762 $23.3981 $22.3650
330079............................ 1.3107 0.8217 $21.1153 $22.1064 $22.5237 $21.9214
330080............................ 1.1864 1.3194 $33.5537 $36.1171 $39.1724 $36.3260
330084............................ 1.0874 0.8217 $19.2135 $22.6365 $21.5455 $21.1058
330085............................ 1.2019 0.9318 $21.8271 $23.2927 $23.9568 $23.0352
330086............................ 1.3273 1.3194 $27.1585 $28.8424 $29.1784 $28.3884
330088............................ 1.0581 1.2739 $29.5181 $31.2631 $31.3973 $30.7659
330090............................ 1.4589 0.8268 $20.9327 $22.7721 $23.6174 $22.4292
330091............................ 1.3887 0.9503 $22.9396 $22.5796 $23.8063 $23.1125
330094............................ 1.2635 0.8900 $21.3659 $22.1495 $23.0001 $22.1769
330095............................ *** * $28.9794 $28.9914 $31.9872 $29.7944
330096............................ 1.0741 0.8217 $21.1648 $22.4895 $22.0337 $21.9119
330097............................ 1.1345 0.8217 $18.6291 $19.2233 $20.3189 $19.3571
330100............................ 0.9578 1.3194 $31.5775 $32.8406 $34.4621 $32.9762
330101............................ 1.8426 1.3194 $38.4810 $39.2601 $38.7503 $38.8324
330102............................ 1.3592 0.9503 $23.5254 $23.6141 $24.8184 $23.9846

[[Page 47547]]

330103............................ 1.1027 0.8217 $17.9017 $18.8763 $21.1452 $19.3116
330104............................ 1.3673 1.3194 $36.8451 $33.7556 $32.8818 $34.4566
330106............................ 1.7553 1.4804 $38.7822 $39.8554 $41.4561 $40.0631
330107............................ 1.2310 1.2739 $29.1958 $31.8528 $31.3888 $30.7790
330108............................ 1.1202 0.8268 $20.2536 $21.4680 $22.2607 $21.3131
330111............................ 1.0428 0.9503 $17.7020 $17.6185 $20.9387 $18.7250
330114............................ *** * $19.2566 * * $19.2566
330115............................ 1.1639 0.9589 $18.5544 $20.5101 $23.3043 $20.7157
330119............................ 1.7652 1.3194 $34.6591 $36.5873 $39.1114 $36.7610
330121............................ 0.9319 * $17.9757 $19.7388 * $18.8764
330122............................ *** * $25.6500 $26.3849 * $26.0090
330125............................ 1.7965 0.9123 $22.8078 $24.6945 $26.7118 $24.8603
330126............................ 1.2876 1.3194 $27.7155 $28.8299 $31.6370 $29.4715
330127............................ 1.2802 1.3194 $42.2836 $43.7479 $44.6103 $43.5622
330128............................ 1.2008 1.3194 $32.7050 $34.5289 $37.7166 $35.0246
330132............................ 1.0872 0.8217 $16.0311 $16.3088 $17.4946 $16.8474
330133............................ 1.3209 1.3194 $35.3136 $44.0704 $36.6962 $38.2248
330135............................ 1.2321 1.3194 $25.6504 $26.9969 $29.0837 $27.3649
330136............................ 1.4834 0.9318 $21.4225 $22.5447 $24.2010 $22.7506
330140............................ 1.8029 0.9589 $21.1787 $23.5774 $25.7573 $23.5011
330141............................ 1.3062 1.2739 $29.3283 $30.6616 $34.8902 $31.6934
330144............................ 1.0366 0.8217 $17.3920 $20.1805 $20.9935 $19.3948
330148............................ 1.0270 * $17.6560 $18.5443 * $18.0744
330151............................ 1.1181 0.8217 $16.4028 $17.6782 $19.1841 $17.7056
330152............................ 1.3111 1.3194 $32.3332 $32.0616 $36.5136 $33.6447
330153............................ 1.7109 0.8607 $21.2843 $21.9935 $24.5219 $22.5953
330154............................ 1.7188 * * * * *
330157............................ 1.3749 0.9318 $23.5522 $23.6939 $25.2312 $24.1798
330158............................ 1.5749 1.3194 $32.7159 $33.0067 $32.2990 $32.6514
330159............................ 1.4004 0.9589 $22.5580 $24.1916 $28.9094 $25.1161
330160............................ 1.5746 1.3194 $32.1266 $34.0373 $34.1960 $33.4347
330162............................ 1.2769 1.3194 $29.6042 $31.3812 $32.1783 $31.0913
330163............................ 1.2220 0.9503 $21.1517 $22.4644 $24.0200 $22.5391
330164............................ 1.4926 0.9123 $23.5427 $24.4306 $28.8481 $25.6753
330166 \h\........................ 1.0649 0.8217 $18.4262 $18.8777 $19.4360 $18.9008
330167............................ 1.7998 1.2876 $30.9667 $33.7365 $34.4748 $33.1276
330169............................ 1.4238 1.3194 $36.2725 $38.3498 $39.3361 $37.9349
330171............................ 1.1784 1.3194 $25.9946 $27.7810 $30.0122 $27.7871
330175............................ 1.1309 0.8217 $20.4628 $21.1944 $22.2067 $21.3007
330177............................ 0.9502 0.8217 $19.0005 $20.1850 $19.6100 $19.6031
330180............................ 1.2380 0.8607 $19.8951 $21.9641 $22.1920 $21.3178
330181............................ 1.3214 1.3194 $37.1218 $35.9334 $38.5351 $37.1999
330182............................ 2.3660 1.3194 $35.2416 $36.3831 $39.6038 $37.1311
330184............................ 1.4168 1.3194 $30.7479 $33.2843 $34.4044 $32.7893
330185............................ 1.2705 1.2739 $28.9787 $31.0179 $32.3466 $30.8714
330188............................ 1.2509 0.9503 $21.1196 $22.6803 $23.9210 $22.6030
330189............................ 0.9309 0.8607 $19.0726 $19.2538 $21.6229 $19.9266
330191............................ 1.2962 0.8607 $20.9392 $22.3719 $24.0232 $22.4577
330193............................ 1.2693 1.3194 $36.2427 $36.9866 $37.1807 $36.8214
330194............................ 1.8239 1.3194 $38.5372 $39.9177 $43.9910 $40.8421
330195............................ 1.7567 1.3194 $36.4249 $38.6867 $40.0206 $38.4696
330196............................ 1.2876 1.3194 $31.1915 $32.5883 $33.2171 $32.3484
330197............................ 1.1380 0.8217 $20.8386 $22.3117 $23.4291 $22.2164
330198............................ 1.3590 1.2876 $25.3622 $29.5359 $30.5485 $28.5487
330199............................ 1.1222 1.3194 $34.1354 $32.7870 $35.0059 $33.9687
330201............................ 1.7233 1.3194 $29.3745 $33.3215 $39.3682 $33.7813
330202............................ 1.2896 1.3194 $30.7990 $34.3545 $38.0129 $34.5293
330203............................ 1.4869 0.9589 $24.7422 $26.2459 $26.5882 $25.8191
330204............................ 1.3437 1.3194 $30.3699 $30.3273 $37.6849 $32.8372
330205............................ 1.2623 1.3194 $29.0622 $30.0101 $32.1617 $30.4707
330208............................ 1.1831 1.3194 $30.6158 $28.2667 $29.6282 $29.4819
330209............................ 1.1850 1.2739 $27.7071 $28.7213 $29.7988 $28.7477
330211............................ 1.1669 0.8217 $20.8224 $21.1094 $22.9966 $21.6469
330212............................ *** * $24.9434 $27.0585 $27.2232 $26.1185
330213............................ 1.1274 0.8217 $20.7967 $21.7208 $22.5191 $21.6931
330214............................ 1.9195 1.3194 $32.7647 $33.7670 $37.8500 $34.8451
330215............................ 1.3208 0.8378 $19.9226 $20.6343 $22.6744 $21.0901

[[Page 47548]]

330218............................ 1.0429 0.9589 $20.6012 $21.4095 $24.1106 $22.0618
330219............................ 1.6506 0.9503 $28.7448 $27.7400 $29.3644 $28.6092
330221............................ 1.4249 1.3194 $34.9345 $34.7033 $36.5539 $35.4233
330222............................ 1.2936 0.8607 $23.5491 $25.9825 $23.9746 $24.4778
330223............................ 1.0359 0.8217 $18.8253 $18.4291 $19.4229 $18.9058
330224............................ 1.2946 1.0217 $22.7847 $23.9379 $25.7850 $24.1687
330225............................ 1.1808 1.2876 $29.1744 $28.9952 $29.2719 $29.1527
330226............................ 1.3168 0.9123 $23.5405 $23.4783 $21.8977 $22.8832
330229 \h\........................ 1.1793 0.8415 $18.5590 $19.5670 $20.6095 $19.5838
330230............................ 1.0030 1.3194 $32.5997 $32.1101 $33.3175 $32.6586
330231............................ 1.0147 1.3194 $30.2184 $33.9324 $36.9619 $33.7652
330232............................ 1.2013 0.8607 $21.1277 $21.4765 $24.4531 $22.3535
330233............................ 1.4520 1.3194 $39.5133 $41.9968 $45.5132 $42.4372
330234............................ 2.2916 1.3194 $37.7135 $36.8500 $40.6314 $38.3961
330235............................ 1.1373 0.9318 $21.4643 $22.1217 $23.3866 $22.3225
330236............................ 1.4476 1.3194 $31.8491 $32.9391 $35.6347 $33.4921
330238............................ 1.2736 0.9123 $18.3846 $19.2407 $20.8639 $19.5443
330239 \h\........................ 1.2341 0.8415 $19.7561 $20.4936 $21.5397 $20.5927
330240............................ 1.2411 1.3194 $37.3866 $40.7478 $39.9450 $39.4043
330241............................ 1.8693 0.9589 $26.7598 $27.7213 $29.0882 $27.8974
330242............................ 1.3070 1.3194 $30.5172 $32.2178 $33.6926 $32.1583
330245............................ 1.9330 0.8378 $20.2037 $21.6857 $22.8003 $21.6000
330246............................ 1.3525 1.2739 $31.8857 $31.6763 $34.6329 $32.7279
330247............................ 0.9562 1.3194 $25.6063 $32.1733 $32.2300 $29.8298
330249............................ 1.2127 0.9589 $19.1469 $21.4345 $22.9834 $21.2588
330250............................ 1.2932 0.9278 $22.1272 $23.0641 $25.1664 $23.4900
330259............................ 1.4393 1.2876 $27.4131 $30.0488 $31.9152 $29.8816
330261............................ 1.2766 1.3194 $30.4771 $30.9356 $30.7942 $30.7386
330263............................ 0.9848 0.8217 $20.0831 $20.8456 $22.4675 $21.1560
330264............................ 1.2498 1.2739 $26.3652 $28.1501 $30.0139 $28.1122
330265............................ 1.2921 0.9123 $18.2547 $19.9414 $20.4635 $19.5583
330267............................ 1.4718 1.3194 $29.0499 $30.3709 $31.5478 $30.3522
330268............................ 0.9523 0.8217 $18.7991 $18.9142 $20.9720 $19.5863
330270............................ 2.0223 1.3194 $36.5976 $38.2605 $42.2111 $39.0845
330273............................ 1.4035 1.3194 $28.8548 $29.5106 $30.4720 $29.6353
330276............................ 1.1215 0.8280 $20.7973 $21.7826 $22.2353 $21.6210
330277............................ 1.1672 0.9195 $21.8866 $25.1438 $25.3582 $24.1682
330279............................ 1.4644 0.9503 $23.8793 $23.4816 $25.2130 $24.2253
330285............................ 1.9863 0.9123 $26.0446 $27.1260 $27.9018 $27.0364
330286............................ 1.3792 1.2739 $31.1344 $32.3244 $33.3552 $32.3237
330290............................ 1.7499 1.3194 $35.5617 $36.3764 $36.9981 $36.3009
330293............................ *** * $17.6506 $19.0290 * $18.3452
330304............................ 1.2859 1.3194 $31.1146 $33.4431 $34.5761 $33.1106
330306............................ 1.4713 1.3194 $30.4426 $30.7551 $35.6640 $32.2831
330307............................ 1.2230 0.9845 $23.8583 $25.4128 $27.5699 $25.6624
330314............................ 1.2551 1.2739 $26.2954 $26.0150 $25.5597 $25.9594
330316............................ 1.3011 1.3194 $33.7857 $33.1512 $34.8623 $33.9322
330327............................ *** * $19.3465 * * $19.3465
330331............................ 1.2271 1.2876 $34.6302 $34.7052 $36.1630 $35.1867
330332............................ 1.2639 1.2876 $30.5104 $31.8389 $33.3050 $32.0164
330333............................ *** * $29.7725 $33.7637 $26.1917 $29.6723
330336............................ *** * $32.9548 * * $32.9548
330338............................ *** * $25.4319 $27.3859 $31.3761 $27.9867
330339............................ 0.8248 0.8607 $20.8424 $22.2812 $22.6569 $21.9390
330340............................ 1.1787 1.2739 $29.8140 $31.4322 $33.9358 $31.7549
330350............................ 1.5082 1.3194 $35.5656 $39.3541 $36.6250 $37.1672
330353............................ 1.1647 1.3194 $35.6821 $38.6962 $37.6549 $37.3737
330354............................ 1.8586 * * * * *
330357............................ 1.2969 1.3194 $36.5461 $34.3965 $35.5975 $35.5017
330372............................ 1.2646 1.2876 $28.2490 $30.1505 $32.6721 $30.3998
330385............................ 1.1337 1.3194 $44.3387 $42.6671 $46.3221 $44.4556
330386............................ 1.2201 1.0677 $25.2064 $25.9228 $27.9943 $26.4367
330389............................ 1.8679 1.3194 $32.2112 $34.7552 $34.7669 $33.9210
330390............................ 1.2873 1.3194 $32.7450 $33.2628 $36.0573 $33.8898
330393............................ 1.7555 1.2739 $33.0953 $34.8213 $34.8095 $34.2742
330394............................ 1.6386 0.8580 $21.3678 $23.3505 $25.2229 $23.3324
330395............................ 1.3987 1.3194 $32.1089 $35.4619 $37.3096 $34.7722

[[Page 47549]]

330396............................ 1.3734 1.3194 $31.2429 $32.5345 $35.0297 $32.9828
330397............................ 1.3696 1.3194 $40.0884 $34.5110 $38.4741 $37.5361
330399............................ 1.1728 1.3194 $32.1248 $33.6753 $32.3688 $32.7392
330401............................ 1.3252 1.2739 $33.8633 $35.7435 $40.6249 $36.8252
330402............................ 0.8016 * * $21.3302 * $21.3302
330403............................ *** * * * $23.1887 $23.1887
340001............................ 1.4865 0.9707 $21.6113 $23.2436 $25.0041 $23.2441
340002............................ 1.7550 0.9577 $24.0145 $25.1099 $27.3349 $25.5169
340003............................ 1.1019 0.8544 $20.8205 $21.5562 $23.3066 $21.9251
340004............................ 1.4225 0.9124 $23.3756 $24.2055 $25.4474 $24.3851
340005............................ 1.0112 0.8544 $20.8150 $22.9830 $22.3814 $22.0177
340007............................ *** * $19.5208 $21.1519 * $20.3174
340008............................ 1.0967 0.9577 $22.7338 $24.2089 $26.6314 $24.5355
340010............................ 1.3267 0.9411 $21.3024 $23.1349 $24.5666 $23.0280
340011............................ 1.0555 0.8544 $18.1926 $18.1843 $19.9484 $18.7756
340012............................ 1.2913 0.8544 $19.6350 $22.0583 $22.7189 $21.4818
340013............................ 1.2464 0.9577 $21.0066 $22.4787 $23.0261 $22.1688
340014............................ 1.5408 0.8951 $22.6757 $24.4831 $25.1872 $24.1069
340015 \h\........................ 1.3668 0.9974 $24.3410 $24.3870 $26.2276 $25.0387
340016............................ 1.2189 0.8544 $20.2859 $22.7574 $23.0359 $22.0228
340017............................ 1.2705 0.9303 $21.7083 $22.8879 $23.8229 $22.8228
340018............................ 1.1437 0.9174 $17.3480 $20.3840 $23.7243 $20.2881
340019............................ 0.9714 * $16.7901 $17.8768 * $17.3292
340020............................ 1.2008 0.8751 $21.3385 $24.1955 $23.7995 $23.1233
340021............................ 1.3123 0.9577 $22.9208 $23.6884 $26.0995 $24.2587
340022............................ *** * $19.9078 * * $19.9078
340023............................ 1.3810 0.9702 $22.3590 $23.2844 $24.4897 $23.4088
340024............................ 1.1661 0.8544 $20.4906 $21.2671 $22.2521 $21.3515
340025............................ 1.2517 0.9303 $20.2864 $20.9915 $21.2276 $20.8493
340027............................ 1.1715 0.9404 $21.0975 $22.6107 $23.6326 $22.4564
340028............................ 1.5576 0.9417 $22.2028 $24.6836 $26.3298 $24.3471
340030............................ 2.0547 1.0200 $26.7753 $27.4664 $29.0122 $27.8175
340032............................ 1.3999 0.9707 $23.2204 $24.8031 $26.7475 $25.0122
340035............................ 1.0339 0.8544 $16.4821 $21.2407 $23.5476 $20.1377
340036............................ 1.1813 0.9668 $20.8313 $22.2089 $25.2077 $22.9528
340037............................ 1.0074 0.8760 $21.9524 $22.5089 $21.6411 $22.0344
340038............................ 1.2006 0.8544 $13.9936 $14.0203 $14.0713 $14.0327
340039............................ 1.2892 0.9577 $24.8246 $25.6605 $27.1275 $25.9204
340040............................ 1.9383 0.9404 $22.4777 $24.1523 $26.3325 $24.3631
340041............................ 1.2382 0.8930 $17.6319 $23.0497 $23.6600 $21.2911
340042............................ 1.1026 0.8544 $21.1107 $22.1107 $23.0236 $22.0702
340044............................ 0.9463 * $18.2154 $21.7089 * $19.7398
340045............................ 0.9932 * $17.4066 $14.5004 $23.1918 $18.0750
340047............................ 1.9018 0.8951 $22.5199 $25.3727 $25.0605 $24.3496
340049............................ 2.0187 1.0200 $21.2734 $22.3082 $30.4827 $24.7548
340050............................ 1.1060 0.9183 $20.3262 $21.4511 $24.2533 $22.0481
340051............................ 1.2486 0.8930 $20.3057 $21.9069 $23.4091 $21.9456
340053............................ 1.6016 0.9707 $24.9768 $26.9361 $27.7261 $26.5947
340055............................ 1.2426 0.8930 $23.2990 $24.3728 $24.1057 $23.9407
340060............................ 1.0677 0.9124 $20.8077 $22.4303 $22.8657 $22.0570
340061............................ 1.8016 1.0200 $25.1081 $26.6657 $27.5594 $26.4994
340064............................ 1.0923 0.8544 $19.4523 $22.3631 $22.9143 $21.5916
340065............................ 1.1839 * $20.3296 $20.8413 * $20.5941
340067............................ *** * $22.2565 * * $22.2565
340068............................ 1.2128 0.9384 $19.4487 $20.8600 $21.8830 $20.7420
340069............................ 1.8902 0.9944 $24.4650 $27.5045 $27.4473 $26.5163
340070............................ 1.2747 0.9341 $22.2605 $23.6045 $24.9033 $23.6142
340071............................ 1.1357 0.9411 $19.9561 $22.1854 $25.4537 $22.5747
340072............................ 1.1901 0.8544 $19.2773 $21.3320 $23.1163 $21.1853
340073............................ 1.3885 0.9944 $26.6829 $29.4189 $30.2061 $28.9141
340075............................ 1.2198 0.8930 $23.2904 $24.1297 $26.0225 $24.4391
340084............................ 1.1791 0.9707 $20.8175 $21.3227 $21.2580 $21.1447
340085 \h\........................ 1.1632 0.9501 $21.7112 $23.0890 $23.9793 $22.8869
340087............................ 1.1851 0.8544 $17.8215 $18.4202 $22.0070 $19.3351
340088............................ 1.3435 * $22.8687 $24.3299 * $23.5994
340090............................ 1.2399 0.9668 $20.3261 $21.7173 $23.4542 $21.9222
340091............................ 1.5409 0.9124 $23.1430 $24.9411 $25.8266 $24.6682

[[Page 47550]]

340096 \h\........................ 1.2085 0.9501 $22.1174 $23.6345 $25.2169 $23.6523
340097............................ 1.1856 0.8544 $20.8690 $22.5775 $24.2127 $22.5886
340098............................ 1.4560 0.9707 $24.2262 $25.4823 $27.3308 $25.7030
340099............................ 1.1870 0.8544 $17.5114 $20.0178 $20.3683 $19.3181
340104............................ 0.8501 0.8760 $12.9949 $14.3252 $15.7521 $14.3947
340106............................ 1.0879 0.8544 $20.1076 $22.6979 $22.4894 $21.8047
340107............................ 1.2195 0.8915 $21.0960 $22.5583 $22.9698 $22.2242
340109............................ 1.3280 0.8832 $20.4341 $22.3826 $23.4419 $22.1467
340113............................ 1.8763 0.9707 $25.0729 $26.0776 $28.2568 $26.5148
340114............................ 1.6302 0.9944 $19.9142 $25.4533 $26.6813 $23.7911
340115............................ 1.6059 0.9944 $23.8284 $25.1907 $25.0212 $24.7040
340116............................ 1.7294 0.8930 $23.9643 $26.1641 $25.3213 $25.1777
340119............................ 1.1322 0.9707 $21.2239 $22.4821 $24.2287 $22.6894
340120............................ 1.0480 0.8544 $19.9860 $21.8548 $23.0916 $21.7078
340121............................ 1.0504 0.9570 $19.9409 $20.3701 $21.7576 $20.7129
340123............................ 1.1938 0.9124 $22.3711 $23.1879 $26.1083 $23.9306
340124............................ 1.0787 0.9411 $17.5691 $18.3866 $20.8018 $18.8482
340126 \h\........................ 1.2300 0.9411 $21.4271 $23.5405 $25.0189 $23.3764
340127............................ 1.1727 0.9944 $22.9672 $24.6096 $25.7831 $24.5262
340129............................ 1.2525 0.9577 $22.3260 $24.1356 $25.4902 $24.1365
340130............................ 1.3763 0.9707 $22.7687 $23.0937 $25.2941 $23.7854
340131............................ 1.5307 0.9404 $24.1370 $25.2989 $27.9358 $25.8415
340132............................ 1.2002 0.8544 $17.8771 $20.4222 $21.3521 $19.8892
340133............................ 1.0161 0.8852 $23.1444 $22.1588 $22.5558 $22.6188
340137............................ 1.0101 0.8930 $33.1751 $29.9903 $21.0642 $28.4915
340138............................ 0.8487 0.9944 $29.5286 $27.4767 $21.3670 $26.2644
340141............................ 1.6488 0.9570 $24.2033 $24.8132 $27.3355 $25.5266
340142............................ 1.1830 0.8544 $20.4320 $22.1298 $22.9907 $21.8836
340143............................ 1.4873 0.8930 $23.0416 $24.8904 $25.3633 $24.4002
340144............................ 1.2457 0.9577 $25.4598 $25.6538 $27.2686 $26.1330
340145............................ 1.2943 0.9577 $21.8120 $23.7028 $23.7131 $23.0768
340146............................ 1.0635 * $20.7252 $18.8354 * $19.6880
340147............................ 1.2141 0.9411 $22.6057 $23.9998 $25.4534 $24.0568
340148............................ 1.3490 0.8951 $20.8156 $22.4205 $23.5880 $22.2985
340151............................ 1.1115 0.8544 $19.2593 $22.2613 $22.0052 $21.1161
340153............................ 1.8758 0.9707 $23.7426 $25.7078 $26.4896 $25.3204
340155............................ 1.4344 1.0200 $26.3663 $28.8758 $30.4940 $28.6096
340156............................ 0.8242 1.4448 * * * *
340158............................ 1.1147 0.9570 $21.7489 $23.4724 $26.4849 $23.8953
340159............................ 1.1662 1.0200 $21.2983 $22.1872 $23.2991 $22.2743
340160............................ 1.2859 0.8544 $18.7569 $19.1330 $20.7525 $19.5589
340166............................ 1.3711 0.9707 $22.8349 $25.7398 $26.0557 $24.9254
340168............................ 0.3956 * $16.8278 $16.8076 $17.3249 $17.0046
340171............................ 1.1940 0.9707 $25.9603 $27.2074 $28.2734 $27.2246
340173............................ 1.2567 0.9944 $23.7037 $26.6128 $27.5072 $26.0994
340176............................ *** * $26.5277 * * $26.5277
340177............................ 1.0581 0.8544 * * $24.7471 $24.7471
340178............................ *** * * * $28.7219 $28.7219
340181............................ 2.1149 0.9303 * * * *
340182............................ 2.7404 1.0200 * * * *
350002............................ 1.7344 0.8769 $20.4398 $20.6474 $22.0283 $21.0339
350003............................ 1.1648 0.8769 $21.0585 $25.3076 $21.8061 $22.5764
350004............................ *** * $28.3773 $27.5891 * $28.0246
350006............................ 1.6936 0.8769 $19.7577 $19.5870 $19.4985 $19.5737
350009............................ 1.0850 0.8769 $20.2558 $20.7014 $23.0873 $21.3437
350010............................ 1.0994 0.8769 $17.2489 $18.5682 $19.1965 $18.3109
350011............................ 1.9994 0.8769 $21.9111 $22.3896 $23.1947 $22.5594
350014............................ 0.9136 0.8769 $16.1718 $18.5360 $17.7565 $17.4777
350015............................ 1.7120 0.8769 $18.5437 $18.6381 $20.1161 $19.1124
350017............................ 1.4490 0.8769 $19.1952 $20.1943 $21.0243 $20.1512
350019 \2\........................ 1.6909 0.8769 $21.3589 $24.2382 $22.1960 $22.5332
350027............................ 1.0607 * $17.6731 $14.2262 * $15.5713
350030............................ 0.9611 0.8769 $18.8822 $19.2282 $18.9978 $19.0373
350043............................ *** * $18.8378 $20.9732 * $19.9618
350058............................ 0.9761 * $15.0196 * * $15.0196
350061............................ 1.0550 * $18.8494 $18.6546 $22.0515 $19.8387
350063............................ 0.9163 1.4448 * * * *

[[Page 47551]]

350064............................ 0.8946 1.4448 * * * *
350070............................ 1.9464 0.8769 * $24.4464 $25.2836 $24.8833
360001............................ 1.3631 0.9595 $22.2387 $23.7750 $23.9101 $23.2970
360002............................ 1.2126 0.8826 $20.7586 $22.6923 $24.5789 $22.7274
360003............................ 1.8536 0.9595 $24.4144 $26.3180 $27.5029 $26.0650
360006............................ 2.0518 0.9857 $24.0814 $25.7041 $28.1698 $26.0230
360007............................ *** * $19.1315 * * $19.1315
360008............................ 1.3213 0.9110 $21.3795 $23.2545 $24.5714 $23.1202
360009............................ 1.6004 0.9271 $22.4076 $23.2659 $23.1012 $22.9250
360010............................ 1.2000 0.8970 $20.6290 $22.0262 $23.1178 $21.9858
360011............................ 1.3439 0.9857 $21.4293 $22.4482 $25.5340 $23.0257
360012............................ 1.3892 0.9857 $24.3618 $25.5913 $27.5470 $25.9629
360013............................ 1.1054 0.9271 $24.4232 $25.1588 $26.8129 $25.4875
360014............................ 1.1501 0.9857 $22.9372 $23.8305 $25.3861 $24.0832
360016............................ 1.4438 0.9595 $22.8430 $24.6587 $26.1283 $24.5377
360017............................ 1.7459 0.9857 $23.6181 $25.4969 $27.2910 $25.5905
360018............................ *** * $29.9085 * * $29.9085
360019............................ 1.3001 0.9207 $23.3006 $24.1105 $25.5926 $24.3472
360020............................ 1.6459 0.9207 $21.5085 $22.3795 $24.4343 $22.8262
360024............................ *** * $22.5356 $24.0612 $23.5793 $23.3219
360025............................ 1.4264 0.9207 $21.6676 $23.6574 $25.5633 $23.7829
360026............................ 1.2976 0.9060 $20.8825 $22.3303 $23.5898 $22.2676
360027............................ 1.6880 0.9207 $23.5907 $24.7093 $25.4894 $24.6187
360029............................ 1.0971 0.9564 $20.4924 $20.8778 $22.7785 $21.4073
360031............................ *** * $24.3482 $24.4324 * $24.3900
360032 \h\........................ 1.1348 0.9271 $21.1743 $22.9759 $23.2638 $22.4807
360034............................ 1.1011 * $21.5621 $25.1366 * $23.3553
360035............................ 1.7292 0.9857 $24.2433 $25.6895 $27.5220 $25.8774
360036............................ 1.2246 0.9207 $22.3567 $25.0910 $27.6094 $25.0649
360037............................ 1.3805 0.9207 $32.6245 $25.1615 $24.3982 $26.6839
360038............................ 1.4223 0.9595 $23.4855 $24.8294 $22.8009 $23.7144
360039............................ 1.4979 0.9857 $23.4642 $22.5921 $24.0218 $23.3755
360040............................ 1.1570 0.8826 $21.3307 $22.8729 $24.0942 $22.7498
360041............................ 1.4614 0.9207 $22.1352 $23.2625 $24.1080 $23.2048
360044............................ 1.0733 0.8826 $19.7212 $20.4724 $21.8411 $20.6845
360046............................ 1.2105 0.9595 $22.8425 $23.8918 $25.0775 $23.9800
360047............................ 0.9609 0.8826 $17.5885 $17.1973 $21.7248 $18.9388
360048............................ 1.7734 0.9564 $24.7150 $27.2274 $28.8107 $26.8831
360049............................ 1.1590 0.9207 $22.4939 $24.2605 $25.8367 $24.2864
360051............................ 1.6784 0.9060 $23.0658 $25.1785 $25.7556 $24.7297
360052............................ 1.5709 0.9060 $22.5005 $23.3285 $24.5405 $23.5101
360054............................ 1.2960 0.8826 $19.2884 $20.3176 $23.0376 $20.9178
360055............................ 1.4051 0.8826 $23.5586 $25.1475 $26.3112 $24.9991
360056............................ 1.5598 0.9595 $22.4475 $23.4638 $23.1024 $22.9631
360058............................ 1.1320 0.8826 $21.0768 $22.7943 $23.4429 $22.4519
360059............................ 1.4973 0.9207 $23.0775 $25.5222 $25.3516 $24.6433
360062............................ 1.5523 0.9857 $24.5746 $26.8091 $28.6518 $26.7475
360064............................ 1.5736 0.8826 $21.3424 $22.8729 $22.2393 $22.1811
360065............................ 1.2094 0.9207 $22.9727 $24.0868 $26.3036 $24.5445
360066............................ 1.5723 0.9271 $24.6806 $25.2316 $27.3362 $25.7779
360068............................ 1.8628 0.9564 $22.1110 $23.7895 $25.8414 $23.9678
360069............................ 1.1368 0.9564 $20.5349 $25.7032 $24.2444 $23.4234
360070............................ 1.6666 0.8976 $21.8228 $23.1687 $24.8863 $23.3191
360071 \h\........................ 1.2226 0.9271 $21.4478 $21.6176 $22.0786 $21.6950
360072............................ 1.4007 0.9857 $21.3736 $23.0464 $24.4332 $23.0100
360074............................ 1.2667 0.9564 $22.2368 $23.6172 $24.9055 $23.6214
360075............................ 1.2223 0.9207 $23.8492 $24.7610 $26.8453 $25.2573
360076............................ 1.4070 0.9595 $22.5863 $22.5943 $25.9369 $23.7285
360077............................ 1.5522 0.9207 $23.3686 $24.7086 $25.6505 $24.5864
360078............................ 1.2933 0.9207 $23.3799 $24.6821 $26.1313 $24.7447
360079............................ 1.7728 0.9595 $25.9623 $25.8762 $26.0935 $25.9804
360080............................ 1.0799 0.8826 $18.7213 $19.5436 $20.8309 $19.7267
360081............................ 1.3290 0.9564 $22.1973 $25.1439 $27.5695 $24.8761
360082............................ 1.4058 0.9207 $25.2254 $27.4264 $27.1197 $26.6255
360084............................ 1.5637 0.8976 $23.3257 $25.2059 $25.8415 $24.8445
360085............................ 2.0948 0.9857 $24.6618 $27.5792 $29.0081 $27.1579
360086............................ 1.5369 0.9060 $21.5983 $22.3005 $22.1859 $22.0265

[[Page 47552]]

360087............................ 1.4204 0.9207 $23.9638 $25.9131 $25.4040 $25.0901
360089............................ 1.1248 0.8826 $21.0229 $21.0253 $22.7951 $21.6142
360090............................ 1.4961 0.9564 $22.6236 $24.4291 $26.7717 $24.5859
360091............................ 1.2239 0.9207 $23.5759 $26.0541 $27.5067 $25.7352
360092............................ 1.2370 0.9857 $21.9732 $23.5100 $25.6618 $23.7647
360093............................ 1.0538 * $21.4623 $24.1238 * $22.7886
360094............................ *** * $22.6440 $27.1864 $26.6348 $24.9723
360095............................ 1.3015 0.9271 $23.6518 $24.6984 $26.1275 $24.8802
360096............................ 1.0962 0.8826 $22.0673 $22.2333 $24.6317 $22.9802
360098............................ 1.4207 0.9207 $22.7644 $23.6413 $24.8447 $23.7933
360099............................ *** * $20.8524 * * $20.8524
360100............................ 1.2206 0.8976 $21.5911 $19.0616 $23.0561 $21.0569
360101............................ 1.4001 0.9207 $26.2875 $27.7584 $26.6208 $26.9092
360102............................ 1.0721 0.9207 * * * *
360106............................ 1.0956 * $19.8658 $21.6450 $24.1588 $21.9428
360107............................ 1.0610 0.9207 $23.6880 $24.5365 $25.9697 $24.7438
360109............................ 1.1010 0.8826 $23.0178 $24.3236 $25.4184 $24.2613
360112............................ 2.0624 1.0570 $25.5910 $26.7880 $28.6784 $26.9982
360113............................ 1.2545 0.9595 $22.3348 $23.5138 $25.6493 $23.7408
360115............................ 1.2688 0.9207 $22.3926 $24.0232 $24.0052 $23.4857
360116............................ 1.2736 0.9595 $21.3809 $23.4049 $18.0655 $20.9510
360118............................ 1.5074 0.9902 $23.0070 $24.2526 $27.7289 $25.0968
360121............................ 1.2399 1.0570 $23.2515 $25.2037 $24.5592 $24.3452
360123............................ 1.4309 0.9207 $23.1310 $24.1761 $22.6523 $23.2730
360125............................ 1.1911 0.9207 $21.1408 $22.6871 $22.1096 $21.9849
360126............................ *** * $22.2409 * * $22.2409
360128............................ 1.0897 * $18.0356 $18.5954 $21.0066 $19.1903
360129............................ 0.9502 * $17.9151 $19.5336 * $18.7493
360130............................ 1.4589 0.9207 $20.1257 $21.7015 $22.9762 $21.5955
360131............................ 1.2615 0.8976 $21.7838 $23.1730 $24.0495 $23.0299
360132............................ 1.2590 0.9595 $23.4179 $25.7991 $25.9453 $25.1258
360133............................ 1.6363 0.9060 $22.0958 $23.9457 $24.6208 $23.6001
360134............................ 1.7249 0.9595 $23.6817 $25.3013 $29.2975 $26.0944
360137............................ 1.7024 0.9207 $23.8947 $25.7647 $26.9522 $25.5442
360141............................ 1.6707 0.8826 $25.1442 $31.0127 $27.7085 $27.9618
360142............................ 0.9787 0.8826 $20.6728 $21.2084 $22.1610 $21.3780
360143............................ 1.3313 0.9207 $22.2275 $23.8938 $24.6306 $23.6169
360144............................ 1.3548 0.9207 $24.7973 $26.7160 $25.7079 $25.7641
360145............................ 1.7973 0.9207 $22.4813 $23.4743 $25.8268 $23.9319
360147............................ 1.3819 0.8826 $20.0409 $22.7172 $24.1953 $22.4020
360148............................ 1.0643 0.8826 $21.3211 $24.4873 $26.1946 $24.0470
360150............................ 1.2073 0.9207 $24.8485 $25.8703 $24.7667 $25.1568
360151............................ 1.5213 0.8976 $21.7215 $22.2179 $24.8629 $22.8949
360152............................ 1.5274 0.9857 $22.9352 $24.9894 $27.9147 $25.0211
360153............................ 0.9727 0.8826 $17.3367 $19.0844 $19.0226 $18.4206
360154............................ 0.9978 * $16.2416 $17.1274 * $16.6874
360155............................ 1.5088 0.9207 $23.0020 $23.9466 $25.3909 $24.1471
360156............................ 1.1585 0.9039 $21.2853 $22.6709 $24.0510 $22.6856
360159............................ 1.2447 0.9857 $23.3359 $25.7108 $33.1613 $27.1828
360161............................ 1.3756 0.8826 $21.5114 $22.6005 $24.3792 $22.8785
360163............................ 1.9069 0.9595 $23.1500 $25.7966 $26.9728 $25.2619
360170............................ 1.2023 0.9857 $22.2815 $22.9359 $24.3620 $23.3031
360172............................ 1.4108 0.9207 $22.7104 $23.4727 $26.3501 $24.1960
360174............................ 1.2246 0.9060 $21.7129 $22.8167 $24.9990 $23.2230
360175............................ 1.2182 0.9857 $22.7887 $24.6152 $26.5949 $24.7311
360177............................ 1.1637 0.8826 $20.8194 $23.4256 $24.4712 $22.9543
360178............................ *** * $18.2393 * * $18.2393
360179............................ 1.5758 0.9595 $23.0678 $25.9429 $28.8645 $26.0273
360180............................ 2.2433 0.9207 $25.1499 $26.8720 $26.1514 $26.0861
360185............................ 1.1997 0.8826 $21.1245 $21.8641 $23.7173 $22.2403
360187............................ 1.5882 0.9060 $21.9499 $23.8362 $24.8173 $23.5639
360189............................ 1.1305 0.9857 $20.0275 $24.2512 $24.2136 $22.8164
360192............................ 1.3344 0.9207 $24.9995 $26.2976 $26.7577 $26.0512
360194............................ 1.1621 * $20.3677 $22.3297 * $21.3611
360195............................ 1.0805 0.9207 $23.1897 $25.8043 $26.1280 $25.1222
360197............................ 1.1010 0.9857 $23.1378 $24.7539 $27.0896 $25.0381
360203............................ 1.1587 0.8826 $19.3642 $21.5564 $22.1414 $21.0862

[[Page 47553]]

360210............................ 1.1833 0.9857 $25.0811 $26.5665 $27.8415 $26.5578
360211............................ 1.5671 0.8832 $22.4529 $23.0884 $22.5449 $22.6945
360212............................ 1.3858 0.9207 $22.8041 $24.5310 $25.2756 $24.2166
360218............................ 1.1880 0.9857 $22.8060 $24.4720 $27.4288 $25.0106
360230............................ 1.6262 0.9207 $24.7681 $26.6444 $27.0223 $26.1931
360234............................ 1.3217 0.9595 $22.1787 $23.3325 $24.3625 $23.2666
360236............................ 1.1633 0.9595 $22.8821 $21.3795 $35.8144 $24.3729
360239............................ 1.3270 0.9060 $23.5802 $24.4398 $25.2474 $24.5362
360241............................ *** * $23.4061 $24.8089 $24.7001 $24.1133
360242............................ 1.9421 * * * * *
360245............................ 0.5583 0.9207 $18.1015 $18.7966 $19.1885 $18.7327
360247............................ 0.3956 0.9857 * $25.1083 $19.8892 $22.3390
360253............................ 2.2766 0.9060 $31.3006 $28.2555 $30.4276 $29.8452
360254............................ *** * $30.0792 * * $30.0792
360255............................ *** * $15.0963 * * $15.0963
360257............................ 1.0823 * * $17.9652 * $17.9652
360259............................ 1.2034 0.9564 * * $25.1338 $25.1338
360260............................ *** * * * $27.3903 $27.3903
360261............................ 1.8245 0.9473 * * $22.5431 $22.5431
360262............................ 1.3722 0.9564 * * $27.1680 $27.1680
360263............................ 1.7091 0.9271 * * $20.8884 $20.8884
360264............................ 2.2623 0.9595 * * * *
360265............................ 2.0629 0.8826 * * * *
360266............................ 2.0862 0.9857 * * * *
360267............................ 2.5734 0.8976 * * * *
360268............................ 1.1877 0.9060 * * * *
370001............................ 1.7009 0.8569 $25.5838 $26.2391 $27.7245 $26.5391
370002............................ 1.1857 0.7607 $18.9544 $19.7718 $20.1479 $19.6308
370004............................ 1.1013 0.8450 $21.5041 $24.7694 $25.3919 $23.7972
370006............................ 1.2175 0.7607 $15.6333 $16.9469 $20.1063 $17.6384
370007............................ 1.0578 0.7607 $16.7598 $17.2084 $17.6547 $17.2160
370008............................ 1.3926 0.9034 $22.1596 $22.7419 $24.2978 $23.1423
370011............................ 1.0967 0.9034 $17.1458 $19.2266 $19.7821 $18.6737
370013............................ 1.5307 0.9034 $21.1512 $22.6451 $24.9295 $22.9792
370014............................ 1.0503 0.8962 $21.8473 $24.8138 $25.3576 $24.0194
370015............................ 0.9755 0.8569 $20.3966 $21.1833 $23.6693 $21.7009
370016 \h\........................ 1.5144 0.8673 $20.4407 $24.2737 $25.4062 $23.3330
370018............................ 1.4275 0.8569 $20.8357 $23.4286 $23.5336 $22.5984
370019............................ 1.2367 0.7607 $18.1260 $19.6761 $21.4474 $19.7475
370020............................ 1.2396 0.7607 $16.8631 $17.4835 $18.5046 $17.6368
370022............................ 1.2026 0.7666 $20.2432 $18.4217 $19.6495 $19.4375
370023............................ 1.2518 0.7691 $19.3386 $20.6002 $21.5762 $20.5441
370025............................ 1.2688 0.8569 $20.2845 $22.0287 $23.5659 $21.9757
370026 \h\........................ 1.5389 0.8673 $21.9140 $22.5734 $23.0848 $22.5236
370028............................ 1.8670 0.9034 $24.1009 $24.8661 $26.6153 $25.1976
370029............................ 1.0497 0.7607 $19.5811 $22.1163 $23.9956 $21.8559
370030............................ 1.0482 0.7607 $18.6541 $20.3315 $23.3037 $20.7201
370032............................ 1.4610 0.9034 $20.0827 $21.6029 $23.4843 $21.7536
370034............................ 1.2055 0.7998 $16.1540 $17.6247 $18.2341 $17.3349
370036............................ 1.0269 0.7607 $16.5844 $16.9222 $17.7576 $17.1504
370037............................ 1.6819 0.9034 $21.0719 $23.1256 $23.9685 $22.7803
370039............................ 1.0974 0.8569 $20.3137 $21.0793 $21.8220 $21.0783
370040............................ 1.0217 0.8247 $18.9981 $21.1061 $22.4048 $20.8291
370041............................ 0.8941 0.8569 $19.0144 $22.0082 $22.3496 $21.1267
370042............................ 0.9463 * $14.0899 $15.3613 * $14.7180
370043............................ 0.9527 * $20.2929 $21.5588 * $20.9707
370045............................ 0.9173 * $12.6613 $14.6370 * $13.6711
370047............................ 1.4476 0.8962 $19.4856 $19.7112 $20.4657 $19.9082
370048............................ 1.1085 0.7607 $15.4768 $17.7273 $19.2464 $17.4431
370049............................ 1.3041 0.9034 $20.4826 $21.6878 $23.2171 $21.8100
370051............................ 1.0513 0.7607 $12.0397 $14.6254 $17.2618 $14.4702
370054............................ 1.2607 0.7607 $20.3788 $21.5521 $21.5043 $21.1653
370056............................ 1.6327 0.7908 $20.4872 $21.7647 $22.0312 $21.4507
370057............................ 0.9482 0.8569 $17.3020 $18.0426 $19.7284 $18.3749
370060............................ 0.9366 0.8569 $23.1897 $23.8007 $18.7592 $21.7395
370064............................ 0.9040 0.7607 $11.9044 $14.1879 $14.2053 $13.4809
370065............................ 1.0317 0.7728 $18.3966 $20.6537 $20.0226 $19.6691

[[Page 47554]]

370072............................ 0.8151 0.7607 $12.5765 $14.6387 $9.9616 $11.8723
370076............................ *** * $19.0230 $21.5461 * $20.2863
370078............................ 1.6275 0.8569 $22.2318 $23.9507 $25.4068 $23.9046
370080............................ 0.9012 0.7607 $16.1444 $17.4857 $18.0665 $17.2314
370082............................ *** * $12.6060 * * $12.6060
370083............................ 0.9426 0.7607 $18.5669 $15.3447 $16.8836 $16.8841
370084............................ 0.9728 0.7607 $16.1278 $17.2735 $16.6514 $16.7384
370089............................ 1.0828 0.7607 $18.0505 $19.9021 $20.4699 $19.4850
370091............................ 1.7106 0.8569 $24.2117 $22.9893 $23.3357 $23.4867
370093............................ 1.6481 0.9034 $23.5685 $25.7296 $26.9774 $25.3740
370094............................ 1.4086 0.9034 $20.6507 $22.0591 $23.1191 $21.9907
370095............................ 0.8962 * $14.3563 $16.5310 * $15.4277
370097............................ 1.3020 0.7908 $20.3218 $21.7150 $22.3267 $21.5064
370099............................ 1.0107 0.8569 $20.2001 $20.5217 $20.5075 $20.4227
370100............................ 0.9798 0.7607 $13.0681 $14.1883 $14.7712 $14.0181
370103............................ 0.9470 0.8053 $15.6110 $16.1408 $17.8018 $16.5505
370105............................ 1.8538 0.9034 $22.4493 $22.1584 $23.8978 $22.8583
370106............................ 1.3548 0.9034 $24.1115 $24.2393 $26.5867 $25.0105
370108............................ *** * $13.8170 * * $13.8170
370112............................ 0.9371 0.8247 $16.5965 $15.4941 $15.4471 $15.8101
370113............................ 1.1531 0.8707 $21.4267 $23.3011 $25.3565 $23.3322
370114............................ 1.5662 0.8569 $19.4933 $21.0603 $21.7880 $20.8230
370123............................ *** * $20.5180 $22.8174 $25.4733 $22.7986
370125............................ 0.8604 * $17.9240 $17.2013 $17.1361 $17.4038
370138............................ 1.0236 0.7607 $19.0403 $19.8308 $18.3113 $19.0435
370139............................ 0.9440 0.7607 $16.3224 $17.8900 $18.5225 $17.5400
370141............................ *** * $24.7859 * * $24.7859
370148............................ 1.4980 0.9034 $22.8526 $24.6194 $25.2348 $24.3075
370149 \h\........................ 1.2123 0.9390 $18.2260 $21.0608 $22.3537 $20.7832
370153............................ 1.0538 0.7607 $17.9692 $18.5417 $19.8349 $18.7951
370154............................ *** * $17.4760 * * $17.4760
370156............................ 1.0073 0.7607 $15.9647 $16.6572 $19.4743 $17.3490
370158............................ 1.0204 0.9034 $17.3412 $17.3161 $18.5578 $17.7592
370166............................ 1.0006 0.8569 $21.3628 $21.9070 $23.1681 $22.1327
370169............................ 0.9033 0.7607 $16.5607 $15.7686 $15.8002 $16.0704
370170............................ 1.0221 1.4448 * * * *
370171............................ 1.5204 1.4448 * * * *
370172............................ 0.8692 1.4448 * * * *
370173............................ 1.0681 1.4448 * * * *
370174............................ 0.9191 1.4448 * * * *
370176............................ 1.1146 0.8569 $22.1456 $23.0324 $25.0509 $23.4362
370177............................ 1.0163 0.7607 $14.0279 $15.6723 $14.7193 $14.7923
370178............................ 0.9012 0.7607 $12.9635 $14.9767 $14.6070 $14.1857
370179............................ 0.9319 0.8569 $21.9673 $22.8322 $23.5794 $22.6918
370180............................ 1.0669 1.4448 * * * *
370183............................ 1.0219 0.8569 $17.9270 $20.5025 $21.8147 $20.0076
370186............................ 0.9039 * $16.3879 * * $16.3879
370190............................ 1.5509 0.8569 $22.3326 $24.9455 $33.1137 $27.0848
370192............................ 1.8038 0.9034 $24.3832 $26.1338 $31.4930 $27.6466
370196............................ 1.0637 0.9034 $23.6334 $29.4383 $22.6824 $25.4359
370199............................ 0.9513 0.9034 $20.7075 $23.7340 $26.0451 $23.4652
370200............................ 1.1695 0.7607 $16.7164 $18.1008 $17.6317 $17.5059
370201............................ 1.7144 0.9034 $18.9906 $23.1240 $23.3550 $21.7730
370202............................ 1.5408 0.8569 $24.0239 $24.4920 $25.1181 $24.5965
370203............................ 1.3869 0.9034 $19.8772 $21.2426 $23.5190 $21.5182
370206............................ 1.5811 0.9034 $22.3471 $27.4495 $26.0912 $25.5795
370207............................ *** * $26.3746 * * $26.3746
370209............................ *** * * $32.8278 * $32.8278
370210............................ 2.2165 0.8569 * $20.0360 $21.2682 $20.6946
370211............................ 0.9595 0.9034 * * $26.5344 $26.5344
370212............................ 1.5535 0.9034 * * $21.0758 $21.0758
370213............................ *** * * * $29.3777 $29.3777
370214............................ 0.8997 0.7607 * * * *
370215............................ 2.5045 0.9034 * * $32.3589 $32.3589
370216............................ 2.5952 0.8569 * * * *
370217............................ 1.0003 0.7607 * * * *
370218............................ 2.3683 0.8569 * * * *

[[Page 47555]]

380001............................ 1.1917 1.1235 $20.9585 $27.8554 $30.0103 $26.2164
380002............................ 1.2041 1.0431 $25.2629 $26.3348 $27.1861 $26.3148
380003............................ *** * $24.6377 * * $24.6377
380004............................ 1.7214 1.1235 $27.5184 $28.2466 $30.5172 $28.8120
380005............................ 1.3710 1.0301 $26.3472 $28.0682 $30.2211 $28.3075
380006............................ 1.1672 * $24.7492 $26.0475 * $25.3948
380007............................ 1.9085 1.1235 $30.0497 $31.5207 $33.9969 $31.9322
380008............................ 1.1295 1.0301 $24.6149 $25.4494 $25.8356 $25.3227
380009............................ 1.9379 1.1235 $26.0012 $30.4198 $31.7042 $29.4616
380010............................ 1.0337 1.1235 $25.5234 $27.5291 $30.2957 $27.8451
380011............................ *** * $21.9382 * * $21.9382
380013............................ *** * $24.1491 * * $24.1491
380014............................ 1.8478 1.0700 $28.4536 $27.7255 $29.9648 $28.7806
380017............................ 1.7770 1.1235 $29.2543 $31.7440 $32.2447 $31.1318
380018............................ 1.8112 1.0301 $27.5171 $27.8952 $28.0701 $27.8359
380020............................ 1.3781 1.0799 $23.7066 $25.8320 $28.3563 $26.0268
380021............................ 1.4279 1.1235 $28.0334 $29.3001 $29.3295 $28.9428
380022............................ 1.2258 1.0502 $26.4794 $27.8683 $29.2642 $27.9316
380023............................ 1.1838 1.0301 $23.0079 $23.7073 $26.5439 $24.4358
380025............................ 1.3001 1.1235 $28.8525 $30.2628 $33.2105 $30.8181
380026............................ 1.1392 * $23.8666 $26.5217 * $25.2072
380027............................ 1.2955 1.0419 $21.5822 $23.8758 $25.5161 $23.7359
380029............................ 1.3050 1.0510 $24.2939 $26.2070 $26.9966 $25.9075
380033............................ 1.6636 1.0799 $30.4783 $29.7995 $30.8767 $30.3883
380035............................ 1.0501 * $26.2434 $26.4784 * $26.3599
380037............................ 1.2406 1.1235 $25.0200 $27.1884 $30.5818 $27.7342
380038............................ 1.2652 1.1235 $29.1804 $30.5903 $34.2303 $31.3814
380039............................ 0.9848 1.1235 $27.5115 $30.1544 $32.3959 $30.0601
380040............................ 1.1935 1.0301 $21.5958 $28.4373 $32.0103 $27.1504
380047............................ 1.7995 1.0772 $26.5017 $27.8385 $29.8627 $28.1638
380050............................ 1.4063 1.0301 $23.1332 $24.2416 $25.6190 $24.3627
380051............................ 1.5965 1.0510 $26.2384 $28.1305 $29.7219 $28.0410
380052............................ 1.1791 1.0301 $21.2567 $22.6799 $24.9476 $22.9567
380056............................ 0.9470 1.0510 $22.3571 $25.0068 $25.1475 $24.2275
380060............................ 1.3974 1.1235 $27.8551 $30.2507 $30.7041 $29.6593
380061............................ 1.6520 1.1235 $27.3827 $29.5145 $29.8217 $28.9273
380066............................ 1.2331 * $23.3581 $27.5412 * $25.5211
380070............................ 1.1830 * $34.1039 * * $34.1039
380071............................ 1.3513 1.1235 $27.9055 $29.5740 $30.2304 $29.2634
380072............................ 0.8571 * $21.9516 $22.5275 * $22.2419
380075............................ 1.3193 1.0301 $25.1930 $27.4795 $29.0368 $27.3082
380081............................ 1.1378 1.0301 $22.1822 $21.0708 $21.8850 $21.7195
380082............................ 1.2295 1.1235 $28.0668 $30.2721 $32.3002 $30.2952
380089............................ 1.2844 1.1235 $29.6989 $30.8396 $33.4214 $31.3234
380090............................ 1.2860 1.2303 $31.8702 $33.6822 $34.4536 $33.3615
380091............................ 1.3349 1.1235 $31.2807 $35.7002 $33.8950 $33.5968
390001............................ 1.6737 0.9834 $21.5154 $22.4407 $22.5309 $22.1581
390002............................ 1.2774 0.8832 $22.0646 $23.0113 $22.4388 $22.5092
390003 \h\........................ 1.1761 0.9834 $19.1857 $21.3182 $21.6478 $20.7084
390004............................ 1.5734 0.9308 $21.3475 $23.4063 $24.3249 $23.1020
390005............................ 0.9917 * $19.0727 $19.0318 * $19.0497
390006............................ 1.8416 0.9139 $23.0378 $23.3960 $25.1216 $23.8687
390008 \h\........................ 1.1617 0.8832 $19.9417 $21.0021 $22.2680 $21.0752
390009............................ 1.7609 0.8737 $21.9459 $24.2789 $25.5482 $23.9471
390010............................ 1.2015 0.8832 $19.4377 $21.6273 $23.5390 $21.5537
390011............................ 1.3462 0.8352 $18.6548 $19.8602 $21.9279 $20.1129
390012............................ 1.2234 1.1028 $28.5114 * $28.5076 $28.5093
390013............................ 1.2242 0.9139 $22.1679 $23.3180 $24.0044 $23.1713
390016 \h\........................ 1.2089 0.8832 $18.1536 $19.9899 $21.9549 $20.1569
390017 \h\........................ *** * $19.1962 $20.6575 * $19.8788
390018............................ *** * $19.9117 * * $19.9117
390019............................ 1.2036 0.9834 $21.2806 $21.5137 $23.4636 $22.1361
390022............................ 1.3229 1.1028 $27.5504 $31.0971 $29.0710 $29.1659
390023............................ 1.2592 1.1028 $25.3767 $27.1600 $31.7149 $28.1614
390024............................ 0.9502 1.1028 $25.9806 $37.4330 $35.3959 $29.4333
390025............................ 0.5326 1.1028 $14.8690 $15.0282 $17.2977 $15.7085
390026............................ 1.2514 1.1028 $24.0326 $27.0802 $29.5157 $26.9256

[[Page 47556]]

390027............................ 1.5554 1.1028 $33.2139 $28.9159 $35.8381 $32.5478
390028............................ 1.6221 0.8832 $24.6796 $23.6616 $25.7246 $24.7268
390029............................ *** * * $24.4276 * $24.4276
390030............................ 1.1890 0.9834 $20.0598 $20.9859 $22.1581 $21.0867
390031............................ 1.2121 0.9491 $20.3568 $21.2949 $22.6828 $21.4388
390032............................ 1.1808 0.8832 $20.8450 $20.9971 $22.7205 $21.5225
390035............................ 1.2294 1.1028 $23.2173 $24.7281 $26.2647 $24.7742
390036............................ 1.4723 0.8832 $20.5751 $23.3858 $24.6032 $22.8336
390037............................ 1.3526 0.8832 $20.1665 $22.9008 $24.7820 $22.6385
390039 \h\........................ 1.1584 0.8340 $18.4580 $17.8461 $20.3787 $18.9083
390040............................ *** * $20.5371 $23.1807 * $21.7860
390041............................ 1.3213 0.8832 $21.0074 $20.6789 $21.5925 $21.0799
390042............................ 1.3558 0.8832 $22.2351 $23.9632 $25.6328 $23.9486
390043............................ 1.1770 0.8289 $19.8641 $20.9835 $22.2549 $21.0509
390044............................ 1.6846 0.9888 $22.4235 $24.2586 $27.1505 $24.6634
390045............................ 1.6020 0.8355 $20.2082 $22.2582 $23.0712 $21.8774
390046............................ 1.5586 0.9447 $23.1271 $25.0825 $27.2630 $25.1787
390048............................ 1.0902 0.9139 $20.3523 $23.6622 $24.9759 $22.9112
390049............................ 1.5998 0.9834 $24.0933 $25.4056 $27.1366 $25.5929
390050............................ 2.0676 0.8832 $22.6951 $24.5424 $26.6931 $24.6339
390052............................ 1.1861 0.8933 $22.1380 $21.6736 $23.3474 $22.4074
390054............................ 1.2038 0.9706 $19.8602 $21.4983 $22.8087 $21.3801
390055............................ *** * $23.5292 $25.5675 $25.6945 $24.9860
390056............................ 1.0708 0.8331 $21.4239 * $19.5537 $20.4834
390057............................ 1.3477 1.1028 $24.8235 $25.1901 $27.9583 $26.0368
390058............................ 1.2896 0.9308 $22.0113 $25.3415 $27.4799 $24.8349
390061............................ 1.5366 0.9706 $24.4550 $25.5012 $28.4538 $26.1704
390062............................ 1.1215 0.8933 $17.6303 $19.0692 $21.4052 $19.4592
390063............................ 1.7830 0.8737 $21.7120 $23.5469 $24.7614 $23.4097
390065............................ 1.2190 1.0802 $23.1384 $23.4021 $25.2188 $23.9720
390066............................ 1.2758 0.9139 $21.7717 $23.0891 $24.2087 $23.0471
390067............................ 1.8416 0.9308 $23.5136 $25.4576 $26.3287 $25.0668
390068............................ 1.3355 0.9706 $21.1177 $25.9890 $25.8291 $24.3019
390070............................ 1.3629 1.1028 $24.4403 $26.9235 $30.9499 $27.4435
390071............................ 0.9938 0.8289 $17.8117 $20.9443 $21.8366 $20.0802
390072 \h\........................ 1.0521 0.9834 $20.0561 $22.0155 $24.9388 $22.3043
390073............................ 1.5860 0.8933 $22.7073 $24.8013 $26.3698 $24.6228
390074............................ 1.1499 0.8832 $21.8456 $21.0941 $22.8545 $21.9412
390075............................ *** * $19.9775 $22.6530 $24.6359 $22.3701
390076............................ 1.3526 1.1028 $21.2039 $18.1276 $27.9004 $21.9007
390079............................ 1.9205 0.8462 $19.9169 $21.4323 $23.3053 $21.5091
390080............................ 1.2863 1.1028 $23.3742 $25.0921 $27.2616 $25.2851
390081............................ 1.2261 1.1028 $28.1056 $28.7974 $30.3840 $29.1503
390084............................ 1.2773 0.8289 $18.3551 $20.7799 $19.8605 $19.6630
390086............................ 1.5753 0.8289 $19.6488 $20.7383 $22.5317 $20.9944
390090............................ 1.8335 0.8832 $22.4688 $20.7474 $25.2014 $22.8601
390091............................ 1.1481 0.8600 $19.7361 $20.8243 $21.5586 $20.7010
390093............................ 1.1857 0.8832 $19.9209 $21.0427 $21.4401 $20.8186
390095............................ 1.1983 0.9834 $18.3939 $21.0754 $23.6240 $20.9725
390096............................ 1.5210 0.9888 $22.9502 $24.4145 $27.0763 $24.8874
390097............................ 1.1981 1.1028 $24.5304 $25.3012 $25.6660 $25.2008
390100............................ 1.7217 0.9706 $23.4155 $26.7267 $27.7208 $26.0717
390101............................ 1.2600 0.9447 $20.1271 $20.1694 $21.9418 $20.7655
390102............................ 1.3487 0.8832 $20.9807 $21.6629 $24.8898 $22.6239
390103............................ 1.0148 0.8832 $21.0637 $18.6703 $20.6775 $20.1561
390104............................ 1.0645 0.8289 $16.5081 $19.1803 $19.6428 $18.4897
390107............................ 1.3834 0.8832 $21.5852 $23.1023 $24.1386 $23.0080
390108............................ 1.2360 1.1028 $23.7842 $24.7486 $27.2661 $25.2833
390109............................ 1.1285 0.9834 $17.2667 $18.7558 $19.9156 $18.6551
390110............................ 1.6141 0.8832 $22.3968 $23.3355 $23.9808 $23.2737
390111............................ 2.0277 1.1028 $30.5814 $30.6809 $32.6510 $31.3439
390112 \h\........................ 1.2130 0.8340 $15.6710 $16.6113 $19.2126 $17.1537
390113............................ 1.3094 0.8600 $20.1160 $21.7729 $22.2591 $21.3940
390114............................ 1.3657 0.8832 $23.6162 $22.6630 $24.0473 $23.4341
390115............................ 1.4597 1.1028 $24.1951 $26.4751 $27.7333 $26.1536
390116............................ 1.2968 1.1028 $24.9581 $28.5563 $30.2722 $28.0177
390117............................ 1.1039 0.8289 $19.0983 $20.0040 $20.3946 $19.8418

[[Page 47557]]

390118............................ 1.1816 0.8289 $17.8460 $19.3332 $21.5001 $19.5328
390119............................ 1.3011 0.9834 $20.3034 $21.2761 $22.2746 $21.3271
390121............................ 1.6883 0.8933 $20.8017 $22.0556 $23.1408 $22.0024
390122............................ 1.0995 0.8289 $18.5130 $21.6981 $22.5785 $20.8388
390123............................ 1.2160 1.1028 $23.2232 $25.2209 $28.6269 $25.7365
390125............................ 1.2682 0.8289 $18.2411 $19.4406 $20.9456 $19.5654
390127............................ 1.3307 1.1028 $25.0836 $28.9238 $30.9374 $28.4999
390128............................ 1.1938 0.8832 $21.3668 $21.8837 $23.1539 $22.1603
390130............................ 1.2722 0.8352 $19.4835 $21.0694 $24.0685 $21.4556
390131............................ 1.3078 0.8832 $19.5296 $21.2164 $22.6306 $21.1571
390132............................ 1.4193 1.1028 $24.6889 $26.8153 $27.7250 $26.4427
390133............................ 1.7317 1.1028 $25.2110 $26.1458 $28.7162 $26.7622
390135............................ *** * $24.0445 * $24.4738 $24.2670
390136............................ 1.1143 0.8832 $21.9531 $24.8042 $22.1415 $22.9715
390137............................ 1.4923 0.9834 $19.5457 $21.8830 $23.4877 $21.5609
390138............................ 1.1914 1.0802 $21.4705 $22.7210 $24.2769 $22.8713
390139............................ 1.3319 1.1028 $26.3622 $28.2089 $30.4246 $28.3708
390142............................ 1.4938 1.1028 $29.8874 $32.0827 $32.5786 $31.5029
390145............................ 1.5150 0.8832 $20.6580 $22.4255 $23.8041 $22.3138
390146............................ 1.2524 0.8342 $21.4580 $22.3260 $25.2460 $23.0540
390147............................ 1.2394 0.8832 $22.3135 $23.6380 $25.0971 $23.6939
390150............................ 1.1849 0.8832 $20.0261 $24.5256 $24.1855 $22.9524
390151............................ 1.2851 1.0802 $24.7843 $25.1422 $27.1539 $25.7127
390152............................ 1.0043 * $21.5474 $11.7774 * $15.1275
390153............................ 1.3870 1.1028 $25.3391 $27.5167 $30.0586 $27.7812
390154............................ 1.2514 0.8289 $19.1300 $20.4408 $20.6982 $20.0794
390156............................ 1.3762 1.1028 $25.0801 $27.8096 $31.2571 $28.0054
390157............................ 1.3060 0.8832 $20.6933 $22.0222 $22.7493 $21.8431
390160............................ 1.1894 0.8832 $19.3598 $19.5942 $21.4877 $20.1709
390162............................ 1.4816 1.0034 $24.0291 * $30.0900 $26.8901
390163............................ 1.2734 0.8832 $18.8585 $19.8863 $22.1741 $20.2736
390164............................ 2.1009 0.8832 $24.2334 $25.1277 $26.4971 $25.3882
390166............................ 1.1601 0.8832 $19.8531 $20.9510 $24.9810 $21.8402
390168............................ 1.4583 0.8832 $20.6777 $21.9344 $24.5820 $22.5085
390169............................ 1.4280 0.9834 $22.7695 $24.1682 $27.2242 $24.7030
390173............................ 1.1927 0.8289 $20.6958 $21.6562 $22.8220 $21.7639
390174............................ 1.7358 1.1028 $28.4490 $30.3725 $32.6265 $30.5109
390176............................ 1.1618 0.8832 $18.0752 $17.1387 * $17.5532
390178............................ 1.3036 0.8600 $17.2384 $19.2731 $20.7270 $19.1018
390179............................ 1.3742 1.1028 $24.0501 $24.8350 $27.2222 $25.3975
390180............................ 1.4593 1.1028 $28.4842 $30.4264 $32.4375 $30.5043
390181............................ 1.0430 0.8289 * $25.7357 $24.4573 $25.1039
390183............................ 1.0924 0.8289 $21.6811 $22.0117 $25.6554 $23.0449
390184............................ 1.0967 0.8832 $21.1962 $21.3407 $22.5519 $21.7060
390185............................ 1.2794 0.9706 $20.4476 $21.8871 $23.0202 $21.7597
390189............................ 1.1225 0.8289 $20.1365 $21.2711 $22.3722 $21.3477
390191............................ 1.1066 0.8289 $18.5972 $19.2308 $20.8761 $19.5306
390192............................ 1.0171 0.9834 $19.1883 $20.0395 $21.2620 $20.1833
390193............................ *** * $18.9764 $18.5516 $20.1024 $19.2196
390194............................ 1.1094 0.9834 $21.5850 $23.1814 $25.4235 $23.4479
390195............................ 1.6530 1.1028 $26.2024 $28.3480 $31.0019 $28.5392
390196............................ 1.6486 * * * * *
390197............................ 1.4055 0.9834 $22.8349 $24.9234 $25.7739 $24.4854
390198............................ 1.1833 0.8737 $17.3937 $16.8529 $18.7222 $17.6295
390199............................ 1.2240 0.8289 $18.9787 $19.9653 $21.3157 $20.1079
390200............................ *** * $19.4471 $23.1486 $23.7471 $21.9484
390201............................ 1.3035 0.9416 $22.7849 $24.8222 $26.3658 $24.6735
390203............................ 1.6417 1.1028 $26.9436 $28.2741 $28.9054 $28.0870
390204............................ 1.2657 1.1028 $23.9673 $25.6342 $28.6829 $26.1129
390211............................ 1.2873 0.8600 $21.0450 $22.4472 $23.1450 $22.2313
390215............................ *** * $25.2617 $26.4180 $28.0402 $26.4046
390217............................ 1.1598 0.8832 $21.4058 $21.3281 $24.3610 $22.3261
390219............................ 1.3040 0.8832 $20.0594 $22.8559 $25.1705 $22.7113
390220............................ 1.1030 1.1028 $23.4385 $24.7553 $41.6138 $28.9098
390222............................ 1.2493 1.1028 $24.9345 $27.0954 $28.7488 $26.9594
390223............................ 1.9327 1.1028 $22.8725 $28.2538 $27.6407 $26.2383
390224............................ 0.8495 0.8462 $16.1289 $18.1226 $18.7624 $17.7120

[[Page 47558]]

390225............................ 1.2019 0.9706 $20.9232 $23.4945 $24.9391 $23.3545
390226............................ 1.7580 1.1028 $25.6917 $27.0061 $28.5890 $27.1866
390228............................ 1.3366 0.8832 $21.0164 $22.5999 $23.3078 $22.3536
390231............................ 1.4457 1.1028 $24.7757 $27.0576 $29.2653 $27.1070
390233............................ 1.3679 0.9447 $21.8043 $22.8667 $24.8690 $23.1907
390235............................ *** * $23.7068 * * $23.7068
390236............................ 1.1484 0.8289 $19.8687 $21.9199 $21.9169 $21.2652
390237............................ 1.5801 0.9834 $23.2054 $24.6316 $26.9533 $24.9348
390238............................ *** * $19.2171 $26.4748 * $22.5836
390246............................ 1.1726 0.8289 $22.0687 $23.3275 $20.1581 $21.8667
390249............................ 0.8825 * $14.7215 * * $14.7215
390256............................ 1.8708 0.9308 $22.6146 $24.2331 $26.3619 $24.4523
390258............................ 1.5526 1.1028 $25.0634 $27.2038 $29.4626 $27.3466
390262............................ *** * $21.3264 * * $21.3264
390263............................ 1.4528 0.9834 $22.0008 $23.4202 $26.0170 $23.9015
390265............................ 1.4641 0.8832 $20.5948 $21.6751 $23.4836 $21.9520
390266............................ 1.1857 0.8600 $18.2424 $19.2836 $20.3918 $19.3171
390267............................ 1.1960 0.8832 $21.4801 $22.5464 $23.1051 $22.3821
390268............................ 1.3183 0.8360 $23.1124 $24.2050 $25.0021 $24.1351
390270............................ 1.4784 0.9706 $22.5258 $24.0837 $24.1496 $23.6565
390272............................ 0.5215 1.1028 * * * *
390278............................ 0.5505 1.1028 $21.1387 $21.6893 $23.6843 $22.1694
390279............................ 1.1500 0.8360 $16.0510 $15.3569 $17.0012 $16.1304
390285............................ 1.5470 1.1028 $30.6300 $33.5347 $35.0427 $33.0866
390286............................ 1.1729 1.1028 $25.4499 $27.4090 $28.1761 $27.0003
390287............................ 1.4347 1.1028 $32.9709 $35.7147 $37.6569 $35.5140
390288............................ *** * $28.0957 $28.5267 $29.7287 $28.6956
390289............................ 1.1071 1.1028 $25.1658 $28.4577 $28.8826 $27.4320
390290............................ 1.9387 1.1028 $31.0967 $36.4991 $37.9040 $35.0787
390291............................ *** * $21.0057 $21.3015 * $21.1542
390294............................ *** * $33.3537 * * $33.3537
390295............................ *** * $26.8862 * * $26.8862
390296............................ *** * $25.6981 * * $25.6981
390297............................ *** * $25.7318 * * $25.7318
390298............................ *** * * $26.8290 * $26.8290
390299............................ *** * * $31.9423 * $31.9423
390300............................ *** * * $40.4697 * $40.4697
390301............................ *** * * * $30.9838 $30.9838
390304............................ 1.1794 1.1028 * * * *
390305............................ 1.9433 0.8832 * * * *
390306............................ 1.7325 0.8832 * * * *
390307............................ 1.3440 0.8600 * * * *
390308............................ 0.8223 1.1028 * * * *
390309............................ 0.9254 1.1028 * * * *
390310............................ 2.3639 0.8289 * * * *
400001............................ 1.2690 0.4621 $11.7572 $16.1114 $13.1847 $13.4859
400002............................ 1.7591 0.4939 $11.6804 $14.8607 $16.7583 $14.1458
400003............................ 1.3684 0.4939 $10.5963 $13.0776 $12.8329 $12.1392
400004............................ 1.1372 0.4621 $11.4041 $10.4716 $14.3108 $11.8780
400005............................ 1.1239 0.4621 $10.5356 $10.2878 $10.7207 $10.5186
400006............................ 1.1832 0.4621 $9.2852 $8.9919 $9.2265 $9.1710
400007............................ 1.1869 0.4621 $8.6022 $8.7152 $9.2463 $8.8511
400009............................ 1.1006 0.3183 $9.4413 $9.2007 $9.3116 $9.3159
400010............................ 0.8274 0.4732 $9.2799 $10.9354 $10.0962 $10.0495
400011............................ 1.0870 0.4621 $8.9111 $8.5868 $8.5534 $8.6726
400012............................ 1.3561 0.4621 $9.0740 $8.3580 $8.3802 $8.5938
400013............................ 1.3120 0.4621 $9.9905 $9.5584 $10.3347 $9.9727
400014............................ 1.3286 0.4019 $11.4580 $11.7023 $12.2169 $11.7941
400015............................ 1.3925 0.4621 * $15.6066 $15.6349 $15.6221
400016............................ 1.3523 0.4621 $14.6491 $15.3497 $14.7607 $14.9193
400017............................ 1.2103 0.4621 $10.7475 $10.1238 $10.2734 $10.3916
400018............................ 1.2290 0.4621 $10.8254 $10.7948 $11.6165 $11.0939
400019............................ 1.3287 0.4621 $13.7007 $14.9892 $12.8029 $13.7525
400021............................ 1.3231 0.4641 $13.5224 $13.8643 $14.1533 $13.8469
400022............................ 1.3548 0.4939 $15.2904 $16.0539 $15.9246 $15.7672
400024............................ 0.8431 0.4019 $9.8650 $9.1316 $12.4649 $10.2156
400026............................ 1.0668 0.3183 $5.9206 $5.2085 $5.8200 $5.6501

[[Page 47559]]

400028............................ 1.2118 0.4939 $9.5266 $10.3354 $10.9808 $10.2872
400032............................ 1.2001 0.4621 $10.7100 $10.7195 $10.2652 $10.5650
400044............................ 1.2951 0.4939 $9.0275 $10.7890 $13.7509 $11.4819
400048............................ 1.1083 0.4621 $10.8618 $14.0887 $10.4266 $11.8488
400061............................ 1.7198 0.4621 $16.5895 $15.1639 $18.9123 $16.8879
400079............................ 1.1394 0.4732 $8.7218 $9.4218 $12.7825 $10.1505
400087............................ 1.2148 0.4621 $10.7118 $9.5860 $10.6849 $10.3421
400094............................ *** * $9.2871 $8.8646 * $9.1244
400098............................ 1.5611 0.4621 $13.8036 $13.7938 $12.8230 $13.4850
400102............................ 1.1411 0.4621 $10.9973 $10.1795 $10.2677 $10.4779
400103............................ 1.7278 0.4019 $11.5797 $12.8288 $9.3859 $10.9876
400104............................ 1.1614 0.4621 $7.1781 $8.2758 $9.3854 $8.1476
400105............................ 1.1409 0.4621 $11.5608 $12.7725 $14.0219 $12.7229
400106............................ 1.1978 0.4621 $10.1241 $9.6902 $11.4507 $10.3951
400109............................ 1.4855 0.4621 $12.8921 $14.2169 $14.2111 $13.7444
400110............................ 1.1119 0.4408 $12.0159 $11.8458 $12.3449 $12.0750
400111............................ 1.0818 0.4732 $12.7701 $13.4777 $14.5029 $13.5496
400112............................ 1.2190 0.4621 $12.2859 $8.9469 $19.3945 $12.3541
400113............................ 1.2194 0.4939 $10.4416 $10.0830 $9.6778 $10.1179
400114............................ 1.0966 0.4621 $9.7444 $12.1920 $11.5478 $11.0784
400115............................ 1.1336 0.4621 $7.0411 $9.1132 $13.7392 $9.2213
400117............................ 1.1139 0.4621 $9.7314 $10.2911 $12.7600 $10.8102
400118............................ 1.2358 0.4621 $12.4590 $11.9324 $12.5743 $12.3218
400120............................ 1.3171 0.4621 $11.8837 $11.9714 $12.7955 $12.2196
400121............................ 1.0708 0.4621 $8.3575 $8.6665 $8.2197 $8.4118
400122............................ 1.9324 0.4621 $9.6644 $9.6463 $11.2325 $10.1283
400123............................ 1.2113 0.4019 $10.5643 $11.8135 $12.3041 $11.5735
400124............................ 2.8401 0.4621 $14.3496 $17.2258 $16.1812 $15.8787
400125............................ 1.1372 0.4156 $10.6642 $10.7425 $11.6386 $11.0069
400126............................ 1.2124 0.4641 * $13.3932 $9.8008 $11.0632
400127............................ 2.2229 0.4621 * * * *
410001............................ 1.3175 1.1274 $24.0033 $27.0309 $28.0816 $26.3767
410004............................ 1.2352 1.1274 $23.6409 $25.4578 $27.4209 $25.5908
410005............................ 1.2881 1.1274 $24.6522 $27.1171 $30.1606 $27.3044
410006............................ 1.2547 1.1274 $26.1372 $27.1842 $29.4395 $27.6190
410007............................ 1.7162 1.1274 $27.7171 $30.1360 $31.8548 $30.0135
410008............................ 1.2160 1.1274 $25.4183 $28.4245 $29.6092 $27.8277
410009............................ 1.2898 1.1274 $26.9135 $27.7337 $29.4094 $28.0697
410010............................ 1.1690 1.1734 $30.3860 $30.7826 $32.8599 $31.3979
410011............................ 1.3123 1.1274 $29.7664 $28.5875 $30.3787 $29.5538
410012............................ 1.7743 1.1274 $28.1791 $32.1679 $32.6009 $31.1120
410013............................ 1.2336 1.1274 $28.9386 $31.7482 $35.4624 $32.1157
420002............................ 1.5354 0.9707 $25.1067 $27.9312 $28.2848 $27.1910
420004............................ 1.9995 0.9240 $23.4579 $26.0279 $27.2620 $25.6238
420005............................ 1.0201 0.8660 $19.5521 $19.8167 $23.1943 $20.8182
420006............................ 1.0887 0.9240 $22.7896 $22.8920 $24.0811 $23.2220
420007............................ 1.5955 0.9175 $22.0228 $25.0395 $25.2650 $24.2318
420009............................ 1.3854 0.9702 $18.6866 $23.8668 $25.5079 $22.5621
420010............................ 1.1980 0.8971 $19.1746 $21.6478 $23.4562 $21.5057
420011............................ 1.1292 1.0001 $17.7300 $20.8895 $21.4030 $20.0081
420014............................ 0.9681 * $21.2045 $21.5658 * $21.3876
420015............................ 1.2696 1.0001 $23.1274 $24.7383 $26.2154 $24.7258
420016............................ 0.9673 0.8660 $17.0051 $17.3837 $17.1229 $17.1752
420018............................ 1.7687 0.9067 $20.4649 $23.6356 $24.8024 $22.8926
420019............................ 1.1234 0.8660 $19.6836 $20.5472 $22.5312 $20.8812
420020............................ 1.2759 0.9240 $22.1616 $24.6592 $25.8883 $24.3667
420023............................ 1.6656 1.0001 $23.2568 $25.1035 $26.7263 $25.0152
420026............................ 1.8862 0.9067 $23.7406 $29.2961 $27.4814 $26.8241
420027............................ 1.5766 0.9198 $21.0637 $22.8322 $25.1692 $23.0401
420030............................ 1.2300 0.9240 $22.6766 $24.2847 $26.0079 $24.3704
420033............................ 1.1298 1.0001 $26.2711 $27.5740 $31.8759 $28.5975
420036............................ 1.2584 0.9577 $20.6649 $21.9641 $22.8294 $21.8110
420037............................ 1.2615 1.0001 $25.5492 $26.8750 $29.4156 $27.3838
420038............................ 1.2639 1.0001 $21.6133 $22.6741 $24.2259 $22.8531
420039............................ 1.0432 0.9174 $21.9737 $24.0637 $25.1148 $23.7048
420043 \h\........................ 1.0874 0.9351 $21.8816 $22.9764 $23.0555 $22.6545
420048............................ 1.2709 0.9067 $21.9517 $23.1515 $24.1923 $23.1348

[[Page 47560]]

420049............................ 1.2340 0.8929 $21.2604 $23.2156 $23.9722 $22.8399
420051............................ 1.5014 0.8971 $20.6629 $23.9455 $24.8026 $23.1828
420053............................ 1.1649 0.8660 $19.9013 $21.1177 $22.2825 $21.1778
420054............................ 1.0290 0.8660 $20.8471 $24.0653 $24.8931 $23.2676
420055............................ 1.0770 0.8660 $19.6817 $20.3599 $21.9764 $20.6871
420056............................ 1.4078 0.8660 $20.0527 $21.1640 $21.6963 $20.9682
420057............................ 1.0461 0.8971 $17.6727 $19.7653 $23.4311 $20.1207
420059............................ 1.0686 * $20.2917 $21.4260 * $20.8684
420061............................ 1.1331 * $19.9789 $20.8684 * $20.4341
420062............................ 1.1085 0.8660 $17.4764 $25.6683 $25.9526 $22.5339
420064............................ 1.2023 0.8929 $20.9057 $22.1290 $23.3610 $22.2043
420065............................ 1.3680 0.9240 $22.0784 $22.8674 $24.5715 $23.1699
420066............................ 0.9805 0.8971 $20.7782 $20.5893 $23.9048 $21.7523
420067............................ 1.2989 0.9300 $22.8104 $24.6038 $25.0345 $24.2301
420068............................ 1.3586 0.9240 $21.7257 $22.2638 $23.4248 $22.4620
420069............................ 1.0761 0.8660 $17.6291 $19.6959 $20.5546 $19.3217
420070............................ 1.2782 0.9067 $20.3664 $22.4370 $23.4355 $22.1331
420071............................ 1.3654 0.9702 $21.8579 $23.1727 $24.9418 $23.3888
420072............................ 1.1026 0.8660 $16.2578 $17.5899 $18.6742 $17.5511
420073............................ 1.3501 0.9067 $21.4718 $24.0274 $24.5813 $23.3018
420074............................ *** * $18.7010 * * $18.7010
420075............................ 0.8901 * $15.9889 $16.4816 * $16.2328
420078............................ 1.8173 1.0001 $24.3273 $25.3032 $28.9112 $26.1920
420079............................ 1.171 0.9240 $23.3992 $25.2939 $25.4935 $24.7672
420080............................ 1.3906 0.9300 $26.7489 $28.4569 $28.4734 $27.9158
420082............................ 1.4934 0.9751 $23.6936 $26.1221 $29.8528 $26.5169
420083............................ 1.3637 0.9175 $24.8508 $25.3043 $27.1322 $25.7973
420085............................ 1.6439 0.9384 $24.4040 $25.3180 $26.8692 $25.5532
420086............................ 1.4056 0.9067 $24.5760 $25.1372 $25.8869 $25.2138
420087............................ 1.7921 0.9240 $22.4526 $23.2230 $24.3609 $23.3441
420088............................ *** * $23.5174 $23.1273 * $23.4240
420089............................ 1.3993 0.9240 $23.3240 $25.2729 $26.0074 $24.9015
420091............................ 1.3155 0.8971 $23.7936 $23.4710 $26.9214 $24.8118
420093............................ 0.9962 0.9175 $21.4678 $25.1457 $27.4766 $24.8258
420097............................ *** * * $24.7809 * $24.7809
420098............................ 1.1527 0.8695 * * * *
420099............................ 1.5769 1.0001 * * * *
430005............................ 1.2246 0.8993 $18.2647 $19.9454 $22.3272 $20.0877
430008 \2\........................ 1.1187 0.9607 $20.0124 $20.9442 $23.3790 $21.4251
430011............................ 1.2454 * $19.9835 $20.6597 * $20.3142
430012............................ 1.2783 0.9607 $21.2588 $22.7530 $24.0850 $22.7129
430013 \2\........................ 1.1798 0.9607 $21.3389 $22.9675 $25.1378 $23.1495
430014............................ 1.2591 0.8769 $22.0285 $25.5387 $26.4964 $24.6896
430015............................ 1.1287 0.9607 $20.5849 $23.2035 $22.7947 $22.1979
430016............................ 1.5924 0.9607 $24.2450 $26.1495 $27.8453 $26.0153
430018............................ *** * $17.9850 * * $17.9850
430023............................ *** * $18.8816 * * $18.8816
430024............................ *** * $18.8357 * * $18.8357
430027............................ 1.7822 0.9607 $22.1807 $23.8477 $26.2139 $24.1495
430029............................ 0.9023 * $18.9464 $20.2708 * $19.6526
430031 \2\........................ 0.9381 0.9607 $15.2321 $15.6112 $16.0346 $15.6358
430033............................ *** * $21.6254 * * $21.6254
430043............................ 1.1653 * $17.9672 $17.2722 * $17.5904
430047............................ 0.9900 0.8551 $18.2774 $21.9116 $18.8982 $19.7432
430048............................ 1.2446 0.9607 $20.0607 $21.1718 $23.0783 $21.5127
430054............................ 0.9435 * $17.8871 * * $17.8871
430060............................ 0.8286 0.9607 $10.6492 $10.2704 * $10.4542
430064............................ 1.0479 0.9607 $14.3407 $16.4314 $17.5376 $16.1075
430077............................ 1.7069 0.9607 $21.6786 $23.4835 $25.1763 $23.4802
430081............................ 0.8933 1.4448 * * * *
430082............................ 0.7728 1.4448 * * * *
430083............................ 0.8284 1.4448 * * * *
430084............................ 0.7621 1.4448 * * * *
430085............................ 0.8598 1.4448 * * * *
430089............................ 1.6477 0.9365 $19.8572 $21.1109 $22.5625 $21.3078
430090............................ 1.4231 0.9607 $25.6873 $26.0851 $25.8460 $25.8845
430091............................ 2.6720 0.9607 $22.2824 $23.8897 $24.3021 $23.6064

[[Page 47561]]

430092............................ 1.8040 0.8551 $19.7354 $20.2570 $20.9486 $20.3194
430093............................ 0.9288 0.8993 $23.8820 $23.1526 $29.5244 $25.7876
430094............................ 1.8192 0.9249 $20.8743 $18.5429 $18.9099 $19.3880
430095............................ 2.3466 0.9607 * $24.7074 $28.1749 $26.5823
430096............................ 1.9928 0.8551 * * $21.6998 $21.6998
440001............................ 1.1332 0.8003 $18.9833 $17.4802 $19.3100 $18.5533
440002............................ 1.6950 0.8955 $22.0178 $23.2177 $24.6664 $23.3294
440003............................ 1.2221 0.9731 $21.6336 $24.5168 $25.9209 $24.0777
440006............................ 1.4174 0.9731 $24.3173 $26.7983 $28.5951 $26.6300
440007............................ 0.9582 0.8003 $14.8015 $13.7042 $25.8236 $17.2437
440008............................ 1.0035 0.8499 $20.9237 $22.1405 $23.4301 $22.0908
440009............................ 1.1945 0.8003 $19.6564 $21.1274 $21.5970 $20.8327
440010............................ 0.9504 0.8003 $16.7270 $16.9060 $17.1803 $16.9489
440011............................ 1.3104 0.8456 $20.5036 $21.6861 $22.5068 $21.6145
440012............................ 1.4955 0.8087 $21.1213 $21.4769 $22.3029 $21.6368
440015............................ 1.8835 0.8456 $23.4485 $22.5583 $23.7422 $23.2495
440016............................ 0.9765 0.8003 $20.1504 $20.0982 $22.1646 $20.8341
440017............................ 1.8069 0.8087 $21.8033 $22.5313 $22.9364 $22.4333
440018............................ 1.1381 0.8003 $21.2242 $21.7239 $23.3444 $22.1229
440019............................ 1.8078 0.8456 $21.8854 $23.8802 $25.2553 $23.6676
440020............................ 1.0621 0.9120 $21.1075 $23.1718 $23.9475 $22.7656
440023............................ 0.9577 * $15.5410 $17.0335 * $16.3078
440024............................ 1.2491 0.8544 $19.9751 $20.3658 $23.2716 $21.1545
440025............................ 1.1929 0.8003 $19.1478 $19.5995 $20.6798 $19.8282
440026............................ *** * $25.1655 $26.9149 $26.8986 $26.2876
440029............................ 1.3437 0.9731 $24.1379 $25.8538 $28.0779 $26.0679
440030............................ 1.2605 0.8059 $19.9056 $20.0586 $22.1217 $20.7764
440031............................ 1.0756 0.8003 $17.0289 $18.0944 $19.6685 $18.2797
440032............................ 1.0233 0.8087 $14.7683 $16.0734 $18.5277 $16.4708
440033............................ 1.0557 0.8003 $17.2637 $18.7749 $20.7917 $19.0076
440034............................ 1.5382 0.8456 $22.2478 $23.1121 $23.5403 $22.9348
440035............................ 1.3499 0.9450 $21.4990 $22.3230 $24.3752 $22.7486
440039............................ 2.0662 0.9731 $25.0874 $26.4647 $28.4678 $26.7675
440040............................ 0.9282 0.8003 $16.9886 $17.7647 $17.8510 $17.5455
440041............................ 0.9443 0.8157 $15.5784 $17.4074 $17.9409 $17.0933
440046............................ 1.1465 0.9731 $22.3380 $25.5329 $26.1341 $24.7333
440047............................ 0.8634 0.8502 $18.7962 $20.4812 $21.4280 $20.2387
440048............................ 1.8493 0.9402 $23.1553 $24.3283 $27.7560 $24.7999
440049............................ 1.5710 0.9402 $21.1930 $22.9755 $25.3043 $23.1991
440050............................ 1.2761 0.9303 $21.1397 $21.8972 $23.1362 $22.0679
440051............................ 0.9475 0.8003 $19.0165 $20.7948 $21.9108 $20.5095
440052............................ 0.9672 0.8003 $18.1935 $20.1875 $21.1133 $19.9032
440053............................ 1.2173 0.9731 $22.0345 $23.9083 $25.4345 $23.8916
440054............................ 1.1288 0.8003 $15.4208 $20.5992 $21.4400 $18.6411
440056............................ 1.1377 0.8324 $19.3108 $20.4088 $22.1068 $20.7270
440057............................ 1.0437 0.8003 $14.1477 $14.6242 $16.4451 $15.0915
440058............................ 1.1803 0.9089 $21.7512 $22.6014 $22.9263 $22.4470
440059............................ 1.5233 0.9450 $22.4248 $23.9301 $26.3551 $24.2545
440060............................ 1.0246 0.8790 $20.2189 $22.7133 $23.3014 $22.1119
440061............................ 1.0985 0.8003 $19.5458 $21.2085 $21.8274 $20.8215
440063............................ 1.6296 0.8014 $19.7468 $21.8578 $22.3256 $21.2848
440064............................ 0.9994 0.9089 $19.4020 $20.9742 $22.0955 $20.8374
440065............................ 1.2298 0.9731 $19.9099 $21.4794 $22.3247 $21.2895
440067............................ 1.1868 0.8456 $19.5643 $22.1410 $23.1089 $21.6500
440068............................ 1.1520 0.9089 $20.9188 $23.1705 $24.5971 $22.9451
440070............................ 0.9587 0.8003 $18.3717 $19.0240 $19.4372 $18.9540
440072............................ 1.2012 0.9148 $19.6579 $20.9294 $27.1443 $22.1374
440073............................ 1.3695 0.9450 $20.7181 $22.2959 $23.9198 $22.3108
440081 \h\........................ 1.1519 0.8456 $18.3141 $19.0328 $19.7878 $19.0770
440082............................ 2.1876 0.9731 $26.1497 $28.7828 $27.9724 $27.6484
440083............................ 0.9129 0.8003 $15.7015 $16.0956 $17.3329 $16.4160
440084............................ 1.1715 0.8003 $15.0510 $15.2825 $16.3738 $15.6128
440091............................ 1.6425 0.9089 $23.0296 $26.1122 $25.6797 $24.9494
440102............................ 1.1396 0.8003 $16.6548 $17.5140 $17.5261 $17.2560
440104............................ 1.7869 0.9089 $21.9870 $23.3731 $25.3739 $23.6244
440105............................ 1.0319 0.8014 $19.2902 $20.7821 $22.3438 $20.8223
440109............................ 0.9845 0.8003 $17.3578 $18.2508 $18.6720 $18.1156

[[Page 47562]]

440110............................ 1.1814 0.8456 $19.9715 $20.9039 $21.3287 $20.7233
440111............................ 1.2601 0.9731 $24.9883 $25.8821 $28.5705 $26.5016
440114............................ 1.0019 0.8526 $20.1152 $21.4271 $24.0147 $21.9369
440115............................ 0.9887 0.8502 $18.5389 $20.0642 $21.7830 $20.1587
440120............................ 1.5911 0.8456 $22.4031 $23.9003 $25.5961 $24.0224
440125............................ 1.5944 0.8456 $21.1018 $21.9337 $22.4196 $21.8367
440130............................ 1.1680 0.8003 $20.6363 $21.6480 $23.4517 $21.9020
440131............................ 1.2349 0.9402 $21.0640 $22.4119 $24.9598 $22.8950
440132............................ 1.2816 0.8003 $18.9580 $20.5716 $21.5085 $20.3655
440133............................ 1.5916 0.9731 $23.3600 $27.5019 $26.2422 $25.6963
440135............................ 1.1005 0.8003 $23.9749 $25.3928 $26.6615 $25.3742
440137............................ 1.0626 0.8003 $16.5529 $18.2073 $20.6663 $18.4329
440141............................ 0.9580 0.8003 $19.2607 $19.4528 $21.3313 $20.0578
440142............................ 0.8635 * $17.7587 * * $17.7587
440143............................ 0.9934 * $19.2978 $21.0374 * $20.1684
440144............................ 1.2202 0.8003 $19.7938 $22.3671 $23.3828 $21.8222
440145............................ 0.9884 0.8003 $18.2019 $20.9863 $20.7875 $19.9424
440147............................ *** * $25.0780 $28.9038 $31.4012 $28.2938
440148............................ 1.1331 0.9450 $20.7693 $23.0697 $24.6412 $22.8692
440149............................ 1.0249 * $18.1316 $19.8020 $20.4562 $19.4498
440150............................ 1.3918 0.9731 $22.8733 $25.4952 $26.8308 $25.0868
440151............................ 1.0949 0.9450 $21.1576 $23.3037 $23.9808 $22.8559
440152............................ 1.8872 0.9402 $22.7498 $25.9495 $26.5513 $25.0265
440153............................ 1.0214 0.8010 $19.9486 $22.7744 $22.2846 $21.7049
440156............................ 1.5036 0.9089 $23.7799 $25.6333 $26.9689 $25.5243
440159............................ 1.4437 0.9402 $20.5719 $21.1073 $22.8645 $21.5659
440161............................ 1.8166 * $26.1354 $28.6774 * $27.4329
440162............................ *** * $20.3909 $16.5305 $21.1418 $19.2406
440166............................ 1.5652 0.9402 $23.1692 $27.1355 $31.0779 $26.9641
440168............................ 0.9909 0.9402 $21.2113 $22.1764 $22.8768 $22.0809
440173............................ 1.6518 0.8456 $20.8442 $20.8723 $22.8846 $21.5657
440174............................ 0.8859 0.8375 $19.2201 $20.7960 $22.0974 $20.6472
440175............................ 1.0647 0.9450 $22.3331 $24.0005 $22.7299 $23.0174
440176............................ 1.3041 0.8087 $20.4861 $22.0079 $23.6659 $22.0556
440180............................ 1.2186 0.8456 $21.2398 $21.9781 $23.3808 $22.2150
440181............................ 0.9292 0.8410 $19.6133 $21.1406 $22.7150 $21.1984
440182............................ 0.9320 0.8003 $19.3928 $20.2630 $22.3612 $20.6845
440183............................ 1.5539 0.9402 $24.9282 $27.7769 $27.1515 $26.6633
440184............................ 1.0116 0.8014 $21.4484 $20.8219 $22.3475 $21.5303
440185............................ 1.1665 0.9089 $22.1845 $23.4172 $23.9052 $23.2612
440186............................ 1.0410 0.9731 $23.0193 $24.6773 $25.7445 $24.4615
440187............................ 1.0873 0.8003 $19.9478 $21.7637 $21.3252 $21.0131
440189............................ 1.3710 0.8955 $23.2866 $24.7851 $27.5435 $25.2579
440192............................ 1.0294 0.9450 $21.3228 $25.1119 $25.7495 $24.1386
440193............................ 1.2635 0.9731 $22.0345 $24.3911 $24.4299 $23.6341
440194............................ 1.3815 0.9731 $24.4508 $26.2498 $26.6527 $25.8291
440197............................ 1.2847 0.9731 $24.2660 $26.4999 $27.1534 $25.9812
440200............................ 0.9486 0.9731 $16.7752 $17.0633 $17.7491 $17.1850
440203............................ 0.9834 0.8003 * $17.7639 $19.3864 $18.5423
440217............................ 1.4086 0.9402 $23.3544 $25.9667 $28.5968 $26.1820
440218............................ 0.8896 0.9731 $20.1377 $26.3741 $24.6465 $23.5719
440220............................ *** * $21.9117 * * $21.9117
440222............................ 0.9594 0.9402 * $28.3879 $29.7292 $29.0585
440225............................ 0.8471 0.8456 * * * *
440226............................ 1.5354 0.8456 * * * *
440227............................ 1.1936 0.9731 * * * *
440228............................ 1.1074 0.9402 * * * *
450002............................ 1.4467 0.9007 $24.0411 $25.4975 $25.7171 $25.1126
450005............................ 1.0676 0.8413 $21.7110 $23.4049 $23.5576 $22.9913
450007............................ 1.3321 0.8978 $18.3738 $19.2875 $20.7321 $19.4904
450008............................ 1.3155 0.8557 $20.1816 $22.0934 $22.9669 $21.7810
450010............................ 1.5300 0.8936 $20.3023 $22.4133 $23.7529 $22.1525
450011............................ 1.7085 0.8902 $22.1472 $24.1576 $24.8831 $23.7448
450014............................ 1.0361 * $20.6936 $22.5001 * $21.5732
450015............................ 1.5818 1.0222 $23.9526 $24.0730 $27.4012 $25.2046
450016............................ *** * $20.1232 $22.1368 * $21.1548
450018............................ 1.3937 0.9996 $22.9019 $24.6443 $26.7999 $24.7633

[[Page 47563]]

450020............................ 0.9512 0.9439 $19.1087 $17.7148 $18.3047 $18.3252
450021............................ 1.8322 1.0222 $25.0769 $28.5578 $29.1350 $27.5806
450023............................ 1.4131 0.8140 $19.1645 $20.9278 $22.0558 $20.7053
450024............................ 1.3715 0.9007 $20.7727 $22.4178 $24.4195 $22.4300
450028............................ 1.6020 0.9835 $22.7775 $25.6030 $26.8250 $25.1270
450029............................ 1.5255 0.8093 $19.9198 $23.9709 $23.2995 $22.4069
450031............................ 1.4886 1.0222 $21.7621 $27.0328 $27.9626 $25.5466
450032............................ 1.2211 0.8758 $20.5217 $20.8306 $27.0748 $22.7202
450033............................ 1.6042 0.9835 $26.5990 $29.0541 $28.4781 $28.0809
450034............................ 1.5499 0.8413 $21.6097 $23.4615 $24.1589 $23.0888
450035............................ 1.5349 0.9996 $24.1860 $25.4580 $26.2838 $25.3196
450037............................ 1.5164 0.8732 $23.1179 $23.1176 $24.2684 $23.5229
450039............................ 1.3931 0.9938 $22.0058 $23.3034 $24.7347 $23.3847
450040............................ 1.7554 0.8781 $21.2990 $23.8047 $24.9590 $23.3165
450042............................ 1.7420 0.8523 $21.8886 $22.6936 $24.1181 $22.9317
450044............................ 1.6814 1.0222 $24.1127 $25.8403 $29.4308 $26.5654
450046............................ 1.5707 0.8549 $20.9239 $22.0695 $23.4907 $22.1959
450047............................ 0.8608 0.9835 $21.8840 $22.7242 $19.8221 $21.4269
450050............................ 0.9394 0.8803 $19.5171 $21.6933 $23.3044 $21.3893
450051............................ 1.7951 1.0222 $24.5533 $27.2523 $28.0411 $26.6907
450052............................ 0.9735 0.8053 $17.6543 $19.7185 $19.7774 $19.2138
450053............................ 0.9596 0.8053 $18.6556 $19.4978 $21.9082 $20.0823
450054............................ 1.6766 0.8557 $23.2915 $25.1229 $24.2782 $24.2283
450055............................ 1.1336 0.8053 $18.2235 $20.5235 $22.1979 $20.3131
450056............................ 1.7962 0.9439 $24.4197 $25.6685 $27.0530 $25.7808
450058............................ 1.5442 0.8978 $22.0158 $24.7442 $25.9653 $24.1658
450059............................ 1.3265 0.9439 $22.8792 $26.8209 $26.6535 $25.4407
450064............................ 1.4250 0.9938 $19.1271 $24.2920 $23.8748 $22.4752
450068............................ 2.0373 0.9996 $24.0925 $26.2864 $27.9633 $26.1666
450072............................ 1.1689 0.9996 $20.3683 $22.5010 $24.0166 $22.2336
450073............................ 0.9446 0.8053 $19.2398 $20.0464 $21.7337 $20.3411
450076............................ 1.6909 * * * * *
450078............................ 0.9333 0.8053 $14.8285 $17.2196 $15.8968 $15.9697
450079............................ 1.5644 1.0222 $24.0085 $27.0443 $28.1096 $26.3674
450080............................ 1.1870 0.8612 $21.0353 $21.2482 $22.9835 $21.7735
450081............................ 1.0552 * $19.2632 * * $19.2632
450082............................ 1.1437 0.8053 $16.6566 $20.9113 $22.0442 $19.8834
450083............................ 1.7669 0.9182 $22.5063 $24.9182 $25.8214 $24.4447
450085............................ 1.0245 0.8053 $18.1922 $19.4524 $22.0840 $19.8958
450087............................ 1.3515 0.9938 $24.5976 $26.4203 $29.1587 $26.8455
450090............................ 1.1590 0.8053 $17.1073 $17.6506 $19.4244 $18.0792
450092............................ 1.1484 0.8053 $16.0199 $20.4921 $23.2071 $19.7031
450094............................ 1.1039 1.0222 $25.8313 $25.3618 $25.2434 $25.4570
450096............................ 1.3896 0.8413 $19.8012 $22.8722 $24.1619 $22.3082
450097............................ 1.4324 0.9996 $22.2467 $24.9380 $26.4965 $24.6105
450098............................ 0.9304 0.8612 $20.4795 $22.9005 $22.6626 $21.9800
450099............................ 1.1823 0.9156 $21.4482 $24.0293 $26.6796 $24.1168
450101............................ 1.5906 0.8523 $20.1473 $20.6575 $23.6905 $21.4670
450102............................ 1.7381 0.9182 $20.9900 $23.1773 $24.5503 $22.9587
450104............................ 1.1789 0.8978 $19.7126 $22.5165 $23.8469 $22.0194
450107............................ 1.4555 0.9007 $23.2209 $23.8770 $25.9326 $24.3252
450108............................ 1.1169 0.8978 $18.8084 $19.3561 $19.4935 $19.2181
450109............................ *** * $15.1459 * * $15.1459
450112............................ *** * $20.2627 $22.5552 * $21.2999
450113............................ *** * $37.8944 * $54.6681 $43.1390
450119............................ 1.3114 0.8936 $20.8840 $24.1392 $25.7008 $23.6793
450121............................ 1.4809 0.9938 $24.6090 $25.8826 $25.7051 $25.4063
450123............................ 1.1197 0.8413 $17.8629 $19.5872 $21.2154 $19.5002
450124............................ 1.7951 0.9439 $24.2788 $26.0280 $27.4198 $26.0262
450126............................ 1.3686 0.9996 $24.1961 $27.3021 $28.3033 $26.6832
450128............................ 1.2540 0.8936 * $21.4190 $23.3633 $22.3457
450130............................ 1.1901 0.8978 $19.6199 $20.2777 $21.5226 $20.5273
450131............................ 1.2257 0.8549 $20.0434 $23.2317 $23.7098 $22.3750
450132............................ 1.5577 0.9883 $22.4680 $26.8476 $28.6954 $25.9595
450133............................ 1.5553 0.9513 $25.3928 $25.0972 $26.8344 $25.8308
450135............................ 1.6939 0.9938 $22.5673 $24.3858 $26.0755 $24.4084
450137............................ 1.6171 0.9938 $24.9732 $27.0081 $30.4254 $27.6976

[[Page 47564]]

450140............................ 0.8931 * $18.3835 $22.4695 * $20.3190
450143............................ 1.0532 0.9439 $18.4204 $19.7487 $21.8705 $20.0996
450144............................ 1.1763 0.9584 $21.3896 $20.9599 $21.3289 $21.2289
450146............................ *** * $16.6808 * * $16.6808
450147............................ 1.4066 0.8140 $21.7248 $24.6203 $23.9771 $23.5121
450148............................ 1.1628 0.9938 $22.1351 $23.5037 $25.3498 $23.7382
450151............................ 1.1936 0.8053 $17.9127 $20.1356 $22.2915 $20.0948
450152............................ 1.1967 0.8557 $20.0146 $21.6351 $22.7463 $21.4376
450154............................ 1.2820 0.8053 $16.5204 $18.6058 $21.2021 $18.7210
450155............................ 1.0357 0.8053 $18.4021 $17.9306 $18.0589 $18.1275
450157............................ 1.0122 * $17.8764 $17.8812 * $17.8788
450160............................ 0.9342 * $20.7736 $21.9118 * $21.3607
450162............................ 1.3737 0.8781 $26.0570 $31.0645 $30.9903 $29.3951
450163............................ 0.9859 0.8187 $19.8194 $20.3280 $23.1400 $21.0903
450165............................ 1.1629 0.8978 $16.1632 $20.2414 $24.3242 $20.2279
450176............................ 1.3413 0.8936 $19.1823 $20.9392 $20.9297 $20.4107
450177............................ 1.2063 0.8053 $17.2637 $19.7657 $21.3322 $19.4690
450178............................ 0.9765 0.8053 $19.1186 $20.2992 $24.7301 $21.2492
450184............................ 1.5408 0.9996 $24.0596 $25.3935 $26.7821 $25.4743
450185............................ 0.9850 * $14.3594 $15.5838 * $14.9644
450187............................ 1.1679 0.9996 $22.6275 $24.2400 $25.6786 $24.2306
450188............................ 0.9332 0.8053 $17.6158 $18.9586 $20.4070 $19.0169
450191............................ 1.1357 0.9439 $23.2261 $25.9078 $26.0298 $25.1584
450192............................ 1.0946 0.9938 $20.1718 $22.5118 $22.5880 $21.7848
450193............................ 2.0472 0.9996 $26.6580 $29.2751 $32.2964 $29.4595
450194............................ 1.3374 0.9938 $22.7310 $22.3348 $24.8972 $23.2572
450196............................ 1.4229 0.9938 $20.1938 $23.6170 $24.7557 $23.2376
450200............................ 1.4551 0.8285 $20.4656 $22.0923 $23.5344 $22.0868
450201............................ 0.9302 0.8053 $19.5907 $20.3350 $20.9809 $20.3028
450203............................ 1.1740 0.9491 $22.9226 $23.3953 $24.1675 $23.5222
450209............................ 1.9039 0.9156 $23.4794 $24.4977 $26.0958 $24.6956
450210............................ 0.9631 0.8053 $16.7851 $19.6340 $19.9832 $18.8463
450211............................ 1.3504 0.9996 $20.0280 $20.7982 $23.8230 $21.4806
450213............................ 1.7973 0.8978 $21.1280 $21.7930 $23.9676 $22.3693
450214............................ 1.1786 0.9996 $22.4543 $23.9112 $25.9598 $24.1177
450219............................ 0.9891 0.8053 $21.0691 $20.8255 $21.7934 $21.2690
450221............................ 1.1410 0.8053 $19.6778 $20.6887 $20.3186 $20.2506
450222............................ 1.5793 0.9996 $23.5033 $26.2975 $27.4426 $25.8797
450224............................ 1.3957 0.9030 $20.4453 $22.2250 $24.1956 $22.3315
450229............................ 1.6507 0.8053 $17.9811 $19.8279 $21.4459 $19.7433
450231............................ 1.6179 0.9156 $21.3086 $23.9532 $25.2852 $23.5313
450234............................ 0.9864 0.8053 $22.3954 $23.6695 $18.4451 $21.2354
450235............................ 0.9187 0.8053 $18.7028 $19.1453 $21.5138 $19.8415
450236............................ 1.0511 0.8053 $17.7373 $19.2987 $22.0788 $19.5556
450237............................ 1.6849 0.8978 $22.4477 $25.1504 $24.8901 $24.1935
450239............................ 0.9333 0.8557 $19.3655 $21.8595 $21.1945 $20.7705
450241............................ 0.9526 0.8053 $17.4151 $18.1155 $18.7957 $18.0879
450243............................ 1.0082 0.8053 $13.0790 $14.0589 $15.4636 $14.1605
450249............................ 0.9883 * $13.1222 $16.5616 * $14.7712
450250............................ *** * $13.3731 * * $13.3731
450253............................ 0.9826 0.9996 $16.6523 $19.6379 $20.6124 $18.9496
450264............................ 0.9237 * $13.5345 $15.4111 * $14.4829
450269............................ 1.0284 * $12.6907 $14.8204 * $13.7206
450270............................ 1.0833 0.8053 $13.9053 $15.0879 $14.4325 $14.4468
450271............................ 1.1604 0.9491 $18.3659 $19.4299 $21.7719 $19.9620
450272............................ 1.2055 0.9439 $21.4520 $23.7933 $25.7392 $23.6800
450276............................ 0.9069 * $12.8895 $16.0264 $16.6319 $15.2952
450280............................ 1.5459 1.0222 $23.1664 $27.4523 $28.7233 $26.4522
450283............................ 1.0663 0.9938 $17.1013 $20.0069 $20.9680 $19.5520
450289............................ 1.3250 0.9996 $23.7108 $27.3864 $28.5665 $26.5635
450292............................ 1.3344 1.0222 $23.4257 $23.5330 $25.0411 $24.0121
450293............................ 0.8831 0.8053 $17.7673 $20.0898 $21.3136 $19.7647
450296............................ 1.0732 0.9996 $20.4483 $29.2006 $27.9690 $25.4406
450299............................ 1.5904 0.8902 $22.9849 $25.8183 $26.4933 $25.0990
450303............................ 0.8440 * $16.1330 * * $16.1330
450306............................ 0.9365 0.8053 $17.6821 $14.6699 $15.9854 $15.8111
450315............................ *** * $26.4677 $27.9780 * $27.2229

[[Page 47565]]

450320............................ *** * $26.8089 * * $26.8089
450324............................ 1.5419 0.9509 $23.8523 $23.6362 $24.9128 $24.1611
450327............................ *** * $14.3848 * * $14.3848
450330............................ 1.2220 0.9996 $22.9947 $24.4310 $25.5820 $24.4245
450340............................ 1.3912 0.8279 $20.0621 $22.7826 $24.0636 $22.3350
450346............................ 1.4004 0.8413 $20.1921 $21.9717 $22.2469 $21.4909
450347............................ 1.1459 0.9996 $21.7142 $22.8133 $27.2203 $23.9176
450348............................ 0.9913 0.8053 $15.6324 $17.0198 $18.7675 $17.1642
450351............................ 1.2263 0.9491 $22.2597 $23.5895 $25.6859 $23.9245
450352............................ 1.1316 1.0222 $21.8138 $23.4297 $24.8012 $23.3447
450353............................ 1.2847 0.8053 $19.5263 $20.9271 $24.4454 $21.5974
450358............................ 2.0232 0.9996 $25.9105 $29.3408 $30.4280 $28.6741
450362............................ 0.9914 0.8539 $20.6340 $22.0223 $25.4372 $22.7898
450369............................ 1.0154 0.8053 $16.5636 $17.5360 $18.4848 $17.6077
450370............................ 1.1827 0.8311 $19.0340 $22.6815 $20.0832 $20.4877
450371............................ *** * $17.3415 * * $17.3415
450372............................ 1.3217 1.0222 $22.9079 $26.8019 $28.3359 $26.0630
450373............................ 0.9098 0.8053 $17.7955 $20.5789 $22.2213 $20.1017
450374............................ 0.9226 0.8053 $15.0670 $17.4509 $23.2285 $18.2702
450378............................ 1.3660 0.9996 $25.8048 $29.5108 $30.7684 $28.7797
450379............................ 1.3962 1.0222 $29.0865 $31.1573 $30.6072 $30.3060
450381............................ 0.9383 0.9439 $19.0584 $20.9200 $22.0482 $20.7572
450388............................ 1.6677 0.8978 $22.4441 $24.1598 $25.8674 $24.3854
450389............................ 1.1979 0.9938 $20.7160 $22.3803 $23.8764 $22.4221
450393............................ *** * $23.8237 $24.6872 $18.4551 $22.6427
450395............................ 1.0292 0.8537 $19.1938 $23.9689 $24.8656 $22.6314
450399............................ 0.9450 0.8053 $19.1571 $19.5928 $18.2074 $18.9826
450400............................ 1.2340 0.8523 $20.1376 $22.0103 $23.1739 $21.7697
450403............................ 1.2939 1.0222 $24.6215 $27.8138 $29.3063 $27.2736
450411............................ 0.9786 0.8053 $16.9558 $17.6570 $19.6086 $18.1139
450417............................ 0.8798 0.9996 $16.1957 $17.8078 $20.0350 $18.0319
450418............................ 1.2682 0.9996 $25.1306 $27.0283 $26.8434 $26.3230
450419............................ 1.1829 0.9938 $26.7662 $28.4122 $31.0404 $28.7694
450422............................ 0.9445 1.0222 $29.0032 $29.5592 $30.6659 $29.7888
450424............................ 1.3043 0.9996 $22.0682 $23.1253 $28.3149 $24.8057
450431............................ 1.5444 0.9439 $22.9545 $24.7346 $25.2477 $24.3602
450438............................ 1.1526 0.9996 $19.2165 $22.0476 $21.9351 $21.1413
450446............................ 0.6565 0.9996 $14.1684 $14.9983 $14.3132 $14.4984
450447............................ 1.2118 0.9938 $21.0247 $22.5602 $23.5047 $22.3940
450451............................ 1.1267 0.9491 $21.1046 $22.3834 $23.3042 $22.3121
450460............................ 0.9508 0.8053 $17.9487 $19.5709 $20.5812 $19.4136
450462............................ 1.6798 1.0222 $24.0081 $25.6952 $27.8923 $25.9496
450464............................ *** * $16.1987 * * $16.1987
450465............................ 1.1088 0.8488 $19.4486 $23.0130 $22.4183 $21.6303
450469............................ 1.4831 0.9509 $24.0794 $26.6781 $28.7890 $26.6238
450473............................ *** * $18.6002 * * $18.6002
450475............................ 1.0070 0.8732 $20.9443 $20.7983 $23.5596 $21.7528
450484............................ 1.3956 0.9996 $23.2881 $23.0604 $25.3527 $23.9206
450488............................ 1.1147 0.8732 $22.5650 $22.3949 $23.9144 $22.9600
450489............................ 1.0293 0.8053 $18.5941 $19.6884 $21.4771 $19.8409
450497............................ 1.0383 0.8053 $17.1327 $17.6614 $18.8344 $17.8832
450498............................ 0.8822 0.8053 $19.2984 $16.4358 $17.7822 $17.7509
450508............................ 1.4234 0.9030 $20.8183 $23.5066 $23.9572 $22.7686
450514............................ 1.1291 0.8413 $21.0116 $21.4034 $22.6552 $21.6987
450517............................ 0.9315 * $14.4246 $15.2707 * $14.8080
450518............................ 1.6511 0.8413 $21.1015 $22.2587 $24.1194 $22.4755
450523............................ *** * $22.3034 $28.6387 * $25.2834
450530............................ 1.1682 0.9996 $23.3005 $26.1998 $28.7451 $26.1850
450534............................ 0.9008 * $22.5156 $20.4715 * $21.4079
450535............................ *** * $23.7255 $29.4427 * $26.5477
450537............................ 1.3614 1.0222 $22.5972 $23.9256 $27.5856 $24.8361
450539............................ 1.2202 0.8053 $18.4299 $20.0343 $21.0442 $19.8677
450545............................ *** * $21.7762 $22.8130 * $22.2858
450547............................ 0.9664 0.9938 $22.6557 $21.8106 $21.6542 $22.0062
450558............................ 1.7818 0.8053 $21.4201 $25.0837 $26.1551 $24.1840
450563............................ 1.3796 0.9938 $27.5671 $27.9427 $28.7289 $28.1251
450565............................ 1.2555 0.8539 $17.2171 $22.1971 $23.8847 $20.9966

[[Page 47566]]

450571............................ 1.5391 0.8279 $21.5688 $20.9651 $22.7703 $21.7784
450573............................ 1.1304 0.8053 $18.6233 $21.6974 $20.1479 $20.0755
450578............................ 0.9374 0.8053 $17.3010 $20.0454 $20.2695 $19.1233
450580............................ 1.1083 0.8053 $18.5225 $20.4293 $21.1574 $20.0321
450584............................ 1.0438 0.8053 $16.9021 $19.0373 $21.0808 $18.9453
450586............................ 0.9752 0.8053 $14.9061 $14.6574 $16.1003 $15.2149
450587............................ 1.1638 0.8053 $19.0648 $19.9712 $20.4512 $19.8609
450591............................ 1.2345 0.9996 $19.6229 $22.4991 $23.9992 $22.0639
450596 \h\........................ 1.1192 1.0299 $24.3714 $24.7477 $25.3317 $24.8345
450597............................ 0.9804 0.8130 $19.9596 $22.9337 $23.1711 $22.1268
450603............................ *** * $20.6138 * * $20.6138
450604............................ 1.2585 0.8053 $19.5288 $20.5273 $20.9514 $20.3776
450605............................ 1.1730 0.8549 $22.0210 $23.8820 $22.2205 $22.7037
450609............................ 1.0151 * $16.6870 $18.3856 * $17.5807
450610............................ 1.6074 0.9996 $24.7706 $22.5451 $26.8710 $24.6655
450614............................ *** * $18.5895 * * $18.5895
450615............................ 0.9562 0.8053 $17.2717 $18.2166 $20.3028 $18.6840
450617............................ 1.4119 0.9996 $22.7514 $25.2211 $26.5026 $24.9284
450620............................ 0.9963 0.8053 $17.1333 $18.1819 $17.7138 $17.6710
450623............................ 1.0807 0.9938 $25.1400 $28.3354 $28.3552 $27.2112
450626............................ 0.9173 * $17.7454 $21.4445 $26.8375 $21.3925
450630............................ 1.5413 0.9996 $24.8096 $27.8856 $29.6796 $27.5230
450631............................ *** * $22.8637 $24.5409 * $23.7681
450634............................ 1.6132 1.0222 $24.8258 $27.0412 $28.1705 $26.8022
450638............................ 1.5906 0.9996 $26.3653 $29.5385 $29.6184 $28.6129
450639............................ 1.5166 0.9938 $24.2919 $27.3593 $29.2669 $27.0735
450641............................ 0.9774 0.8053 $17.4072 $17.0805 $17.5845 $17.3565
450643............................ 1.3324 0.8093 $20.2000 $20.9674 $21.1205 $20.7972
450644............................ 1.4557 0.9996 $24.4574 $27.2047 $29.0186 $27.0517
450646............................ 1.3717 0.9007 $21.8500 $22.6541 $23.8908 $22.8626
450647............................ 1.8252 1.0222 $26.8276 $28.8881 $30.7334 $28.8704
450648............................ 0.9121 * $17.3678 $18.2826 * $17.7872
450649............................ 0.9495 * $17.5761 $18.1118 * $17.8381
450651............................ 1.6339 1.0222 $26.9215 $28.9829 $32.4822 $29.5833
450653............................ 1.1250 0.9307 $22.7236 $21.8654 $23.2603 $22.6099
450654............................ 0.9105 0.8053 $16.3057 $19.6054 $19.9992 $18.6631
450656............................ 1.4088 0.9030 $20.7824 $22.7284 $23.8280 $22.4984
450658............................ 0.9058 0.8053 $19.6855 $19.9597 $20.5398 $20.0788
450659............................ 1.4571 0.9996 $26.0224 $28.8671 $30.1727 $28.5108
450661............................ 1.1789 0.9883 $20.0716 $21.5537 $23.2989 $21.6941
450662............................ 1.5509 0.9835 $26.3794 $24.5815 $28.0913 $26.3697
450665............................ 0.8701 * $15.8571 $17.2566 $18.6054 $17.2495
450668............................ 1.5078 0.9007 $24.0081 $26.4508 $26.2375 $25.5681
450669............................ 1.2177 1.0222 $25.0200 $25.6411 $27.4507 $26.1045
450670............................ 1.3444 0.9996 $19.9621 $22.0495 $25.1575 $22.3620
450672............................ 1.7311 0.9938 $25.3106 $26.7785 $27.6359 $26.6135
450673............................ 1.0701 0.8319 $16.3319 $19.4030 * $17.7858
450674............................ 0.9544 * $24.8137 $26.8081 * $25.8948
450675............................ 1.4447 0.9938 $24.8661 $26.1555 $28.7765 $26.7882
450677............................ 1.3508 0.9938 $22.9529 $24.0218 $27.3728 $24.7773
450678............................ 1.4249 1.0222 $28.1917 $30.1134 $30.1500 $29.5324
450683............................ 1.1505 1.0222 $24.5013 $24.0080 $24.6609 $24.3870
450684............................ 1.2328 0.9996 $23.8945 $26.2906 $27.6789 $25.9648
450686............................ 1.6362 0.8781 $17.9181 $21.0565 $23.2367 $20.7924
450688............................ 1.2067 1.0222 $21.7922 $23.7796 $27.9057 $24.4771
450690............................ 1.5005 0.9182 $33.1576 $28.7529 $28.2531 $29.5860
450694............................ 1.0995 0.9996 $21.4784 $22.3081 $23.5790 $22.4747
450697............................ 1.3398 0.8978 $20.8951 $21.2662 $23.7155 $22.0489
450698............................ 0.8879 0.8053 $18.1764 $18.5436 $18.6494 $18.4560
450700............................ 0.9342 * $17.3458 $18.6373 * $18.0024
450702............................ 1.5147 0.8732 $22.2953 $24.8628 $25.6147 $24.3137
450709............................ 1.2721 0.9996 $23.4246 $25.0932 $25.4855 $24.7135
450711............................ 1.6188 0.8936 $22.1489 $24.8277 $28.0104 $25.1428
450712............................ *** * $18.4547 * * $18.4547
450713............................ 1.5285 0.9439 $24.4002 $26.7190 $27.2801 $26.1943
450715............................ 1.2751 1.0222 * $16.1897 $28.0365 $20.5948
450716............................ 1.2400 0.9996 $24.8614 $28.8043 $30.8440 $28.2641

[[Page 47567]]

450718............................ 1.2057 0.9439 $24.9162 $27.6672 $27.3408 $26.7229
450723............................ 1.4250 1.0222 $24.1618 $27.0055 $28.0812 $26.5571
450724............................ *** * $21.9630 * * $21.9630
450727............................ *** * $16.0843 * * $16.0843
450730............................ 1.3060 1.0222 $27.8476 $30.7567 $29.9430 $29.5510
450733............................ *** * $23.8143 $25.5624 $26.4976 $25.4115
450742............................ 1.2106 1.0222 $25.1295 $26.3414 $26.1190 $25.8920
450743............................ 1.4856 1.0222 $23.7424 $24.7397 $27.3213 $25.3404
450746............................ 0.9624 0.8053 $11.1672 $16.9209 $12.4748 $13.1222
450747............................ 1.2120 0.9938 $21.5883 $24.2674 $22.2870 $22.7471
450749............................ 1.0156 0.8053 $17.8696 $18.4095 $17.8227 $18.0184
450751............................ 1.2544 0.8285 $23.3154 $22.9070 $19.3265 $21.7472
450754............................ 0.9201 0.8053 $19.2827 $21.3043 $20.8968 $20.5167
450755............................ 0.9728 0.8781 $19.2768 $19.5168 $18.0092 $18.8178
450758............................ 1.2417 1.0222 $22.8713 $24.0226 $25.6548 $24.1232
450760............................ 1.1481 0.9007 $23.2959 $25.7453 $24.6349 $24.3909
450761............................ 0.8514 0.8053 $15.5151 $16.2605 $15.7483 $15.8642
450763............................ 1.1347 0.8289 $19.8939 $21.4171 $22.4905 $21.2790
450766............................ 1.8764 1.0222 $27.2499 $28.8576 $30.0441 $28.7197
450770............................ 1.1592 0.9439 $19.9412 $20.1763 $20.3656 $20.1550
450771............................ 1.6473 1.0222 $25.0490 $26.0618 $31.3924 $27.9152
450774............................ 1.7574 0.9996 $21.7906 $24.8562 $24.9683 $23.8170
450775............................ 1.2079 0.9996 $23.6621 $25.3924 $24.4006 $24.5023
450776............................ 0.9805 * $14.6695 * * $14.6695
450779............................ 1.2281 0.9938 $23.8882 $22.5857 $26.9908 $24.4772
450780............................ 1.8676 0.8978 $21.9046 $22.8688 $23.9516 $22.9443
450788............................ 1.5572 0.8549 $21.4467 $24.2643 $25.4172 $23.7014
450795............................ 1.1356 0.9996 $19.1371 $28.1448 $23.7510 $23.4235
450796............................ 2.1987 0.9156 $22.4973 $24.7564 $27.9734 $25.1133
450797............................ *** * $18.6839 $23.8708 $20.5379 $20.9547
450801............................ 1.4958 0.8285 $19.7790 $22.2426 $23.0373 $21.7315
450803............................ 1.2419 0.9996 $23.8343 $26.3054 $30.6093 $27.0662
450804............................ 1.8238 0.9996 $22.8275 $26.0003 $26.0980 $25.0247
450808............................ 1.5928 0.9439 $18.6555 $22.8247 $23.8067 $21.6597
450809............................ 1.5794 0.9439 $23.8758 $24.7763 $26.3659 $25.0664
450811............................ 1.8227 0.8936 $22.7583 $23.1022 $25.8491 $24.4306
450813............................ 1.1010 0.8248 $21.7208 $22.1326 $25.5949 $23.1456
450817............................ *** * $28.4441 * * $28.4441
450820............................ 1.2204 0.9996 $26.9121 $27.9187 $30.5288 $28.8719
450822............................ 1.1446 1.0222 $26.7821 $29.7067 $31.1431 $29.3455
450824............................ 2.4144 0.9439 $24.5885 * $26.7803 $25.7897
450825............................ 1.4991 0.8936 $18.8510 $18.7069 $20.2959 $19.3490
450827............................ 1.4354 0.8319 $29.5838 $21.1788 $20.9704 $23.0851
450828............................ 1.1790 0.8053 $20.9509 $21.4128 $22.3667 $21.5956
450829............................ *** * $14.4463 $18.2860 $19.5014 $17.2726
450830............................ 0.9415 0.9584 $24.7834 $26.9917 $28.1617 $26.6450
450831............................ 1.6975 0.9996 * $20.0581 $22.7885 $21.7038
450832............................ 1.1361 0.9996 $24.8572 $26.4725 $26.6628 $26.1075
450833............................ 1.1880 1.0222 $18.3196 $26.1256 $26.0044 $23.5951
450834............................ 1.3968 0.8902 $21.7217 $22.7691 $21.2204 $21.8968
450835............................ *** * $24.8374 * * $24.8374
450837............................ *** * $24.2964 * * $24.2964
450838............................ 1.1224 0.8053 * $15.0454 $15.8026 $15.4717
450839............................ 0.9384 0.8758 * $21.1905 $22.9711 $22.0566
450840............................ 1.0125 1.0222 * $29.5215 $31.1914 $30.4233
450841............................ 1.6639 0.9835 * $17.6635 $18.9468 $18.3289
450842............................ *** * * $23.0945 * $23.0945
450844............................ 1.2802 0.9996 * $34.4235 $28.7296 $30.4450
450845............................ 1.8830 0.9007 * $26.5040 $27.7461 $27.1743
450846............................ *** * * $24.0791 * $24.0791
450847............................ 1.1998 0.9996 * $26.8892 $27.6854 $27.3036
450848............................ 1.1978 0.9996 * $26.5609 $27.8100 $27.1855
450850............................ 1.5011 0.9513 * * $22.1334 $22.1334
450851............................ 2.4409 1.0222 * * $30.1213 $30.1213
450852............................ *** * * * $30.0191 $30.0191
450853............................ 2.0332 1.0222 * * * *
450855............................ 1.5141 0.9835 * * * *

[[Page 47568]]

450856............................ 2.1787 0.8978 * * * *
450858............................ 2.0535 0.9938 * * * *
450860............................ 2.3115 0.9996 * * * *
450861............................ 1.7724 0.8732 * * * *
450862............................ 1.1272 0.9996 * * * *
450864............................ 2.1054 0.9182 * * * *
450865............................ 1.0980 0.9439 * * * *
450866............................ 1.4767 0.8549 * * * *
450867............................ 1.2710 0.9439 * * * *
450868............................ 1.9100 0.9883 * * * *
450869............................ 1.4134 0.8936 * * * *
450870............................ 1.5311 0.9996 * * * *
450871............................ 1.8928 0.9439 * * * *
450872............................ 1.2891 0.9938 * * * *
450873............................ 3.2128 0.8978 * * * *
450874............................ 1.6081 1.0222 * * * *
450875............................ 1.5726 0.9156 * * * *
450876............................ 2.3412 0.8781 * * * *
450877............................ 1.4156 0.9007 * * * *
450878............................ 2.7131 0.8978 * * * *
450879............................ 1.6032 0.8093 * * * *
450880............................ 1.5062 0.9938 * * * *
450881............................ 1.3511 0.8549 * * * *
450882............................ 1.4154 0.9182 * * * *
450883............................ 2.0287 1.0222 * * * *
450884............................ 1.0601 0.8732 * * * *
450885............................ 1.3287 1.0222 * * * *
460001............................ 1.8912 0.9484 $24.8844 $25.6932 $27.0757 $25.8934
460003............................ 1.5251 0.9424 $26.5141 $24.3527 $26.1372 $25.6304
460004............................ 1.6710 0.9424 $24.3409 $25.2191 $26.4498 $25.3907
460005............................ 1.4452 0.9424 $25.0063 $22.6809 $23.5633 $23.6783
460006............................ 1.2988 0.9424 $23.4200 $24.4350 $25.4787 $24.4752
460007............................ 1.3349 0.9407 $23.3603 $24.2875 $25.6686 $24.4644
460008............................ 1.3638 0.9424 $24.8233 $24.4453 $26.5672 $25.2587
460009............................ 1.9243 0.9424 $24.5865 $25.0984 $26.2833 $25.3688
460010............................ 2.1081 0.9424 $25.1240 $26.2331 $27.4648 $26.2912
460011............................ 1.2796 0.9484 $21.2634 $22.3601 $23.4023 $22.3027
460013............................ 1.3598 0.9484 $23.1467 $23.4765 $25.2448 $23.9897
460014............................ 1.0871 0.9424 $22.6125 $23.9400 $24.1412 $23.6345
460015............................ 1.3061 0.9174 $23.1068 $24.0939 $25.6576 $24.3035
460016............................ *** * $18.7453 * * $18.7453
460017............................ 1.3428 0.8518 $20.7789 $21.7082 $23.0388 $21.8220
460018 \h\........................ 0.8785 1.2082 $16.7143 $18.8942 $20.3755 $18.6334
460019............................ 1.1075 0.8126 $18.1995 $20.3625 $19.9900 $19.5496
460020............................ 1.0596 0.8126 $15.2162 $19.4960 $19.5669 $17.9384
460021............................ 1.6969 1.1237 $23.8565 $24.9725 $26.3420 $25.1139
460023............................ 1.1724 0.9484 $25.0874 $25.0376 $25.3094 $25.1556
460025............................ 0.9642 * $22.3098 $18.7978 * $20.4201
460026............................ 0.9859 0.8126 $21.9316 $22.7589 $24.1547 $22.9505
460029............................ 1.0962 * $24.4379 * * $24.4379
460030............................ 1.1340 0.8126 $21.2546 $22.6129 $23.4679 $22.4925
460032............................ 0.9822 * $21.2715 $22.8987 * $22.1308
460033............................ 0.9225 0.8126 $21.7216 $22.7816 $22.0248 $22.1909
460035............................ 0.9306 0.8126 $16.9657 $16.9019 $17.5723 $17.1694
460036............................ 1.2605 0.9484 $23.9910 $25.2647 $27.2865 $25.5949
460037............................ 0.8792 0.8126 $20.0323 $19.8478 $21.1035 $20.3240
460039............................ 1.0049 0.9039 $26.3795 $27.5912 $28.5656 $27.5288
460041............................ 1.3290 0.9424 $23.5132 $24.0431 $25.2744 $24.2809
460042............................ 1.3456 0.9424 $22.0844 $23.5819 $22.9949 $22.8865
460043............................ 0.9252 0.9484 $26.0277 $26.6870 $28.2089 $27.0296
460044............................ 1.2503 0.9424 $24.7138 $25.7342 $26.6795 $25.7463
460047............................ 1.6480 0.9424 $24.9214 $25.1721 $25.7920 $25.3219
460049............................ 1.9646 0.9424 $21.9357 $23.0683 $24.5164 $23.1856
460051............................ 1.1714 0.9424 $22.7540 $23.4970 $25.5881 $24.0241
460052............................ 1.4469 0.9484 $23.1717 $24.0797 $25.3163 $24.2177
460053............................ *** * $23.2274 * * $23.2274
460054............................ 1.7584 0.9174 * $23.5227 $25.8668 $24.6922

[[Page 47569]]

470001............................ 1.2107 1.1319 $23.5882 $24.5499 $27.7329 $25.2768
470003............................ 1.8911 1.1274 $24.1739 $24.6660 $26.4919 $25.1321
470005............................ 1.3365 1.0189 $24.9625 $25.7288 $29.8255 $26.8311
470006............................ 1.1911 1.0189 $21.6036 $26.0884 $26.9651 $24.9417
470008............................ 1.1620 * $20.7659 $21.8951 * $21.3386
470010............................ 1.1547 * $23.2072 $22.9777 $26.1273 $24.1019
470011............................ 1.2118 1.0982 $24.6034 $25.9246 $28.3911 $26.3395
470012............................ 1.2312 1.0189 $20.5072 $22.9159 $24.3425 $22.6924
470018............................ 1.1718 1.0476 $21.2904 $25.9300 $28.3419 $25.0848
470023............................ 1.2182 * $24.1395 $26.7486 * $25.4614
470024............................ 1.1526 1.0189 $22.4659 $23.7745 $25.2427 $23.8783
490001............................ 1.0933 0.8697 $22.3622 $21.7111 $21.9953 $22.0191
490002............................ 1.0694 0.8025 $17.5098 $18.5220 $19.5613 $18.6066
490003............................ *** * $20.9783 $23.8112 $27.3456 $23.8351
490004............................ 1.2856 0.9771 $22.7154 $24.4580 $25.4597 $24.2345
490005............................ 1.6321 1.0802 $25.2213 $27.6425 $28.5744 $27.1963
490006............................ 1.1903 * $13.4277 $16.7679 * $15.2211
490007............................ 2.2537 0.8832 $22.2526 $24.9533 $26.2481 $24.5292
490009............................ 1.9369 1.0184 $25.2181 $27.5905 $29.0740 $27.2278
490011............................ 1.4455 0.8832 $20.0136 $22.4410 $24.5687 $22.4266
490012............................ 1.0101 0.8025 $15.8346 $18.3697 $19.2275 $17.8014
490013............................ 1.2579 0.8697 $19.5094 $21.4838 $22.4772 $21.1592
490015............................ *** * $21.2557 $22.5641 * $21.9516
490017............................ 1.4111 0.8832 $20.7691 $22.9632 $24.6845 $22.9273
490018............................ 1.2599 0.9771 $22.0810 $23.2215 $24.5196 $23.2792
490019 \h\........................ 1.1526 1.2168 $23.3077 $24.4524 $25.9761 $24.6213
490020............................ 1.2675 0.9309 $21.2094 $23.6611 $24.8001 $23.2943
490021............................ 1.4510 0.8697 $22.2537 $23.5930 $24.6440 $23.5199
490022............................ 1.4942 1.0928 $24.4682 $25.0277 $28.0749 $25.8811
490023............................ 1.2305 1.0928 $24.9734 $28.8354 $29.7774 $27.9947
490024............................ 1.6861 0.8506 $21.2619 $21.7268 $23.0982 $22.0522
490027............................ 1.1502 0.8025 $20.3644 $19.8345 $18.9409 $19.7128
490031............................ 1.1149 * $18.4826 $22.4300 $22.0579 $20.9706
490032............................ 1.8941 0.9309 $23.6489 $22.8942 $25.1381 $23.9005
490033............................ 1.0545 1.0928 $24.4370 $27.6355 $30.0909 $27.5418
490037............................ 1.1617 0.8025 $17.5104 $19.0583 $21.3035 $19.2834
490038............................ 1.1629 0.8047 $18.1405 $19.6427 $22.3976 $20.0632
490040............................ 1.5260 1.0928 $27.0513 $30.1820 $32.8738 $30.0780
490041............................ 1.4210 0.8832 $19.9314 $22.2955 $24.5738 $22.3542
490042............................ 1.2653 0.8025 $19.5127 $20.5845 $21.8749 $20.7701
490043............................ 1.1834 1.0928 $25.4354 $28.2969 $30.8871 $28.4640
490044............................ 1.3934 0.8832 $20.8739 $22.1324 $20.8351 $21.2628
490045............................ 1.3093 1.0928 $24.7131 $27.2132 $28.8279 $27.0743
490046............................ 1.5630 0.8832 $22.0040 $24.6391 $25.6328 $24.1719
490047............................ 1.0180 0.8989 $19.8220 $21.9156 $22.5424 $21.3597
490048............................ 1.4326 0.8442 $22.3138 $24.1639 $25.0097 $23.8716
490050............................ 1.5381 1.0928 $26.1521 $29.4660 $30.5037 $28.7334
490052............................ 1.6805 0.8832 $19.2480 $21.4035 $22.8889 $21.2086
490053............................ 1.3101 0.8087 $18.6541 $20.9367 $21.8432 $20.4783
490057............................ 1.5890 0.8832 $22.1612 $25.1898 $26.1128 $24.5153
490059............................ 1.5707 0.9309 $23.3895 $26.1518 $28.7276 $26.1974
490060............................ 1.0326 0.8025 $20.6028 $21.0828 $22.4200 $21.3908
490063............................ 1.8508 1.0928 $31.0162 $29.4216 $30.3632 $30.2230
490066............................ 1.3227 0.8832 $22.1034 $23.3835 $24.7146 $23.4575
490067............................ 1.1949 0.9309 $20.4058 $21.8730 $22.9188 $21.7183
490069............................ 1.5281 0.9309 $20.6957 $24.4542 $26.8791 $24.1400
490071............................ 1.2916 0.9309 $25.4678 $27.0374 $28.4381 $27.0687
490073............................ 1.6246 1.0928 $27.6711 $25.2859 $31.7743 $27.8898
490075............................ 1.4433 0.8506 $22.3230 $22.8303 $23.8191 $23.0000
490077............................ 1.3282 1.0184 $22.2643 $24.8309 $26.0800 $24.4773
490079............................ 1.2836 0.8951 $19.2196 $19.8100 $23.4728 $20.7435
490084............................ 1.1993 0.8192 $19.8598 $22.7945 $24.5965 $22.3566
490088............................ 1.0701 0.8697 $19.7549 $21.4818 $22.4186 $21.1984
490089............................ 1.0571 0.8442 $21.1522 $21.2123 $22.6461 $21.7546
490090............................ 1.1232 0.8025 $20.3015 $21.3410 $22.2907 $21.2854
490092............................ 1.1162 0.9309 $23.8364 $21.6466 $23.8656 $23.0587
490093............................ 1.4419 0.8832 $20.7388 $23.6779 $25.0751 $23.2941

[[Page 47570]]

490094............................ 1.0191 0.9309 $21.9886 $26.0755 $26.5726 $25.0296
490097............................ 1.0192 0.8025 $18.1022 $23.5366 $23.8005 $21.5573
490098............................ 1.2373 0.8025 $19.7116 $20.9805 $21.7231 $20.8214
490101............................ 1.2797 1.0928 $28.5200 $30.1800 $30.4285 $29.7644
490104............................ 0.8032 0.9309 $28.0286 $33.1215 $17.3295 $24.4559
490105............................ 0.7403 0.8087 $40.6821 $38.2813 $24.7923 $34.3492
490106............................ 0.9467 0.9771 $31.6541 $30.1492 $23.0199 $28.3157
490107............................ 1.2712 1.0928 $26.5312 $28.7296 $29.7000 $28.3786
490108............................ 0.9960 0.8697 $28.7277 $27.9090 $22.4345 $26.3471
490109............................ 0.9901 0.9309 $28.0978 $28.0548 $21.9878 $25.9914
490110............................ 1.3190 0.8107 $23.6080 $21.3126 $22.5974 $22.4319
490111............................ 1.2958 0.8025 $19.4041 $20.6373 $22.0199 $20.6805
490112............................ 1.6780 0.9309 $23.6028 $25.8312 $26.6453 $25.4222
490113............................ 1.2749 1.0928 $28.0893 $29.1786 $29.5698 $28.9669
490114............................ 0.9738 0.8025 $19.9725 $20.0555 $20.9116 $20.3167
490115............................ 1.1853 0.8025 $19.9151 $20.3615 $21.4666 $20.5969
490116............................ 1.1376 0.8025 $19.7007 $21.3083 $22.9017 $21.2429
490117............................ 1.2083 0.8025 $15.6078 $17.4111 $18.0277 $17.0302
490118............................ 1.7166 0.9309 $25.2230 $26.8810 $27.4050 $26.6600
490119............................ 1.3223 0.8832 $21.3883 $23.7813 $25.2549 $23.5234
490120............................ 1.3949 0.8832 $22.2389 $23.1535 $24.4434 $23.3020
490122............................ 1.4407 1.0928 $27.3509 $28.7020 $31.0449 $29.0227
490123............................ 1.1014 0.8025 $20.9506 $22.9511 $23.9233 $22.6075
490124............................ *** * $21.3713 $29.7939 * $25.7258
490126............................ 1.2494 0.8025 $20.4660 $23.1423 $22.2859 $21.9403
490127............................ 1.1159 0.8025 $17.8070 $19.4005 $20.4289 $19.2585
490130............................ 1.3278 0.8832 $18.6038 $22.0769 $22.8512 $21.1640
490132............................ *** * $19.5849 * * $19.5849
490133............................ *** * * * $26.5683 $26.5683
490134............................ 1.0280 0.8025 * * * *
490135............................ 0.7108 0.8442 * * * *
500001............................ 1.6005 1.1562 $26.6420 $26.7502 $29.3707 $27.5939
500002............................ 1.4190 1.0480 $24.0374 $25.0665 $25.3347 $24.8482
500003............................ 1.2854 1.1562 $27.3435 $28.4174 $29.6341 $28.5098
500005............................ 1.8323 1.1562 $28.9512 $31.4415 $32.0972 $30.7955
500007............................ 1.2993 1.0688 $23.5774 $26.1318 $28.0476 $25.9648
500008............................ 1.9468 1.1562 $28.9380 $31.0128 $31.8837 $30.6288
500011............................ 1.3733 1.1562 $27.6762 $28.3391 $30.6508 $28.9502
500012............................ 1.6030 1.0480 $26.2263 $29.2045 $30.6856 $28.7227
500014............................ 1.6603 1.1562 $27.4248 $30.1061 $33.7536 $30.6058
500015............................ 1.4325 1.1562 $27.3397 $30.1596 $32.0592 $29.8941
500016............................ 1.6712 1.1562 $27.7863 $29.3634 $31.4221 $29.6282
500019............................ 1.2772 1.0693 $25.7691 $26.9702 $28.6669 $27.1697
500021............................ 1.3194 1.0793 $26.4648 $28.5926 $30.1690 $28.5893
500023............................ 1.1440 * $23.9513 $27.3823 * $25.6872
500024............................ 1.7104 1.0982 $27.2967 $29.3946 $30.7917 $29.1683
500025............................ 1.7397 1.1562 $29.0400 $31.7335 $34.7252 $31.7861
500026............................ 1.4646 1.1562 $28.7532 $31.4152 $33.2937 $31.1325
500027............................ 1.5653 1.1562 $30.6901 $29.5939 $34.2175 $31.5063
500030............................ 1.5850 1.1693 $29.0487 $30.5926 $32.7446 $30.8324
500031............................ 1.2010 1.0959 $26.0740 $28.5398 $31.2186 $28.5887
500033............................ 1.3030 1.0480 $25.4345 $26.6704 $29.4627 $27.2338
500036............................ 1.3831 1.0480 $25.4753 $26.0223 $27.0072 $26.1929
500037............................ 1.0377 1.0480 $23.5414 $24.6548 $26.9969 $25.0377
500039............................ 1.4538 1.1562 $26.1409 $27.9651 $29.8809 $28.0919
500041............................ 1.3106 1.1235 $24.9004 $26.9101 $26.7829 $26.2464
500044............................ 1.9846 1.0887 $27.0880 $26.9323 $30.3164 $28.1645
500049............................ 1.3037 1.0480 $26.6407 $25.6104 $27.1819 $26.4960
500050............................ 1.4538 1.1235 $25.0907 $26.8971 $29.9791 $27.4347
500051............................ 1.7670 1.1562 $26.9538 $29.0100 $31.9406 $29.4441
500052............................ 1.3564 1.1562 * * * *
500053............................ 1.2591 1.0608 $26.0112 $26.8074 $28.4130 $27.1467
500054............................ 2.0344 1.0887 $27.1965 $28.8062 $30.8067 $28.9786
500055............................ *** * $25.3095 * * $25.3095
500057............................ 1.3870 * $21.0357 $21.4393 * $21.2461
500058............................ 1.6695 1.0608 $27.3411 $28.4247 $30.4699 $28.8635
500060............................ 1.3027 1.1562 $31.7480 $33.5169 $34.1523 $33.1768

[[Page 47571]]

500064............................ 1.7633 1.1562 $29.2539 $31.1459 $31.5371 $30.6791
500065............................ 1.2534 * $26.5880 $26.0960 * $26.3295
500071............................ 1.1937 * $23.2071 * * $23.2071
500072............................ 1.1555 1.1562 $27.5706 $29.3087 $33.4863 $30.1715
500074............................ *** * $21.9019 * * $21.9019
500077............................ 1.4845 1.0887 $26.5692 $27.8819 $29.4199 $28.0167
500079............................ 1.3547 1.0793 $27.1775 $28.4934 $29.6623 $28.4444
500084............................ 1.3241 1.1562 $26.5864 $27.6306 $29.3484 $27.9397
500086............................ 1.2860 * $25.9705 * * $25.9705
500088............................ 1.3895 1.1562 $30.1689 $31.2757 $33.4302 $31.6945
500092............................ 0.9229 * $20.8601 $23.2466 * $22.0417
500104............................ 1.0850 * $26.8007 $27.0034 * $26.9067
500108............................ 1.6584 1.0793 $27.4156 $28.7206 $29.4244 $28.5667
500110............................ 1.1842 * $24.8448 $25.4785 * $25.1652
500118............................ 1.1235 * $26.1971 $28.1074 * $27.1693
500119............................ 1.3675 1.0887 $25.1576 $27.2335 $30.9999 $27.7928
500122............................ 1.2120 1.0480 $26.9006 $27.4405 $30.1396 $28.2069
500124............................ 1.4141 1.1562 $24.8357 $28.6598 $31.5438 $28.2647
500129............................ 1.5421 1.0793 $27.8351 $30.0223 $30.7536 $29.5772
500134............................ 0.5051 1.1562 $21.3921 $24.2990 $26.8608 $24.3808
500138............................ 1.0850 * * * * *
500139............................ 1.5453 1.0982 $27.7281 $29.2357 $31.6591 $29.5383
500141............................ 1.2808 1.1562 $28.2968 $30.7478 $30.5456 $29.9289
500143............................ 0.4899 1.0982 $19.0982 $20.7093 $22.1419 $20.7552
500147............................ 0.8386 1.0480 * $16.3669 $24.5807 $16.9814
500148............................ 1.1214 1.0480 * $18.2168 $22.2161 $20.0814
510001............................ 1.9255 0.8832 $21.4247 $22.9351 $23.4477 $22.6536
510002............................ 1.1692 0.8442 $20.9822 $22.4751 $25.9597 $23.1031
510006............................ 1.2555 0.8832 $21.0214 $22.2947 $23.5727 $22.3142
510007............................ 1.5691 0.9473 $23.4411 $24.3499 $25.2835 $24.3672
510008............................ 1.1973 0.9518 $22.7595 $24.5293 $24.6959 $24.0287
510012............................ 0.9588 0.7734 $16.7710 $18.5816 $18.2845 $17.8391
510013............................ 1.1829 0.7734 $19.7937 $19.9710 $20.8782 $20.2065
510015............................ 0.9570 * $17.9040 * * $17.9040
510018............................ 1.0130 0.8293 $19.9490 $21.8475 $20.5556 $20.7431
510022............................ 1.8454 0.8446 $22.7534 $24.1481 $24.2125 $23.7112
510023............................ 1.2765 0.7813 $17.9267 $19.4321 $20.4908 $19.2664
510024............................ 1.7302 0.8832 $21.3662 $23.3115 $24.0444 $22.9061
510026............................ 1.0194 0.7734 $16.5389 $18.0855 $16.6192 $17.0257
510028............................ 1.0034 * $4.6544 $23.0518 $21.7134 $23.1596
510029............................ 1.2652 0.8446 $19.8202 $21.7527 $22.4556 $21.3887
510030............................ 1.1840 0.8324 $19.8220 $22.3658 $21.5583 $21.2766
510031............................ 1.3935 0.8446 $20.5743 $21.6294 $21.7637 $21.3498
510033............................ 1.3919 0.8295 $19.6921 $21.0707 $23.0305 $21.2329
510038............................ 1.0348 0.7734 $16.1016 $16.8744 $17.2832 $16.7659
510039............................ 1.2761 0.7846 $17.6173 $19.1280 $19.5468 $18.7692
510043............................ 0.9124 * $15.5857 $16.0586 * $15.8328
510046............................ 1.3006 0.8293 $19.2802 $21.2792 $21.2540 $20.5978
510047............................ 1.1387 0.8832 $22.1953 $23.2093 $24.0954 $23.1668
510048............................ 1.1193 0.7734 $16.3761 $17.6785 $17.5096 $17.1529
510050............................ 1.5322 0.7846 $18.9990 $20.1943 $19.9766 $19.7250
510053............................ 1.1441 0.7734 $18.1054 $20.7538 $20.8609 $19.9625
510055............................ 1.4649 0.9473 $27.7422 $29.3962 $30.7868 $29.3287
510058............................ 1.2960 0.8295 $20.1104 $21.9352 $22.6976 $21.6021
510059............................ 0.6597 0.8446 $18.1543 $18.8712 $21.9550 $19.5138
510061............................ 0.9980 * $14.8848 $15.3355 * $15.1074
510062............................ 1.1657 0.7734 $21.3405 $21.1568 $23.3216 $21.9387
510067............................ 1.1851 0.7734 $18.0113 $22.1582 $21.2099 $20.4433
510068............................ 1.1255 1.0928 $19.9056 $20.0007 $23.1011 $21.0310
510070............................ 1.1911 0.8293 $20.0974 $21.1895 $23.2382 $21.5724
510071............................ 1.2969 0.8293 $19.4029 $21.5439 $23.1685 $21.4107
510072............................ 1.0729 0.7734 $18.4566 $19.7990 $20.1997 $19.5568
510077............................ 1.1634 0.9110 $20.9153 $22.8104 $23.6585 $22.4770
510082............................ 1.1080 0.7734 $17.2891 $16.4742 $19.1878 $17.5963
510085............................ 1.2085 0.8446 $20.6364 $22.6563 $23.7173 $22.3503
510086............................ 1.0952 0.7734 $16.3051 $17.8234 $17.5933 $17.2267
510088............................ 0.9948 * $16.4373 $18.3401 * $17.3534

[[Page 47572]]

510089............................ *** * * * $27.7062 $27.7062
520002............................ 1.2818 0.9954 $22.0838 $23.7316 $24.9950 $23.6544
520003............................ 1.1894 * $20.4234 $21.8662 * $21.1608
520004............................ 1.3553 0.9548 $22.8530 $24.4711 $25.4639 $24.2888
520008............................ 1.6058 1.0150 $26.0931 $27.8127 $29.8354 $27.9737
520009............................ 1.6967 0.9507 $21.5169 $23.4265 $26.1503 $23.6455
520010............................ 1.1229 * $26.3965 $28.5569 * $27.4794
520011............................ 1.2646 0.9507 $22.7880 $23.7785 $25.2747 $23.9992
520013............................ 1.3824 0.9507 $23.1173 $24.4766 $26.6225 $24.8211
520014............................ 1.0852 * $20.4281 $22.1064 * $21.2683
520015............................ 1.1605 * $22.8094 $23.0403 * $22.9239
520017............................ 1.1534 0.9507 $21.7542 $23.4044 $24.6676 $23.3009
520019............................ 1.2740 0.9507 $22.6895 $24.9871 $26.7433 $24.8231
520021............................ 1.3888 1.0646 $24.1284 $25.4872 $26.6935 $25.4468
520024............................ 1.0767 * $17.5368 $18.5072 * $18.0423
520026............................ 1.1060 * $25.0504 $26.1056 * $25.6168
520027............................ 1.2807 1.0150 $22.2089 $26.2516 $27.6771 $25.6136
520028............................ 1.2640 1.0429 $24.3592 $25.7778 $25.4164 $25.1844
520030............................ 1.7815 0.9954 $23.9474 $25.3807 $27.0185 $25.5053
520032............................ 1.1395 * $22.7220 $25.3059 * $24.0314
520033............................ 1.3048 0.9507 $22.2650 $23.9791 $25.0854 $23.8247
520034............................ 1.1321 0.9507 $22.6160 $23.6563 $23.9850 $23.4634
520035............................ 1.2930 0.9584 $20.8563 $23.2625 $24.7767 $23.0160
520037............................ 1.7966 0.9954 $25.0587 $28.6984 $29.7234 $27.8508
520038............................ 1.2111 1.0150 $23.1036 $24.6650 $26.6470 $24.8476
520040............................ 1.3871 1.0150 $21.5671 $23.8501 $27.2325 $24.2221
520041............................ 1.1135 1.0654 $22.6216 $22.8236 $22.7596 $22.7396
520042............................ 1.0925 * $21.9935 $24.0788 * $23.0540
520044............................ 1.3353 0.9584 $22.7627 $24.9387 $26.0191 $24.5777
520045............................ 1.5315 0.9507 $24.1624 $24.5844 $26.0030 $24.9427
520047............................ 0.9448 * $22.5686 $25.5346 * $24.0011
520048............................ 1.6734 0.9507 $20.5069 $23.1653 $25.1724 $22.8848
520049............................ 2.1816 0.9507 $22.7424 $24.1083 $25.9256 $24.2130
520051............................ 1.6481 1.0150 $27.6695 $28.8249 $28.4880 $28.3551
520057............................ 1.1630 0.9625 $21.2729 $23.3205 $25.3745 $23.3399
520058............................ *** * $23.2907 * * $23.2907
520059............................ 1.2689 1.0434 $24.1863 $26.5596 $28.0906 $26.3220
520060............................ 1.3044 0.9507 $21.1271 $22.0132 $23.8817 $22.3382
520062............................ 1.2988 1.0150 $23.7166 $24.9988 $28.2215 $25.7059
520063............................ 1.1399 1.0150 $23.3037 $25.3674 $27.4101 $25.4095
520064............................ 1.5081 1.0150 $24.3043 $27.1120 $28.6101 $26.6968
520066............................ 1.5467 1.0429 $23.9212 $25.8812 $27.1657 $25.6782
520068............................ 0.8965 0.9507 $21.4413 $23.4746 $24.8184 $23.2981
520069............................ *** * $32.6484 * * $32.6484
520070............................ 1.7413 0.9507 $22.0590 $23.9908 $24.8935 $23.6970
520071............................ 1.2243 0.9988 $23.4832 $26.3154 $27.6202 $25.7950
520075............................ 1.5645 0.9507 $23.7322 $26.0600 $27.1699 $25.6758
520076............................ 1.1878 1.0429 $22.2993 $24.0879 $26.1698 $24.2625
520078............................ 1.5329 1.0150 $23.4414 $25.7662 $27.5989 $25.6772
520083............................ 1.7400 1.0654 $25.7108 $27.0012 $28.8407 $27.2481
520084............................ 1.0630 * $24.7909 $25.5777 * $25.1765
520087............................ 1.6720 0.9548 $22.8974 $24.5280 $27.3374 $24.8782
520088............................ 1.3449 0.9988 $23.8938 $26.0882 $26.9936 $25.7252
520089............................ 1.5576 1.0654 $24.4435 $26.6013 $30.0448 $27.0527
520091............................ 1.2792 0.9507 $22.8914 $24.8269 $24.6320 $24.0764
520092............................ 1.0343 * $21.8662 $23.4043 * $22.6433
520094............................ *** * $22.3925 $25.3166 $25.7567 $24.5483
520095............................ 1.1997 1.0429 $25.1402 $28.6376 $26.7863 $26.8360
520096............................ 1.3385 0.9988 $21.1759 $22.9929 $24.5758 $22.9775
520097............................ 1.4029 0.9507 $23.6512 $25.1135 $26.3321 $25.1104
520098............................ 2.0235 1.0654 $25.8184 $28.0730 $30.6150 $28.2679
520100............................ 1.2871 0.9551 $21.7072 $24.5914 $26.2161 $24.1896
520102............................ 1.0893 0.9988 $23.7739 $25.6146 $26.8234 $25.4621
520103............................ 1.6079 1.0150 $23.5984 $25.5361 $27.9147 $25.8275
520107............................ 1.2288 0.9507 $25.7379 $27.7413 $28.3431 $27.2253
520109............................ 1.0449 0.9507 $20.6357 $22.4048 $23.3271 $22.1487
520111............................ *** * $26.9666 $26.3095 * $26.6016

[[Page 47573]]

520112............................ 1.1268 * $19.1409 $20.4034 * $19.7623
520113............................ 1.2767 0.9507 $24.0822 $26.7926 $27.4135 $26.1479
520114............................ 1.1723 * $21.9847 $22.0536 * $22.0194
520116............................ 1.2125 0.9988 $23.9066 $26.3057 $26.9902 $25.8557
520117............................ 1.0299 * $21.9915 $22.0023 * $21.9973
520123............................ 1.0697 * $21.2360 $22.2430 * $21.7461
520130............................ *** * $20.0277 * * $20.0277
520132............................ 1.1196 0.9584 $19.5140 $21.6025 $23.1941 $21.3823
520134............................ *** * $20.8502 * * $20.8502
520135............................ 0.9154 * $18.8254 $18.5618 * $18.6918
520136............................ 1.6288 1.0150 $23.2573 $25.5145 $27.7703 $25.5032
520138............................ 1.8595 1.0150 $25.1434 $26.9047 $28.4394 $26.8513
520139............................ 1.2667 1.0150 $23.7727 $25.4424 $26.5110 $25.3279
520140............................ 1.6795 1.0150 $23.9176 $26.1616 $28.4433 $26.1128
520145............................ *** * $25.0770 * * $25.0770
520148............................ 1.2321 * $22.4299 $26.2258 * $24.3567
520151............................ 1.0412 * $20.1995 $22.9592 * $21.5728
520152............................ 1.0642 0.9507 $22.5440 $23.2493 $24.9392 $23.6620
520154............................ 1.1649 * $23.2635 $23.7160 * $23.4910
520156............................ 1.0583 * $23.7157 $24.9258 * $24.3330
520160............................ 1.8346 0.9507 $22.9475 $24.3528 $25.7588 $24.4208
520161............................ 0.9291 * $22.1857 $24.0673 * $23.1340
520170............................ 1.3020 1.0150 $25.5470 $25.6124 $27.2221 $26.1781
520173............................ 1.0993 1.0226 $24.4723 $26.2224 $28.0995 $26.3133
520177............................ 1.6514 1.0150 $27.5560 $28.4663 $30.7317 $29.0456
520178............................ 0.9717 0.9507 $22.3193 $23.0419 $20.2666 $21.8785
520189............................ 1.1196 1.0646 $23.1658 $26.3172 $28.4720 $26.3169
520192............................ *** * $22.5641 * * $22.5641
520193............................ 1.6120 0.9507 * * $26.0885 $26.0885
520194............................ 1.6325 1.0150 * * $24.9408 $24.9408
520195............................ 0.3856 1.0150 * * $36.6973 $36.6973
520196............................ 1.5394 0.9507 * * $35.1043 $35.1043
520197............................ 2.9023 1.0150 * * * *
520198............................ 1.2053 0.9507 * * * *
520199............................ 2.5005 1.0150 * * * *
530002............................ 1.1639 0.9249 $23.8852 $25.2983 $26.8356 $25.4030
530004............................ *** * $19.7857 * * $19.7857
530006............................ 1.1388 0.9249 $21.3429 $22.8344 $24.9318 $23.0266
530007............................ 1.2503 0.9249 $22.3309 $19.3476 $20.4391 $20.6774
530008 \2\........................ 1.2306 0.9249 $21.8714 $23.8271 $23.8589 $23.1777
530009............................ 0.9743 0.9249 $22.0450 $24.2426 $26.8316 $24.1997
530010 \2\........................ 1.2580 0.9249 $21.4890 $23.9255 $25.8482 $23.7290
530011............................ 1.0395 0.9249 $22.5720 $24.1396 $24.8245 $23.8464
530012............................ 1.7093 0.9249 $22.4716 $24.3454 $25.2526 $24.0014
530014............................ 1.6048 0.9249 $21.7314 $23.6907 $24.5947 $23.3995
530015............................ 1.2734 0.9887 $25.3915 $26.3107 $27.6876 $26.4934
530016............................ 1.3338 * $21.0666 $21.6575 * $21.3685
530017............................ 0.9854 0.9249 $19.5630 $23.5415 $25.3362 $22.8987
530023............................ 1.1516 * $22.5535 $24.1493 $21.3813 $22.6451
530025............................ 1.2853 1.0136 $25.4693 $27.7988 $28.6938 $27.3568
530026............................ *** * $21.0732 * * $21.0732
530029............................ *** * $19.9691 * * $19.9691
530031............................ 0.9626 * $16.8825 $16.3472 * $16.6017
530032............................ 1.0395 0.9249 $19.4449 $22.6584 $25.7728 $22.4852
----------------------------------------------------------------------------------------------------------------
\1\ Based on salaries adjusted for occupational mix, according to the calculation in section III.F. of the
preamble to this final rule.
\2\ These hospitals are assigned a wage index value under a special exceptions policy (FY 2005 IPPS final rule,
69 FR 49105).
\3\ The transfer-adjusted case-mix index is based on the billed DRG on the FY 2004 MedPAR.
\h\ These hospitals are assigned a wage index value according to section III.B.3.d of the preamble to this final
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 47574]]

Table 3A.--FY 2006 and 3-Year Average Hourly Wage for Urban Areas by
CBSA
[*Based on 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
Sebastian, PR.
10420.............. Akron, OH................ 25.1189 23.9584
10500.............. Albany, GA............... 24.1796 26.6197
10580.............. Albany-Schenectady-Troy, 24.1014 22.6789
NY.
10740.............. Albuquerque, NM.......... 27.1248 25.7999
10780.............. Alexandria, LA........... 22.5148 21.3129
10900.............. Allentown-Bethlehem- 27.5389 25.5762
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............ 33.3083 31.9786
11300.............. Anderson, IN............. 24.1549 23.0714
11340.............. Anderson, SC............. 25.1692 23.0401
11460.............. Ann Arbor, MI............ 30.4505 29.1802
11500.............. Anniston-Oxford, AL...... 21.5588 20.7900
11540.............. Appleton, WI............. 25.9098 24.1044
11700.............. Asheville, NC............ 26.0511 24.5466
12020.............. Athens-Clarke County, GA. 27.5156 26.2160
12060.............. Atlanta-Sandy Springs- 27.3919 26.2708
Marietta, GA.
12100.............. Atlantic City, NJ........ 32.4848 29.4864
12220.............. Auburn-Opelika, AL....... 22.6976 21.8061
12260.............. Augusta-Richmond County, 27.3055 25.0262
GA-SC.
12420.............. Austin-Round Rock, TX.... 26.4319 25.2266
12540.............. Bakersfield, CA.......... 29.3597 26.7401
12580.............. Baltimore-Towson, MD..... 27.6740 26.1267
12620.............. Bangor, ME............... 27.9343 26.2399
12700.............. Barnstable Town, MA...... 35.2615 33.3166
12940.............. Baton Rouge, LA.......... 24.0727 22.2182
12980.............. Battle Creek, MI......... 26.5750 24.8236
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- Gaithersburg- 32.0899 29.4426
Frederick, MD.
13740.............. Billings, MT............. 24.7710 23.5742
13780.............. Binghamton, NY........... 24.0264 22.4051
13820.............. Birmingham-Hoover, AL.... 25.0894 23.9488
13900.............. Bismarck, ND............. 21.2118 20.2286
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........ 32.3479 30.7412
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- 35.2864 33.7913
Norwalk, CT.
15180.............. Brownsville-Harlingen, TX 27.5422 26.6603
15260.............. Brunswick, GA............ 26.1311 28.6493
15380.............. Buffalo-Niagara Falls, NY 26.6130 24.9557
15500.............. Burlington, NC........... 24.9033 23.6142
15540.............. Burlington-South 26.3427 24.9877
Burlington, VT.
15764.............. Cambridge-Newton- 31.2691 29.3376
Framingham, MA.
15804.............. Camden, NJ............... 29.4132 28.1192
15940.............. Canton-Massillon, OH..... 25.0564 23.6833
15980.............. Cape Coral-Fort Myers, FL 26.1090 25.0248
16180.............. Carson City, NV.......... 28.6158 27.0192
16220.............. Casper, WY............... 25.2526 24.0014
16300.............. Cedar Rapids, IA......... 24.6804 23.4375
16580.............. Champaign-Urbana, IL..... 26.8325 25.4853
16620.............. Charleston, WV........... 23.6532 22.9870
16700.............. Charleston-North 25.8747 24.5912
Charleston, SC.
16740.............. Charlotte-Gastonia- 27.1833 25.6469
Concord, NC-SC.
16820.............. Charlottesville, VA...... 28.5185 26.7670
16860.............. Chattanooga, TN-GA....... 25.4537 24.0895
16940.............. Cheyenne, WY............. 24.5947 23.3995
16974.............. Chicago-Naperville- 30.2086 28.6207
Joliet, IL.
17020.............. Chico, CA................ 29.4447 27.4655

[[Page 47575]]

17140.............. Cincinnati-Middletown, OH- 26.8708 25.0243
KY-IN.
17300.............. Clarksville, TN-KY....... 23.1419 21.5444
17420.............. Cleveland, TN............ 22.8430 21.2185
17460.............. Cleveland-Elyria-Mentor, 25.7836 25.0847
OH.
17660.............. Coeur d'Alene, ID........ 26.9749 25.1364
17780.............. College Station-Bryan, TX 24.9298 23.8756
17820.............. Colorado Springs, CO..... 26.4562 25.5473
17860.............. Columbia, MO............. 23.3470 22.3003
17900.............. Columbia, SC............. 25.3899 24.0229
17980.............. Columbus, GA-AL.......... 23.9764 22.7919
18020.............. Columbus, IN............. 26.8458 25.0573
18140.............. Columbus, OH............. 27.6046 25.7378
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.. 28.6253 26.6921
19140.............. Dalton, GA............... 25.3917 24.9002
19180.............. Danville, IL............. 25.3127 22.9099
19260.............. Danville, VA............. 23.8191 23.0000
19340.............. Davenport-Moline-Rock 24.3881 23.2416
Island, IA-IL.
19380.............. Dayton, OH............... 25.3708 24.5739
19460.............. Decatur, AL.............. 23.7138 22.9734
19500.............. Decatur, IL.............. 22.5852 21.4281
19660.............. Deltona-Daytona Beach- 26.0389 23.9763
Ormond Beach, FL.
19740.............. Denver-Aurora, CO........ 29.9610 28.5121
19780.............. Des Moines, IA........... 27.0740 24.6825
19804.............. Detroit-Livonia-Dearborn, 29.2241 27.2889
MI.
20020.............. Dothan, AL............... 21.7218 20.2740
20100.............. Dover, DE................ 27.4921 25.9420
20220.............. Dubuque, IA.............. 25.2183 23.4077
20260.............. Duluth, MN-WI............ 28.5692 26.9746
20500.............. Durham, NC............... 28.5649 27.3142
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.............. 25.2243 24.0882
21500.............. Erie, PA................. 24.4677 22.8915
21604.............. Essex County, MA......... 29.4964 27.9829
21660.............. Eugene-Springfield, OR... 30.2425 29.1289
21780.............. Evansville, IN-KY........ 24.4379 22.4161
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- 24.3098 22.6799
Rogers, AR-MO.
22380.............. Flagstaff, AZ............ 33.8333 30.2808
22420.............. Flint, MI................ 29.8067 28.6898
22500.............. Florence, SC............. 25.1218 23.2632
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........ 23.0943 21.9290
23020.............. Fort Walton Beach- 24.8333 23.4332
Crestview-Destin, FL.
23060.............. Fort Wayne, IN........... 27.4082 25.7154
23104.............. Fort Worth-Arlington, TX. 26.5774 24.9346
23420.............. Fresno, CA............... 29.6408 27.6994
23460.............. Gadsden, AL.............. 22.3074 21.3197
23540.............. Gainesville, FL.......... 26.2530 25.0755
23580.............. Gainesville, GA.......... 24.8893 24.3617
23844.............. Gary, IN................. 26.2968 24.6962
24020.............. Glens Falls, NY.......... 24.0232 22.4577
24140.............. Goldsboro, NC............ 24.5666 23.0280
24220.............. Grand Forks, ND-MN....... 22.1960 22.4966
24300.............. Grand Junction, CO....... 26.8293 25.6655

[[Page 47576]]

24340.............. Grand Rapids-Wyoming, MI. 26.2918 24.8538
24500.............. Great Falls, MT.......... 25.2873 23.4084
24540.............. Greeley, CO.............. 26.8470 25.0779
24580.............. Green Bay, WI............ 26.5187 25.1688
24660.............. Greensboro-High Point, NC 25.5495 24.2161
24780.............. Greenville, NC........... 26.3325 24.3631
24860.............. Greenville, SC........... 28.0058 25.6717
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 24.4948
25500.............. Harrisonburg, VA......... 25.4597 24.2345
25540.............. Hartford-West Hartford- 31.0129 29.5961
East Hartford, CT.
25620.............. Hattiesburg, MS.......... 21.3089 19.6542
25860.............. Hickory-Lenoir-Morganton, 25.0061 24.2967
NC.
25980.............. \1\ Hinesville-Fort ........... ...........
Stewart, GA.
26100.............. Holland-Grand Haven, MI.. 25.4579 24.5609
26180.............. Honolulu, HI............. 31.3996 29.2678
26300.............. Hot Springs, AR.......... 25.2584 24.0637
26380.............. Houma-Bayou Cane- 22.1079 20.5356
Thibodaux, LA.
26420.............. Houston- Sugar Land- 27.9917 26.1333
Baytown, TX.
26580.............. Huntington-Ashland, WV-KY- 26.5266 25.1442
OH.
26620.............. Huntsville, AL........... 25.5407 23.9283
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 28.0936
28100.............. Kankakee-Bradley, IL..... 30.0693 28.0168
28140.............. Kansas City, MO-KS....... 26.4999 25.3015
28420.............. Kennewick-Richland-Pasco, 29.7070 27.8472
WA.
28660.............. Killeen-Temple-Fort Hood, 23.9626 23.6807
TX.
28700.............. Kingsport-Bristol- 22.5380 21.6666
Bristol, TN-VA.
28740.............. Kingston, NY............. 25.9268 24.2968
28940.............. Knoxville, TN............ 23.6812 22.7352
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 20.7364
29404.............. Lake County-Kenosha 29.2180 27.4051
County, IL-WI.
29460.............. Lakeland, FL............. 24.9925 23.4702
29540.............. Lancaster, PA............ 27.1801 25.5025
29620.............. Lansing-East Lansing, MI. 27.4106 25.6482
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 23.8890
30620.............. Lima, OH................. 25.7797 24.7454
30700.............. Lincoln, NE.............. 28.5262 26.8068
30780.............. Little Rock-North Little 24.5286 23.3089
Rock, AR.
30860.............. Logan, UT-ID............. 25.6905 24.2109

[[Page 47577]]

30980.............. Longview, TX............. 24.4521 23.4643
31020.............. Longview, WA............. 26.7829 26.2464
31084.............. Los Angeles-Long Beach- 33.0239 31.0836
Glendale, CA.
31140.............. Louisville, KY-IN........ 25.9154 24.2971
31180.............. Lubbock, TX.............. 24.5905 22.6838
31340.............. Lynchburg, VA............ 24.3559 23.5846
31420.............. Macon, GA................ 26.5343 25.0025
31460.............. Madera, CA............... 24.4061 22.5247
31540.............. Madison, WI.............. 29.8344 27.4212
31700.............. Manchester-Nashua, NH.... 28.9688 27.6888
31900.............. Mansfield, OH............ 27.7289 25.0968
32420.............. Mayaguez, PR............. 11.2545 11.3971
32580.............. McAllen-Edinburg-Mission, 25.0238 22.9932
TX.
32780.............. Medford, OR.............. 28.6299 27.7062
32820.............. Memphis, TN-MS-AR........ 26.3296 24.2774
32900.............. Merced, CA............... 31.1184 27.6673
33124.............. Miami-Miami Beach- 27.2956 25.9760
Kendall, FL.
33140.............. Michigan City-La Porte, 26.3221 24.7313
IN.
33260.............. Midland, TX.............. 26.6395 25.3824
33340.............. Milwaukee-Waukesha-West 28.4248 26.6213
Allis, WI.
33460.............. Minneapolis-St. Paul- 30.9505 29.1179
Bloomington, MN-WI.
33540.............. Missoula, MT............. 26.4227 24.2896
33660.............. Mobile, AL............... 22.1176 20.9653
33700.............. Modesto, CA.............. 33.3566 31.0924
33740.............. Monroe, LA............... 22.5035 20.9918
33780.............. Monroe, MI............... 26.4882 25.0486
33860.............. Montgomery, AL........... 24.1674 21.7986
34060.............. Morgantown, WV........... 23.6097 22.7263
34100.............. Morristown, TN........... 22.3067 20.9421
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 25.0051 23.7988
Myrtle Beach, SC.
34900.............. Napa, CA................. 35.3683 32.9923
34940.............. Naples-Marco Island, FL.. 28.3230 26.9127
34980.............. Nashville-Davidson-- 27.2496 26.0281
Murfreesboro, TN.
35004.............. Nassau-Suffolk, NY....... 35.6748 34.1135
35084.............. Newark-Union, NJ-PA...... 33.2663 30.9022
35300.............. New Haven-Milford, CT.... 33.3518 31.3675
35380.............. New Orleans-Metairie- 25.1827 23.9688
Kenner, LA.
35644.............. New York-White Plains- 36.9486 35.2809
Wayne, NY-NJ.
35660.............. Niles-Benton Harbor, MI.. 24.8541 23.3997
35980.............. Norwich-New London, CT... 31.8526 30.4467
36084.............. Oakland-Fremont-Hayward, 42.9160 40.0373
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 23.8010
36500.............. Olympia, WA.............. 30.5859 28.9079
36540.............. Omaha-Council Bluffs, NE- 26.7314 25.5148
IA.
36740.............. Orlando-Kissimmee, FL.... 26.4642 25.3744
36780.............. Oshkosh-Neenah, WI....... 25.6249 23.9585
36980.............. Owensboro, KY............ 24.6348 22.4970
37100.............. Oxnard-Thousand Oaks- 32.5213 29.7621
Ventura, CA.
37340.............. Palm Bay-Melbourne- 27.5289 25.7640
Titusville, FL.
37460.............. Panama City-Lynn Haven, 22.4111 21.3800
FL.
37620.............. Parkersburg-Marietta- 23.2293 21.6543
Vienna, WV-OH.
37700.............. Pascagoula, MS........... 22.8397 21.4591
37860.............. Pensacola-Ferry Pass- 22.6287 22.0289
Brent, FL.
37900.............. Peoria, IL............... 24.7705 23.2523
37964.............. Philadelphia, PA......... 30.8816 28.8533
38060.............. Phoenix-Mesa-Scottsdale, 28.3642 26.6290
AZ.
38220.............. Pine Bluff, AR........... 24.3824 22.1870
38300.............. Pittsburgh, PA........... 24.7324 23.2424
38340.............. Pittsfield, MA........... 28.4877 27.1701
38540.............. Pocatello, ID............ 26.1526 24.5528
38660.............. Ponce, PR................ 13.8322 12.8492
38860.............. Portland-South Portland- 29.0440 26.7442
Biddeford, ME.

[[Page 47578]]

38900.............. Portland-Vancouver- 31.4628 29.7783
Beaverton, OR-WA.
38940.............. Port St. Lucie-Fort 28.3669 26.5761
Pierce, FL.
39100.............. Poughkeepsie-Newburgh- 30.5020 29.4326
Middletown, NY.
39140.............. Prescott, AZ............. 27.6508 26.3318
39300.............. Providence-New Bedford- 30.6740 28.8463
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......... 27.0728 25.4570
39660.............. Rapid City, SD........... 25.1848 23.5321
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- 30.8793 29.3344
Ontario, CA.
40220.............. Roanoke, VA.............. 23.4915 22.4289
40340.............. Rochester, MN............ 31.1302 30.1737
40380.............. Rochester, NY............ 25.5478 24.5634
40420.............. Rockford, IL............. 27.9047 25.7272
40484.............. Rockingham County- 29.0055 27.0997
Strafford County, NH.
40580.............. Rocky Mount, NC.......... 24.9648 23.7216
40660.............. Rome, GA................. 26.3370 23.8100
40900.............. Sacramento--Arden-Arcade-- 36.2611 32.0875
Roseville, CA.
40980.............. Saginaw-Saginaw Township 25.5958 25.5607
North, MI.
41060.............. St. Cloud, MN............ 28.0585 26.2839
41100.............. St. George, UT........... 26.3420 25.1139
41140.............. St. Joseph, MO-KS........ 26.7587 25.8174
41180.............. St. Louis, MO-IL......... 25.0846 23.8052
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....... 26.3906 25.4257
41660.............. San Angelo, TX........... 23.1837 21.9567
41700.............. San Antonio, TX.......... 25.1428 23.6261
41740.............. San Diego-Carlsbad-San 31.9401 29.7863
Marcos, CA.
41780.............. Sandusky, OH............. 25.2762 23.6583
41884.............. San Francisco-San Mateo- 41.9335 38.9830
Redwood City, CA.
41900.............. San German-Cabo Rojo, PR. 12.9971 13.4135
41940.............. San Jose-Sunnyvale-Santa 42.2523 39.0890
Clara, CA.
41980.............. San Juan-Caguas-Guaynabo, 12.9393 12.3162
PR.
42020.............. San Luis Obispo-Paso 31.7731 29.7965
Robles, CA.
42044.............. Santa Ana-Anaheim-Irvine, 32.3373 30.4076
CA.
42060.............. Santa Barbara-Santa 32.7103 28.9597
Maria, 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 34.6300
42260.............. Sarasota-Bradenton- 26.9389 25.6422
Venice, FL.
42340.............. Savannah, GA............. 26.5021 24.9741
42540.............. Scranton--Wilkes-Barre, 23.8629 22.4039
PA.
42644.............. Seattle-Bellevue-Everett, 32.3767 30.4445
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..... 26.2251 24.1116
43620.............. Sioux Falls, SD.......... 26.9029 24.9570
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.......... 24.6057 23.2284
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............. 31.7251 28.5148
44940.............. Sumter, SC............... 23.4355 22.1331
45060.............. Syracuse, NY............. 26.8515 25.0736
45104.............. Tacoma, WA............... 30.0701 28.9533
45220.............. Tallahassee, FL.......... 24.3724 22.7559

[[Page 47579]]

45300.............. Tampa-St. Petersburg- 25.9983 24.1939
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............... 25.2779 23.7062
46140.............. Tulsa, OK................ 23.9970 23.2073
46220.............. Tuscaloosa, AL........... 24.2170 22.0794
46340.............. Tyler, TX................ 25.7125 24.7325
46540.............. Utica-Rome, NY........... 23.4607 22.0280
46660.............. Valdosta, GA............. 24.8233 22.3922
46700.............. Vallejo-Fairfield, CA.... 41.7968 38.4584
46940.............. Vero Beach, FL........... 26.4579 25.3120
47020.............. Victoria, TX............. 22.7937 21.7204
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.. 28.4356 26.3659
47380.............. Waco, TX................. 23.8678 22.0171
47580.............. Warner Robins, GA........ 24.2312 22.6117
47644.............. Warren-Farmington Hills- 27.6345 26.2898
Troy, MI.
47894.............. Washington-Arlington- 30.6032 28.8853
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.............. 25.6747 24.4913
48660.............. Wichita Falls, TX........ 23.2954 21.9177
48700.............. Williamsport, PA......... 23.3959 21.9847
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............ 30.8984 29.3325
49420.............. Yakima, WA............... 28.4267 27.0566
49500.............. Yauco, PR................ 12.3449 12.0750
49620.............. York-Hanover, PA......... 26.1806 24.2981
49660.............. Youngstown-Warren- 24.0832 23.4825
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 short-
term, acute care 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]
------------------------------------------------------------------------
FY 2006 3-Year
CBSA code Nonurban area average average
hourly wage hourly wage
------------------------------------------------------------------------
01................. Alabama.................. 20.8999 19.9031
02................. Alaska................... 33.5065 31.3627
03................. Arizona.................. 24.5771 23.5781
04................. Arkansas................. 20.9832 19.6639
05................. California............... 30.9228 27.8406
06................. Colorado................. 26.2370 24.4898
07................. Connecticut.............. 32.8379 31.4900
08................. Delaware................. 26.8262 25.1791
10................. Florida.................. 24.0373 22.7337
11................. Georgia.................. 21.5043 20.4917
12................. Hawaii................... 29.6476 27.4203
13................. Idaho.................... 22.5556 21.6648
14................. Illinois................. 23.1784 21.7802
15................. Indiana.................. 24.1547 22.8438
16................. Iowa..................... 23.8311 22.1480
17................. Kansas................... 22.5158 21.1668
18................. Kentucky................. 21.7864 20.5845

[[Page 47580]]

19................. Louisiana................ 20.8290 19.5825
20................. Maine.................... 24.7292 23.4474
21................. Maryland................. 26.2028 24.3521
22................. Massachusetts \1\........ ........... ...........
23................. Michigan................. 24.9169 23.3830
24................. Minnesota................ 25.5734 24.3287
25................. Mississippi.............. 21.5293 20.3356
26................. Missouri................. 22.1677 20.6486
27................. Montana.................. 24.5083 22.9955
28................. Nebraska................. 24.2446 23.2964
29................. Nevada................... 25.3983 24.4345
30................. New Hampshire............ 30.2715 26.9284
31................. New Jersey \1\........... ........... ...........
32................. New Mexico............... 24.1961 22.4946
33................. New York................. 22.8722 21.6322
34................. North Carolina........... 23.9254 22.5449
35................. North Dakota............. 20.3602 20.0194
36................. Ohio..................... 24.7151 23.1099
37................. Oklahoma................. 21.2973 20.1405
38................. Oregon................... 27.4930 25.9289
39................. Pennsylvania............. 23.2122 21.9228
40................. Puerto Rico \1\.......... ........... ...........
41................. Rhode Island \1\......... ........... ...........
42................. South Carolina........... 24.2524 22.7760
43................. South Dakota............. 23.9456 21.9995
44................. Tennessee................ 22.1887 20.8141
45................. Texas.................... 22.4960 20.9804
46................. Utah..................... 22.7561 21.7591
47................. Vermont.................. 27.4761 24.9413
49................. Virginia................. 22.4742 21.2303
50................. Washington............... 29.4354 27.3014
51................. West Virginia............ 21.6576 20.5854
52................. Wisconsin................ 26.6228 24.7285
53................. Wyoming.................. 25.9018 24.1183
------------------------------------------------------------------------
\1\ All counties in the State or Territory 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.

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............ 0.8053 0.8622
Callahan County, TX
Jones County, TX
Taylor County, TX
10380................ Aguadilla-Isabela-San 0.4732 0.5991
Sebastian, PR.
Aguada Municipio, PR
Aguadilla Municipio, PR
Anasco Municipio, PR
Isabela Municipio, PR
Lares Municipio, PR
Moca Municipio, PR
Rinc0n Municipio, PR
San Sebastian Municipio,
PR
10420................ Akron, OH.................. 0.8970 0.9283
Portage County, OH
Summit County, OH
10500................ Albany, GA................. 0.8634 0.9043
Baker County, GA
Dougherty County, GA
Lee County, GA
Terrell County, GA
Worth County, GA
10580................ Albany-Schenectady-Troy, NY 0.8607 0.9024
Albany County, NY
Rensselaer County, NY
Saratoga County, NY

[[Page 47581]]

Schenectady County, NY
Schoharie County, NY
10740................ Albuquerque, NM............ 0.9686 0.9784
Bernalillo County, NM
Sandoval County, NM
Torrance County, NM
Valencia County, NM
10780................ Alexandria, LA............. 0.8040 0.8612
Grant Parish, LA
Rapides Parish, LA
10900................ Allentown-Bethlehem-Easton, 0.9834 0.9886
PA-NJ (PA Hospitals).
Warren County, NJ
Carbon County, PA
Lehigh County, PA
Northampton County, PA
10900................ \2\ Allentown-Bethlehem- 1.1227 1.0825
Easton, PA-NJ (NJ
Hospitals).
Warren County, NJ
Carbon County, PA
Lehigh County, PA
Northampton County, PA
11020................ Altoona, PA................ 0.8933 0.9256
Blair County, PA
11100................ Amarillo, TX............... 0.9156 0.9414
Armstrong County, TX
Carson County, TX
Potter County, TX
Randall County, TX
11180................ Ames, IA................... 0.9537 0.9681
Story County, IA
11260................ \2\ Anchorage, AK.......... 1.1965 1.1307
Anchorage Municipality,
AK
Matanuska-Susitna
Borough, AK
11300................ Anderson, IN............... 0.8626 0.9037
Madison County, IN
11340................ Anderson, SC............... 0.8988 0.9295
Anderson County, SC
11460................ Ann Arbor, MI.............. 1.0874 1.0591
Washtenaw County, MI
11500................ Anniston-Oxford, AL........ 0.7717 0.8374
Calhoun County, AL
11540................ \2\ Appleton, WI........... 0.9507 0.9660
Calumet County, WI
Outagamie County, WI
11700................ Asheville, NC.............. 0.9303 0.9517
Buncombe County, NC
Haywood County, NC
Henderson County, NC
Madison County, NC
12020................ Athens-Clarke County, GA... 0.9826 0.9881
Clarke County, GA
Madison County, GA
Oconee County, GA
Oglethorpe County, GA
12060................ \1\ Atlanta-Sandy Springs- 0.9782 0.9850
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
Haralson County, GA

[[Page 47582]]

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.......... 1.1600 1.1070
Atlantic County, NJ
12220................ Auburn-Opelika, AL......... 0.8105 0.8660
Lee County, AL
12260................ Augusta-Richmond County, GA- 0.9751 0.9829
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.. 0.9439 0.9612
Bastrop County, TX
Caldwell County, TX
Hays County, TX
Travis County, TX
Williamson County, TX
12540................ \2\ Bakersfield, CA........ 1.1042 1.0702
Kern County, CA
12580................ \1\ Baltimore-Towson, MD... 0.9882 0.9919
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................. 0.9975 0.9983
Penobscot County, ME
12700................ Barnstable Town, MA........ 1.2592 1.1710
Barnstable County, MA
12940................ Baton Rouge, LA............ 0.8596 0.9016
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........... 0.9490 0.9648
Calhoun County, MI
13020................ Bay City, MI............... 0.9525 0.9672
Bay County, MI
13140................ Beaumont-Port Arthur, TX... 0.8413 0.8884
Hardin County, TX
Jefferson County, TX
Orange County, TX
13380................ Bellingham, WA............. 1.1693 1.1131
Whatcom County, WA
13460................ Bend, OR................... 1.0772 1.0522
Deschutes County, OR
13644................ \1\ Bethesda-Gaithersburg- 1.1459 1.0978
Frederick, MD.
Frederick County, MD
Montgomery County, MD
13740................ Billings, MT............... 0.8846 0.9195
Carbon County, MT

[[Page 47583]]

Yellowstone County, MT
13780................ Binghamton, NY............. 0.8580 0.9004
Broome County, NY
Tioga County, NY
13820................ \1\ Birmingham-Hoover, AL.. 0.8959 0.9275
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............... 0.7575 0.8268
Burleigh County, ND
Morton County, ND
13980................ \2\ Blacksburg- 0.8025 0.8601
Christiansburg-Radford, VA.
Giles County, VA
Montgomery County, VA
Pulaski County, VA
Radford City, VA
14020................ \2\ Bloomington, IN........ 0.8626 0.9037
Greene County, IN
Monroe County, IN
Owen County, IN
14060................ Bloomington-Normal, IL..... 0.9074 0.9356
McLean County, IL
14260................ Boise City-Nampa, ID....... 0.9039 0.9331
Ada County, ID
Boise County, ID
Canyon County, ID
Gem County, ID
Owyhee County, ID
14484................ \1\ Boston-Quincy, MA...... 1.1551 1.1038
Norfolk County, MA
Plymouth County, MA
Suffolk County, MA
14500................ Boulder, CO................ 0.9733 0.9816
Boulder County, CO
14540................ Bowling Green, KY.......... 0.8214 0.8740
Edmonson County, KY
Warren County, KY
14740................ Bremerton-Silverdale, WA... 1.0670 1.0454
Kitsap County, WA
14860................ Bridgeport-Stamford- 1.2601 1.1715
Norwalk, CT.
Fairfield County, CT
15180................ Brownsville-Harlingen, TX.. 0.9835 0.9887
Cameron County, TX
15260................ Brunswick, GA.............. 0.9331 0.9537
Brantley County, GA
Glynn County, GA
McIntosh County, GA
15380................ \1\ Buffalo-Niagara Falls, 0.9503 0.9657
NY.
Erie County, NY
Niagara County, NY
15500................ Burlington, NC............. 0.8893 0.9228
Alamance County, NC
15540................ \2\ Burlington-South 1.0189 1.0129
Burlington, VT.
Chittenden County, VT
Franklin County, VT
Grand Isle County, VT
15764................ \1\ Cambridge-Newton- 1.1166 1.0785
Framingham, MA.
Middlesex County, MA
15804................ \1,\ \2\ Camden, NJ........ 1.1227 1.0825
Burlington County, NJ
Camden County, NJ
Gloucester County, NJ
15940................ Canton-Massillon, OH....... 0.8948 0.9267
Carroll County, OH
Stark County, OH
15980................ Cape Coral-Fort Myers, FL.. 0.9323 0.9531

[[Page 47584]]

Lee County, FL
16180................ Carson City, NV............ 1.0219 1.0149
Carson City, NV
16220................ \2\ Casper, WY............. 0.9249 0.9479
Natrona County, WY
16300................ Cedar Rapids, IA........... 0.8813 0.9171
Benton County, IA
Jones County, IA
Linn County, IA
16580................ Champaign-Urbana, IL....... 0.9582 0.9712
Champaign County, IL
Ford County, IL
Piatt County, IL
16620................ Charleston, WV............. 0.8446 0.8908
Boone County, WV
Clay County, WV
Kanawha County, WV
Lincoln County, WV
Putnam County, WV
16700................ Charleston-North 0.9240 0.9473
Charleston, SC.
Berkeley County, SC
Charleston County, SC
Dorchester County, SC
16740................ \1\ Charlotte-Gastonia- 0.9707 0.9798
Concord, NC-SC.
Anson County, NC
Cabarrus County, NC
Gaston County, NC
Mecklenburg County, NC
Union County, NC
York County, SC
16820................ Charlottesville, VA........ 1.0184 1.0126
Albemarle County, VA
Fluvanna County, VA
Greene County, VA
Nelson County, VA
Charlottesville City, VA
16860................ Chattanooga, TN-GA......... 0.9089 0.9367
Catoosa County, GA
Dade County, GA
Walker County, GA
Hamilton County, TN
Marion County, TN
Sequatchie County, TN
16940................ \2\ Cheyenne, WY........... 0.9249 0.9479
Laramie County, WY
16974................ \1\ Chicago-Naperville- 1.0787 1.0532
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.............. 1.1042 1.0702
Butte County, CA
17140................ \1\ Cincinnati-Middletown, 0.9595 0.9721
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
Clermont County, OH

[[Page 47585]]

Hamilton County, OH
Warren County, OH
17300................ Clarksville, TN-KY......... 0.8264 0.8776
Christian County, KY
Trigg County, KY
Montgomery County, TN
Stewart County, TN
17420................ Cleveland, TN.............. 0.8157 0.8698
Bradley County, TN
Polk County, TN
17460................ \1\ Cleveland-Elyria- 0.9207 0.9450
Mentor, OH.
Cuyahoga County, OH
Geauga County, OH
Lake County, OH
Lorain County, OH
Medina County, OH
17660................ Coeur d'Alene, ID.......... 0.9633 0.9747
Kootenai County, ID
17780................ College Station-Bryan, TX.. 0.8902 0.9234
Brazos County, TX
Burleson County, TX
Robertson County, TX
17820................ Colorado Springs, CO....... 0.9447 0.9618
El Paso County, CO
Teller County, CO
17860................ Columbia, MO............... 0.8357 0.8843
Boone County, MO
Howard County, MO
17900................ Columbia, SC............... 0.9067 0.9351
Calhoun County, SC
Fairfield County, SC
Kershaw County, SC
Lexington County, SC
Richland County, SC
Saluda County, SC
17980................ Columbus, GA-AL............ 0.8562 0.8991
Russell County, AL
Chattahoochee County, GA
Harris County, GA
Marion County, GA
Muscogee County, GA
18020................ Columbus, IN............... 0.9586 0.9715
Bartholomew County, IN
18140................ \1\ Columbus, OH........... 0.9857 0.9902
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......... 0.8549 0.8982
Aransas County, TX
Nueces County, TX
San Patricio County, TX
18700................ Corvallis, OR.............. 1.0700 1.0474
Benton County, OR
19060................ \2\ Cumberland, MD-WV (MD 0.9357 0.9555
Hospitals).
Allegany County, MD
Mineral County, WV
19060................ Cumberland, MD-WV (WV 0.9300 0.9515
Hospitals).
Allegany County, MD
Mineral County, WV
19124................ \1\ Dallas-Plano-Irving, TX 1.0222 1.0151
Collin County, TX
Dallas County, TX
Delta County, TX
Denton County, TX
Ellis County, TX

[[Page 47586]]

Hunt County, TX
Kaufman County, TX
Rockwall County, TX
19140................ Dalton, GA................. 0.9067 0.9351
Murray County, GA
Whitfield County, GA
19180................ Danville, IL............... 0.9039 0.9331
Vermilion County, IL
19260................ Danville, VA............... 0.8506 0.8951
Pittsylvania County, VA
Danville City, VA
19340................ Davenport-Moline-Rock 0.8709 0.9097
Island, IA-IL.
Henry County, IL
Mercer County, IL
Rock Island County, IL
Scott County, IA
19380................ Dayton, OH................. 0.9060 0.9346
Greene County, OH
Miami County, OH
Montgomery County, OH
Preble County, OH
19460................ Decatur, AL................ 0.8509 0.8953
Lawrence County, AL
Morgan County, AL
19500................ \2\ Decatur, IL............ 0.8279 0.8787
Macon County, IL
19660................ Deltona-Daytona Beach- 0.9298 0.9514
Ormond Beach, FL.
Volusia County, FL
19740................ \1\ Denver-Aurora, CO...... 1.0699 1.0474
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............. 0.9668 0.9771
Dallas County, IA
Guthrie County, IA
Madison County, IA
Polk County, IA
Warren County, IA
19804................ \1\ Detroit-Livonia- 1.0436 1.0297
Dearborn, MI.
Wayne County, MI
20020................ Dothan, AL................. 0.7757 0.8404
Geneva County, AL
Henry County, AL
Houston County, AL
20100................ Dover, DE.................. 0.9817 0.9874
Kent County, DE
20220................ Dubuque, IA................ 0.9005 0.9307
Dubuque County, IA
20260................ Duluth, MN-WI.............. 1.0226 1.0154
Carlton County, MN
St. Louis County, MN
Douglas County, WI
20500................ Durham, NC................. 1.0200 1.0137
Chatham County, NC
Durham County, NC
Orange County, NC
Person County, NC
20740................ \2\ Eau Claire, WI......... 0.9507 0.9660
Chippewa County, WI
Eau Claire County, WI
20764................ \1\ Edison, NJ............. 1.1290 1.0866
Middlesex County, NJ
Monmouth County, NJ

[[Page 47587]]

Ocean County, NJ
Somerset County, NJ
20940................ \2\ El Centro, CA.......... 1.1042 1.0702
Imperial County, CA
21060................ Elizabethtown, KY.......... 0.8807 0.9167
Hardin County, KY
Larue County, KY
21140................ Elkhart-Goshen, IN......... 0.9606 0.9728
Elkhart County, IN
21300................ Elmira, NY................. 0.8268 0.8779
Chemung County, NY
21340................ El Paso, TX................ 0.9007 0.9309
El Paso County, TX
21500................ Erie, PA................... 0.8737 0.9117
Erie County, PA
21604................ \2\ Essex County, MA....... 1.0715 1.0484
Essex County, MA
21660................ Eugene-Springfield, OR..... 1.0799 1.0540
Lane County, OR
21780................ Evansville, IN-KY.......... 0.8727 0.9110
Gibson County, IN
Posey County, IN
Vanderburgh County, IN
Warrick County, IN
Henderson County, KY
Webster County, KY
21820................ \2\ Fairbanks, AK.......... 1.1965 1.1307
Fairbanks North Star
Borough, AK
21940................ Fajardo, PR................ 0.4156 0.5481
Ceiba Municipio, PR
Fajardo Municipio, PR
Luquillo Municipio, PR
22020................ Fargo, ND-MN (ND Hospitals) 0.8769 0.9140
Clay County, MN
Cass County, ND
22020................ \2\ Fargo, ND-MN (MN 0.9132 0.9397
Hospitals).
Clay County, MN
Cass County, ND
22140................ \2\ Farmington, NM......... 0.8640 0.9047
San Juan County, NM
22180................ Fayetteville, NC........... 0.9417 0.9597
Cumberland County, NC
Hoke County, NC
22220................ Fayetteville-Springdale- 0.8707 0.9095
Rogers, AR-MO.
Benton County, AR
Madison County, AR
Washington County, AR
McDonald County, MO
22380................ Flagstaff, AZ.............. 1.2082 1.1383
Coconino County, AZ
22420................ Flint, MI.................. 1.0644 1.0437
Genesee County, MI
22500................ Florence, SC............... 0.8971 0.9283
Darlington County, SC
Florence County, SC
22520................ Florence-Muscle Shoals, AL. 0.8297 0.8800
Colbert County, AL
Lauderdale County, AL
22540................ Fond du Lac, WI............ 0.9639 0.9751
Fond du Lac County, WI
22660................ Fort Collins-Loveland, CO.. 1.0136 1.0093
Larimer County, CO
22744................ \1\ Fort Lauderdale-Pompano 1.0497 1.0338
Beach-Deerfield Beach, FL.
Broward County, FL
22900................ Fort Smith, AR-OK.......... 0.8247 0.8764
Crawford County, AR
Franklin County, AR
Sebastian County, AR
Le Flore County, OK
Sequoyah County, OK

[[Page 47588]]

23020................ Fort Walton Beach-Crestview- 0.8868 0.9210
Destin, FL.
Okaloosa County, FL
23060................ Fort Wayne, IN............. 0.9787 0.9854
Allen County, IN
Wells County, IN
Whitley County, IN
23104................ \1\ Fort Worth-Arlington, 0.9491 0.9649
TX.
Johnson County, TX
Parker County, TX
Tarrant County, TX
Wise County, TX
23420................ \2\ Fresno, CA............. 1.1042 1.0702
Fresno County, CA
23460................ Gadsden, AL................ 0.7966 0.8558
Etowah County, AL
23540................ Gainesville, FL............ 0.9375 0.9568
Alachua County, FL
Gilchrist County, FL
23580................ Gainesville, GA............ 0.8888 0.9224
Hall County, GA
23844................ Gary, IN................... 0.9390 0.9578
Jasper County, IN
Lake County, IN
Newton County, IN
Porter County, IN
24020................ Glens Falls, NY............ 0.8579 0.9004
Warren County, NY
Washington County, NY
24140................ Goldsboro, NC.............. 0.8773 0.9143
Wayne County, NC
24220................ Grand Forks, ND-MN (ND 0.7926 0.8528
Hospitals).
Polk County, MN
Grand Forks County, ND
24220................ \2\ Grand Forks, ND-MN (MN 0.9132 0.9397
Hospitals).
Polk County, MN
Grand Forks County, ND
24300................ Grand Junction, CO......... 0.9581 0.9711
Mesa County, CO
24340................ Grand Rapids-Wyoming, MI... 0.9389 0.9577
Barry County, MI
Ionia County, MI
Kent County, MI
Newaygo County, MI
24500................ Great Falls, MT............ 0.9065 0.9350
Cascade County, MT
24540................ Greeley, CO................ 0.9587 0.9715
Weld County, CO
24580................ \2\ Green Bay, WI.......... 0.9507 0.9660
Brown County, WI
Kewaunee County, WI
Oconto County, WI
24660................ Greensboro-High Point, NC.. 0.9124 0.9391
Guilford County, NC
Randolph County, NC
Rockingham County, NC
24780................ Greenville, NC............. 0.9404 0.9588
Greene County, NC
Pitt County, NC
24860................ Greenville, SC............. 1.0001 1.0001
Greenville County, SC
Laurens County, SC
Pickens County, SC
25020................ Guayama, PR................ 0.3183 0.4566
Arroyo Municipio, PR
Guayama Municipio, PR
Patillas Municipio, PR
25060................ Gulfport-Biloxi, MS........ 0.8913 0.9242
Hancock County, MS
Harrison County, MS
Stone County, MS

[[Page 47589]]

25180................ Hagerstown-Martinsburg, MD- 0.9518 0.9667
WV.
Washington County, MD
Berkeley County, WV
Morgan County, WV
25260................ \2\ Hanford-Corcoran, CA... 1.1042 1.0702
Kings County, CA
25420................ Harrisburg-Carlisle, PA.... 0.9308 0.9521
Cumberland County, PA
Dauphin County, PA
Perry County, PA
25500................ Harrisonburg, VA........... 0.9092 0.9369
Rockingham County, VA
Harrisonburg City, VA
25540................ \1,\ \2\ Hartford-West 1.1726 1.1152
Hartford-East Hartford, CT.
Hartford County, CT........
Litchfield County, CT......
Middlesex County, CT.......
Tolland County, CT.........
25620................ \2\ Hattiesburg, MS........ 0.7688 0.8352
Forrest County, MS
Lamar County, MS
Perry County, MS
25860................ Hickory-Lenoir-Morganton, 0.8930 0.9254
NC.
Alexander County, NC
Burke County, NC
Caldwell County, NC
Catawba County, NC
25980................ Hinesville-Fort Stewart, GA 0.7679 0.8346
Liberty County, GA
Long County, GA
26100................ Holland-Grand Haven, MI.... 0.9124 0.9391
Ottawa County, MI
26180................ Honolulu, HI............... 1.1213 1.0816
Honolulu County, HI
26300................ Hot Springs, AR............ 0.9020 0.9318
Garland County, AR
26380................ Houma-Bayou Cane-Thibodaux, 0.7895 0.8506
LA.
Lafourche Parish, LA
Terrebonne Parish, LA
26420................ \1\ Houston-Sugar Land- 0.9996 0.9997
Baytown, 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- 0.9473 0.9636
OH.
Boyd County, KY
Greenup County, KY
Lawrence County, OH
Cabell County, WV
Wayne County, WV
26620................ Huntsville, AL............. 0.9120 0.9389
Limestone County, AL
Madison County, AL
26820................ Idaho Falls, ID............ 0.8689 0.9083
Bonneville County, ID
Jefferson County, ID
26900................ \1\ Indianapolis, IN....... 0.9912 0.9940
Boone County, IN
Brown County, IN
Hamilton County, IN
Hancock County, IN
Hendricks County, IN
Johnson County, IN
Marion County, IN

[[Page 47590]]

Morgan County, IN
Putnam County, IN
Shelby County, IN
26980................ Iowa City, IA.............. 0.9741 0.9822
Johnson County, IA
Washington County, IA
27060................ Ithaca, NY................. 0.9845 0.9894
Tompkins County, NY
27100................ Jackson, MI................ 0.9291 0.9509
Jackson County, MI
27140................ Jackson, MS................ 0.8304 0.8805
Copiah County, MS
Hinds County, MS
Madison County, MS
Rankin County, MS
Simpson County, MS
27180................ Jackson, TN................ 0.8955 0.9272
Chester County, TN
Madison County, TN
27260................ \1\ Jacksonville, FL....... 0.9294 0.9511
Baker County, FL
Clay County, FL
Duval County, FL
Nassau County, FL
St. Johns County, FL
27340................ \2\ Jacksonville, NC....... 0.8544 0.8978
Onslow County, NC
27500................ Janesville, WI............. 0.9551 0.9690
Rock County, WI
27620................ Jefferson City, MO......... 0.8381 0.8861
Callaway County, MO
Cole County, MO
Moniteau County, MO
Osage County, MO
27740................ \2\ Johnson City, TN....... 0.8003 0.8585
Carter County, TN
Unicoi County, TN
Washington County, TN
27780................ Johnstown, PA.............. 0.8340 0.8831
Cambria County, PA
27860................ Jonesboro, AR.............. 0.7960 0.8554
Craighead County, AR
Poinsett County, AR
27900................ Joplin, MO................. 0.8585 0.9008
Jasper County, MO
Newton County, MO
28020................ Kalamazoo-Portage, MI...... 1.0393 1.0267
Kalamazoo County, MI
Van Buren County, MI
28100................ Kankakee-Bradley, IL....... 1.0738 1.0500
Kankakee County, IL
28140................ \1\ Kansas City, MO-KS..... 0.9463 0.9629
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, 1.0608 1.0412
WA.
Benton County, WA
Franklin County, WA

[[Page 47591]]

28660................ Killeen-Temple-Fort Hood, 0.8557 0.8988
TX.
Bell County, TX
Coryell County, TX
Lampasas County, TX
28700................ Kingsport-Bristol-Bristol, 0.8087 0.8647
TN-VA.
Hawkins County, TN
Sullivan County, TN
Bristol City, VA
Scott County, VA
Washington County, VA
28740................ Kingston, NY............... 0.9258 0.9486
Ulster County, NY
28940................ Knoxville, TN.............. 0.8456 0.8915
Anderson County, TN
Blount County, TN
Knox County, TN
Loudon County, TN
Union County, TN
29020................ Kokomo, IN................. 0.9546 0.9687
Howard County, IN
Tipton County, IN
29100................ La Crosse, WI-MN........... 0.9548 0.9688
Houston County, MN
La Crosse County, WI
29140................ Lafayette, IN.............. 0.8721 0.9105
Benton County, IN
Carroll County, IN
Tippecanoe County, IN
29180................ Lafayette, LA.............. 0.8420 0.8889
Lafayette Parish, LA
St. Martin Parish, LA
29340................ Lake Charles, LA........... 0.7839 0.8464
Calcasieu Parish, LA
Cameron Parish, LA
29404................ Lake County-Kenosha County, 1.0434 1.0295
IL-WI.
Lake County, IL
Kenosha County, WI
29460................ Lakeland, FL............... 0.8925 0.9251
Polk County, FL
29540................ Lancaster, PA.............. 0.9706 0.9798
Lancaster County, PA
29620................ Lansing-East Lansing, MI... 0.9788 0.9854
Clinton County, MI
Eaton County, MI
Ingham County, MI
29700................ Laredo, TX................. 0.8093 0.8651
Webb County, TX
29740................ \2\ Las Cruces, NM......... 0.8640 0.9047
Dona Ana County, NM
29820................ \1\ Las Vegas-Paradise, NV. 1.1404 1.0941
Clark County, NV
29940................ Lawrence, KS............... 0.8530 0.8968
Douglas County, KS
30020................ Lawton, OK................. 0.7908 0.8515
Comanche County, OK
30140................ Lebanon, PA................ 0.8645 0.9051
Lebanon County, PA
30300................ Lewiston, ID-WA (ID 0.9868 0.9909
Hospitals).
Nez Perce County, ID
Asotin County, WA
30300................ \2\ Lewiston, ID-WA (WA 1.0480 1.0326
Hospitals).
Nez Perce County, ID
Asotin County, WA
30340................ Lewiston-Auburn, ME........ 0.9322 0.9531
Androscoggin County, ME
30460................ Lexington-Fayette, KY...... 0.9051 0.9340
Bourbon County, KY
Clark County, KY
Fayette County, KY
Jessamine County, KY

[[Page 47592]]

Scott County, KY
Woodford County, KY
30620................ Lima, OH................... 0.9271 0.9495
Allen County, OH
30700................ Lincoln, NE................ 1.0187 1.0128
Lancaster County, NE
Seward County, NE
30780................ Little Rock-North Little 0.8759 0.9133
Rock, AR.
Faulkner County, AR
Grant County, AR
Lonoke County, AR
Perry County, AR
Pulaski County, AR
Saline County, AR
30860................ Logan, UT-ID............... 0.9174 0.9427
Franklin County, ID
Cache County, UT
30980................ Longview, TX............... 0.8732 0.9113
Gregg County, TX
Rusk County, TX
Upshur County, TX
31020................ \2\ Longview, WA........... 1.0480 1.0326
Cowlitz County, WA
31084................ \1\ Los Angeles-Long Beach- 1.1793 1.1196
Glendale, CA.
Los Angeles County, CA
31140................ \1\ Louisville, KY-IN...... 0.9254 0.9483
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................ 0.8781 0.9148
Crosby County, TX
Lubbock County, TX
31340................ Lynchburg, VA.............. 0.8697 0.9088
Amherst County, VA
Appomattox County, VA
Bedford County, VA
Campbell County, VA
Bedford City, VA
Lynchburg City, VA
31420................ Macon, GA.................. 0.9475 0.9637
Bibb County, GA
Crawford County, GA
Jones County, GA
Monroe County, GA
Twiggs County, GA
31460................ \2\ Madera, CA............. 1.1042 1.0702
Madera County, CA
31540................ Madison, WI................ 1.0654 1.0443
Columbia County, WI
Dane County, WI
Iowa County, WI
31700................ \2\ Manchester-Nashua, NH.. 1.1561 1.1044
Hillsborough County, NH
Merrimack County, NH
31900................ Mansfield, OH.............. 0.9902 0.9933
Richland County, OH
32420................ Mayaguez, PR............... 0.4019 0.5357
Hormigueros Municipio, PR
Mayaguez Municipio, PR
32580................ McAllen-Edinburg-Mission, 0.8936 0.9259
TX.

[[Page 47593]]

Hidalgo County, TX
32780................ \2\ Medford, OR............ 1.0301 1.0205
Jackson County, OR
32820................ \1\ Memphis, TN-MS-AR...... 0.9402 0.9587
Crittenden County, AR
DeSoto County, MS
Marshall County, MS
Tate County, MS
Tunica County, MS
Fayette County, TN
Shelby County, TN
Tipton County, TN
32900................ Merced, CA................. 1.1112 1.0749
Merced County, CA
33124................ \1\ Miami-Miami Beach- 0.9747 0.9826
Kendall, FL.
Miami-Dade County, FL
33140................ Michigan City-La Porte, IN. 0.9400 0.9585
LaPorte County, IN
33260................ Midland, TX................ 0.9513 0.9664
Midland County, TX
33340................ \1\ Milwaukee-Waukesha-West 1.0150 1.0102
Allis, WI.
Milwaukee County, WI
Ozaukee County, WI
Washington County, WI
Waukesha County, WI
33460................ \1\ Minneapolis-St. Paul- 1.1052 1.0709
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............... 0.9526 0.9673
Missoula County, MT
33660................ Mobile, AL................. 0.7898 0.8508
Mobile County, AL
33700................ Modesto, CA................ 1.1960 1.1304
Stanislaus County, CA
33740................ Monroe, LA................. 0.8036 0.8609
Ouachita Parish, LA
Union Parish, LA
33780................ Monroe, MI................. 0.9459 0.9626
Monroe County, MI
33860................ Montgomery, AL............. 0.8630 0.9040
Autauga County, AL
Elmore County, AL
Lowndes County, AL
Montgomery County, AL
34060................ Morgantown, WV............. 0.8431 0.8897
Monongalia County, WV
Preston County, WV
34100................ \2\ Morristown, TN......... 0.8003 0.8585
Grainger County, TN
Hamblen County, TN
Jefferson County, TN
34580................ \2\ Mount Vernon-Anacortes, 1.0480 1.0326
WA.
Skagit County, WA
34620................ Muncie, IN................. 0.8943 0.9264
Delaware County, IN
34740................ Muskegon-Norton Shores, MI. 0.9667 0.9771
Muskegon County, MI
34820................ Myrtle Beach-Conway-North 0.8929 0.9254
Myrtle Beach, SC.
Horry County, SC

[[Page 47594]]

34900................ Napa, CA................... 1.2630 1.1734
Napa County, CA
34940................ Naples-Marco Island, FL.... 1.0114 1.0078
Collier County, FL
34980................ \1\ Nashville-Davidson-- 0.9731 0.9815
Murfreesboro, TN.
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..... 1.2739 1.1803
Nassau County, NY
Suffolk County, NY
35084................ \1\ Newark-Union, NJ-PA.... 1.1879 1.1251
Essex County, NJ
Hunterdon County, NJ
Morris County, NJ
Sussex County, NJ
Union County, NJ
Pike County, PA
35300................ New Haven-Milford, CT...... 1.1910 1.1272
New Haven County, CT
35380................ \1\ New Orleans-Metairie- 0.8993 0.9299
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-White Plains- 1.3194 1.2090
Wayne, 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 0.8966 0.9280
Berrien County, MI
35980................ \2\ Norwich-New London, CT. 1.1726 1.1152
New London County, CT
36084................ \1\ Oakland-Fremont- 1.5463 1.3478
Hayward, CA.
Alameda County, CA
Contra Costa County, CA
36100................ Ocala, FL.................. 0.8946 0.9266
Marion County, FL
36140................ \2\ Ocean City, NJ......... 1.1227 1.0825
Cape May County, NJ
36220................ Odessa, TX................. 0.9883 0.9920
Ector County, TX
36260................ Ogden-Clearfield, UT....... 0.9039 0.9331
Davis County, UT
Morgan County, UT
Weber County, UT
36420................ \1\ Oklahoma City, OK...... 0.9034 0.9328
Canadian County, OK
Cleveland County, OK

[[Page 47595]]

Grady County, OK
Lincoln County, OK
Logan County, OK
McClain County, OK
Oklahoma County, OK
36500................ Olympia, WA................ 1.0959 1.0647
Thurston County, WA
36540................ Omaha-Council Bluffs, NE-IA 0.9546 0.9687
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-Kissimmee, FL.. 0.9450 0.9620
Lake County, FL
Orange County, FL
Osceola County, FL
Seminole County, FL
36780................ \2\ Oshkosh-Neenah, WI..... 0.9507 0.9660
Winnebago County, WI
36980................ Owensboro, KY.............. 0.8797 0.9160
Daviess County, KY
Hancock County, KY
McLean County, KY
37100................ Oxnard-Thousand Oaks- 1.1613 1.1078
Ventura, CA.
Ventura County, CA
37340................ Palm Bay-Melbourne- 0.9830 0.9883
Titusville, FL.
Brevard County, FL
37460................ \2\ Panama City-Lynn Haven, 0.8584 0.9007
FL.
Bay County, FL
37620................ Parkersburg-Marietta- 0.8295 0.8798
Vienna, WV-OH (WV
Hospitals).
Washington County, OH
Pleasants County, WV
Wirt County, WV
Wood County, WV
37620................ \2\ Parkersburg-Marietta- 0.8826 0.9180
Vienna, WV-OH (OH
Hospitals).
Washington County, OH
Pleasants County, WV
Wirt County, WV
Wood County, WV
37700................ Pascagoula, MS............. 0.8156 0.8697
George County, MS
Jackson County, MS
37860................ \2\ Pensacola-Ferry Pass- 0.8584 0.9007
Brent, FL.
Escambia County, FL
Santa Rosa County, FL
37900................ Peoria, IL................. 0.8845 0.9194
Marshall County, IL
Peoria County, IL
Stark County, IL
Tazewell County, IL
Woodford County, IL
37964................ \1\ Philadelphia, PA....... 1.1028 1.0693
Bucks County, PA
Chester County, PA
Delaware County, PA
Montgomery County, PA
Philadelphia County, PA
38060................ \1\ Phoenix-Mesa- 1.0129 1.0088
Scottsdale, AZ.
Maricopa County, AZ
Pinal County, AZ
38220................ Pine Bluff, AR............. 0.8707 0.9095
Cleveland County, AR
Jefferson County, AR
Lincoln County, AR
38300................ \1\ Pittsburgh, PA......... 0.8832 0.9185
Allegheny County, PA

[[Page 47596]]

Armstrong County, PA
Beaver County, PA
Butler County, PA
Fayette County, PA
Washington County, PA
Westmoreland County, PA
38340................ \2\ Pittsfield, MA......... 1.0715 1.0484
Berkshire County, MA
38540................ Pocatello, ID.............. 0.9394 0.9581
Bannock County, ID
Power County, ID
38660................ Ponce, PR.................. 0.4939 0.6169
Juana Diaz Municipio, PR
Ponce Municipio, PR
Villalba Municipio, PR
38860................ Portland-South Portland- 1.0371 1.0253
Biddeford, ME.
Cumberland County, ME
Sagadahoc County, ME
York County, ME
38900................ \1\ Portland-Vancouver- 1.1235 1.0830
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, 1.0151 1.0103
FL.
Martin County, FL
St. Lucie County, FL
39100................ Poughkeepsie-Newburgh- 1.0892 1.0603
Middletown, NY.
Dutchess County, NY
Orange County, NY
39140................ Prescott, AZ............... 0.9422 0.9600
Yavapai County, AZ
39300................ \1\ Providence-New Bedford- 1.0954 1.0644
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............. 0.9484 0.9644
Juab County, UT
Utah County, UT
39380................ \2\ Pueblo, CO............. 0.9369 0.9563
Pueblo County, CO
39460................ Punta Gorda, FL............ 0.9265 0.9491
Charlotte County, FL
39540................ \2\ Racine, WI............. 0.9507 0.9660
Racine County, WI
39580................ Raleigh-Cary, NC........... 0.9668 0.9771
Franklin County, NC
Johnston County, NC
Wake County, NC
39660................ Rapid City, SD............. 0.8993 0.9299
Meade County, SD
Pennington County, SD
39740................ Reading, PA................ 0.9688 0.9785
Berks County, PA
39820................ Redding, CA................ 1.2195 1.1456
Shasta County, CA
39900................ Reno-Sparks, NV............ 1.0973 1.0657
Storey County, NV
Washoe County, NV
40060................ \1\ Richmond, VA........... 0.9309 0.9521
Amelia County, VA
Caroline County, VA
Charles City County, VA
Chesterfield County, VA

[[Page 47597]]

Cumberland County, VA
Dinwiddie County, VA
Goochland County, VA
Hanover County, VA
Henrico County, VA
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,\ \2\ Riverside-San 1.1042 1.0702
Bernardino-Ontario, CA.
Riverside County, CA
San Bernardino County, CA
40220................ Roanoke, VA................ 0.8442 0.8905
Botetourt County, VA
Craig County, VA
Franklin County, VA
Roanoke County, VA
Roanoke City, VA
Salem City, VA
40340................ Rochester, MN.............. 1.1116 1.0751
Dodge County, MN
Olmsted County, MN
Wabasha County, MN
40380................ \1\ Rochester, NY.......... 0.9123 0.9391
Livingston County, NY
Monroe County, NY
Ontario County, NY
Orleans County, NY
Wayne County, NY
40420................ Rockford, IL............... 0.9965 0.9976
Boone County, IL
Winnebago County, IL
40484................ \2\ Rockingham County- 1.1561 1.1044
Strafford County, NH.
Rockingham County, NH
Strafford County, NH
40580................ Rocky Mount, NC............ 0.8915 0.9244
Edgecombe County, NC
Nash County, NC
40660................ Rome, GA................... 0.9405 0.9589
Floyd County, GA
40900................ \1\ Sacramento--Arden- 1.2949 1.1936
Arcade--Roseville, CA.
El Dorado County, CA
Placer County, CA
Sacramento County, CA
Yolo County, CA
40980................ Saginaw-Saginaw Township 0.9140 0.9403
North, MI.
Saginaw County, MI
41060................ St. Cloud, MN.............. 1.0020 1.0014
Benton County, MN
Stearns County, MN
41100................ St. George, UT............. 0.9407 0.9590
Washington County, UT
41140................ St. Joseph, MO-KS.......... 0.9555 0.9693
Doniphan County, KS
Andrew County, MO
Buchanan County, MO
DeKalb County, MO
41180................ St. Louis, MO-IL........... 0.8958 0.9274
Bond County, IL
Calhoun County, IL
Clinton County, IL
Jersey County, IL
Macoupin County, IL

[[Page 47598]]

Madison County, IL
Monroe County, IL
St. Clair County, IL
Crawford County, MO
Franklin County, MO
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.................. 1.0435 1.0296
Marion County, OR
Polk County, OR
41500................ Salinas, CA................ 1.4126 1.2669
Monterey County, CA
41540................ \2\ Salisbury, MD.......... 0.9357 0.9555
Somerset County, MD
Wicomico County, MD
41620................ Salt Lake City, UT......... 0.9424 0.9602
Salt Lake County, UT
Summit County, UT
Tooele County, UT
41660................ San Angelo, TX............. 0.8279 0.8787
Irion County, TX
Tom Green County, TX
41700................ \1\ San Antonio, TX........ 0.8978 0.9288
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 1.1406 1.0943
Marcos, CA.
San Diego County, CA
41780................ Sandusky, OH............... 0.9026 0.9322
Erie County, OH
41884................ \1\ San Francisco-San Mateo- 1.4974 1.3185
Redwood City, CA.
Marin County, CA
San Francisco County, CA
San Mateo County, CA
41900................ San German-Cabo Rojo, PR... 0.4641 0.5911
Cabo Rojo Municipio, PR
Lajas Municipio, PR
Sabana Grande Municipio,
PR
San German Municipio, PR
41940................ \1\ San Jose-Sunnyvale- 1.5088 1.3253
Santa Clara, CA.
San Benito County, CA
Santa Clara County, CA
41980................ \1\ San Juan-Caguas- 0.4621 0.5894
Guaynabo, PR.
Aguas Buenas Municipio,
PR
Aibonito Municipio, PR
Arecibo Municipio, PR
Barceloneta Municipio, PR
Barranquitas Municipio,
PR
Bayamon Municipio, PR
Caguas Municipio, PR
Camuy Municipio, PR
Canovanas Municipio, PR
Carolina Municipio, PR
Catano Municipio, PR
Cayey Municipio, PR
Ciales Municipio, PR
Cidra Municipio, PR
Comerio Municipio, PR
Corozal Municipio, PR
Dorado Municipio, PR

[[Page 47599]]

Florida Municipio, PR
Guaynabo Municipio, PR
Gurabo Municipio, PR
Hatillo Municipio, PR
Humacao Municipio, PR
Juncos Municipio, PR
Las Piedras Municipio, PR
Loiza Municipio, PR
Manati Municipio, PR
Maunabo Municipio, PR
Morovis Municipio, PR
Naguabo Municipio, PR
Naranjito Municipio, PR
Orocovis Municipio, PR
Quebradillas Municipio,
PR
Rio 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 1.1346 1.0903
Robles, CA.
San Luis Obispo County,
CA
42044................ \1\ Santa Ana-Anaheim- 1.1547 1.1035
Irvine, CA.
Orange County, CA
42060................ Santa Barbara-Santa Maria, 1.1681 1.1123
CA.
Santa Barbara County, CA
42100................ Santa Cruz-Watsonville, CA. 1.5144 1.3287
Santa Cruz County, CA
42140................ Santa Fe, NM............... 1.0897 1.0606
Santa Fe County, NM
42220................ Santa Rosa-Petaluma, CA.... 1.3467 1.2261
Sonoma County, CA
42260................ Sarasota-Bradenton-Venice, 0.9634 0.9748
FL.
Manatee County, FL
Sarasota County, FL
42340................ Savannah, GA............... 0.9464 0.9630
Bryan County, GA
Chatham County, GA
Effingham County, GA
42540................ Scranton--Wilkes-Barre, PA. 0.8521 0.8962
Lackawanna County, PA
Luzerne County, PA
Wyoming County, PA
42644................ \1\ Seattle-Bellevue- 1.1562 1.1045
Everett, WA.
King County, WA
Snohomish County, WA
43100................ \2\ Sheboygan, WI.......... 0.9507 0.9660
Sheboygan County, WI
43300................ Sherman-Denison, TX........ 0.9509 0.9661
Grayson County, TX
43340................ Shreveport-Bossier City, LA 0.8758 0.9132
Bossier Parish, LA
Caddo Parish, LA
De Soto Parish, LA
43580................ Sioux City, IA-NE-SD....... 0.9365 0.9561
Woodbury County, IA
Dakota County, NE
Dixon County, NE
Union County, SD
43620................ Sioux Falls, SD............ 0.9607 0.9729
Lincoln County, SD
McCook County, SD
Minnehaha County, SD
Turner County, SD
43780................ South Bend-Mishawaka, IN-MI 0.9775 0.9845
St. Joseph County, IN

[[Page 47600]]

Cass County, MI
43900................ Spartanburg, SC............ 0.9174 0.9427
Spartanburg County, SC
44060................ Spokane, WA................ 1.0887 1.0599
Spokane County, WA
44100................ Springfield, IL............ 0.8787 0.9153
Menard County, IL
Sangamon County, IL
44140................ \2\ Springfield, MA........ 1.0715 1.0484
Franklin County, MA
Hampden County, MA
Hampshire County, MA
44180................ Springfield, MO............ 0.8242 0.8760
Christian County, MO
Dallas County, MO
Greene County, MO
Polk County, MO
Webster County, MO
44220................ \2\ Springfield, OH........ 0.8826 0.9180
Clark County, OH
44300................ State College, PA.......... 0.8360 0.8846
Centre County, PA
44700................ Stockton, CA............... 1.1329 1.0892
San Joaquin County, CA
44940................ \2\ Sumter, SC............. 0.8660 0.9062
Sumter County, SC
45060................ Syracuse, NY............... 0.9589 0.9717
Madison County, NY
Onondaga County, NY
Oswego County, NY
45104................ Tacoma, WA................. 1.0738 1.0500
Pierce County, WA
45220................ Tallahassee, FL............ 0.8703 0.9093
Gadsden County, FL
Jefferson County, FL
Leon County, FL
Wakulla County, FL
45300................ \1\ Tampa-St. Petersburg- 0.9328 0.9535
Clearwater, FL.
Hernando County, FL
Hillsborough County, FL
Pasco County, FL
Pinellas County, FL
45460................ \2\ Terre Haute, IN........ 0.8626 0.9037
Clay County, IN
Sullivan County, IN
Vermillion County, IN
Vigo County, IN
45500................ Texarkana, TX-Texarkana, AR 0.8285 0.8791
Miller County, AR
Bowie County, TX
45780................ Toledo, OH................. 0.9564 0.9699
Fulton County, OH
Lucas County, OH
Ottawa County, OH
Wood County, OH
45820................ Topeka, KS................. 0.8912 0.9242
Jackson County, KS
Jefferson County, KS
Osage County, KS
Shawnee County, KS
Wabaunsee County, KS
45940................ \2\ Trenton-Ewing, NJ...... 1.1227 1.0825
Mercer County, NJ
46060................ Tucson, AZ................. 0.9027 0.9323
Pima County, AZ
46140................ Tulsa, OK.................. 0.8569 0.8996
Creek County, OK
Okmulgee County, OK
Osage County, OK
Pawnee County, OK

[[Page 47601]]

Rogers County, OK
Tulsa County, OK
Wagoner County, OK
46220................ Tuscaloosa, AL............. 0.8648 0.9053
Greene County, AL
Hale County, AL
Tuscaloosa County, AL
46340................ Tyler, TX.................. 0.9182 0.9432
Smith County, TX
46540................ Utica-Rome, NY............. 0.8378 0.8859
Herkimer County, NY
Oneida County, NY
46660................ Valdosta, GA............... 0.8864 0.9207
Brooks County, GA
Echols County, GA
Lanier County, GA
Lowndes County, GA
46700................ Vallejo-Fairfield, CA...... 1.4925 1.3155
Solano County, CA
46940................ Vero Beach, FL............. 0.9448 0.9619
Indian River County, FL
47020................ Victoria, TX............... 0.8140 0.8686
Calhoun County, TX
Goliad County, TX
Victoria County, TX
47220................ \2\ Vineland-Millville- 1.1227 1.0825
Bridgeton, NJ.
Cumberland County, NJ
47260................ \1\ Virginia Beach-Norfolk- 0.8832 0.9185
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 1.1042 1.0702
Tulare County, CA
47380................ Waco, TX................... 0.8523 0.8963
McLennan County, TX
47580................ Warner Robins, GA.......... 0.8653 0.9057
Houston County, GA
47644................ \1\ Warren-Farmington Hills- 0.9868 0.9909
Troy, MI.
Lapeer County, MI
Livingston County, MI
Macomb County, MI
Oakland County, MI
St. Clair County, MI
47894................ \1\ Washington-Arlington- 1.0928 1.0627
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

[[Page 47602]]

Alexandria City, VA
Fairfax City, VA
Falls Church City, VA
Fredericksburg City, VA
Manassas City, VA
Manassas Park City, VA
Jefferson County, WV
47940................ Waterloo-Cedar Falls, IA... 0.8555 0.8986
Black Hawk County, IA
Bremer County, IA
Grundy County, IA
48140................ Wausau, WI................. 0.9954 0.9968
Marathon County, WI
48260................ Weirton-Steubenville, WV-OH 0.7813 0.8445
(WV Hospitals).
Jefferson County, OH
Brooke County, WV
Hancock County, WV
48260................ \2\ Weirton-Steubenville, 0.8826 0.9180
WV-OH (OH Hospitals).
Jefferson County, OH
Brooke County, WV
Hancock County, WV
48300................ \2\ Wenatchee, WA.......... 1.0480 1.0326
Chelan County, WA
Douglas County, WA
48424................ \1\ West Palm Beach-Boca 1.0051 1.0035
Raton-Boynton Beach, FL.
Palm Beach County, FL
48540................ \2\ Wheeling, WV-OH (WV 0.7734 0.8386
Hospitals).
Belmont County, OH
Marshall County, WV
Ohio County, WV
48540................ \2\ Wheeling, WV-OH (OH 0.8826 0.9180
Hospitals).
Belmont County, OH
Marshall County, WV
Ohio County, WV
48620................ Wichita, KS................ 0.9168 0.9422
Butler County, KS
Harvey County, KS
Sedgwick County, KS
Sumner County, KS
48660................ Wichita Falls, TX.......... 0.8319 0.8816
Archer County, TX
Clay County, TX
Wichita County, TX
48700................ Williamsport, PA........... 0.8355 0.8842
Lycoming County, PA
48864................ Wilmington, DE-MD-NJ (DE, 1.0516 1.0351
MD Hospitals).
New Castle County, DE
Cecil County, MD
Salem County, NJ
48864................ \2\ Wilmington, DE-MD-NJ 1.1227 1.0825
(NJ Hospitals).
New Castle County, DE
Cecil County, MD
Salem County, NJ
48900................ Wilmington, NC............. 0.9570 0.9704
Brunswick County, NC
New Hanover County, NC
Pender County, NC
49020................ Winchester, VA-WV.......... 1.0204 1.0139
Frederick County, VA
Winchester City, VA
Hampshire County, WV
49180................ Winston-Salem, NC.......... 0.8951 0.9269
Davie County, NC
Forsyth County, NC
Stokes County, NC
Yadkin County, NC
49340................ Worcester, MA.............. 1.1034 1.0697
Worcester County, MA
49420................ \2\ Yakima, WA............. 1.0480 1.0326
Yakima County, WA

[[Page 47603]]

49500................ Yauco, PR.................. 0.4408 0.5707
Guanica Municipio, PR
Guayanilla Municipio, PR
Penuelas Municipio, PR
Yauco Municipio, PR
49620................ York-Hanover, PA........... 0.9349 0.9549
York County, PA
49660................ \2\ Youngstown-Warren- 0.8826 0.9180
Boardman, OH-PA (OH
Hospitals).
Mahoning County, OH
Trumbull County, OH
Mercer County, PA
49660................ Youngstown-Warren-Boardman, 0.8600 0.9019
OH-PA (PA Hospitals).
Mahoning County, OH
Trumbull County, OH
Mercer County, PA
49700................ \2\ Yuba City, CA.......... 1.1042 1.0702
Sutter County, CA
Yuba County, CA
49740................ Yuma, AZ................... 0.9179 0.9430
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 (GAF) for Rural
Areas by CBSA
------------------------------------------------------------------------
Wage
CBSA code Nonurban area index GAF
------------------------------------------------------------------------
1.................... Alabama.................... 0.7463 0.8184
2.................... Alaska..................... 1.1965 1.1307
3.................... Arizona.................... 0.9007 0.9309
4.................... Arkansas................... 0.7493 0.8207
5.................... California................. 1.1042 1.0702
6.................... Colorado................... 0.9369 0.9563
7.................... Connecticut................ 1.1726 1.1152
8.................... Delaware................... 0.9579 0.9710
0.................... Florida.................... 0.8584 0.9007
1.................... Georgia.................... 0.7679 0.8346
2.................... Hawaii..................... 1.0587 1.0398
3.................... Idaho...................... 0.8689 0.9083
4.................... Illinois................... 0.8279 0.8787
5.................... Indiana.................... 0.8626 0.9037
6.................... Iowa....................... 0.8553 0.8985
7.................... Kansas..................... 0.8076 0.8639
8.................... Kentucky................... 0.7780 0.8421
9.................... Louisiana.................. 0.7438 0.8165
20................... Maine...................... 0.8831 0.9184
21................... Maryland................... 0.9357 0.9555
22................... Massachusetts \1\.......... 1.0715 1.0484
23................... Michigan................... 0.8966 0.9280
24................... Minnesota.................. 0.9132 0.9397
25................... Mississippi................ 0.7688 0.8352
26................... Missouri................... 0.7919 0.8523
27................... Montana.................... 0.8752 0.9128
28................... Nebraska................... 0.8658 0.9060
29................... Nevada..................... 0.9070 0.9353
30................... New Hampshire.............. 1.1561 1.1044
31................... New Jersey1................ 1.1227 1.0825
32................... New Mexico................. 0.8640 0.9047
33................... New York................... 0.8217 0.8742
34................... North Carolina............. 0.8544 0.8978
35................... North Dakota............... 0.7271 0.8039
36................... Ohio....................... 0.8826 0.9180
37................... Oklahoma................... 0.7607 0.8292
38................... Oregon..................... 1.0301 1.0205
39................... Pennsylvania............... 0.8289 0.8794
40................... Puerto Rico \1\............ ......... .........
41................... Rhode Island \1\........... 1.0954 1.0644
42................... South Carolina............. 0.8660 0.9062

[[Page 47604]]

43................... South Dakota............... 0.8551 0.8983
44................... Tennessee.................. 0.8003 0.8585
45................... Texas...................... 0.8053 0.8622
46................... Utah....................... 0.8126 0.8675
47................... Vermont.................... 1.0189 1.0129
49................... Virginia................... 0.8025 0.8601
50................... Washington................. 1.0480 1.0326
51................... West Virginia.............. 0.7734 0.8386
52................... Wisconsin.................. 0.9507 0.9660
53................... Wyoming.................... 0.9249 0.9479
------------------------------------------------------------------------
\1\ All counties in the State or Territory 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 the FY 2005 final rule, 69 FR 49109.

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................ 0.8053 0.8622
10420................ Akron, OH.................. 0.8970 0.9283
10580................ Albany-Schenectady-Troy, NY 0.8607 0.9024
10740................ Albuquerque, NM............ 0.9548 0.9688
10780................ Alexandria, LA............. 0.8040 0.8612
10900................ Allentown-Bethlehem-Easton, 0.9834 0.9886
PA-NJ.
11020................ Altoona, PA................ 0.8933 0.9256
11100................ Amarillo, TX............... 0.9156 0.9414
11180................ Ames, IA................... 0.9272 0.9496
11460................ Ann Arbor, MI.............. 1.0570 1.0387
11500................ Anniston-Oxford, AL........ 0.7717 0.8374
11700................ Asheville, NC.............. 0.9303 0.9517
12020................ Athens-Clarke County, GA... 0.9694 0.9789
12060................ Atlanta-Sandy Springs- 0.9782 0.9850
Marietta, GA.
12420................ Austin-Round Rock, TX...... 0.9439 0.9612
12620................ Bangor, ME................. 0.9975 0.9983
12700................ Barnstable Town, MA........ 1.2303 1.1525
12940................ Baton Rouge, LA............ 0.8461 0.8919
13020................ Bay City, MI............... 0.9525 0.9672
13780................ Binghamton, NY............. 0.8462 0.8919
13820................ Birmingham-Hoover, AL...... 0.8959 0.9275
14260................ Boise City-Nampa, ID....... 0.9039 0.9331
14484................ Boston-Quincy, MA.......... 1.1274 1.0856
14540................ Bowling Green, KY.......... 0.8214 0.8740
15380................ Buffalo-Niagara Falls, NY.. 0.9503 0.9657
15540................ Burlington-South 0.9278 0.9500
Burlington, VT.
15764................ Cambridge-Newton- 1.1561 1.1044
Framingham, MA (NH
Hospitals).
15764................ Cambridge-Newton- 1.0982 1.0662
Framingham, MA (VT
Hospitals).
16180................ Carson City, NV............ 0.9776 0.9846
16220................ Casper, WY................. 0.9249 0.9479
16580................ Champaign-Urbana, IL....... 0.9262 0.9489
16620................ Charleston, WV (WV 0.8293 0.8797
Hospitals).
16620................ Charleston, WV (OH 0.8826 0.9180
Hospitals).
16700................ Charleston-North 0.9240 0.9473
Charleston, SC.
16740................ Charlotte-Gastonia-Concord, 0.9577 0.9708
NC-SC.
16820................ Charlottesville, VA........ 0.9771 0.9843
16860................ Chattanooga, TN-GA......... 0.9089 0.9367
16974................ Chicago-Naperville-Joliet, 1.0646 1.0438
IL.
17140................ Cincinnati-Middletown, OH- 0.9595 0.9721
KY-IN.
17300................ Clarksville, TN-KY......... 0.8084 0.8645
17460................ Cleveland-Elyria-Mentor, OH 0.9207 0.9450
17780................ College Station-Bryan, TX.. 0.8902 0.9234
17860................ Columbia, MO............... 0.8357 0.8843
17900................ Columbia, SC............... 0.9067 0.9351
17980................ Columbus, GA-AL............ 0.8394 0.8870
18140................ Columbus, OH............... 0.9857 0.9902
18700................ Corvallis, OR.............. 1.0301 1.0205
19124................ Dallas-Plano-Irving, TX.... 0.9938 0.9958
19380................ Dayton, OH................. 0.9060 0.9346
19460................ Decatur, AL................ 0.8509 0.8953

[[Page 47605]]

19740................ Denver-Aurora, CO.......... 1.0507 1.0344
19780................ Des Moines, IA............. 0.9430 0.9606
19804................ Detroit-Livonia-Dearborn, 1.0436 1.0297
MI.
20260................ Duluth, MN-WI.............. 1.0226 1.0154
20500................ Durham, NC................. 0.9944 0.9962
20764................ Edison, NJ................. 1.1290 1.0866
21060................ Elizabethtown, KY.......... 0.8278 0.8786
21500................ Erie, PA................... 0.8415 0.8885
21660................ Eugene-Springfield, OR..... 1.0419 1.0285
21780................ Evansville, IN-KY.......... 0.8499 0.8946
22020................ Fargo, ND-MN (ND, SD 0.8769 0.9140
Hospitals).
22020................ Fargo, ND-MN (MN Hospitals) 0.9132 0.9397
22180................ Fayetteville, NC........... 0.9183 0.9433
22220................ Fayetteville-Springdale- 0.8707 0.9095
Rogers, AR-MO.
22380................ Flagstaff, AZ.............. 1.1382 1.0927
22420................ Flint, MI.................. 1.0461 1.0313
22540................ Fond du Lac, WI............ 0.9507 0.9660
22660................ Fort Collins-Loveland, CO.. 1.0136 1.0093
22744................ Ft Lauderdale-Pompano Beach- 1.0497 1.0338
Deerfield Beach, FL.
22900................ Fort Smith, AR-OK.......... 0.7998 0.8581
23020................ Fort Walton Beach-Crestview- 0.8584 0.9007
Destin, FL.
23060................ Fort Wayne, IN............. 0.9787 0.9854
23104................ Fort Worth-Arlington, TX... 0.9491 0.9649
23540................ Gainesville, FL............ 0.9375 0.9568
23844................ Gary, IN................... 0.9390 0.9578
24340................ Grand Rapids-Wyoming, MI... 0.9389 0.9577
24500................ Great Falls, MT............ 0.9065 0.9350
24540................ Greeley, CO................ 0.9587 0.9715
24580................ Green Bay, WI (WI 0.9507 0.9660
Hospitals).
24580................ Green Bay, WI (MI 0.9470 0.9634
Hospitals).
24780................ Greenville, NC............. 0.9404 0.9588
24860................ Greenville, SC............. 0.9702 0.9795
25060................ Gulfport-Biloxi, MS........ 0.8603 0.9021
25420................ Harrisburg-Carlisle, PA.... 0.9139 0.9402
25500................ Harrisonburg, VA........... 0.8989 0.9296
25540................ Hartford-West Hartford-East 1.1726 1.1152
Hartford, CT (CT
Hospitals).
25540................ Hartford-West Hartford-East 1.1075 1.0724
Hartford, CT (MA
Hospitals).
25860................ Hickory-Lenoir-Morganton, 0.8930 0.9254
NC.
26100................ Holland-Grand Haven, MI.... 0.9124 0.9391
26180................ Honolulu, HI............... 1.1213 1.0816
26300................ Hot Springs, AR............ 0.8842 0.9192
26420................ Houston-Sugar Land-Baytown, 0.9996 0.9997
TX.
26580................ Huntington-Ashland, WV-KY- 0.9110 0.9382
OH.
26620................ Huntsville, AL............. 0.9120 0.9389
26900................ Indianapolis, IN........... 0.9766 0.9839
26980................ Iowa City, IA.............. 0.9556 0.9694
27060................ Ithaca, NY................. 0.9195 0.9441
27140................ Jackson, MS................ 0.8174 0.8710
27180................ Jackson, TN................ 0.8790 0.9155
27260................ Jacksonville, FL........... 0.9294 0.9511
27860................ Jonesboro, AR.............. 0.7784 0.8424
27900................ Joplin, MO................. 0.8450 0.8911
28020................ Kalamazoo-Portage, MI...... 1.0393 1.0267
28100................ Kankakee-Bradley, IL....... 1.0738 1.0500
28140................ Kansas City, MO-KS......... 0.9463 0.9629
28420................ Kennewick-Richland-Pasco, 1.0480 1.0326
WA.
28700................ Kingsport-Bristol-Bristol, 0.8087 0.8647
TN-VA.
28740................ Kingston, NY............... 0.8900 0.9233
28940................ Knoxville, TN.............. 0.8456 0.8915
29180................ Lafayette, LA.............. 0.8420 0.8889
29404................ Lake County-Kenosha County, 1.0434 1.0295
IL-WI.
29460................ Lakeland, FL............... 0.8925 0.9251
29620................ Lansing-East Lansing, MI... 0.9788 0.9854
29740................ Las Cruces, NM............. 0.8640 0.9047
29820................ Las Vegas-Paradise, NV..... 1.1237 1.0831
30020................ Lawton, OK................. 0.7666 0.8336
30460................ Lexington-Fayette, KY...... 0.8732 0.9113
30620................ Lima, OH................... 0.9271 0.9495
30700................ Lincoln, NE................ 0.9656 0.9763
30780................ Little Rock-North Little 0.8558 0.8989
Rock, AR.

[[Page 47606]]

30980................ Longview, TX............... 0.8612 0.9027
31084................ Los Angeles-Long Beach- 1.1687 1.1127
Santa Ana, CA.
31140................ Louisville, KY-IN.......... 0.9254 0.9483
31180................ Lubbock, TX................ 0.8781 0.9148
31340................ Lynchburg, VA.............. 0.8697 0.9088
31420................ Macon, GA.................. 0.9078 0.9359
31540................ Madison, WI................ 1.0429 1.0292
31700................ Manchester-Nashua, NH...... 1.1561 1.1044
32780................ Medford, OR................ 1.0301 1.0205
32820................ Memphis, TN-MS-AR.......... 0.9148 0.9408
33124................ Miami-Miami Beach-Kendall, 0.9747 0.9826
FL.
33260................ Midland, TX................ 0.9307 0.9520
33340................ Milwaukee-Waukesha-West 0.9988 0.9992
Allis, WI.
33460................ Minneapolis-St. Paul- 1.0900 1.0608
Bloomington, MN-WI.
33540................ Missoula, MT............... 0.9526 0.9673
33660................ Mobile, AL................. 0.7898 0.8508
33700................ Modesto, CA................ 1.1960 1.1304
33860................ Montgomery, AL............. 0.8300 0.8802
34060................ Morgantown, WV............. 0.8324 0.8819
34740................ Muskegon-Norton Shores, MI. 0.9667 0.9771
34980................ Nashville-Davidson-- 0.9450 0.9620
Murfreesboro, TN.
35084................ Newark-Union, NJ-PA........ 1.1879 1.1251
35380................ New Orleans-Metairie- 0.8993 0.9299
Kenner, LA.
35644................ New York-White Plains- 1.3194 1.2090
Wayne, NY-NJ.
36084................ Oakland-Fremont-Hayward, CA 1.5463 1.3478
36100................ Ocala, FL.................. 0.8946 0.9266
36140................ Ocean City, NJ............. 1.0279 1.0190
36220................ Odessa, TX................. 0.9584 0.9713
36260................ Ogden-Clearfield, UT....... 0.9039 0.9331
36420................ Oklahoma City, OK.......... 0.9034 0.9328
36500................ Olympia, WA................ 1.0959 1.0647
36540................ Omaha-Council Bluffs, NE-IA 0.9546 0.9687
36740................ Orlando-Kissimmee, FL...... 0.9450 0.9620
37860................ Pensacola-Ferry Pass-Brent, 0.8081 0.8642
FL.
37900................ Peoria, IL................. 0.8743 0.9121
37964................ Philadelphia, PA........... 1.1028 1.0693
38220................ Pine Bluff, AR............. 0.8091 0.8650
38300................ Pittsburgh, PA............. 0.8832 0.9185
38340................ Pittsfield, MA............. 1.0189 1.0129
38540................ Pocatello, ID.............. 0.9394 0.9581
38860................ Portland-South Portland- 0.9874 0.9914
Biddeford, ME.
38900................ Portland-Vancouver- 1.1235 1.0830
Beaverton, OR-WA.
38940................ Port St. Lucie-Fort Pierce, 1.0151 1.0103
FL.
39100................ Poughkeepsie-Newburgh- 1.0677 1.0459
Middletown, NY.
39340................ Provo-Orem, UT............. 0.9484 0.9644
39580................ Raleigh-Cary, NC........... 0.9411 0.9593
39740................ Reading, PA................ 0.9491 0.9649
39820................ Redding, CA................ 1.1897 1.1263
39900................ Reno-Sparks, NV (NV 1.0794 1.0537
Hospitals).
39900................ Reno-Sparks, NV (CA 1.1042 1.0702
Hospitals).
40060................ Richmond, VA............... 0.9309 0.9521
40220................ Roanoke, VA................ 0.8442 0.8905
40340................ Rochester, MN.............. 1.1116 1.0751
40380................ Rochester, NY.............. 0.9123 0.9391
40420................ Rockford, IL............... 0.9664 0.9769
40484................ Rockingham County, NH...... 1.0492 1.0334
40660................ Rome, GA................... 0.9405 0.9589
40900................ Sacramento--Arden-Arcade-- 1.2949 1.1936
Roseville, CA.
40980................ Saginaw-Saginaw Township 0.8966 0.9280
North, MI.
41060................ St. Cloud, MN.............. 0.9775 0.9845
41100................ St. George, UT............. 0.9407 0.9590
41180................ St. Louis, MO-IL........... 0.8958 0.9274
41620................ Salt Lake City, UT......... 0.9424 0.9602
41700................ San Antonio, TX............ 0.8978 0.9288
41884................ San Francisco-San Mateo- 1.4740 1.3043
Redwood City, CA.
41980................ San Juan-Caguas-Guaynabo, 0.4621 0.5894
PR.
42044................ Santa Ana-Anaheim-Irvine, 1.1296 1.0870
CA.
42140................ Santa Fe, NM............... 1.0152 1.0104
42220................ Santa Rosa-Petaluma, CA.... 1.3467 1.2261
42260................ Sarasota-Bradenton-Venice, 0.9634 0.9748
FL.

[[Page 47607]]

42340................ Savannah, GA............... 0.9300 0.9515
42644................ Seattle-Bellevue-Everett, 1.1562 1.1045
WA.
43300................ Sherman-Denison, TX........ 0.8962 0.9277
43340................ Shreveport-Bossier City, LA 0.8758 0.9132
43620................ Sioux Falls, SD............ 0.9607 0.9729
43780................ South Bend-Mishawaka, IN-MI 0.9775 0.9845
43900................ Spartanburg, SC............ 0.9174 0.9427
44060................ Spokane, WA................ 1.0711 1.0482
44180................ Springfield, MO............ 0.8242 0.8760
44300................ State College, PA.......... 0.8289 0.8794
44940................ Sumter, SC................. 0.8660 0.9062
45060................ Syracuse, NY............... 0.9318 0.9528
45300................ Tampa-St. Petersburg- 0.9328 0.9535
Clearwater, FL.
45500................ Texarkana, TX-Texarkana, AR 0.8285 0.8791
45820................ Topeka, KS................. 0.8776 0.9145
46140................ Tulsa, OK.................. 0.8569 0.8996
46220................ Tuscaloosa, AL............. 0.8648 0.9053
46340................ Tyler, TX.................. 0.9030 0.9325
46660................ Valdosta, GA............... 0.8701 0.9091
46700................ Vallejo-Fairfield, CA...... 1.3972 1.2574
47260................ Virginia Beach-Norfolk- 0.8832 0.9185
Newport News, VA.
47380................ Waco, TX................... 0.8523 0.8963
47894................ Washington-Arlington- 1.0802 1.0543
Alexandria DC-VA.
48140................ Wausau, WI................. 0.9954 0.9968
48620................ Wichita, KS................ 0.8977 0.9288
48700................ Williamsport, PA........... 0.8289 0.8794
48864................ Wilmington, DE-MD-NJ (DE 1.0325 1.0221
Hospitals).
48864................ Wilmington, DE-MD-NJ (NJ 1.1227 1.0825
Hospitals).
48900................ Wilmington, NC............. 0.9384 0.9574
49020................ Winchester, VA-WV.......... 1.0204 1.0139
49180................ Winston-Salem, NC.......... 0.8951 0.9269
49660................ Youngstown-Warren-Boardman, 0.8826 0.9180
OH-PA (OH Hospitals).
49660................ Youngstown-Warren-Boardman, 0.8600 0.9019
OH-PA (PA Hospitals).
04................... Arkansas................... 0.7493 0.8207
05................... California................. 1.1042 1.0702
07................... Connecticut................ 1.1726 1.1152
10................... Florida (FL Hospitals)..... 0.8584 0.9007
10................... Florida (GA Hosp.)......... 0.8385 0.8864
14................... Illinois................... 0.8279 0.8787
15................... Indiana.................... 0.8626 0.9037
16................... Iowa....................... 0.8553 0.8985
17................... Kansas..................... 0.8076 0.8639
19................... Louisiana.................. 0.7438 0.8165
23................... Michigan................... 0.8966 0.9280
26................... Missouri................... 0.7919 0.8523
30................... New Hampshire (VT 1.1319 1.0885
Hospitals).
33................... New York................... 0.8217 0.8742
37................... Oklahoma................... 0.7607 0.8292
38................... Oregon..................... 1.0301 1.0205
39................... Pennsylvania............... 0.8289 0.8794
44................... Tennessee.................. 0.8003 0.8585
45................... Texas...................... 0.8053 0.8622
50................... Washington (WA Hospitals).. 1.0480 1.0326
50................... Washington (ID Hospitals).. 1.0095 1.0065
53................... Wyoming.................... 0.9249 0.9479
------------------------------------------------------------------------

Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA
----------------------------------------------------------------------------------------------------------------
Wage index--
CBSA code Area Wage index GAF reclassified GAF--reclassified
hospitals hospitals
----------------------------------------------------------------------------------------------------------------
10380................ Aguadilla-Isabela-San 1.0347 1.0236 ................... .................
Sebastian, PR.
21940................ Fajardo, PR............ 0.9089 0.9367 ................... .................
25020................ Guayama, PR............ 0.6960 0.7802 ................... .................
32420................ Mayaguez, PR........... 0.8789 0.9154 ................... .................
38660................ Ponce, PR.............. 1.0802 1.0543 ................... .................
41900................ San German-Cabo Rojo, 1.0150 1.0102 ................... .................
PR.

[[Page 47608]]

41980................ San Juan-Caguas- 1.0104 1.0071 1.0104 1.0071
Guaynabo, PR.
49500................ Yauco, PR.............. 0.9640 0.9752 ................... .................
----------------------------------------------------------------------------------------------------------------

Table 4J.--Out-Migration Adjustment--FY 2006
[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, reclassified under section 508 of Pub. L. 108-173, or
redesignated under section 1886(d)(8) of the Act. Hospitals were given 45 days from the date of publication of
the FY 2006 IPPS proposed rule to review their individual situations to determine whether to submit a request to
withdraw their reclassification/redesignation and receive the out-migration adjustment instead. Hospitals that
have already been reclassified under section 1886(d)(10) of the Act, reclassified under section 508 of Pub. L.
108-173, or redesignated under section 1886(d)(8) of the Act and did not withdraw their reclassification/
redesignation for FY 2006 are designated with an asterisk]
----------------------------------------------------------------------------------------------------------------
Out-
Provider No. Asterisk migration Qualifying county name
note 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........................................ * 0.0235 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........................................ ........... 0.0451 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
010164........................................ * 0.0310 Talladega
040014........................................ * 0.0159 White
040019........................................ * 0.0697 St. Francis
040047........................................ * 0.0090 Randolph
040069........................................ * 0.0140 Mississippi
040071........................................ ........... 0.0026 Jefferson
040076........................................ * 0.1075 Hot Spring
040100........................................ * 0.0159 White
050008........................................ ........... 0.0026 San Francisco
050009........................................ * 0.0478 Napa
050013........................................ * 0.0478 Napa
050014........................................ * 0.0131 Amador
050016........................................ ........... 0.0103 San Luis Obispo
050042........................................ * 0.0219 Tehama
050046........................................ ........... 0.0156 Ventura
050047........................................ ........... 0.0026 San Francisco
050055........................................ ........... 0.0026 San Francisco
050065........................................ * 0.0029 Orange
050069........................................ * 0.0029 Orange
050073........................................ * 0.0269 Solano
050076........................................ * 0.0026 San Francisco
050082........................................ ........... 0.0156 Ventura
050084........................................ ........... 0.0555 San Joaquin
050089........................................ * 0.0152 San Bernardino
050090........................................ * 0.0308 Sonoma
050099........................................ * 0.0152 San Bernardino

[[Page 47609]]

050101........................................ ........... 0.0269 Solano
050117........................................ ........... 0.0463 Merced
050118........................................ * 0.0555 San Joaquin
050122........................................ ........... 0.0555 San Joaquin
050129........................................ * 0.0152 San Bernardino
050133........................................ ........... 0.0170 Yuba
050136........................................ * 0.0308 Sonoma
050140........................................ * 0.0152 San Bernardino
050150........................................ * 0.0316 Nevada
050152........................................ ........... 0.0026 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........................................ * 0.0026 San Francisco
050230........................................ * 0.0029 Orange
050232........................................ ........... 0.0103 San Luis Obispo
050236........................................ ........... 0.0156 Ventura
050245........................................ * 0.0152 San Bernardino
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
050367........................................ ........... 0.0269 Solano
050385........................................ * 0.0308 Sonoma
050394........................................ ........... 0.0156 Ventura
050407........................................ ........... 0.0026 San Francisco
050426........................................ * 0.0029 Orange
050444........................................ ........... 0.0463 Merced
050454........................................ ........... 0.0026 San Francisco
050457........................................ ........... 0.0026 San Francisco
050469........................................ * 0.0152 San Bernardino
050476........................................ ........... 0.0257 Lake
050494........................................ * 0.0316 Nevada
050506........................................ ........... 0.0103 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

[[Page 47610]]

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........................................ ........... 0.0103 San Luis Obispo
050667........................................ * 0.0478 Napa
050668........................................ * 0.0026 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
050731........................................ ........... 0.0152 San Bernardino
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
070034........................................ * 0.0047 Fairfield
080001........................................ ........... 0.0063 New Castle
080003........................................ ........... 0.0063 New Castle
100014........................................ ........... 0.0118 Volusia
100017........................................ ........... 0.0118 Volusia
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........................................ ........... 0.0125 Columbia
100118........................................ * 0.0398 Flagler
100156........................................ ........... 0.0125 Columbia
100175........................................ ........... 0.0231 De Soto
100212........................................ ........... 0.0060 Marion
100232........................................ ........... 0.0347 Putnam
100236........................................ ........... 0.0021 Charlotte
100252........................................ * 0.0233 Okeechobee
100290........................................ ........... 0.0582 Sumter
110023........................................ * 0.0500 Gordon
110027........................................ ........... 0.0387 Franklin
110029........................................ * 0.0063 Hall
110041........................................ * 0.0777 Habersham
110069........................................ * 0.0474 Houston
110124........................................ ........... 0.0428 Wayne
110136........................................ ........... 0.0261 Baldwin
110150........................................ * 0.0261 Baldwin
110153........................................ * 0.0474 Houston
110187........................................ * 0.1172 Lumpkin
110189........................................ * 0.0031 Fannin
110190........................................ ........... 0.0182 Macon

[[Page 47611]]

110205........................................ * 0.0779 Gilmer
130003........................................ * 0.0095 Nez Perce
130024........................................ ........... 0.0275 Bonner
130049........................................ * 0.0349 Kootenai
130066........................................ ........... 0.0349 Kootenai
140012........................................ * 0.0220 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
140130........................................ ........... 0.0147 Lake
140155........................................ ........... 0.0027 Kankakee
140160........................................ * 0.0286 Stephenson
140161........................................ * 0.0138 Livingston
140186........................................ ........... 0.0027 Kankakee
140202........................................ ........... 0.0147 Lake
140205........................................ ........... 0.0163 Boone
140234........................................ * 0.0346 La Salle
140291........................................ * 0.0147 Lake
540022........................................ ........... 0.0249 Montgomery
540030........................................ * 0.0201 Henry
540035........................................ ........... 0.0083 Porter
540045........................................ ........... 0.0416 De Kalb
540060........................................ ........... 0.0051 Vermillion
540062........................................ ........... 0.0153 Decatur
540065........................................ * 0.0139 Jackson
540076........................................ * 0.0189 Marshall
540088........................................ * 0.0196 Madison
540091........................................ ........... 0.0573 Huntington
540102........................................ * 0.0160 Starke
540113........................................ * 0.0196 Madison
540122........................................ ........... 0.0199 Ripley
640013........................................ ........... 0.0218 Muscatine
640026........................................ * 0.0496 Boone
640030........................................ ........... 0.0040 Story
640032........................................ ........... 0.0272 Jasper
640080........................................ * 0.0049 Clinton
740137........................................ * 0.0336 Douglas
840012........................................ * 0.0083 Hardin
840066........................................ * 0.0567 Logan
840127........................................ * 0.0352 Franklin
840128........................................ ........... 0.0282 Lawrence
190001........................................ * 0.0645 Washington
190003........................................ * 0.0107 Iberia
190010........................................ ........... 0.0401 Tangipahoa
190015........................................ * 0.0401 Tangipahoa
190017........................................ ........... 0.0235 St. Landry
190054........................................ ........... 0.0107 Iberia
190078........................................ ........... 0.0235 St. Landry
190088........................................ ........... 0.0705 Webster
190099........................................ * 0.0390 Avoyelles
190106........................................ * 0.0238 Allen
190133........................................ ........... 0.0238 Allen
190144........................................ ........... 0.0705 Webster
190184........................................ ........... 0.0161 Caldwell
190190........................................ ........... 0.0161 Caldwell
190191........................................ * 0.0235 St. Landry
190246........................................ ........... 0.0161 Caldwell
200002........................................ * 0.0129 Lincoln
200013........................................ ........... 0.0186 Waldo
200024........................................ * 0.0071 Androscoggin

[[Page 47612]]

200032........................................ ........... 0.0466 Oxford
200034........................................ * 0.0071 Androscoggin
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
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
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
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
230121........................................ * 0.0691 Shiawassee
230130........................................ * 0.0091 Oakland

[[Page 47613]]

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
230269........................................ * 0.0091 Oakland
230277........................................ * 0.0091 Oakland
230279........................................ * 0.0487 Livingston
240013........................................ * 0.0226 Morrison
240018........................................ * 0.1196 Goodhue
240021........................................ ........... 0.0920 Le Sueur
240044........................................ ........... 0.0868 Winona
240064........................................ * 0.0138 Itasca
240069........................................ * 0.0419 Steele
240071........................................ * 0.0454 Rice
240152........................................ * 0.0735 Kanabec
240154........................................ ........... 0.0138 Itasca
240187........................................ * 0.0506 Mc Leod
240211........................................ * 0.0705 Pine
250040........................................ * 0.0294 Jackson
250045........................................ ........... 0.0042 Hancock
260011........................................ ........... 0.0007 Cole
260025........................................ * 0.0078 Marion
260047........................................ * 0.0007 Cole
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
290049........................................ ........... 0.0026 Carson City
300011........................................ * 0.0069 Hillsborough
300012........................................ * 0.0069 Hillsborough
300017........................................ ........... 0.0361 Rockingham
300020........................................ * 0.0069 Hillsborough
300023........................................ ........... 0.0361 Rockingham
300029........................................ ........... 0.0361 Rockingham
300034........................................ * 0.0069 Hillsborough
310002........................................ * 0.0351 Essex
310009........................................ * 0.0351 Essex
310010........................................ ........... 0.0092 Mercer
310011........................................ ........... 0.0115 Cape May
310013........................................ * 0.0351 Essex
310018........................................ * 0.0351 Essex
310021........................................ * 0.0092 Mercer
310038........................................ * 0.0350 Middlesex
310039........................................ ........... 0.0350 Middlesex
310044........................................ ........... 0.0092 Mercer
310054........................................ * 0.0351 Essex
310070........................................ * 0.0350 Middlesex
310076........................................ * 0.0351 Essex
310078........................................ * 0.0351 Essex
310083........................................ * 0.0351 Essex
310092........................................ ........... 0.0092 Mercer
310093........................................ * 0.0351 Essex

[[Page 47614]]

310096........................................ * 0.0351 Essex
310108........................................ ........... 0.0350 Middlesex
310110........................................ ........... 0.0092 Mercer
310119........................................ * 0.0351 Essex
310123........................................ ........... 0.0351 Essex
310124........................................ ........... 0.0350 Middlesex
320003........................................ ........... 0.0629 San Miguel
320011........................................ ........... 0.0442 Rio Arriba
320018........................................ ........... 0.0063 Dona Ana
320085........................................ ........... 0.0063 Dona Ana
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
330181........................................ * 0.0137 Nassau
330182........................................ * 0.0137 Nassau
330191........................................ * 0.0026 Warren
330198........................................ ........... 0.0137 Nassau
330205........................................ * 0.0560 Orange
330209........................................ * 0.0560 Orange
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
330372........................................ ........... 0.0137 Nassau
330386........................................ * 0.1139 Sullivan
340015........................................ ........... 0.0267 Rowan
340020........................................ ........... 0.0207 Lee
340021........................................ * 0.0216 Cleveland
340037........................................ ........... 0.0216 Cleveland
340039........................................ * 0.0144 Iredell
340069........................................ * 0.0053 Wake
340070........................................ ........... 0.0448 Alamance
340073........................................ * 0.0053 Wake
340085........................................ ........... 0.0377 Davidson
340096........................................ ........... 0.0377 Davidson
340104........................................ ........... 0.0216 Cleveland
340114........................................ * 0.0053 Wake
340126........................................ * 0.0161 Wilson
340127........................................ * 0.0961 Granville
340129........................................ * 0.0144 Iredell
340133........................................ ........... 0.0308 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
360036........................................ * 0.0263 Wayne
360065........................................ * 0.0141 Huron
360070........................................ ........... 0.0028 Stark
360078........................................ * 0.0159 Portage
360084........................................ ........... 0.0028 Stark
360086........................................ * 0.0168 Clark
360095........................................ * 0.0087 Hancock
360100........................................ ........... 0.0028 Stark

[[Page 47615]]

360107........................................ * 0.0213 Sandusky
360131........................................ ........... 0.0028 Stark
360151........................................ ........... 0.0028 Stark
360156........................................ ........... 0.0213 Sandusky
360175........................................ * 0.0159 Clinton
360187........................................ * 0.0168 Clark
360197........................................ * 0.0092 Logan
360267........................................ ........... 0.0028 Stark
370004........................................ * 0.0193 Ottawa
370014........................................ * 0.0831 Bryan
370015........................................ * 0.0463 Mayes
370023........................................ ........... 0.0084 Stephens
370065........................................ ........... 0.0121 Craig
370113........................................ * 0.0205 Delaware
370149........................................ ........... 0.0356 Pottawatomie
370179........................................ * 0.0314 Okfuskee
380002........................................ ........... 0.0130 Josephine
380008........................................ * 0.0201 Linn
380022........................................ ........... 0.0201 Linn
380029........................................ ........... 0.0075 Marion
380051........................................ ........... 0.0075 Marion
380056........................................ ........... 0.0075 Marion
390011........................................ ........... 0.0012 Cambria
390044........................................ ........... 0.0200 Berks
390046........................................ ........... 0.0098 York
390056........................................ ........... 0.0042 Huntingdon
390065........................................ * 0.0501 Adams
390066........................................ * 0.0259 Lebanon
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........................................ ........... 0.0200 Northampton
390201........................................ ........... 0.1127 Monroe
390233........................................ ........... 0.0098 York
420007........................................ ........... 0.0001 Spartanburg
420020........................................ * 0.0035 Georgetown
420027........................................ ........... 0.0210 Anderson
420030........................................ * 0.0103 Colleton
420039........................................ * 0.0153 Union
420043........................................ ........... 0.0177 Cherokee
420068........................................ * 0.0097 Orangeburg
420070........................................ * 0.0101 Sumter
420083........................................ ........... 0.0001 Spartanburg
420093........................................ ........... 0.0001 Spartanburg
420098........................................ ........... 0.0035 Georgetown
440008........................................ * 0.0663 Henderson
440024........................................ ........... 0.0387 Bradley
440030........................................ ........... 0.0056 Hamblen
440035........................................ * 0.0441 Montgomery
440047........................................ ........... 0.0499 Gibson
440056........................................ ........... 0.0321 Jefferson
440060........................................ * 0.0499 Gibson
440063........................................ ........... 0.0011 Washington
440067........................................ * 0.0056 Hamblen
440073........................................ * 0.0513 Maury
440105........................................ ........... 0.0011 Washington
440114........................................ ........... 0.0523 Lauderdale
440115........................................ ........... 0.0499 Gibson
440148........................................ * 0.0568 De Kalb

[[Page 47616]]

440153........................................ ........... 0.0007 Cocke
440174........................................ ........... 0.0372 Haywood
440181........................................ ........... 0.0407 Hardeman
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
450121........................................ * 0.0097 Tarrant
450135........................................ * 0.0097 Tarrant
450137........................................ * 0.0097 Tarrant
450144........................................ * 0.0573 Andrews
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........................................ ........... 0.0486 Palo Pinto
450596........................................ ........... 0.0808 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
450872........................................ * 0.0097 Tarrant
450880........................................ * 0.0097 Tarrant
460017........................................ ........... 0.0392 Box Elder
460036........................................ * 0.0700 Wasatch
460039........................................ * 0.0392 Box Elder
470018........................................ ........... 0.0287 Windsor
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

[[Page 47617]]

500021........................................ ........... 0.0055 Pierce
500024........................................ ........... 0.0023 Thurston
500039........................................ * 0.0174 Kitsap
500041........................................ * 0.0118 Cowlitz
500079........................................ ........... 0.0055 Pierce
500108........................................ ........... 0.0055 Pierce
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
520028........................................ * 0.0157 Green
520035........................................ ........... 0.0077 Sheboygan
520044........................................ ........... 0.0077 Sheboygan
520057........................................ ........... 0.0118 Sauk
520059........................................ * 0.0200 Racine
520071........................................ * 0.0239 Jefferson
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, Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay (LOS)
--------------------------------------------------------------------------------------------------------------------------------------------------------
FY 2006 postacute
DRG FY 2006 postacute care special pay MDC TYPE DRG title Relative Geometric Arithmetic
care transfer DRG transfer DRG weights mean LOS mean LOS
--------------------------------------------------------------------------------------------------------------------------------------------------------
1................... Yes................. No................. 01 SURG............... CRANIOTOMY AGE >17 W 3.4347 7.6 10.1
CC.
2................... Yes................. No................. 01 SURG............... CRANIOTOMY AGE >17 W/ 1.9587 3.5 4.6
O CC.
3................... No.................. No................. 01 SURG *............. CRANIOTOMY AGE 0-17.. 1.9860 12.7 12.7
4................... No.................. No................. 01 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
5................... No.................. No................. 01 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
6................... No.................. No................. 01 SURG............... CARPAL TUNNEL RELEASE 0.7878 2.2 3.0
7................... Yes................. Yes................ 01 SURG............... PERIPH & CRANIAL 2.6978 6.7 9.7
NERVE & OTHER NERV
SYST PROC W CC.
8................... Yes................. Yes................ 01 SURG............... PERIPH & CRANIAL 1.5635 2.0 3.0
NERVE & OTHER NERV
SYST PROC W/O CC.
9................... No.................. No................. 01 MED................ SPINAL DISORDERS & 1.4045 4.5 6.4
INJURIES.
10.................. Yes................. No................. 01 MED................ NERVOUS SYSTEM 1.2222 4.6 6.2
NEOPLASMS W CC.
11.................. Yes................. No................. 01 MED................ NERVOUS SYSTEM 0.8736 2.9 3.8
NEOPLASMS W/O CC.
12.................. Yes................. No................. 01 MED................ DEGENERATIVE NERVOUS 0.8998 4.3 5.5
SYSTEM DISORDERS.
13.................. Yes................. No................. 01 MED................ MULTIPLE SCLEROSIS & 0.8575 4.0 5.0
CEREBELLAR ATAXIA.
14.................. Yes................. No................. 01 MED................ INTRACRANIAL 1.2456 4.5 5.8
HEMORRHAGE OR
CEREBRAL INFARCTION.
15.................. Yes................. No................. 01 MED................ NONSPECIFIC CVA & 0.9421 3.7 4.6
PRECEREBRAL
OCCLUSION W/O
INFARCT.
16.................. Yes................. No................. 01 MED................ NONSPECIFIC 1.3351 5.0 6.5
CEREBROVASCULAR
DISORDERS W CC.

[[Page 47618]]

17.................. Yes................. No................. 01 MED................ NONSPECIFIC 0.7229 2.5 3.2
CEREBROVASCULAR
DISORDERS W/O CC.
18.................. Yes................. No................. 01 MED................ CRANIAL & PERIPHERAL 0.9903 4.1 5.3
NERVE DISORDERS W CC.
19.................. Yes................. No................. 01 MED................ CRANIAL & PERIPHERAL 0.7077 2.7 3.5
NERVE DISORDERS W/O
CC.
20.................. Yes................. No................. 01 MED................ NERVOUS SYSTEM 2.7865 8.0 10.4
INFECTION EXCEPT
VIRAL MENINGITIS.
21.................. No.................. No................. 01 MED................ VIRAL MENINGITIS..... 1.4451 4.9 6.3
22.................. No.................. No................. 01 MED................ HYPERTENSIVE 1.1304 4.0 5.2
ENCEPHALOPATHY.
23.................. No.................. No................. 01 MED................ NONTRAUMATIC STUPOR & 0.7712 3.0 3.9
COMA.
24.................. Yes................. No................. 01 MED................ SEIZURE & HEADACHE 0.9970 3.6 4.8
AGE >17 W CC.
25.................. Yes................. No................. 01 MED................ SEIZURE & HEADACHE 0.6180 2.5 3.1
AGE >17 W/O CC.
26.................. No.................. No................. 01 MED................ SEIZURE & HEADACHE 1.8191 3.4 6.3
AGE 0-17.
27.................. No.................. No................. 01 MED................ TRAUMATIC STUPOR & 1.3531 3.2 5.2
COMA, COMA >1 HR.
28.................. Yes................. No................. 01 MED................ TRAUMATIC STUPOR & 1.3353 4.4 5.9
COMA, COMA <1 HR AGE
>17 W CC.
29.................. Yes................. No................. 01 MED................ TRAUMATIC STUPOR & 0.7212 2.6 3.4
COMA, COMA <1 HR AGE
>17 W/O CC.
30.................. No.................. No................. 01 MED *.............. TRAUMATIC STUPOR & 0.3359 2.0 2.0
COMA, COMA <1 HR AGE
0-17.
31.................. No.................. No................. 01 MED................ CONCUSSION AGE >17 W 0.9567 3.0 4.0
CC.
32.................. No.................. No................. 01 MED................ CONCUSSION AGE >17 W/ 0.6194 1.9 2.4
O CC.
33.................. No.................. No................. 01 MED *.............. CONCUSSION AGE 0-17.. 0.2109 1.6 1.6
34.................. Yes................. No................. 01 MED................ OTHER DISORDERS OF 1.0062 3.7 4.8
NERVOUS SYSTEM W CC.
35.................. Yes................. No................. 01 MED................ OTHER DISORDERS OF 0.6241 2.4 3.0
NERVOUS SYSTEM W/O
CC.
36.................. No.................. No................. 02 SURG............... RETINAL PROCEDURES... 0.7288 1.3 1.6
37.................. No.................. No................. 02 SURG............... ORBITAL PROCEDURES... 1.1858 2.7 4.2
38.................. No.................. No................. 02 SURG............... PRIMARY IRIS 0.6975 2.5 3.5
PROCEDURES.
39.................. No.................. No................. 02 SURG............... LENS PROCEDURES WITH 0.7108 1.7 2.4
OR WITHOUT
VITRECTOMY.
40.................. No.................. No................. 02 SURG............... EXTRAOCULAR 0.9627 3.0 4.1
PROCEDURES EXCEPT
ORBIT AGE >17.
41.................. No.................. No................. 02 SURG *............. EXTRAOCULAR 0.3419 1.6 1.6
PROCEDURES EXCEPT
ORBIT AGE 0-17.
42.................. No.................. No................. 02 SURG............... INTRAOCULAR 0.7852 2.0 2.8
PROCEDURES EXCEPT
RETINA, IRIS & LENS.
43.................. No.................. No................. 02 MED................ HYPHEMA.............. 0.6141 2.4 3.1
44.................. No.................. No................. 02 MED................ ACUTE MAJOR EYE 0.6874 3.9 4.8
INFECTIONS.
45.................. No.................. No................. 02 MED................ NEUROLOGICAL EYE 0.7474 2.5 3.1
DISORDERS.
46.................. No.................. No................. 02 MED................ OTHER DISORDERS OF 0.7524 3.2 4.2
THE EYE AGE >17 W CC.
47.................. No.................. No................. 02 MED................ OTHER DISORDERS OF 0.5203 2.3 2.9
THE EYE AGE >17 W/O
CC.
48.................. No.................. No................. 02 MED *.............. OTHER DISORDERS OF 0.3012 2.9 2.9
THE EYE AGE 0-17.
49.................. No.................. No................. 03 SURG............... MAJOR HEAD & NECK 1.6361 3.1 4.4
PROCEDURES.
50.................. No.................. No................. 03 SURG............... SIALOADENECTOMY...... 0.8690 1.5 1.8
51.................. No.................. No................. 03 SURG............... SALIVARY GLAND 0.8809 1.9 2.8
PROCEDURES EXCEPT
SIALOADENECTOMY.
52.................. No.................. No................. 03 SURG............... CLEFT LIP & PALATE 0.8348 1.5 1.9
REPAIR.
53.................. No.................. No................. 03 SURG............... SINUS & MASTOID 1.3269 2.4 3.9
PROCEDURES AGE >17.
54.................. No.................. No................. 03 SURG *............. SINUS & MASTOID 0.4882 3.2 3.2
PROCEDURES AGE 0-17.
55.................. No.................. No................. 03 SURG............... MISCELLANEOUS EAR, 0.9597 2.0 3.1
NOSE, MOUTH & THROAT
PROCEDURES.
56.................. No.................. No................. 03 SURG............... RHINOPLASTY.......... 0.8711 1.8 2.6
57.................. No.................. No................. 03 SURG............... T&A PROC, EXCEPT 1.0428 2.3 3.6
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY,
AGE >17.

[[Page 47619]]

58.................. No.................. No................. 03 SURG *............. T&A PROC, EXCEPT 0.2772 1.5 1.5
TONSILLECTOMY &/OR
ADENOIDECTOMY ONLY,
AGE 0-17.
59.................. No.................. No................. 03 SURG............... TONSILLECTOMY &/OR 0.8082 1.8 2.6
ADENOIDECTOMY ONLY,
AGE >17.
60.................. No.................. No................. 03 SURG *............. TONSILLECTOMY &/OR 0.2110 1.5 1.5
ADENOIDECTOMY ONLY,
AGE 0-17.
61.................. No.................. No................. 03 SURG............... MYRINGOTOMY W TUBE 1.2867 3.3 5.4
INSERTION AGE >17.
62.................. No.................. No................. 03 SURG *............. MYRINGOTOMY W TUBE 0.2989 1.3 1.3
INSERTION AGE 0-17.
63.................. No.................. No................. 03 SURG............... OTHER EAR, NOSE, 1.3983 3.0 4.5
MOUTH & THROAT O.R.
PROCEDURES.
64.................. No.................. No................. 03 MED................ EAR, NOSE, MOUTH & 1.1663 4.1 6.1
THROAT MALIGNANCY.
65.................. No.................. No................. 03 MED................ DYSEQUILIBRIUM....... 0.5991 2.3 2.8
66.................. No.................. No................. 03 MED................ EPISTAXIS............ 0.5958 2.4 3.1
67.................. No.................. No................. 03 MED................ EPIGLOTTITIS......... 0.7725 2.9 3.7
68.................. No.................. No................. 03 MED................ OTITIS MEDIA & URI 0.6611 3.2 4.0
AGE >17 W CC.
69.................. No.................. No................. 03 MED................ OTITIS MEDIA & URI 0.4850 2.5 3.0
AGE >17 W/O CC.
70.................. No.................. No................. 03 MED................ OTITIS MEDIA & URI 0.4210 2.1 2.3
AGE 0-17.
71.................. No.................. No................. 03 MED................ LARYNGOTRACHEITIS.... 0.7524 3.2 4.0
72.................. No.................. No................. 03 MED................ NASAL TRAUMA & 0.7449 2.6 3.4
DEFORMITY.
73.................. Yes................. No................. 03 MED................ OTHER EAR, NOSE, 0.8527 3.3 4.4
MOUTH & THROAT
DIAGNOSES AGE >17.
74.................. No.................. No................. 03 MED *.............. OTHER EAR, NOSE, 0.3398 2.1 2.1
MOUTH & THROAT
DIAGNOSES AGE 0-17.
75.................. Yes................. No................. 04 SURG............... MAJOR CHEST 3.0732 7.6 9.9
PROCEDURES.
76.................. Yes................. No................. 04 SURG............... OTHER RESP SYSTEM 2.8830 8.4 11.1
O.R. PROCEDURES W CC.
77.................. Yes................. No................. 04 SURG............... OTHER RESP SYSTEM 1.1857 3.3 4.7
O.R. PROCEDURES W/O
CC.
78.................. Yes................. No................. 04 MED................ PULMONARY EMBOLISM... 1.2427 5.4 6.4
79.................. Yes................. No................. 04 MED................ RESPIRATORY 1.6238 6.7 8.5
INFECTIONS &
INFLAMMATIONS AGE
>17 W CC.
80.................. Yes................. No................. 04 MED................ RESPIRATORY 0.8947 4.4 5.5
INFECTIONS &
INFLAMMATIONS AGE
>17 W/O CC.
81.................. No.................. No................. 04 MED *.............. RESPIRATORY 1.5383 6.1 6.1
INFECTIONS &
INFLAMMATIONS AGE 0-
17.
82.................. Yes................. No................. 04 MED................ RESPIRATORY NEOPLASMS 1.3936 5.1 6.8
83.................. Yes................. No................. 04 MED................ MAJOR CHEST TRAUMA W 0.9828 4.2 5.3
CC.
84.................. Yes................. No................. 04 MED................ MAJOR CHEST TRAUMA W/ 0.5799 2.6 3.2
O CC.
85.................. Yes................. No................. 04 MED................ PLEURAL EFFUSION W CC 1.2405 4.8 6.3
86.................. Yes................. No................. 04 MED................ PLEURAL EFFUSION W/O 0.6974 2.8 3.6
CC.
87.................. No.................. No................. 04 MED................ PULMONARY EDEMA & 1.3654 4.9 6.4
RESPIRATORY FAILURE.
88.................. No.................. No................. 04 MED................ CHRONIC OBSTRUCTIVE 0.8778 4.0 4.9
PULMONARY DISEASE.
89.................. Yes................. No................. 04 MED................ SIMPLE PNEUMONIA & 1.0320 4.7 5.7
PLEURISY AGE >17 W
CC.
90.................. Yes................. No................. 04 MED................ SIMPLE PNEUMONIA & 0.6104 3.2 3.8
PLEURISY AGE >17 W/O
CC.
91.................. No.................. No................. 04 MED................ SIMPLE PNEUMONIA & 0.8124 3.4 4.4
PLEURISY AGE 0-17.
92.................. Yes................. No................. 04 MED................ INTERSTITIAL LUNG 1.1853 4.8 6.1
DISEASE W CC.
93.................. Yes................. No................. 04 MED................ INTERSTITIAL LUNG 0.7150 3.1 3.9
DISEASE W/O CC.
94.................. No.................. No................. 04 MED................ PNEUMOTHORAX W CC.... 1.1354 4.6 6.2
95.................. No.................. No................. 04 MED................ PNEUMOTHORAX W/O CC.. 0.6035 2.9 3.6
96.................. No.................. No................. 04 MED................ BRONCHITIS & ASTHMA 0.7303 3.6 4.4
AGE >17 W CC.
97.................. No.................. No................. 04 MED................ BRONCHITIS & ASTHMA 0.5364 2.8 3.4
AGE >17 W/O CC.
98.................. No.................. No................. 04 MED *.............. BRONCHITIS & ASTHMA 0.5560 3.7 3.7
AGE 0-17.
99.................. No.................. No................. 04 MED................ RESPIRATORY SIGNS & 0.7094 2.4 3.1
SYMPTOMS W CC.

[[Page 47620]]

100................. No.................. No................. 04 MED................ RESPIRATORY SIGNS & 0.5382 1.7 2.1
SYMPTOMS W/O CC.
101................. Yes................. No................. 04 MED................ OTHER RESPIRATORY 0.8733 3.3 4.3
SYSTEM DIAGNOSES W
CC.
102................. Yes................. No................. 04 MED................ OTHER RESPIRATORY 0.5402 2.0 2.5
SYSTEM DIAGNOSES W/O
CC.
103................. No.................. No................. PRE SURG............... HEART TRANSPLANT OR 18.5617 23.7 37.7
IMPLANT OF HEART
ASSIST SYSTEM.
104................. Yes................. No................. 05 SURG............... CARDIAC VALVE & OTH 8.2201 12.7 14.9
MAJOR CARDIOTHORACIC
PROC W CARD CATH.
105................. Yes................. No................. 05 SURG............... CARDIAC VALVE & OTH 6.0192 8.4 10.2
MAJOR CARDIOTHORACIC
PROC W/O CARD CATH.
106................. No.................. No................. 05 SURG............... CORONARY BYPASS W 7.0346 9.5 11.2
PTCA.
107................. No.................. No................. 05 SURG............... NO LONGER VALID...... 0.0000 13.5 13.5
108................. Yes................. No................. 05 SURG............... OTHER CARDIOTHORACIC 5.8789 8.6 11.0
PROCEDURES.
109................. No.................. No................. 05 SURG............... NO LONGER VALID...... 0.0000 12.1 12.1
110................. No.................. No................. 05 SURG............... MAJOR CARDIOVASCULAR 3.8417 5.7 8.4
PROCEDURES W CC.
111................. No.................. No................. 05 SURG............... MAJOR CARDIOVASCULAR 2.4840 2.6 3.4
PROCEDURES W/O CC.
112................. No.................. No................. 05 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
113................. Yes................. No................. 05 SURG............... AMPUTATION FOR CIRC 3.1682 10.8 13.7
SYSTEM DISORDERS
EXCEPT UPPER LIMB &
TOE.
114................. Yes................. No................. 05 SURG............... UPPER LIMB & TOE 1.7354 6.7 8.9
AMPUTATION FOR CIRC
SYSTEM DISORDERS.
115................. No.................. No................. 05 SURG............... NO LONGER VALID...... 0.0000 15.8 15.8
116................. No.................. No................. 05 SURG............... NO LONGER VALID...... 0.0000 9.3 9.3
117................. No.................. No................. 05 SURG............... CARDIAC PACEMAKER 1.3223 2.6 4.2
REVISION EXCEPT
DEVICE REPLACEMENT.
118................. No.................. No................. 05 SURG............... CARDIAC PACEMAKER 1.6380 2.1 3.0
DEVICE REPLACEMENT.
119................. No.................. No................. 05 SURG............... VEIN LIGATION & 1.3456 3.3 5.5
STRIPPING.
120................. Yes................. No................. 05 SURG............... OTHER CIRCULATORY 2.3853 5.9 9.2
SYSTEM O.R.
PROCEDURES.
121................. Yes................. No................. 05 MED................ CIRCULATORY DISORDERS 1.6136 5.3 6.6
W AMI & MAJOR COMP,
DISCHARGED ALIVE.
122................. No.................. No................. 05 MED................ CIRCULATORY DISORDERS 0.9847 2.8 3.5
W AMI W/O MAJOR
COMP, DISCHARGED
ALIVE.
123................. No.................. No................. 05 MED................ CIRCULATORY DISORDERS 1.5407 2.9 4.8
W AMI, EXPIRED.
124................. No.................. No................. 05 MED................ CIRCULATORY DISORDERS 1.4425 3.3 4.4
EXCEPT AMI, W CARD
CATH & COMPLEX DIAG.
125................. No.................. No................. 05 MED................ CIRCULATORY DISORDERS 1.0948 2.1 2.7
EXCEPT AMI, W CARD
CATH W/O COMPLEX
DIAG.
126................. Yes................. No................. 05 MED................ ACUTE & SUBACUTE 2.7440 9.4 12.0
ENDOCARDITIS.
127................. Yes................. No................. 05 MED................ HEART FAILURE & SHOCK 1.0345 4.1 5.2
128................. No.................. No................. 05 MED................ DEEP VEIN 0.6949 4.4 5.2
THROMBOPHLEBITIS.
129................. No.................. No................. 05 MED................ CARDIAC ARREST, 1.0404 1.7 2.6
UNEXPLAINED.
130................. Yes................. No................. 05 MED................ PERIPHERAL VASCULAR 0.9425 4.4 5.5
DISORDERS W CC.
131................. Yes................. No................. 05 MED................ PERIPHERAL VASCULAR 0.5566 3.2 3.9
DISORDERS W/O CC.
132................. No.................. No................. 05 MED................ ATHEROSCLEROSIS W CC. 0.6273 2.2 2.8
133................. No.................. No................. 05 MED................ ATHEROSCLEROSIS W/O 0.5337 1.8 2.2
CC.
134................. No.................. No................. 05 MED................ HYPERTENSION......... 0.6068 2.4 3.1
135................. No.................. No................. 05 MED................ CARDIAC CONGENITAL & 0.8917 3.2 4.3
VALVULAR DISORDERS
AGE >17 W CC.
136................. No.................. No................. 05 MED................ CARDIAC CONGENITAL & 0.6214 2.2 2.8
VALVULAR DISORDERS
AGE >17 W/O CC.

[[Page 47621]]

137................. No.................. No................. 05 MED *.............. CARDIAC CONGENITAL & 0.8288 3.3 3.3
VALVULAR DISORDERS
AGE 0-17.
138................. No.................. No................. 05 MED................ CARDIAC ARRHYTHMIA & 0.8287 3.0 3.9
CONDUCTION DISORDERS
W CC.
139................. No.................. No................. 05 MED................ CARDIAC ARRHYTHMIA & 0.5227 2.0 2.4
CONDUCTION DISORDERS
W/O CC.
140................. No.................. No................. 05 MED................ ANGINA PECTORIS...... 0.5116 2.0 2.4
141................. No.................. No................. 05 MED................ SYNCOPE & COLLAPSE W 0.7521 2.7 3.5
CC.
142................. No.................. No................. 05 MED................ SYNCOPE & COLLAPSE W/ 0.5852 2.0 2.5
O CC.
143................. No.................. No................. 05 MED................ CHEST PAIN........... 0.5659 1.7 2.1
144................. Yes................. No................. 05 MED................ OTHER CIRCULATORY 1.2761 4.1 5.8
SYSTEM DIAGNOSES W
CC.
145................. Yes................. No................. 05 MED................ OTHER CIRCULATORY 0.5835 2.1 2.6
SYSTEM DIAGNOSES W/O
CC.
146................. Yes................. No................. 06 SURG............... RECTAL RESECTION W CC 2.6621 8.6 10.0
147................. Yes................. No................. 06 SURG............... RECTAL RESECTION W/O 1.4781 5.2 5.8
CC.
148................. Yes................. No................. 06 SURG............... MAJOR SMALL & LARGE 3.4479 10.0 12.3
BOWEL PROCEDURES W
CC.
149................. Yes................. No................. 06 SURG............... MAJOR SMALL & LARGE 1.4324 5.4 6.0
BOWEL PROCEDURES W/O
CC.
150................. Yes................. No................. 06 SURG............... PERITONEAL 2.8061 8.9 11.0
ADHESIOLYSIS W CC.
151................. Yes................. No................. 06 SURG............... PERITONEAL 1.2641 4.0 5.1
ADHESIOLYSIS W/O CC.
152................. No.................. No................. 06 SURG............... MINOR SMALL & LARGE 1.8783 6.7 8.0
BOWEL PROCEDURES W
CC.
153................. No.................. No................. 06 SURG............... MINOR SMALL & LARGE 1.0821 4.5 5.0
BOWEL PROCEDURES W/O
CC.
154................. Yes................. No................. 06 SURG............... STOMACH, ESOPHAGEAL & 4.0399 9.9 13.3
DUODENAL PROCEDURES
AGE >17 W CC.
155................. Yes................. No................. 06 SURG............... STOMACH, ESOPHAGEAL & 1.2889 3.1 4.1
DUODENAL PROCEDURES
AGE >17 W/O CC.
156................. No.................. No................. 06 SURG *............. STOMACH, ESOPHAGEAL & 0.8535 6.0 6.0
DUODENAL PROCEDURES
AGE 0-17.
157................. Yes................. No................. 06 SURG............... ANAL & STOMAL 1.3356 4.1 5.8
PROCEDURES W CC.
158................. Yes................. No................. 06 SURG............... ANAL & STOMAL 0.6657 2.1 2.6
PROCEDURES W/O CC.
159................. No.................. No................. 06 SURG............... HERNIA PROCEDURES 1.4081 3.8 5.1
EXCEPT INGUINAL &
FEMORAL AGE >17 W CC.
160................. No.................. No................. 06 SURG............... HERNIA PROCEDURES 0.8431 2.2 2.7
EXCEPT INGUINAL &
FEMORAL AGE >17 W/O
CC.
161................. No.................. No................. 06 SURG............... INGUINAL & FEMORAL 1.1931 3.1 4.4
HERNIA PROCEDURES
AGE >17 W CC.
162................. No.................. No................. 06 SURG............... INGUINAL & FEMORAL 0.6785 1.7 2.1
HERNIA PROCEDURES
AGE >17 W/O CC.
163................. No.................. No................. 06 SURG............... HERNIA PROCEDURES AGE 0.6723 2.2 2.9
0-17.
164................. No.................. No................. 06 SURG............... APPENDECTOMY W 2.2476 6.6 8.0
COMPLICATED
PRINCIPAL DIAG W CC.
165................. No.................. No................. 06 SURG............... APPENDECTOMY W 1.1868 3.6 4.2
COMPLICATED
PRINCIPAL DIAG W/O
CC.
166................. No.................. No................. 06 SURG............... APPENDECTOMY W/O 1.4521 3.3 4.5
COMPLICATED
PRINCIPAL DIAG W CC.
167................. No.................. No................. 06 SURG............... APPENDECTOMY W/O 0.8929 1.9 2.2
COMPLICATED
PRINCIPAL DIAG W/O
CC.
168................. No.................. No................. 03 SURG............... MOUTH PROCEDURES W CC 1.2662 3.3 4.9
169................. No.................. No................. 03 SURG............... MOUTH PROCEDURES W/O 0.7297 1.8 2.3
CC.
170................. Yes................. No................. 06 SURG............... OTHER DIGESTIVE 2.9612 7.8 11.0
SYSTEM O.R.
PROCEDURES W CC.
171................. Yes................. No................. 06 SURG............... OTHER DIGESTIVE 1.1905 3.1 4.1
SYSTEM O.R.
PROCEDURES W/O CC.
172................. Yes................. No................. 06 MED................ DIGESTIVE MALIGNANCY 1.4125 5.1 7.0
W CC.
173................. Yes................. No................. 06 MED................ DIGESTIVE MALIGNANCY 0.7443 2.7 3.6
W/O CC.
174................. No.................. No................. 06 MED................ G.I. HEMORRHAGE W CC. 1.0060 3.8 4.7
175................. No.................. No................. 06 MED................ G.I. HEMORRHAGE W/O 0.5646 2.4 2.9
CC.
176................. Yes................. No................. 06 MED................ COMPLICATED PEPTIC 1.1246 4.1 5.2
ULCER.

[[Page 47622]]

177................. No.................. No................. 06 MED................ UNCOMPLICATED PEPTIC 0.9166 3.6 4.4
ULCER W CC.
178................. No.................. No................. 06 MED................ UNCOMPLICATED PEPTIC 0.7013 2.6 3.1
ULCER W/O CC.
179................. No.................. No................. 06 MED................ INFLAMMATORY BOWEL 1.0911 4.5 5.9
DISEASE.
180................. Yes................. No................. 06 MED................ G.I. OBSTRUCTION W CC 0.9784 4.2 5.4
181................. Yes................. No................. 06 MED................ G.I. OBSTRUCTION W/O 0.5614 2.8 3.3
CC.
182................. No.................. aNo................ 06 MED................ ESOPHAGITIS, 0.8413 3.4 4.4
GASTROENT & MISC
DIGEST DISORDERS AGE
>17 W CC.
183................. No.................. No................. 06 MED................ ESOPHAGITIS, 0.5848 2.3 2.9
GASTROENT & MISC
DIGEST DISORDERS AGE
>17 W/O CC.
184................. No.................. No................. 06 MED................ ESOPHAGITIS, 0.5663 2.5 3.3
GASTROENT & MISC
DIGEST DISORDERS AGE
0-17.
185................. No.................. No................. 03 MED................ DENTAL & ORAL DIS 0.8702 3.2 4.5
EXCEPT EXTRACTIONS &
RESTORATIONS, AGE
>17.
186................. No.................. No................. 03 MED *.............. DENTAL & ORAL DIS 0.3253 2.9 2.9
EXCEPT EXTRACTIONS &
RESTORATIONS, AGE 0-
17.
187................. No.................. No................. 03 MED................ DENTAL EXTRACTIONS & 0.8363 3.1 4.2
RESTORATIONS.
188................. Yes................. No................. 06 MED................ OTHER DIGESTIVE 1.1290 4.2 5.6
SYSTEM DIAGNOSES AGE
>17 W CC.
189................. Yes................. No................. 06 MED................ OTHER DIGESTIVE 0.6064 2.4 3.1
SYSTEM DIAGNOSES AGE
>17 W/O CC.
190................. No.................. No................. 06 MED................ OTHER DIGESTIVE 0.6179 3.1 4.4
SYSTEM DIAGNOSES AGE
0-17.
191................. Yes................. No................. 07 SURG............... PANCREAS, LIVER & 3.9680 9.0 12.9
SHUNT PROCEDURES W
CC.
192................. Yes................. No................. 07 SURG............... PANCREAS, LIVER & 1.6793 4.3 5.7
SHUNT PROCEDURES W/O
CC.
193................. No.................. No................. 07 SURG............... BILIARY TRACT PROC 3.2818 9.9 12.1
EXCEPT ONLY
CHOLECYST W OR W/O
C.D.E. W CC.
194................. No.................. No................. 07 SURG............... BILIARY TRACT PROC 1.5748 5.6 6.7
EXCEPT ONLY
CHOLECYST W OR W/O
C.D.E. W/O CC.
195................. No.................. No................. 07 SURG............... CHOLECYSTECTOMY W 3.0530 8.8 10.6
C.D.E. W CC.
196................. No.................. No................. 07 SURG............... CHOLECYSTECTOMY W 1.6031 4.9 5.7
C.D.E. W/O CC.
197................. Yes................. No................. 07 SURG............... CHOLECYSTECTOMY 2.5425 7.5 9.2
EXCEPT BY
LAPAROSCOPE W/O
C.D.E. W CC.
198................. Yes................. No................. 07 SURG............... CHOLECYSTECTOMY 1.1604 3.7 4.3
EXCEPT BY
LAPAROSCOPE W/O
C.D.E. W/O CC.
199................. No.................. No................. 07 SURG............... HEPATOBILIARY 2.4073 6.8 9.5
DIAGNOSTIC PROCEDURE
FOR MALIGNANCY.
200................. No.................. No................. 07 SURG............... HEPATOBILIARY 2.7868 6.5 9.8
DIAGNOSTIC PROCEDURE
FOR NON-MALIGNANCY.
201................. No.................. No................. 07 SURG............... OTHER HEPATOBILIARY 3.7339 9.9 13.7
OR PANCREAS O.R.
PROCEDURES.
202................. No.................. No................. 07 MED................ CIRRHOSIS & ALCOHOLIC 1.3318 4.7 6.2
HEPATITIS.
203................. No.................. No................. 07 MED................ MALIGNANCY OF 1.3552 4.9 6.5
HEPATOBILIARY SYSTEM
OR PANCREAS.
204................. No.................. No................. 07 MED................ DISORDERS OF PANCREAS 1.1249 4.2 5.6
EXCEPT MALIGNANCY.
205................. Yes................. No................. 07 MED................ DISORDERS OF LIVER 1.2059 4.4 6.0
EXCEPT
MALIG,CIRR,ALC HEPA
W CC.
206................. Yes................. No................. 07 MED................ DISORDERS OF LIVER 0.7292 3.0 3.9
EXCEPT
MALIG,CIRR,ALC HEPA
W/O CC.
207................. No.................. No................. 07 MED................ DISORDERS OF THE 1.1746 4.1 5.3
BILIARY TRACT W CC.
208................. No.................. No................. 07 MED................ DISORDERS OF THE 0.6895 2.3 2.9
BILIARY TRACT W/O CC.
209................. No.................. No................. 08 SURG............... NO LONGER VALID...... 0.0000 17.1 17.1

[[Page 47623]]

210................. Yes................. Yes................ 08 SURG............... HIP & FEMUR 1.9059 6.1 6.9
PROCEDURES EXCEPT
MAJOR JOINT AGE >17
W CC.
211................. Yes................. Yes................ 08 SURG............... HIP & FEMUR 1.2690 4.4 4.7
PROCEDURES EXCEPT
MAJOR JOINT AGE >17
W/O CC.
212................. No.................. No................. 08 SURG............... HIP & FEMUR 1.2877 2.4 2.9
PROCEDURES EXCEPT
MAJOR JOINT AGE 0-17.
213................. Yes................. No................. 08 SURG............... AMPUTATION FOR 2.0428 7.2 9.7
MUSCULOSKELETAL
SYSTEM & CONN TISSUE
DISORDERS.
214................. No.................. No................. 08 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
215................. No.................. No................. 08 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
216................. Yes................. No................. 08 SURG............... BIOPSIES OF 1.9131 3.3 5.8
MUSCULOSKELETAL
SYSTEM & CONNECTIVE
TISSUE.
217................. Yes................. No................. 08 SURG............... WND DEBRID & SKN GRFT 3.0596 9.3 13.2
EXCEPT HAND,FOR
MUSCSKELET & CONN
TISS DIS.
218................. Yes................. No................. 08 SURG............... LOWER EXTREM & HUMER 1.6648 4.4 5.6
PROC EXCEPT
HIP,FOOT,FEMUR AGE
>17 W CC.
219................. Yes................. No................. 08 SURG............... LOWER EXTREM & HUMER 1.0443 2.6 3.1
PROC EXCEPT
HIP,FOOT,FEMUR AGE
>17 W/O CC.
220................. No.................. No................. 08 SURG *............. LOWER EXTREM & HUMER 0.5913 5.3 5.3
PROC EXCEPT
HIP,FOOT,FEMUR AGE 0-
17.
221................. No.................. No................. 08 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
222................. No.................. No................. 08 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
223................. No.................. No................. 08 SURG............... MAJOR SHOULDER/ELBOW 1.1164 2.3 3.2
PROC, OR OTHER UPPER
EXTREMITY PROC W CC.
224................. No.................. No................. 08 SURG............... SHOULDER,ELBOW OR 0.8185 1.6 1.9
FOREARM PROC,EXC
MAJOR JOINT PROC, W/
O CC.
225................. Yes................. No................. 08 SURG............... FOOT PROCEDURES...... 1.2251 3.7 5.2
226................. Yes................. No................. 08 SURG............... SOFT TISSUE 1.5884 4.5 6.5
PROCEDURES W CC.
227................. Yes................. No................. 08 SURG............... SOFT TISSUE 0.8311 2.1 2.6
PROCEDURES W/O CC.
228................. No.................. No................. 08 SURG............... MAJOR THUMB OR JOINT 1.1459 2.8 4.1
PROC,OR OTH HAND OR
WRIST PROC W CC.
229................. No.................. No................. 08 SURG............... HAND OR WRIST PROC, 0.6976 1.9 2.5
EXCEPT MAJOR JOINT
PROC, W/O CC.
230................. No.................. No................. 08 SURG............... LOCAL EXCISION & 1.3174 3.7 5.6
REMOVAL OF INT FIX
DEVICES OF HIP &
FEMUR.
231................. No.................. No................. 08 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
232................. No.................. No................. 08 SURG............... ARTHROSCOPY.......... 0.9702 1.8 2.8
233................. Yes................. Yes................ 08 SURG............... OTHER MUSCULOSKELET 1.9184 4.6 6.8
SYS & CONN TISS O.R.
PROC W CC.
234................. Yes................. Yes................ 08 SURG............... OTHER MUSCULOSKELET 1.2219 2.0 2.8
SYS & CONN TISS O.R.
PROC W/O CC.
235................. Yes................. No................. 08 MED................ FRACTURES OF FEMUR... 0.7768 3.8 4.8
236................. Yes................. No................. 08 MED................ FRACTURES OF HIP & 0.7407 3.8 4.6
PELVIS.
237................. No.................. No................. 08 MED................ SPRAINS, STRAINS, & 0.6090 3.0 3.7
DISLOCATIONS OF HIP,
PELVIS & THIGH.
238................. Yes................. No................. 08 MED................ OSTEOMYELITIS........ 1.4401 6.7 8.7
239................. Yes................. No................. 08 MED................ PATHOLOGICAL 1.0767 5.0 6.2
FRACTURES &
MUSCULOSKELETAL &
CONN TISS MALIGNANCY.
240................. Yes................. No................. 08 MED................ CONNECTIVE TISSUE 1.4051 5.0 6.7
DISORDERS W CC.
241................. Yes................. No................. 08 MED................ CONNECTIVE TISSUE 0.6629 3.0 3.7
DISORDERS W/O CC.
242................. No.................. No................. 08 MED................ SEPTIC ARTHRITIS..... 1.1504 5.1 6.7
243................. No.................. No................. 08 MED................ MEDICAL BACK PROBLEMS 0.7658 3.6 4.5
244................. Yes................. No................. 08 MED................ BONE DISEASES & 0.7200 3.6 4.5
SPECIFIC
ARTHROPATHIES W CC.
245................. Yes................. No................. 08 MED................ BONE DISEASES & 0.4583 2.5 3.1
SPECIFIC
ARTHROPATHIES W/O CC.
246................. No.................. No................. 08 MED................ NON-SPECIFIC 0.5932 2.8 3.6
ARTHROPATHIES.

[[Page 47624]]

247................. No.................. No................. 08 MED................ SIGNS & SYMPTOMS OF 0.5795 2.6 3.3
MUSCULOSKELETAL
SYSTEM & CONN TISSUE.
248................. No.................. No................. 08 MED................ TENDONITIS, MYOSITIS 0.8554 3.8 4.8
& BURSITIS.
249................. No.................. No................. 08 MED................ AFTERCARE, 0.7095 2.7 3.9
MUSCULOSKELETAL
SYSTEM & CONNECTIVE
TISSUE.
250................. Yes................. No................. 08 MED................ FX, SPRN, STRN & DISL 0.6974 3.2 3.9
OF FOREARM, HAND,
FOOT AGE >17 W CC.
251................. Yes................. No................. 08 MED................ FX, SPRN, STRN & DISL 0.4749 2.3 2.8
OF FOREARM, HAND,
FOOT AGE >17 W/O CC.
252................. No.................. No................. 08 MED *.............. FX, SPRN, STRN & DISL 0.2567 1.8 1.8
OF FOREARM, HAND,
FOOT AGE 0-17.
253................. Yes................. No................. 08 MED................ FX, SPRN, STRN & DISL 0.7747 3.8 4.6
OF UPARM,LOWLEG EX
FOOT AGE >17 W CC.
254................. Yes................. No................. 08 MED................ FX, SPRN, STRN & DISL 0.4588 2.6 3.1
OF UPARM,LOWLEG EX
FOOT AGE >17 W/O CC.
255................. No.................. No................. 08 MED *.............. FX, SPRN, STRN & DISL 0.2990 2.9 2.9
OF UPARM,LOWLEG EX
FOOT AGE 0-17.
256................. Yes................. No................. 08 MED................ OTHER MUSCULOSKELETAL 0.8509 3.9 5.1
SYSTEM & CONNECTIVE
TISSUE DIAGNOSES.
257................. No.................. No................. 09 SURG............... TOTAL MASTECTOMY FOR 0.8967 2.0 2.6
MALIGNANCY W CC.
258................. No.................. No................. 09 SURG............... TOTAL MASTECTOMY FOR 0.7138 1.5 1.7
MALIGNANCY W/O CC.
259................. No.................. No................. 09 SURG............... SUBTOTAL MASTECTOMY 0.9671 1.8 2.8
FOR MALIGNANCY W CC.
260................. No.................. No................. 09 SURG............... SUBTOTAL MASTECTOMY 0.7032 1.2 1.4
FOR MALIGNANCY W/O
CC.
261................. No.................. No................. 09 SURG............... BREAST PROC FOR NON- 0.9732 1.6 2.2
MALIGNANCY EXCEPT
BIOPSY & LOCAL
EXCISION.
262................. No.................. No................. 09 SURG............... BREAST BIOPSY & LOCAL 0.9766 3.3 4.8
EXCISION FOR NON-
MALIGNANCY.
263................. Yes................. No................. 09 SURG............... SKIN GRAFT &/OR 2.1130 8.6 11.4
DEBRID FOR SKN ULCER
OR CELLULITIS W CC.
264................. Yes................. No................. 09 SURG............... SKIN GRAFT &/OR 1.0635 5.0 6.5
DEBRID FOR SKN ULCER
OR CELLULITIS W/O CC.
265................. Yes................. No................. 09 SURG............... SKIN GRAFT &/OR 1.6593 4.4 6.8
DEBRID EXCEPT FOR
SKIN ULCER OR
CELLULITIS W CC.
266................. Yes................. No................. 09 SURG............... SKIN GRAFT &/OR 0.8637 2.3 3.2
DEBRID EXCEPT FOR
SKIN ULCER OR
CELLULITIS W/O CC.
267................. No.................. No................. 09 SURG............... PERIANAL & PILONIDAL 0.8962 2.8 4.2
PROCEDURES.
268................. No.................. No................. 09 SURG............... SKIN, SUBCUTANEOUS 1.1326 2.4 3.5
TISSUE & BREAST
PLASTIC PROCEDURES.
269................. Yes................. No................. 09 SURG............... OTHER SKIN, SUBCUT 1.8352 6.2 8.6
TISS & BREAST PROC W
CC.
270................. Yes................. No................. 09 SURG............... OTHER SKIN, SUBCUT 0.8313 2.7 3.9
TISS & BREAST PROC W/
O CC.
271................. Yes................. No................. 09 MED................ SKIN ULCERS.......... 1.0195 5.6 7.1
272................. Yes................. No................. 09 MED................ MAJOR SKIN DISORDERS 0.9860 4.5 5.9
W CC.
273................. Yes................. No................. 09 MED................ MAJOR SKIN DISORDERS 0.5539 2.9 3.7
W/O CC.
274................. No.................. No................. 09 MED................ MALIGNANT BREAST 1.1294 4.7 6.3
DISORDERS W CC.
275................. No.................. No................. 09 MED................ MALIGNANT BREAST 0.5340 2.4 3.3
DISORDERS W/O CC.
276................. No.................. No................. 09 MED................ NON-MALIGNANT BREAST 0.6892 3.5 4.5
DISORDERS.
277................. Yes................. No................. 09 MED................ CELLULITIS AGE >17 W 0.8676 4.6 5.6
CC.

[[Page 47625]]

278................. Yes................. No................. 09 MED................ CELLULITIS AGE >17 W/ 0.5391 3.4 4.1
O CC.
279................. No.................. No................. 09 MED *.............. CELLULITIS AGE 0-17.. 0.7822 4.2 4.2
280................. Yes................. No................. 09 MED................ TRAUMA TO THE SKIN, 0.7313 3.2 4.1
SUBCUT TISS & BREAST
AGE >17 W CC.
281................. Yes................. No................. 09 MED................ TRAUMA TO THE SKIN, 0.4913 2.3 2.9
SUBCUT TISS & BREAST
AGE >17 W/O CC.
282................. No.................. No................. 09 MED *.............. TRAUMA TO THE SKIN, 0.2600 2.2 2.2
SUBCUT TISS & BREAST
AGE 0-17.
283................. Yes................. No................. 09 MED................ MINOR SKIN DISORDERS 0.7423 3.5 4.6
W CC.
284................. Yes................. No................. 09 MED................ MINOR SKIN DISORDERS 0.4563 2.4 3.0
W/O CC.
285................. Yes................. No................. 10 SURG............... AMPUTAT OF LOWER LIMB 2.1831 8.2 10.5
FOR
ENDOCRINE,NUTRIT,&
METABOL DISORDERS.
286................. No.................. No................. 10 SURG............... ADRENAL & PITUITARY 1.9390 4.0 5.5
PROCEDURES.
287................. Yes................. No................. 10 SURG............... SKIN GRAFTS & WOUND 1.9470 7.8 10.4
DEBRID FOR ENDOC,
NUTRIT & METAB
DISORDERS.
288................. No.................. No................. 10 SURG............... O.R. PROCEDURES FOR 2.0384 3.2 4.1
OBESITY.
289................. No.................. No................. 10 SURG............... PARATHYROID 0.9315 1.7 2.6
PROCEDURES.
290................. No.................. No................. 10 SURG............... THYROID PROCEDURES... 0.8891 1.6 2.1
291................. No.................. No................. 10 SURG............... THYROGLOSSAL 1.0877 1.6 2.8
PROCEDURES.
292................. Yes................. No................. 10 SURG............... OTHER ENDOCRINE, 2.6395 7.3 10.3
NUTRIT & METAB O.R.
PROC W CC.
293................. Yes................. No................. 10 SURG............... OTHER ENDOCRINE, 1.3472 3.2 4.5
NUTRIT & METAB O.R.
PROC W/O CC.
294................. Yes................. No................. 10 MED................ DIABETES AGE >35..... 0.7652 3.3 4.3
295................. No.................. No................. 10 MED................ DIABETES AGE 0-35.... 0.7267 2.8 3.7
296................. Yes................. No................. 10 MED................ NUTRITIONAL & MISC 0.8187 3.7 4.8
METABOLIC DISORDERS
AGE >17 W CC.
297................. Yes................. No................. 10 MED................ NUTRITIONAL & MISC 0.4879 2.5 3.1
METABOLIC DISORDERS
AGE >17 W/O CC.
298................. No.................. No................. 10 MED................ NUTRITIONAL & MISC 0.5486 2.5 3.9
METABOLIC DISORDERS
AGE 0-17.
299................. No.................. No................. 10 MED................ INBORN ERRORS OF 1.0329 3.7 5.2
METABOLISM.
300................. Yes................. No................. 10 MED................ ENDOCRINE DISORDERS W 1.0922 4.6 6.0
CC.
301................. Yes................. No................. 10 MED................ ENDOCRINE DISORDERS W/ 0.6118 2.7 3.4
O CC.
302................. No.................. No................. 11 SURG............... KIDNEY TRANSPLANT.... 3.1679 7.0 8.2
303................. No.................. No................. 11 SURG............... KIDNEY,URETER & MAJOR 2.2183 5.8 7.4
BLADDER PROCEDURES
FOR NEOPLASM.
304................. Yes................. No................. 11 SURG............... KIDNEY,URETER & MAJOR 2.3761 6.1 8.6
BLADDER PROC FOR NON-
NEOPL W CC.
305................. Yes................. No................. 11 SURG............... KIDNEY,URETER & MAJOR 1.1595 2.6 3.2
BLADDER PROC FOR NON-
NEOPL W/O CC.
306................. No.................. No................. 11 SURG............... PROSTATECTOMY W CC... 1.2700 3.6 5.5
307................. No.................. No................. 11 SURG............... PROSTATECTOMY W/O CC. 0.6202 1.7 2.1
308................. No.................. No................. 11 SURG............... MINOR BLADDER 1.6349 3.9 6.1
PROCEDURES W CC.
309................. No.................. No................. 11 SURG............... MINOR BLADDER 0.9085 1.6 2.0
PROCEDURES W/O CC.
310................. No.................. No................. 11 SURG............... TRANSURETHRAL 1.1898 3.0 4.5
PROCEDURES W CC.
311................. No.................. No................. 11 SURG............... TRANSURETHRAL 0.6432 1.5 1.9
PROCEDURES W/O CC.
312................. No.................. No................. 11 SURG............... URETHRAL PROCEDURES, 1.1159 3.2 4.8
AGE >17 W CC.
313................. No.................. No................. 11 SURG............... URETHRAL PROCEDURES, 0.6783 1.7 2.2
AGE >17 W/O CC.
314................. No.................. No................. 11 SURG *............. URETHRAL PROCEDURES, 0.5012 2.3 2.3
AGE 0-17.
315................. No.................. No................. 11 SURG............... OTHER KIDNEY & 2.0823 3.6 6.8
URINARY TRACT O.R.
PROCEDURES.
316................. Yes................. No................. 11 MED................ RENAL FAILURE........ 1.2692 4.9 6.4
317................. No.................. No................. 11 MED................ ADMIT FOR RENAL 0.7942 2.4 3.5
DIALYSIS.
318................. No.................. No................. 11 MED................ KIDNEY & URINARY 1.1539 4.2 5.8
TRACT NEOPLASMS W CC.

[[Page 47626]]

319................. No.................. No................. 11 MED................ KIDNEY & URINARY 0.6385 2.1 2.8
TRACT NEOPLASMS W/O
CC.
320................. Yes................. No................. 11 MED................ KIDNEY & URINARY 0.8658 4.2 5.2
TRACT INFECTIONS AGE
>17 W CC.
321................. Yes................. No................. 11 MED................ KIDNEY & URINARY 0.5652 3.0 3.6
TRACT INFECTIONS AGE
>17 W/O CC.
322................. No.................. No................. 11 MED................ KIDNEY & URINARY 0.5498 2.9 3.4
TRACT INFECTIONS AGE
0-17.
323................. No.................. No................. 11 MED................ URINARY STONES W CC, 0.8214 2.3 3.1
&/OR ESW LITHOTRIPSY.
324................. No.................. No................. 11 MED................ URINARY STONES W/O CC 0.5050 1.6 1.9
325................. No.................. No................. 11 MED................ KIDNEY & URINARY 0.6436 2.9 3.7
TRACT SIGNS &
SYMPTOMS AGE >17 W
CC.
326................. No.................. No................. 11 MED................ KIDNEY & URINARY 0.4391 2.1 2.6
TRACT SIGNS &
SYMPTOMS AGE >17 W/O
CC.
327................. No.................. No................. 11 MED *.............. KIDNEY & URINARY 0.3748 3.1 3.1
TRACT SIGNS &
SYMPTOMS AGE 0-17.
328................. No.................. No................. 11 MED................ URETHRAL STRICTURE 0.7079 2.6 3.5
AGE >17 W CC.
329................. No.................. No................. 11 MED................ URETHRAL STRICTURE 0.4701 1.5 1.8
AGE >17 W/O CC.
330................. No.................. No................. 11 MED *.............. URETHRAL STRICTURE 0.3227 1.6 1.6
AGE 0-17.
331................. Yes................. No................. 11 MED................ OTHER KIDNEY & 1.0619 4.1 5.5
URINARY TRACT
DIAGNOSES AGE >17 W
CC.
332................. Yes................. No................. 11 MED................ OTHER KIDNEY & 0.6160 2.4 3.1
URINARY TRACT
DIAGNOSES AGE >17 W/
O CC.
333................. No.................. No................. 11 MED................ OTHER KIDNEY & 0.9669 3.5 5.3
URINARY TRACT
DIAGNOSES AGE 0-17.
334................. No.................. No................. 12 SURG............... MAJOR MALE PELVIC 1.4368 3.5 4.3
PROCEDURES W CC.
335................. No.................. No................. 12 SURG............... MAJOR MALE PELVIC 1.1004 2.4 2.7
PROCEDURES W/O CC.
336................. No.................. No................. 12 SURG............... TRANSURETHRAL 0.8425 2.5 3.3
PROSTATECTOMY W CC.
337................. No.................. No................. 12 SURG............... TRANSURETHRAL 0.5747 1.7 1.9
PROSTATECTOMY W/O CC.
338................. No.................. No................. 12 SURG............... TESTES PROCEDURES, 1.3772 3.9 6.2
FOR MALIGNANCY.
339................. No.................. No................. 12 SURG............... TESTES PROCEDURES, 1.1866 3.2 5.1
NON-MALIGNANCY AGE
>17.
340................. No.................. No................. 12 SURG *............. TESTES PROCEDURES, 0.2868 2.4 2.4
NON-MALIGNANCY AGE 0-
17.
341................. No.................. No................. 12 SURG............... PENIS PROCEDURES..... 1.2622 1.9 3.2
342................. No.................. No................. 12 SURG............... CIRCUMCISION AGE >17. 0.8737 2.5 3.4
343................. No.................. No................. 12 SURG *............. CIRCUMCISION AGE 0-17 0.1559 1.7 1.7
344................. No.................. No................. 12 SURG............... OTHER MALE 1.2475 1.7 2.7
REPRODUCTIVE SYSTEM
O.R. PROCEDURES FOR
MALIGNANCY.
345................. No.................. No................. 12 SURG............... OTHER MALE 1.1472 3.1 4.8
REPRODUCTIVE SYSTEM
O.R. PROC EXCEPT FOR
MALIGNANCY.
346................. No.................. No................. 12 MED................ MALIGNANCY, MALE 1.0441 4.2 5.7
REPRODUCTIVE SYSTEM,
W CC.
347................. No.................. No................. 12 MED................ MALIGNANCY, MALE 0.6104 2.2 3.1
REPRODUCTIVE SYSTEM,
W/O CC.
348................. No.................. No................. 12 MED................ BENIGN PROSTATIC 0.7188 3.2 4.1
HYPERTROPHY W CC.
349................. No.................. No................. 12 MED................ BENIGN PROSTATIC 0.4210 1.9 2.4
HYPERTROPHY W/O CC.
350................. No.................. No................. 12 MED................ INFLAMMATION OF THE 0.7289 3.5 4.5
MALE REPRODUCTIVE
SYSTEM.
351................. No.................. No................. 12 MED *.............. STERILIZATION, MALE.. 0.2392 1.3 1.3
352................. No.................. No................. 12 MED................ OTHER MALE 0.7360 2.9 4.0
REPRODUCTIVE SYSTEM
DIAGNOSES.

[[Page 47627]]

353................. No.................. No................. 13 SURG............... PELVIC EVISCERATION, 1.8504 4.7 6.3
RADICAL HYSTERECTOMY
& RADICAL VULVECTOMY.
354................. No.................. No................. 13 SURG............... UTERINE,ADNEXA PROC 1.5135 4.6 5.7
FOR NON-OVARIAN/
ADNEXAL MALIG W CC.
355................. No.................. No................. 13 SURG............... UTERINE,ADNEXA PROC 0.8824 2.8 3.1
FOR NON-OVARIAN/
ADNEXAL MALIG W/O CC.
356................. No.................. No................. 13 SURG............... FEMALE REPRODUCTIVE 0.7428 1.7 1.9
SYSTEM
RECONSTRUCTIVE
PROCEDURES.
357................. No.................. No................. 13 SURG............... UTERINE & ADNEXA PROC 2.2237 6.5 8.1
FOR OVARIAN OR
ADNEXAL MALIGNANCY.
358................. No.................. No................. 13 SURG............... UTERINE & ADNEXA PROC 1.1448 3.2 4.0
FOR NON-MALIGNANCY W
CC.
359................. No.................. No................. 13 SURG............... UTERINE & ADNEXA PROC 0.7948 2.2 2.4
FOR NON-MALIGNANCY W/
O CC.
360................. No.................. No................. 13 SURG............... VAGINA, CERVIX & 0.8582 2.0 2.6
VULVA PROCEDURES.
361................. No.................. No................. 13 SURG............... LAPAROSCOPY & 1.0847 2.2 3.0
INCISIONAL TUBAL
INTERRUPTION.
362................. No.................. No................. 13 SURG *............. ENDOSCOPIC TUBAL 0.3057 1.4 1.4
INTERRUPTION.
363................. No.................. No................. 13 SURG............... D&C, CONIZATION & 0.9728 2.7 3.8
RADIO-IMPLANT, FOR
MALIGNANCY.
364................. No.................. No................. 13 SURG............... D&C, CONIZATION 0.8709 3.0 4.2
EXCEPT FOR
MALIGNANCY.
365................. No.................. No................. 13 SURG............... OTHER FEMALE 2.0408 5.3 7.7
REPRODUCTIVE SYSTEM
O.R. PROCEDURES.
366................. No.................. No................. 13 MED................ MALIGNANCY, FEMALE 1.2348 4.8 6.6
REPRODUCTIVE SYSTEM
W CC.
367................. No.................. No................. 13 MED................ MALIGNANCY, FEMALE 0.5728 2.3 3.0
REPRODUCTIVE SYSTEM
W/O CC.
368................. No.................. No................. 13 MED................ INFECTIONS, FEMALE 1.1684 5.2 6.7
REPRODUCTIVE SYSTEM.
369................. No.................. No................. 13 MED................ MENSTRUAL & OTHER 0.6310 2.4 3.3
FEMALE REPRODUCTIVE
SYSTEM DISORDERS.
370................. No.................. No................. 14 SURG............... CESAREAN SECTION W CC 0.8974 4.1 5.2
371................. No.................. No................. 14 SURG............... CESAREAN SECTION W/O 0.6066 3.1 3.4
CC.
372................. No.................. No................. 14 MED................ VAGINAL DELIVERY W 0.5027 2.5 3.2
COMPLICATING
DIAGNOSES.
373................. No.................. No................. 14 MED................ VAGINAL DELIVERY W/O 0.3556 2.0 2.2
COMPLICATING
DIAGNOSES.
374................. No.................. No................. 14 SURG............... VAGINAL DELIVERY W 0.6712 2.5 2.8
STERILIZATION &/OR
D&C.
375................. No.................. No................. 14 SURG *............. VAGINAL DELIVERY W 0.5837 4.4 4.4
O.R. PROC EXCEPT
STERIL &/OR D&C.
376................. No.................. No................. 14 MED................ POSTPARTUM & POST 0.5242 2.6 3.4
ABORTION DIAGNOSES W/
O O.R. PROCEDURE.
377................. No.................. No................. 14 SURG............... POSTPARTUM & POST 1.6996 2.9 4.5
ABORTION DIAGNOSES W
O.R. PROCEDURE.
378................. No.................. No................. 14 MED................ ECTOPIC PREGNANCY.... 0.7472 1.9 2.3
379................. No.................. No................. 14 MED................ THREATENED ABORTION.. 0.3578 2.0 2.8
380................. No.................. No................. 14 MED................ ABORTION W/O D&C..... 0.3925 1.6 2.1
381................. No.................. No................. 14 SURG............... ABORTION W D&C, 0.6034 1.6 2.2
ASPIRATION CURETTAGE
OR HYSTEROTOMY.
382................. No.................. No................. 14 MED................ FALSE LABOR.......... 0.2070 1.3 1.4
383................. No.................. No................. 14 MED................ OTHER ANTEPARTUM 0.5053 2.6 3.7
DIAGNOSES W MEDICAL
COMPLICATIONS.
384................. No.................. No................. 14 MED................ OTHER ANTEPARTUM 0.3225 1.8 2.6
DIAGNOSES W/O
MEDICAL
COMPLICATIONS.
385................. No.................. No................. 15 MED *.............. NEONATES, DIED OR 1.3930 1.8 1.8
TRANSFERRED TO
ANOTHER ACUTE CARE
FACILITY.
386................. No.................. No................. 15 MED *.............. EXTREME IMMATURITY OR 4.5935 17.9 17.9
RESPIRATORY DISTRESS
SYNDROME, NEONATE.
387................. No.................. No................. 15 MED *.............. PREMATURITY W MAJOR 3.1372 13.3 13.3
PROBLEMS.

[[Page 47628]]

388................. No.................. No................. 15 MED *.............. PREMATURITY W/O MAJOR 1.8929 8.6 8.6
PROBLEMS.
389................. No.................. No................. 15 MED *.............. FULL TERM NEONATE W 3.2226 4.7 4.7
MAJOR PROBLEMS.
390................. No.................. No................. 15 MED *.............. NEONATE W OTHER 1.1406 3.4 3.4
SIGNIFICANT PROBLEMS.
391................. No.................. No................. 15 MED *.............. NORMAL NEWBORN....... 0.1544 3.1 3.1
392................. No.................. No................. 16 SURG............... SPLENECTOMY AGE >17.. 3.0459 6.5 9.2
393................. No.................. No................. 16 SURG *............. SPLENECTOMY AGE 0-17. 1.3645 9.1 9.1
394................. No.................. No................. 16 SURG............... OTHER O.R. PROCEDURES 1.9109 4.5 7.4
OF THE BLOOD AND
BLOOD FORMING ORGANS.
395................. Yes................. No................. 16 MED................ RED BLOOD CELL 0.8328 3.2 4.3
DISORDERS AGE >17.
396................. No.................. No................. 16 MED *.............. RED BLOOD CELL 0.8323 2.6 4.3
DISORDERS AGE 0-17.
397................. No.................. No................. 16 MED................ COAGULATION DISORDERS 1.2986 3.7 5.1
398................. No.................. No................. 16 MED................ RETICULOENDOTHELIAL & 1.2082 4.4 5.7
IMMUNITY DISORDERS W
CC.
399................. No.................. No................. 16 MED................ RETICULOENDOTHELIAL & 0.6674 2.7 3.3
IMMUNITY DISORDERS W/
O CC.
400................. No.................. No................. 17 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
401................. Yes................. No................. 17 SURG............... LYMPHOMA & NON-ACUTE 2.9678 8.0 11.3
LEUKEMIA W OTHER
O.R. PROC W CC.
402................. Yes................. No................. 17 SURG............... LYMPHOMA & NON-ACUTE 1.1810 2.8 4.1
LEUKEMIA W OTHER
O.R. PROC W/O CC.
403................. Yes................. No................. 17 MED................ LYMPHOMA & NON-ACUTE 1.8432 5.8 8.1
LEUKEMIA W CC.
404................. Yes................. No................. 17 MED................ LYMPHOMA & NON-ACUTE 0.9265 3.0 4.2
LEUKEMIA W/O CC.
405................. No.................. No................. 17 MED *.............. ACUTE LEUKEMIA W/O 1.9346 4.9 4.9
MAJOR O.R. PROCEDURE
AGE 0-17.
406................. No.................. No................. 17 SURG............... MYELOPROLIF DISORD OR 2.7897 7.0 9.9
POORLY DIFF NEOPL W
MAJ O.R.PROC W CC.
407................. No.................. No................. 17 SURG............... MYELOPROLIF DISORD OR 1.2289 3.0 3.8
POORLY DIFF NEOPL W
MAJ O.R.PROC W/O CC.
408................. No.................. No................. 17 SURG............... MYELOPROLIF DISORD OR 2.2460 4.8 8.2
POORLY DIFF NEOPL W
OTHER O.R.PROC.
409................. No.................. No................. 17 MED................ RADIOTHERAPY......... 1.2074 4.3 5.8
410................. No.................. No................. 17 MED................ CHEMOTHERAPY W/O 1.1069 3.0 3.8
ACUTE LEUKEMIA AS
SECONDARY DIAGNOSIS.
411................. No.................. No................. 17 MED................ HISTORY OF MALIGNANCY 0.3635 2.5 3.3
W/O ENDOSCOPY.
412................. No.................. No................. 17 MED................ HISTORY OF MALIGNANCY 0.8451 1.8 2.8
W ENDOSCOPY.
413................. No.................. No................. 17 MED................ OTHER MYELOPROLIF DIS 1.3048 5.0 6.8
OR POORLY DIFF NEOPL
DIAG W CC.
414................. No.................. No................. 17 MED................ OTHER MYELOPROLIF DIS 0.7788 3.0 4.0
OR POORLY DIFF NEOPL
DIAG W/O CC.
415................. Yes................. No................. 18 SURG............... O.R. PROCEDURE FOR 3.9890 11.0 14.8
INFECTIOUS &
PARASITIC DISEASES.
416................. Yes................. No................. 18 MED................ SEPTICEMIA AGE >17... 1.6774 5.6 7.5
417................. No.................. No................. 18 MED................ SEPTICEMIA AGE 0-17.. 1.1689 3.2 4.1
418................. Yes................. No................. 18 MED................ POSTOPERATIVE & POST- 1.0716 4.8 6.2
TRAUMATIC INFECTIONS.
419................. No.................. No................. 18 MED................ FEVER OF UNKNOWN 0.8453 3.4 4.4
ORIGIN AGE >17 W CC.
420................. No.................. No................. 18 MED................ FEVER OF UNKNOWN 0.6077 2.7 3.4
ORIGIN AGE >17 W/O
CC.
421................. No.................. No................. 18 MED................ VIRAL ILLNESS AGE >17 0.7664 3.1 4.1
422................. No.................. No................. 18 MED................ VIRAL ILLNESS & FEVER 0.6171 2.6 3.7
OF UNKNOWN ORIGIN
AGE 0-17.
423................. Yes................. No................. 18 MED................ OTHER INFECTIOUS & 1.9196 6.0 8.4
PARASITIC DISEASES
DIAGNOSES.

[[Page 47629]]

424................. No.................. No................. 19 SURG............... O.R. PROCEDURE W 2.2773 7.3 12.4
PRINCIPAL DIAGNOSES
OF MENTAL ILLNESS.
425................. No.................. No................. 19 MED................ ACUTE ADJUSTMENT 0.6191 2.6 3.5
REACTION &
PSYCHOSOCIAL
DYSFUNCTION.
426................. No.................. No................. 19 MED................ DEPRESSIVE NEUROSES.. 0.4656 3.0 4.1
427................. No.................. No................. 19 MED................ NEUROSES EXCEPT 0.5135 3.2 4.7
DEPRESSIVE.
428................. No.................. No................. 19 MED................ DISORDERS OF 0.6981 4.6 7.3
PERSONALITY &
IMPULSE CONTROL.
429................. Yes................. No................. 19 MED................ ORGANIC DISTURBANCES 0.7919 4.3 5.6
& MENTAL RETARDATION.
430................. Yes................. No................. 19 MED................ PSYCHOSES............ 0.6483 5.8 7.9
431................. No.................. No................. 19 MED................ CHILDHOOD MENTAL 0.5178 4.0 5.9
DISORDERS.
432................. No.................. No................. 19 MED................ OTHER MENTAL DISORDER 0.6282 2.9 4.3
DIAGNOSES.
433................. No.................. No................. 20 MED................ ALCOHOL/DRUG ABUSE OR 0.2776 2.2 3.0
DEPENDENCE, LEFT AMA.
434................. No.................. No................. 20 MED................ NO LONGER VALID...... 0.0000 0.0 0.0
435................. No.................. No................. 20 MED................ NO LONGER VALID...... 0.0000 0.0 0.0
436................. No.................. No................. 20 MED................ NO LONGER VALID...... 0.0000 0.0 0.0
437................. No.................. No................. 20 MED................ NO LONGER VALID...... 0.0000 0.0 0.0
438................. No.................. No................. 20 ................... NO LONGER VALID...... 0.0000 0.0 0.0
439................. No.................. No................. 21 SURG............... SKIN GRAFTS FOR 1.9398 5.4 8.9
INJURIES.
440................. Yes................. No................. 21 SURG............... WOUND DEBRIDEMENTS 1.9457 5.9 9.2
FOR INJURIES.
441................. No.................. No................. 21 SURG............... HAND PROCEDURES FOR 0.9382 2.3 3.4
INJURIES.
442................. Yes................. No................. 21 SURG............... OTHER O.R. PROCEDURES 2.5660 6.0 8.9
FOR INJURIES W CC.
443................. Yes................. No................. 21 SURG............... OTHER O.R. PROCEDURES 0.9943 2.6 3.4
FOR INJURIES W/O CC.
444................. Yes................. No................. 21 MED................ TRAUMATIC INJURY AGE 0.7556 3.2 4.1
>17 W CC.
445................. Yes................. No................. 21 MED................ TRAUMATIC INJURY AGE 0.5033 2.2 2.8
>17 W/O CC.
446................. No.................. No................. 21 MED *.............. TRAUMATIC INJURY AGE 0.2999 2.4 2.4
0-17.
447................. No.................. No................. 21 MED................ ALLERGIC REACTIONS 0.5569 1.9 2.6
AGE >17.
448................. No.................. No................. 21 MED *.............. ALLERGIC REACTIONS 0.0987 2.9 2.9
AGE 0-17.
449................. No.................. No................. 21 MED................ POISONING & TOXIC 0.8529 2.6 3.7
EFFECTS OF DRUGS AGE
>17 W CC.
450................. No.................. No................. 21 MED................ POISONING & TOXIC 0.4282 1.6 2.0
EFFECTS OF DRUGS AGE
>17 W/O CC.
451................. No.................. No................. 21 MED *.............. POISONING & TOXIC 0.2663 2.1 2.1
EFFECTS OF DRUGS AGE
0-17.
452................. No.................. No................. 21 MED................ COMPLICATIONS OF 1.0462 3.5 4.9
TREATMENT W CC.
453................. No.................. No................. 21 MED................ COMPLICATIONS OF 0.5285 2.2 2.8
TREATMENT W/O CC.
454................. No.................. No................. 21 MED................ OTHER INJURY, 0.8141 2.9 4.1
POISONING & TOXIC
EFFECT DIAG W CC.
455................. No.................. No................. 21 MED................ OTHER INJURY, 0.4725 1.7 2.2
POISONING & TOXIC
EFFECT DIAG W/O CC.
456................. No.................. No................. 22 ................... NO LONGER VALID...... 0.0000 0.0 0.0
457................. No.................. No................. 22 MED................ NO LONGER VALID...... 0.0000 0.0 0.0
458................. No.................. No................. 22 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
459................. No.................. No................. 22 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
460................. No.................. No................. 22 MED................ NO LONGER VALID...... 0.0000 0.0 0.0
461................. No.................. No................. 23 SURG............... O.R. PROC W DIAGNOSES 1.3974 3.0 5.1
OF OTHER CONTACT W
HEALTH SERVICES.
462................. Yes................. No................. 23 MED................ REHABILITATION....... 0.8700 8.9 10.8
463................. Yes................. No................. 23 MED................ SIGNS & SYMPTOMS W CC 0.6960 3.1 3.9
464................. Yes................. No................. 23 MED................ SIGNS & SYMPTOMS W/O 0.5055 2.4 2.9
CC.
465................. No.................. No................. 23 MED................ AFTERCARE W HISTORY 0.6224 2.4 3.8
OF MALIGNANCY AS
SECONDARY DIAGNOSIS.
466................. No.................. No................. 23 MED................ AFTERCARE W/O HISTORY 0.7806 2.8 5.3
OF MALIGNANCY AS
SECONDARY DIAGNOSIS.
467................. No.................. No................. 23 MED................ OTHER FACTORS 0.4803 2.0 2.7
INFLUENCING HEALTH
STATUS.

[[Page 47630]]

468................. Yes................. No................. ......... ................... EXTENSIVE O.R. 4.0031 9.7 13.2
PROCEDURE UNRELATED
TO PRINCIPAL
DIAGNOSIS.
469................. No.................. No................. ......... **................. PRINCIPAL DIAGNOSIS 0.0000 0.0 0.0
INVALID AS DISCHARGE
DIAGNOSIS.
470................. No.................. No................. ......... **................. UNGROUPABLE.......... 0.0000 0.0 0.0
471................. Yes................. Yes................ 08 SURG............... BILATERAL OR MULTIPLE 3.1391 4.5 5.1
MAJOR JOINT PROCS OF
LOWER EXTREMITY.
472................. No.................. No................. 22 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
473................. No.................. No................. 17 MED................ ACUTE LEUKEMIA W/O 3.4231 7.4 12.7
MAJOR O.R. PROCEDURE
AGE >17.
474................. No.................. No................. 04 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
475................. Yes................. No................. 04 MED................ RESPIRATORY SYSTEM 3.6091 8.1 11.3
DIAGNOSIS WITH
VENTILATOR SUPPORT.
476................. No.................. No................. ......... SURG............... PROSTATIC O.R. 2.1822 7.4 10.5
PROCEDURE UNRELATED
TO PRINCIPAL
DIAGNOSIS.
477................. Yes................. No................. ......... SURG............... NON-EXTENSIVE O.R. 2.0607 5.8 8.7
PROCEDURE UNRELATED
TO PRINCIPAL
DIAGNOSIS.
478................. No.................. No................. 05 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
479................. No.................. No................. 05 SURG............... OTHER VASCULAR 1.4434 2.1 2.8
PROCEDURES W/O CC.
480................. No.................. No................. PRE SURG............... LIVER TRANSPLANT AND/ 8.9693 13.7 18.0
OR INTESTINAL
TRANSPLANT.
481................. No.................. No................. PRE SURG............... BONE MARROW 6.2321 18.2 21.7
TRANSPLANT.
482................. Yes................. No................. PRE SURG............... TRACHEOSTOMY FOR 3.3387 9.6 12.1
FACE,MOUTH & NECK
DIAGNOSES.
483................. No.................. No................. PRE SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
484................. No.................. No................. 24 SURG............... CRANIOTOMY FOR 5.1438 9.3 12.8
MULTIPLE SIGNIFICANT
TRAUMA.
485................. Yes................. No................. 24 SURG............... LIMB REATTACHMENT, 3.4952 8.4 10.2
HIP AND FEMUR PROC
FOR MULTIPLE
SIGNIFICANT TRA.
486................. No.................. No................. 24 SURG............... OTHER O.R. PROCEDURES 4.7323 8.5 12.5
FOR MULTIPLE
SIGNIFICANT TRAUMA.
487................. Yes................. No................. 24 MED................ OTHER MULTIPLE 1.9459 5.3 7.3
SIGNIFICANT TRAUMA.
488................. No.................. No................. 25 SURG............... HIV W EXTENSIVE O.R. 4.4353 11.8 16.4
PROCEDURE.
489................. No.................. No................. 25 MED................ HIV W MAJOR RELATED 1.8058 5.9 8.4
CONDITION.
490................. No.................. No................. 25 MED................ HIV W OR W/O OTHER 1.0639 3.8 5.4
RELATED CONDITION.
491................. No.................. No................. 08 SURG............... MAJOR JOINT & LIMB 1.6780 2.6 3.1
REATTACHMENT
PROCEDURES OF UPPER
EXTREMITY.
492................. No.................. No................. 17 MED................ CHEMOTHERAPY W ACUTE 3.5926 8.8 13.7
LEUKEMIA OR W USE OF
HI DOSE CHEMOAGENT.
493................. No.................. No................. 07 SURG............... LAPAROSCOPIC 1.8333 4.5 6.1
CHOLECYSTECTOMY W/O
C.D.E. W CC.
494................. No.................. No................. 07 SURG............... LAPAROSCOPIC 1.0285 2.1 2.7
CHOLECYSTECTOMY W/O
C.D.E. W/O CC.
495................. No.................. No................. PRE SURG............... LUNG TRANSPLANT...... 8.5736 14.0 17.3
496................. No.................. No................. 08 SURG............... COMBINED ANTERIOR/ 6.0932 6.4 8.8
POSTERIOR SPINAL
FUSION.
497................. Yes................. Yes................ 08 SURG............... SPINAL FUSION EXCEPT 3.6224 5.0 5.9
CERVICAL W CC.
498................. Yes................. Yes................ 08 SURG............... SPINAL FUSION EXCEPT 2.7791 3.4 3.8
CERVICAL W/O CC.
499................. No.................. No................. 08 SURG............... BACK & NECK 1.3831 3.1 4.3
PROCEDURES EXCEPT
SPINAL FUSION W CC.
500................. No.................. No................. 08 SURG............... BACK & NECK 0.9046 1.8 2.2
PROCEDURES EXCEPT
SPINAL FUSION W/O CC.
501................. Yes................. No................. 08 SURG............... KNEE PROCEDURES W PDX 2.6462 8.5 10.4
OF INFECTION W CC.
502................. Yes................. No................. 08 SURG............... KNEE PROCEDURES W PDX 1.4462 4.9 5.9
OF INFECTION W/O CC.

[[Page 47631]]

503................. No.................. No................. 08 SURG............... KNEE PROCEDURES W/O 1.2038 2.9 3.8
PDX OF INFECTION.
504................. No.................. No................. 22 SURG............... EXTEN. BURNS OR FULL 11.8018 21.7 27.3
THICKNESS BURN W/MV
96+HRS W/SKIN GFT.
505................. No.................. No................. 22 MED................ EXTEN. BURNS OR FULL 2.2953 2.4 4.6
THICKNESS BURN W/MV
96+HRS W/O SKIN GFT.
506................. No.................. No................. 22 SURG............... FULL THICKNESS BURN W 4.0939 11.2 15.9
SKIN GRAFT OR INHAL
INJ W CC OR SIG
TRAUMA.
507................. No.................. No................. 22 SURG............... FULL THICKNESS BURN W 1.7369 5.8 8.5
SKIN GRFT OR INHAL
INJ W/O CC OR SIG
TRAUMA.
508................. No.................. No................. 22 MED................ FULL THICKNESS BURN W/ 1.2767 5.1 7.4
O SKIN GRFT OR INHAL
INJ W CC OR SIG
TRAUMA.
509................. No.................. No................. 22 MED................ FULL THICKNESS BURN W/ 0.8217 3.6 5.2
O SKIN GRFT OR INH
INJ W/O CC OR SIG
TRAUMA.
510................. No.................. No................. 22 MED................ NON-EXTENSIVE BURNS W 1.1817 4.4 6.4
CC OR SIGNIFICANT
TRAUMA.
511................. No.................. No................. 22 MED................ NON-EXTENSIVE BURNS W/ 0.7424 2.6 4.1
O CC OR SIGNIFICANT
TRAUMA.
512................. No.................. No................. PRE SURG............... SIMULTANEOUS PANCREAS/ 5.3660 10.7 12.8
KIDNEY TRANSPLANT.
513................. No.................. No................. PRE SURG............... PANCREAS TRANSPLANT.. 5.9669 8.9 9.9
514................. No.................. No................. 05 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
515................. No.................. No................. 05 SURG............... CARDIAC DEFIBRILLATOR 5.5205 2.6 4.3
IMPLANT W/O CARDIAC
CATH.
516................. No.................. No................. 05 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
517................. No.................. No................. 05 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
518................. No.................. No................. 05 SURG............... PERC CARDIO PROC W/O 1.6544 1.8 2.5
CORONARY ARTERY
STENT OR AMI.
519................. No.................. No................. 08 SURG............... CERVICAL SPINAL 2.4695 3.0 4.8
FUSION W CC.
520................. No.................. No................. 08 SURG............... CERVICAL SPINAL 1.6788 1.6 2.0
FUSION W/O CC.
521................. Yes................. No................. 20 MED................ ALCOHOL/DRUG ABUSE OR 0.6939 4.2 5.6
DEPENDENCE W CC.
522................. Yes................. No................. 20 MED................ ALC/DRUG ABUSE OR 0.4794 7.7 9.6
DEPEND W
REHABILITATION
THERAPY W/O CC.
523................. No.................. No................. 20 MED................ ALC/DRUG ABUSE OR 0.3793 3.2 3.9
DEPEND W/O
REHABILITATION
THERAPY W/O CC.
524................. No.................. No................. 01 MED................ TRANSIENT ISCHEMIA... 0.7288 2.6 3.2
525................. No.................. No................. 05 SURG............... OTHER HEART ASSIST 11.4282 7.2 13.6
SYSTEM IMPLANT.
526................. No.................. No................. 05 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
527................. No.................. aNo................ 05 SURG............... NO LONGER VALID...... 0.0000 0.0 0.0
528................. No.................. No................. 01 SURG............... INTRACRANIAL VASCULAR 7.0505 13.8 17.2
PROC W PDX
HEMORRHAGE.
529................. Yes................. No................. 01 SURG............... VENTRICULAR SHUNT 2.3160 5.3 8.3
PROCEDURES W CC.
530................. Yes................. No................. 01 SURG............... VENTRICULAR SHUNT 1.2041 2.4 3.1
PROCEDURES W/O CC.
531................. Yes................. No................. 01 SURG............... SPINAL PROCEDURES W 3.1279 6.5 9.6
CC.
532................. Yes................. No................. 01 SURG............... SPINAL PROCEDURES W/O 1.4195 2.8 3.7
CC.
533................. No.................. No................. 01 SURG............... EXTRACRANIAL 1.5767 2.4 3.8
PROCEDURES W CC.
534................. No.................. No................. 01 SURG............... EXTRACRANIAL 1.0201 1.5 1.8
PROCEDURES W/O CC.
535................. No.................. No................. 05 SURG............... CARDIAC DEFIB IMPLANT 7.9738 7.9 10.3
W CARDIAC CATH W AMI/
HF/SHOCK.
536................. No.................. No................. 05 SURG............... CARDIAC DEFIB IMPLANT 6.9144 5.9 7.6
W CARDIAC CATH W/O
AMI/HF/SHOCK.
537................. Yes................. No................. 08 SURG............... LOCAL EXCIS & REMOV 1.8360 4.8 6.9
OF INT FIX DEV
EXCEPT HIP & FEMUR W
CC.
538................. Yes................. No................. 08 SURG............... LOCAL EXCIS & REMOV 0.9833 2.1 2.8
OF INT FIX DEV
EXCEPT HIP & FEMUR W/
O CC.
539................. No.................. No................. 17 SURG............... LYMPHOMA & LEUKEMIA W 3.2782 7.0 10.8
MAJOR OR PROCEDURE W
CC.

[[Page 47632]]

540................. No.................. No................. 17 SURG............... LYMPHOMA & LEUKEMIA W 1.1940 2.6 3.6
MAJOR OR PROCEDURE W/
O CC.
541................. Yes................. No................. PRE SURG............... ECMO OR TRACH W MV 19.8038 38.1 45.7
96+HRS OR PDX EXC
FACE, MOUTH & NECK W
MAJ O.R..
542................. Yes................. No................. PRE SURG............... TRACH W MV 96+HRS OR 12.8719 29.1 35.1
PDX EXC FACE, MOUTH
& NECK W/O MAJ O.R..
543................. Yes................. No................. 01 SURG............... CRANIOTOMY W/IMPLANT 4.4184 8.5 12.3
OF CHEMO AGENT OR
ACUTE COMPLX CNS PDX.
544................. Yes................. Yes................ 08 SURG............... MAJOR JOINT 1.9643 4.1 4.5
REPLACEMENT OR
REATTACHMENT OF
LOWER EXTREMITY.
545................. Yes................. Yes................ 08 SURG............... REVISION OF HIP OR 2.4827 4.5 5.2
KNEE REPLACEMENT.
546................. No.................. No................. 08 SURG............... SPINAL FUSION EXC 5.0739 7.1 8.8
CERV WITH CURVATURE
OF THE SPINE OR
MALIG.
547................. Yes................. No................. 05 SURG............... CORONARY BYPASS W 6.1948 10.8 12.3
CARDIAC CATH W MAJOR
CV DX.
548................. Yes................. No................. 05 SURG............... CORONARY BYPASS W 4.7198 8.2 9.0
CARDIAC CATH W/O
MAJOR CV DX.
549................. Yes................. Yes................ 05 SURG............... CORONARY BYPASS W/O 5.0980 8.7 10.3
CARDIAC CATH W MAJOR
CV DX.
550................. Yes................. Yes................ 05 SURG............... CORONARY BYPASS W/O 3.6151 6.2 6.9
CARDIAC CATH W/O
MAJOR CV DX.
551................. No.................. No................. 05 SURG............... PERMANENT CARDIAC 3.1007 4.4 6.4
PACEMAKER IMPL W MAJ
CV DX OR AICD LEAD
OR GNRTR.
552................. No.................. No................. 05 SURG............... OTHER PERMANENT 2.0996 2.5 3.5
CARDIAC PACEMAKER
IMPLANT W/O MAJOR CV
DX.
553................. Yes................. No................. 05 SURG............... OTHER VASCULAR 3.0957 6.6 9.7
PROCEDURES W CC W
MAJOR CV DX.
554................. Yes................. No................. 05 SURG............... OTHER VASCULAR 2.0721 4.0 5.9
PROCEDURES W CC W/O
MAJOR CV DX.
555................. No.................. No................. 05 SURG............... PERCUTANEOUS 2.4315 3.4 4.7
CARDIOVASCULAR PROC
W MAJOR CV DX.
556................. No.................. No................. 05 SURG............... PERCUTANEOUS 1.9132 1.6 2.1
CARDIOVASC PROC W
NON-DRUG-ELUTING
STENT W/O MAJ CV DX.
557................. No.................. No................. 05 SURG............... PERCUTANEOUS 2.8717 3.0 4.1
CARDIOVASCULAR PROC
W DRUG-ELUTING STENT
W MAJOR CV DX.
558................. No.................. No................. 05 SURG............... PERCUTANEOUS 2.2108 1.5 1.9
CARDIOVASCULAR PROC
W DRUG-ELUTING STENT
W/O MAJ CV DX.
559................. No.................. No................. 01 MED................ ACUTE ISCHEMIC STROKE 2.2473 5.8 7.2
WITH USE OF
THROMBOLYTIC AGENT.
--------------------------------------------------------------------------------------------------------------------------------------------------------
* Medicare data have been supplemented by data from 19 States for low volume DRGs.
** DRGs 469 and 470 contain vases which could not be assigned to valid DRGs.
Note: Geometric mean is used only to determine payment for transfer cases.
Note: Arithmetic mean is 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, 387
depletion, 15 \1\, 389 \1\, 490
unspecified. 25 \2\

[[Page 47633]]

276.51........ Dehydration..... Y 10 296, 297, 298, 387
15 \1\, 389 \1\, 490
25 \2\
276.52........ Hypovolemia..... Y 10 296, 297, 298, 387
15 \1\, 389 \1\, 490
25 \2\
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.
327.13........ Recurrent N 19 432
hypersomnia.
327.14........ Hypersomnia due N 19 432
to medical
condition
classified
elsewhere.
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.
327.25 *...... Congenital N PRE 482
central 1 34, 35
alveolar
hypoventilation
syndrome.
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
327.30 *...... Circadian rhythm N PRE 482
sleep disorder, 1 34, 35
unspecified.
327.31 *...... Circadian rhythm N PRE 482
sleep disorder, 1 34, 35
delayed sleep
phase type.
327.32 *...... Circadian rhythm N PRE 482
sleep disorder, 1 34, 35
advanced sleep
phase type.
327.33 *...... Circadian rhythm N PRE 482
sleep disorder, 1 34, 35
irregular sleep-
wake type.
327.34 *...... Circadian rhythm N PRE 482
sleep disorder, 1 34, 35
free-running
type.
327.35 *...... Circadian rhythm N PRE 482
sleep disorder, 1 34, 35
jet lag type.
327.36 *...... Circadian rhythm N PRE 482
sleep disorder, 1 34, 35
shift work type.
327.37 *...... Circadian rhythm N PRE 482
sleep disorder 1 34, 35
in conditions
classified
elsewhere.
327.39 *...... Other circadian N PRE 482
rhythm sleep 1 34, 35
disorder.
327.40 *...... Organic N PRE 482
parasomnia, 3 73, 74
unspecified.
327.41 *...... Confusional N PRE 482
arousals. 1 34, 35
327.42 *...... REM sleep N PRE 482
behavior 3 73, 74
disorder.
327.43 *...... Recurrent N PRE 482
isolated sleep 1 34, 35
paralysis.
327.44 *...... Parasomnia in N PRE 482
conditions 3 73, 74
classified
elsewhere.

[[Page 47634]]

327.49 *...... Other organic N PRE 482
parasomnia. 3 73, 74
327.51 *...... Periodic limb N PRE 482
movement 1 34, 35
disorder.
327.52 *...... Sleep related N PRE 482
leg cramps. 1 34, 35
327.53 *...... Sleep related N PRE 482
bruxism. 3 73, 74
327.59 *...... Other organic N PRE 482
sleep related 3 73, 74
movement
disorders.
327.8 *....... Other organic N PRE 482
sleep disorders. 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.
567.31 *...... Psoas muscle Y 6 188, 189, 190
abscess. 15 387 \1\, 389 \1\
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).
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

[[Page 47635]]

585.9......... Chronic kidney Y PRE 512, 513
disease, 11 315, 316
unspecified.
599.60........ Urinary Y 11 331, 332, 333
obstruction, 15 387 \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.
770.13 *...... Aspiration of N 15 387 \3\, 389 \3\
clear amniotic
fluid without
respiratory
symptoms.
770.14 *...... Aspiration of Y 15 387 \3\, 389 \3\
clear amniotic
fluid with
respiratory
symptoms.
770.15 *...... Aspiration of N 15 387 \3\, 389 \3\
blood without
respiratory
symptoms.
770.16 *...... Aspiration of Y 15 387 \3\, 389 \3\
blood 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.
770.85 *...... Aspiration of N 15 387 \3\, 389 \3\
postnatal
stomach
contents
without
respiratory
symptoms.
770.86 *...... Aspiration of Y 15 387 \3\, 389 \3\
postnatal
stomach
contents 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........ Personal N 23 467
history,
Infections of
the central
nervous system.
V12.60........ Personal N 23 467
history,
Unspecified
disease of
respiratory
system.
V12.61........ Personal N 23 467
history,
Pneumonia
(recurrent).
V12.69........ Personal N 23 467
history, Other
diseases of
respiratory
system.
V13.02........ Personal N 23 467
history,
Urinary (tract)
infection.
V13.03........ Personal N 23 467
history,
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.
V58.11 *...... Encounter for N 17 410, 492
antineoplastic
chemotherapy.
V58.12 *...... Encounter for N 17 410, 492
immunotherapy
for neoplastic
condition.
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.

[[Page 47636]]

V64.09........ Vaccination not N 23 467
carried out for
other reason.
V69.5......... Behavioral N 23 467
insomnia of
childhood.
V72.42 *...... Pregnancy N 23 467
examination or
test, positive
result.
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.
* These diagnosis codes were discussed at the March 31-April 1, 2005 ICD-
9-CM Coordination and Maintenance Committee meeting and were not
finalized in time to include in the proposed rule.

Table 6B.--New Procedure Codes
------------------------------------------------------------------------
Procedure code Description OR MDC DRG
------------------------------------------------------------------------
00.18 *....... Infusion of N
immunosuppressi
ve antibody
therapy during
induction phase
of solid organ
transplantation.
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.
00.66 *....... Percutaneous Y 5 106, 518, 555, 556,
transluminal 557, 558
coronary
angioplasty
[PTCA] or
coronary
atherectomy.
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 21 442, 443
component. 24 485
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.
00.74 *....... Hip replacement N
bearing
surface, metal
on polyethylene.
00.75 *....... Hip replacement N
bearing
surface, metal-
on-metal.
00.76 *....... Hip replacement N
bearing
surface,
ceramic-on-
ceramic.
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.

[[Page 47637]]

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).
01.26 *....... Insertion of N
catheter into
cranial cavity.
01.27 *....... Removal of N
catheter from
cranial cavity.
37.41......... Implantation of Y 5 110, 111
prosthetic
cardiac support
device around
the heart.
37.49......... Other repair of Y 5 110, 111
heart and 21 442, 443
pericardium. 24 486
39.73 *....... Endovascular Y 5 110, 111
implantation of 11 315
graft in 21 442, 443
thoracic aorta. 24 486
81.18 *....... Subtalar joint Y 8 233, 234
arthroereisis. 21 442, 443
24 486
84.56......... Insertion of N
(cement) spacer.
84.57......... Removal of N
(cement) spacer.
84.58 *....... Implantation of Y 1 531, 532
interspinous 8 499, 500
process 21 442, 443
decompression 24 486
device.
84.71 *....... Application of N
external
fixator device,
monoplanar
system.
84.72 *....... Application of N
external
fixator device,
ring system.
84.73 *....... Application of N
hybrid external
fixator device.
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.
92.20 *....... Infusion of N
liquid
brachytherapy
radioisotope.
------------------------------------------------------------------------
* These procedure codes were discussed at the March 31-April 1, 2005 ICD-
9-CM Coordination and Maintenance Committee meeting and were not
finalized in time to include with the proposed rule.

Table 6C.--Invalid Diagnosis Codes
------------------------------------------------------------------------
Diagnosis code Description CC MDC DRG
------------------------------------------------------------------------
276.5......... Volume depletion Y 10 296, 297, 298
15 387 \1\, 389 \1\
25 \2\ 490
287.3......... Primary Y 16 397
thrombocytopeni
a.
567.2......... Other Y 6 188, 189, 190
suppurative 15 387 \1\, 389 \1\
peritonitis.
567.8......... 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.
V58.1 *....... Chemotherapy.... N 17 410, 492
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.
* This diagnosis code was discussed at the March 31-April 1, 2005 ICD-9-
CM Coordination and Maintenance Committee meeting, but not finalized
in time to include in the FY 2006 IPPS proposed rule.

[[Page 47638]]

Table 6D.--Invalid Procedure Codes
------------------------------------------------------------------------
Procedure code Description OR MDC DRG
------------------------------------------------------------------------
36.01 * \1\... Single vessel Y 5 106, 516, 517, 518,
percutaneous 526, 527
transluminal
coronary
angioplasty
[PTCA] or
coronary
atherectomy
without mention
of thrombolytic
agent.
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
81.61 *....... 360 degree Y 1 531, 532
spinal fusion, 8 497, 498
single incision 21 442, 443
approach. 24 486
------------------------------------------------------------------------
* These procedure codes were discussed at the March 31-April 1, 2005 ICD-
9-CM Coordination and Maintenance Committee meeting and were not
finalized in time to include with the proposed rule.
\1\ Code 36.01 was listed as a revised code in Table 6F of the proposed
rule. We are deleting this code and creating new code 00.66 instead.
Code 00.66 is listed on Table 6B.

Table 6E.--Revised Diagnosis Code Titles
------------------------------------------------------------------------
Diagnosis code Description CC MDC DRG
------------------------------------------------------------------------
285.21 *...... Anemia in Y 16 395, 396
chronic kidney
disease.
307.45 *...... Circadian rhythm N 19 432
sleep disorder
of nonorganic
origin.
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 5 121, 124, 127, 535,
heart and 15 547, 549, 551, 553,
kidney disease, 555, 557,
malignant, with 387, 389 \1\
heart failure.
404.02........ Hypertensive Y 11 315, 316
heart and
kidney disease,
malignant, with
chronic kidney
disease.
404.03........ Hypertensive Y 5 121, 124, 127, 535,
heart and 15 547, 549, 551, 553,
kidney disease, 555, 557
malignant, with 387, 389 \1\
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 5 121, 124, 127, 535,
heart and 15 547, 549, 551, 553,
kidney disease, 555, 557
benign, with 387, 389 \1\
heart failure.
404.12........ Hypertensive Y 11 315, 316
heart and
kidney disease,
benign, with
chronic kidney
disease.
404.13........ Hypertensive Y 5 121, 124, 127, 535,
heart and 15 547, 549, 551, 553,
kidney disease, 555, 557
benign, with 387, 389 \1\
heart failure
and chronic
kidney disease.
404.90........ Hypertensive N 5 134
heart and
kidney disease,
unspecified,
without heart
failure or
chronic kidney
disease.
404.91........ Hypertensive Y 5 121, 124, 127, 535,
heart and 15 547, 549, 551, 553,
kidney disease, 555, 557
unspecified, 387, 389 \1\
with heart
failure.
404.92........ Hypertensive Y 11 315, 316
heart and
kidney disease,
unspecified,
with chronic
kidney disease.
404.93........ Hypertensive Y 5 121, 124, 127, 535,
heart and 15 547, 549, 551, 553,
kidney disease, 555, 557
unspecified, 387, 389 \1\
with heart
failure and
chronic kidney
disease.

[[Page 47639]]

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.
780.55 *...... Disruption of 24 N 19 432
hour sleep wake
cycle,
unspecified.
780.57........ Unspecified N PRE 482
sleep apnea. 3 73, 74
780.58 *...... Sleep related N 19 432
movement
disorder,
unspecified.
------------------------------------------------------------------------
\1\ Major Problem in DRG 387 & 389.
* These diagnosis codes were discussed at the March 31-April 1, 2005 ICD-
9-CM Coordination and Maintenance Committee meeting and were not
finalized in time to include with the proposed rule.

Table 6F.--Revised Procedure Code Titles
------------------------------------------------------------------------
Procedure code Description OR MDC DRG
------------------------------------------------------------------------
37.79......... Revision or Y 1 7, 8
relocation of 5 117
cardiac device 9 269, 270
pocket. 21 442, 443
24 486
78.10 *....... Application of Y 8 233, 234
external 21 442, 443
fixator device, 24 486
unspecified
site.
78.11 *....... Application of Y 4 76, 77
external 8 233, 234
fixator device, 21 442, 443
scapula, 24 486
clavicle, and
thorax [ribs
and sternum].
78.12 *....... Application of Y 8 218, 219, 220
external 21 442, 443
fixator device, 24 486
humerus.
78.13 *....... Application of Y 8 233, 234
external 21 442, 443
fixator device, 24 486
radius and ulna.
78.14 *....... Application of Y 8 228, 229
external 21 441
fixator device, 24 486
carpals and
metacarpals.
78.15 *....... Application of Y 8 210, 211, 212
external 21 442, 443
fixator device, 24 485
femur.
78.16 *....... Application of Y 8 501, 502, 503
external 21 442, 443
fixator device, 24 486
patella.
78.17 *....... Application of Y 8 218, 219, 220
external 21 442, 443
fixator device, 24 486
tibia and
fibula.
78.18 *....... Application of Y 8 225
external 21 442, 443
fixator device, 24 486
tarsals and
metatarsals.
78.19 *....... Application of Y 8 233, 234
external 21 442, 443
fixator device, 24 486
other.
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.
86.94......... Insertion or Y 1 7, 8
replacement of
single array
neurostimulator
pulse
generator, not
specified as
rechargeable.
86.95......... Insertion or Y 1 7, 8
replacement of
dual array
neurostimulator
pulse
generator, not
specified as
rechargeable.
------------------------------------------------------------------------
* These procedure codes were discussed at the March 31-April 1, 2005 ICD-
9-CM Coordination and Maintenance Committee meeting and were not
finalized in time to include with the proposed rule.

[[Page 47640]]

Table 6G.--Additions to the CC Exclusions List
[CCs that are added to the list are included in this table. 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
*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

[[Page 47641]]

2581
2588
2589
2592
*27410
5851
5852
5853
5854
5855
5856
5859
*27411
59960
59969
*27419
5851
5852
5853
5854
5855
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

[[Page 47642]]

2872
28730
28731
28732
28733
28739
2874
2875
2878
2879
*28732
2860
2861
2862
2863
2864
2865
2866
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

[[Page 47643]]

*29285
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
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
56738
56739
56781
56782
56789
*5671
56721
56722
56723
56729
56738
56739
56781
56782
56789
*56721
5670
5671
56721
56722
56723
56729
56738
56739
56781
56782
56789
5679
*56722
5670
5671
56721
56722
56723
56729
56738
56739
56781
56782
56789
5679
*56723
5670
5671
56721
56722
56723
56729
56738
56739
56781
56782
56789
5679
*56729
5670
5671
56721
56722
56723
56729
56738
56739
56781
56782
56789
5679
*56731
56731
7280
72886
72888
*56738
5670
5671
56721
56722
56723
56729
56738
56739
56781
56782
56789
5679

[[Page 47644]]

*56739
5670
5671
56721
56722
56723
56729
56738
56739
56781
56782
56789
5679
*56781
5670
5671
56721
56722
56723
56729
56738
56739
56781
56782
56789
5679
*56782
5670
5671
56721
56722
56723
56729
56738
56739
56781
56782
56789
5679
*56789
5670
5671
56721
56722
56723
56729
56738
56739
56781
56782
56789
5679
*5679
56721
56722
56723
56729
56738
56739
56781
56782
56789
*56989
56721
56722
56723
56729
56738
56739
56781
56782
56789
*5699
56721
56722
56723
56729
56738
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

[[Page 47645]]

5859
*5824
5851
5852
5853
5854
5855
5856
5859
*58281
5851
5852
5853
5854
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
*58381
5851
5852
5853
5854
5855
5856
5859
*58389
5851
5852
5853
5854
5855
5856
5859
*5839
5851
5852
5853
5854
5855
5856
5859
*5845
5851
5852
5853
5854
5855
5856
5859
*5846
5851
5852
5853
5854
5855
5856
5859
*5847
5851
5852
5853
5854
5855
5856
5859
*5848
5851
5852
5853
5854
5855
5856
5859
*5849
5851
5852
5853
5854
5855
5856
5859
*5851
5800
5804
58081
58089
5809
5810
5811
5812
5813
58181
58189
5819
5834
5845
5846
5847
5848
5849
5851
5852
5853
5854
5855
5856
5859
59010
59011
5902
5903
59080
59081
5909
591
*5852
5800
5804
58081
58089
5809
5810
5811
5812
5813
58181
58189
5819
5834
5845
5846
5847
5848
5849
5851
5852
5853

[[Page 47646]]

5854
5855
5856
5859
59010
59011
5902
5903
59080
59081
5909
591
*5853
5800
5804
58081
58089
5809
5810
5811
5812
5813
58181
58189
5819
5834
5845
5846
5847
5848
5849
5851
5852
5853
5854
5855
5856
5859
59010
59011
5902
5903
59080
59081
5909
591
*5854
5800
5804
58081
58089
5809
5810
5811
5812
5813
58181
58189
5819
5834
5845
5846
5847
5848
5849
5851
5852
5853
5854
5855
5856
5859
59010
59011
5902
5903
59080
59081
5909
591
*5855
5800
5804
58081
58089
5809
5810
5811
5812
5813
58181
58189
5819
5834
5845
5846
5847
5848
5849
5851
5852
5853
5854
5855
5856
5859
59010
59011
5902
5903
59080
59081
5909
591
*5856
5800
5804
58081
58089
5809
5810
5811
5812
5813
58181
58189
5819
5834
5845
5846
5847
5848
5849
5851
5852
5853
5854
5855
5856
5859
59010
59011
5902
5903
59080
59081
5909
591
*5859
5800
5804
58081
58089
5809
5810
5811
5812
5813
58181
58189
5819
5834
5845
5846
5847
5848
5849
5851
5852
5853
5854
5855
5856
5859
59010
59011
5902
5903
59080
59081
5909
591
*586
5851
5852
5853
5854
5855
5856
5859
*587
5851
5852
5853
5854
5855
5856
5859
*5880
5851
5852

[[Page 47647]]

5853
5854
5855
5856
5859
*5881
5851
5852
5853
5854
5855
5856
5859
*58881
5851
5852
5853
5854
5855
5856
5859
*58889
5851
5852
5853
5854
5855
5856
5859
*5889
5851
5852
5853
5854
5855
5856
5859
*5890
5851
5852
5853
5854
5855
5856
5859
*5891
5851
5852
5853
5854
5855
5856
5859
*5899
5851
5852
5853
5854
5855
5856
5859
*59000
5851
5852
5853
5854
5855
5856
5859
*59001
5851
5852
5853
5854
5855
5856
5859
*59010
5851
5852
5853
5854
5855
5856
5859
*59011
5851
5852
5853
5854
5855
5856
5859
*5902
5851
5852
5853
5854
5855
5856
5859
*5903
5851
5852
5853
5854
5855
5856
5859
*59080
5851
5852
5853
5854
5855
5856
5859
*59081
5851
5852
5853
5854
5855
5856
5859
*5909
5851
5852
5853
5854
5855
5856
5859
*591
5851
5852
5853
5854
5855
5856
5859
*5921
59960
59969
*5929
59960
59969
*5930
5851
5852
5853
5854
5855
5856
5859
*5931
5851
5852
5853
5854
5855
5856
5859
*5932
5851
5852
5853
5854
5855
5856
5859
*5933
59960
59969
*5934
59960
59969
*5935
59960
59969
*59389
5851
5852
5853
5854
5855
5856
5859
59960
59969
*5939
5851
5852
5853
5854
5855
5856
5859
59960
59969
*5940

[[Page 47648]]

59960
59969
*5941
59960
59969
*5942
59960
59969
*5948
59960
59969
*5949
59960
59969
*5950
59960
59969
*5951
59960
59969
*5952
59960
59969
*5953
59960
59969
*5954
59960
59969
*59581
59960
59969
*59582
59960
59969
*59589
59960
59969
*5959
59960
59969
*5960
59960
59969
*59651
59960
59969
*59652
59960
59969
*59653
59960
59969
*59654
59960
59969
*59655
59960
59969
*59659
59960
59969
*5968
59960
59969
*5969
59960
59969
*5970
59960
59969
*59780
59960
59969
*59781
59960
59969
*59789
59960
59969
*59800
59960
59969
*59801
59960
59969
*5981
59960
59969
*5982
59960
59969
*5988
59960
59969
*5989
59960
59969
*5990
59960
59969
*5991
59960
59969
*5992
59960
59969
*5993
59960
59969
*5994
59960
59969
*5995
59960
59969
*59960
5921
5935
5950
5951
5952
5954
59581
59582
59589
5959
5970
5981
5982
5990
5994
59960
59969
78820
78829
*59969
5921
5935
5950
5951
5952
5954
59581
59582
59589
5959
5970
5981
5982
5990
5994
59960
59969
78820
78829
*5997
5851
5852
5853
5854
5855
5856
5859
59960
59969
*59981
5851
5852
5853
5854
5855
5856
5859
59960
59969
*59982
5851
5852
5853
5854
5855
5856
5859
59960
59969
*59983
5851
5852
5853
5854
5855
5856
5859
59960
59969
*59984
5851
5852
5853
5854

[[Page 47649]]

5855
5856
5859
59960
59969
*59989
5851
5852
5853
5854
5855
5856
5859
59960
59969
*5999
5851
5852
5853
5854
5855
5856
5859
59960
59969
*60000
59960
59969
*60001
59960
59969
*60010
59960
59969
*60011
59960
59969
*60020
59960
59969
*60021
59960
59969
*6003
59960
59969
*60090
59960
59969
*60091
59960
59969
*6010
59960
59969
*6011
59960
59969
*6012
59960
59969
*6013
59960
59969
*6014
59960
59969
*6018
59960
59969
*6019
59960
59969
*6020
59960
59969
*6021
59960
59969
*6022
59960
59969
*6023
59960
59969
*6028
59960
59969
*6029
59960
59969
*7280
56731
*72811
56731
*72812
56731
*72813
56731
*72819
56731
*7282
56731
*7283
56731
*72881
56731
*72886
56731
*7530
5851
5852
5853
5854
5855
5856
5859
59960
59969
*75310
5851
5852
5853
5854
5855
5856
5859
59960
59969
*75311
5851
5852
5853
5854
5855
5856
5859
59960
59969
*75312
5851
5852
5853
5854
5855
5856
5859
59960
59969
*75313
5851
5852
5853
5854
5855
5856
5859
59960
59969
*75314
5851
5852
5853
5854
5855
5856
5859
59960
59969
*75315
5851
5852
5853
5854
5855
5856
5859
59960
59969
*75316
5851
5852
5853
5854
5855
5856
5859
59960
59969
*75317
5851
5852
5853
5854
5855
5856
5859
59960
59969
*75319
5851

[[Page 47650]]

5852
5853
5854
5855
5856
5859
59960
59969
*75320
5851
5852
5853
5854
5855
5856
5859
59960
59969
*75321
5851
5852
5853
5854
5855
5856
5859
59960
59969
*75322
5851
5852
5853
5854
5855
5856
5859
59960
59969
*75323
5851
5852
5853
5854
5855
5856
5859
59960
59969
*75329
5851
5852
5853
5854
5855
5856
5859
59960
59969
*7533
5851
5852
5853
5854
5855
5856
5859
59960
59969
*7534
59960
59969
*7535
59960
59969
*7536
59960
59969
*7537
59960
59969
*7538
59960
59969
*7539
5851
5852
5853
5854
5855
5856
5859
59960
59969
*7685
77012
77014
77016
77018
77086
*7686
77012
77014
77016
77018
77086
*7689
77012
77014
77016
77018
77086
*769
77012
77014
77016
77018
77086
*7700
77012
77014
77016
77018
77086
*77010
7685
769
7700
77012
77014
77016
77018
7702
7703
7704
7705
7707
77084
77086
*77011
7685
769
7700
77012
77014
77016
77018
7702
7703
7704
7705
7707
77084
77086
*77012
7685
769
7700
77012
77014
77016
77018
7702
7703
7704
7705
7707
77084
77086
*77013
7685
769
7700
77012
77014
77016
77018
7702
7703
7704
7705
7707
77084
77086
*77014
7685
769
7700
77012
77014
77016
77018
7702
7703
7704
7705
7707
77084
77086
*77015
7685
769

[[Page 47651]]

7700
77012
77014
77016
77018
7702
7703
7704
7705
7707
77084
77086
*77016
7685
769
7700
77012
77014
77016
77018
7702
7703
7704
7705
7707
77084
77086
*77017
7685
769
7700
77012
77014
77016
77018
7702
7703
7704
7705
7707
77084
77086
*77018
7685
769
7700
77012
77014
77016
77018
7702
7703
7704
7705
7707
77084
77086
*7702
77012
77014
77016
77018
77086
*7703
77012
77014
77016
77018
77086
*7704
77012
77014
77016
77018
77086
*7705
77012
77014
77016
77018
77086
*7706
77012
77014
77016
77018
77086
*7707
77012
77014
77016
77018
77086
*77081
77012
77014
77016
77018
77086
*77082
77012
77014
77016
77018
77086
*77083
77012
77014
77016
77018
77086
*77084
77012
77014
77016
77018
77086
*77085
7685
769
7700
77012
77014
77016
77018
7702
7703
7704
7705
7707
77084
77086
*77086
7685
769
7700
77012
77014
77016
77018
7702
7703
7704
7705
7707
77084
77086
*77089
77012
77014
77016
77018
77086
*7709
77012
77014
77016
77018
77086
*77981
77012
77014
77016
77018
77086
*77982
77012
77014
77016
77018
77086
*77983
77012
77014
77016
77018
77086
*77984
76501
76502
76503
76504
76505
76506
76507
76508
7670
76711
7685
769
7700
77012
77014
77016
77018
7702
7703
7704
7705
7707
77084

[[Page 47652]]

77086
7710
7711
7713
77181
77183
77210
77211
77212
77213
77214
7722
7724
7725
7730
7731
7732
7733
7734
7740
7741
7742
77430
77431
77439
7744
7745
7747
7751
7752
7753
7754
7755
7756
7757
7760
7761
7762
7763
7771
7772
7775
7776
7780
7790
7791
7797
*77989
77012
77014
77016
77018
77086
*78091
79901
79902
*78092
79901
79902
*78093
79901
79902
*78094
79901
79902
*78095
04082
44024
78001
78003
7801
78031
78039
7817
7854
78550
78551
78552
78559
7863
78820
78829
7895
7907
7911
7913
79901
79902
7991
7994
*78099
79901
79902
*7881
59960
59969
*7980
79901
79902
*79901
79901
79902
7991
*79902
79901
79902
7991
*7991
79901
79902
*79981
79901
79902
*79989
79901
79902
*99640
99640
99641
99642
99643
99644
99645
99646
99647
99649
99657
99660
99666
99667
99669
99670
99677
99678
99679
*99641
99640
99641
99642
99643
99644
99645
99646
99647
99649
99657
99660
99666
99667
99669
99670
99677
99678
99679
*99642
99640
99641
99642
99643
99644
99645
99646
99647
99649
99657
99660
99666
99667
99669
99670
99677
99678
99679
*99643
99640
99641
99642
99643
99644
99645
99646
99647
99649
99657
99660
99666
99667
99669
99670
99677
99678
99679
*99644
99640
99641
99642
99643
99644
99645
99646
99647

[[Page 47653]]

99649
99657
99660
99666
99667
99669
99670
99677
99678
99679
*99645
99640
99641
99642
99643
99644
99645
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
99642
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
99642
99643
99644
99645
99646
99647
99649
*V460
V4613
V4614
*V4611
V4613
V4614
*V4612
V4613
V4614
*V4613
V4611
V4612
V4613
V4614
*V4614

[[Page 47654]]

V4611
V4612
V4613
V4614
*V462
V4613
V4614
*V468
V4613
V4614
*V469
V4613
V4614

Table 6H.--Deletions From the CC Exclusions List
[CCs that are deleted from the list are included in this table. 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
*25091
585
*25092
585
*25093
585
*27410
585
*27411
5996
*27419
585
*2760
2765
*2761
2765
*2762
2765
*2763
2765
*2764
2765
*2765
2760
2761
2762
2763
2764
2765
2766
2767
2769
*2766
2765
*2767
2765
*2768
2765
*2769
2765
*2860
2873
*2861
2873
*2862
2873
*2863
2873
*2864
2873
*2865
2873
*2866
2873
*2867
2873
*2869
2873
*2870
2873
*2871
2873
*2872
2873
*2873
2860
2861
2862
2863
2864
2865
2866
2867
2869
2870
2871
2872
2873
2874
2875
2878
2879
*2874
2873
*2875
2873
*2878
2873
*2879
2873
*28981
2873
*28982
2873
*28989
2873
*2899
2873
*34461
5996
*5670
5672
5678
*5671
5672
5678
*5672
5670
5671
5672
5678
5679
*5678
5670
5671
5672
5678
5679
*5679
5672
5678
*56989
5672
5678
*5699
5672
5678
*5800

[[Page 47655]]

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
*5848
585
*5849
585
*585
5800
5804
58081
58089
5809
5810
5811
5812
5813
58181
58189
5819
5834
5845
5846
5847
5848
5849
585
59010
59011
5902
5903
59080
59081
5909
591
*586
585
*587
585
*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
5996
*5939
585
5996
*5940
5996
*5941
5996
*5942
5996
*5948
5996
*5949
5996
*5950
5996
*5951
5996
*5952
5996
*5953
5996
*5954
5996
*59581
5996
*59582
5996
*59589
5996
*5959
5996
*5960
5996
*59651
5996
*59652
5996
*59653
5996
*59654
5996
*59655
5996
*59659
5996
*5968
5996
*5969
5996

[[Page 47656]]

*5970
5996
*59780
5996
*59781
5996
*59789
5996
*59800
5996
*59801
5996
*5981
5996
*5982
5996
*5988
5996
*5989
5996
*5990
5996
*5991
5996
*5992
5996
*5993
5996
*5994
5996
*5995
5996
*5996
5921
5935
5950
5951
5952
5954
59581
59582
59589
5959
5970
5981
5982
5990
5994
5996
78820
78829
*5997
585
5996
*59981
585
5996
*59982
585
5996
*59983
585
5996
*59984
585
5996
*59989
585
5996
*5999
585
5996
*60000
5996
*60001
5996
*60010
5996
*60011
5996
*60020
5996
*60021
5996
*6003
5996
*60090
5996
*60091
5996
*6010
5996
*6011
5996
*6012
5996
*6013
5996
*6014
5996
*6018
5996
*6019
5996
*6020
5996
*6021
5996
*6022
5996
*6023
5996
*6028
5996
*6029
5996
*7530
585
5996
*75310
585
5996
*75311
585
5996
*75312
585
5996
*75313
585
5996
*75314
585
5996
*75315
585
5996
*75316
585
5996
*75317
585
5996
*75319
585
5996
*75320
585
5996
*75321
585
5996
*75322
585
5996
*75323
585
5996
*75329
585
5996
*7533
585
5996
*7534
5996
*7535
5996
*7536
5996
*7537
5996
*7538
5996
*7539
585
5996
*7685
7701
*7686
7701
*7689
7701
*769
7701
*7700
7701
*7701
7685
769
7700
7701
7702
7703
7704
7705
7707
77084
*7702
7701
*7703

[[Page 47657]]

7701
*7704
7701
*7705
7701
*7706
7701
*7707
7701
*77081
7701
*77082
7701
*77083
7701
*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
9964
*99881
9964
*99883
9964
*99889
9964
*9989
9964

Table 7A.--Medicare Prospective Payment System Selected Percentile Lengths of Stay
[FY 2004 MedPAR Update March 2005 GROUPER V22.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1............................................................ 23,402 9.8463 3 5 8 13 19
2............................................................ 10,428 4.5661 1 2 4 6 9
3............................................................ 4 9.5000 1 1 8 14 15
6............................................................ 413 3.0363 1 1 2 4 7
7............................................................ 15,700 9.3193 2 4 7 12 19
8............................................................ 3,735 2.8600 1 1 2 4 7
9............................................................ 1,970 6.2162 1 3 4 7 12
10........................................................... 19,627 6.0182 2 3 5 8 12
11........................................................... 3,290 3.7620 1 2 3 5 7
12........................................................... 54,743 5.3802 2 3 4 6 10
13........................................................... 7,425 4.9494 2 3 4 6 8
14........................................................... 238,142 5.6618 2 3 4 7 11
15........................................................... 76,495 4.5219 1 2 4 6 8
16........................................................... 16,350 6.3544 2 3 5 8 12
17........................................................... 3,024 3.2183 1 2 2 4 6
18........................................................... 33,332 5.2661 2 3 4 7 10
19........................................................... 8,625 3.4419 1 2 3 4 6
20........................................................... 6,591 9.8490 3 5 8 13 19
21........................................................... 2,218 6.3120 2 3 5 8 13
22........................................................... 3,333 5.2187 2 2 4 7 10
23........................................................... 10,801 3.8931 1 2 3 5 7
24........................................................... 64,348 4.7323 1 2 4 6 9
25........................................................... 28,409 3.1271 1 2 3 4 6
26........................................................... 18 6.2778 1 2 3 4 8
27........................................................... 5,462 5.1531 1 1 3 6 11
28........................................................... 17,705 5.7497 1 3 4 7 12
29........................................................... 6,356 3.3211 1 1 3 4 6
30........................................................... 1 19.0000 19 19 19 19 19
31........................................................... 5,189 3.9726 1 2 3 5 8
32........................................................... 2,030 2.3975 1 1 2 3 5
34........................................................... 28,017 4.7706 1 2 4 6 9
35........................................................... 7,947 3.0042 1 1 3 4 6
36........................................................... 1,477 1.6019 1 1 1 1 3
37........................................................... 1,253 4.1564 1 1 3 5 9
38........................................................... 56 3.5179 1 1 2 4 6
39........................................................... 449 2.3742 1 1 1 2 5
40........................................................... 1,395 4.1004 1 1 4 5 8
42........................................................... 1,156 2.7578 1 1 2 4 6

[[Page 47658]]

43........................................................... 125 3.1440 1 1 2 4 6
44........................................................... 1,171 4.7976 2 3 4 6 8
45........................................................... 2,819 3.0816 1 2 2 4 6
46........................................................... 3,837 4.1780 1 2 3 5 8
47........................................................... 1,346 2.8886 1 1 2 4 5
49........................................................... 2,490 4.3831 1 2 3 5 8
50........................................................... 2,183 1.8140 1 1 1 2 3
51........................................................... 191 2.7539 1 1 1 3 6
52........................................................... 166 1.9759 1 1 1 2 4
53........................................................... 2,241 3.9487 1 1 2 5 9
54........................................................... 1 7.0000 7 7 7 7 7
55........................................................... 1,364 3.1239 1 1 2 4 7
56........................................................... 445 2.5730 1 1 1 3 6
57........................................................... 705 4.1447 1 1 2 5 9
59........................................................... 104 2.6058 1 1 1 3 6
60........................................................... 8 3.2500 1 1 2 4 4
61........................................................... 222 5.3694 1 1 3 7 12
63........................................................... 2,880 4.4705 1 2 3 5 9
64........................................................... 3,370 6.0576 1 2 4 8 13
65........................................................... 41,607 2.7731 1 1 2 3 5
66........................................................... 8,052 3.1333 1 1 2 4 6
67........................................................... 420 3.6810 1 2 3 4 7
68........................................................... 17,401 3.9725 1 2 3 5 7
69........................................................... 4,841 3.0283 1 2 3 4 5
70........................................................... 26 2.3462 1 2 2 3 3
71........................................................... 68 4.0000 1 2 3 5 7
72........................................................... 1,073 3.4418 1 2 3 4 7
73........................................................... 7,996 4.3779 1 2 3 6 9
74........................................................... 4 2.5000 2 2 2 3 3
75........................................................... 45,262 9.8107 3 5 7 12 20
76........................................................... 47,617 10.8370 3 5 8 13 21
77........................................................... 2,173 4.6558 1 2 4 6 9
78........................................................... 45,896 6.2537 2 4 6 8 10
79........................................................... 171,263 8.2002 3 4 7 10 15
80........................................................... 7,757 5.3673 2 3 4 7 10
81........................................................... 5 9.8000 3 3 11 13 14
82........................................................... 65,516 6.6893 2 3 5 9 13
83........................................................... 7,091 5.2293 2 3 4 7 10
84........................................................... 1,502 3.1478 1 2 3 4 6
85........................................................... 21,990 6.2299 2 3 5 8 12
86........................................................... 1,868 3.6156 1 2 3 5 7
87........................................................... 83,132 6.4294 2 3 5 8 12
88........................................................... 415,743 4.9005 2 3 4 6 9
89........................................................... 553,059 5.6479 2 3 5 7 10
90........................................................... 46,079 3.8094 2 2 3 5 7
91........................................................... 48 4.3542 1 2 3 5 9
92........................................................... 16,584 5.9982 2 3 5 8 11
93........................................................... 1,613 3.8407 1 2 3 5 7
94........................................................... 13,459 6.1299 2 3 5 8 12
95........................................................... 1,631 3.6297 1 2 3 5 7
96........................................................... 59,418 4.3758 2 2 4 5 8
97........................................................... 27,175 3.3845 1 2 3 4 6
98........................................................... 9 2.5556 1 2 3 3 3
99........................................................... 21,688 3.1166 1 1 2 4 6
100.......................................................... 7,002 2.1133 1 1 2 3 4
101.......................................................... 23,315 4.2565 1 2 3 5 8
102.......................................................... 5,292 2.4934 1 1 2 3 5
103.......................................................... 748 37.8115 8 12 23 49 79
104.......................................................... 21,097 14.4820 6 8 12 18 25
105.......................................................... 31,872 9.9383 4 6 8 12 18
106.......................................................... 3,549 11.1972 5 7 9 13 19
107.......................................................... 70,700 10.4839 5 7 9 12 17
108.......................................................... 8,933 9.8282 1 5 8 12 19
109.......................................................... 51,135 7.7541 4 5 6 9 13
110.......................................................... 57,502 8.3925 1 3 7 11 17
111.......................................................... 10,144 3.4310 1 1 3 5 7
113.......................................................... 37,476 12.6142 4 6 10 16 24
114.......................................................... 8,583 8.4620 2 4 7 11 16
115.......................................................... 22,284 6.8149 1 2 5 9 14
116.......................................................... 119,388 4.2595 1 1 3 6 9

[[Page 47659]]

117.......................................................... 5,173 4.2295 1 1 2 5 10
118.......................................................... 7,652 3.0387 1 1 2 4 7
119.......................................................... 998 5.4920 1 1 3 7 13
120.......................................................... 36,527 9.0471 1 3 6 12 20
121.......................................................... 160,225 6.2477 2 3 5 8 12
122.......................................................... 62,124 3.3835 1 2 3 4 6
123.......................................................... 33,796 4.8114 1 1 3 6 11
124.......................................................... 131,668 4.3935 1 2 3 6 9
125.......................................................... 96,650 2.7212 1 1 2 3 5
126.......................................................... 5,867 11.3414 3 6 9 14 21
127.......................................................... 699,142 5.1265 2 3 4 6 10
128.......................................................... 5,201 5.1650 2 3 5 6 9
129.......................................................... 3,781 2.6006 1 1 1 3 6
130.......................................................... 89,637 5.4262 1 3 5 7 10
131.......................................................... 23,960 3.8028 1 2 4 5 7
132.......................................................... 117,958 2.8045 1 1 2 3 5
133.......................................................... 7,345 2.1799 1 1 2 3 4
134.......................................................... 42,681 3.1055 1 2 2 4 6
135.......................................................... 7,481 4.2929 1 2 3 5 8
136.......................................................... 1,137 2.7502 1 1 2 3 5
138.......................................................... 208,073 3.9146 1 2 3 5 7
139.......................................................... 79,030 2.4358 1 1 2 3 5
140.......................................................... 38,463 2.4369 1 1 2 3 5
141.......................................................... 122,553 3.4612 1 2 3 4 6
142.......................................................... 52,544 2.4784 1 1 2 3 5
143.......................................................... 250,910 2.0938 1 1 2 3 4
144.......................................................... 100,554 5.7002 1 2 4 7 12
145.......................................................... 6,244 2.6099 1 1 2 3 5
146.......................................................... 10,816 9.8879 5 6 8 12 17
147.......................................................... 2,652 5.8111 3 4 6 7 9
148.......................................................... 136,357 12.0947 5 7 9 15 22
149.......................................................... 20,021 5.9451 3 4 6 7 9
150.......................................................... 22,835 10.8915 4 6 9 14 20
151.......................................................... 5,389 5.1297 1 2 5 7 10
152.......................................................... 5,038 8.0369 3 5 7 9 14
153.......................................................... 2,104 4.9729 2 3 5 6 8
154.......................................................... 28,656 13.0578 3 6 10 16 25
155.......................................................... 6,190 4.1359 1 2 3 6 8
156.......................................................... 6 24.1667 1 5 9 27 27
157.......................................................... 8,309 5.7232 1 2 4 7 12
158.......................................................... 4,131 2.6069 1 1 2 3 5
159.......................................................... 19,267 5.1221 1 2 4 7 10
160.......................................................... 12,067 2.6627 1 1 2 3 5
161.......................................................... 10,462 4.3990 1 2 3 6 9
162.......................................................... 5,528 2.0801 1 1 1 3 4
163.......................................................... 10 2.9000 1 1 2 3 6
164.......................................................... 5,986 7.9820 3 5 7 10 14
165.......................................................... 2,541 4.2082 2 3 4 5 7
166.......................................................... 4,973 4.5025 1 2 3 5 9
167.......................................................... 4,682 2.2179 1 1 2 3 4
168.......................................................... 1,557 4.9030 1 2 3 6 10
169.......................................................... 767 2.2934 1 1 2 3 5
170.......................................................... 17,580 10.7956 2 5 8 14 22
171.......................................................... 1,494 4.1031 1 2 3 5 8
172.......................................................... 33,081 6.8370 2 3 5 9 14
173.......................................................... 2,410 3.5921 1 1 3 5 7
174.......................................................... 269,091 4.7026 2 3 4 6 9
175.......................................................... 32,812 2.8895 1 2 2 4 5
176.......................................................... 14,625 5.1424 2 3 4 6 10
177.......................................................... 8,603 4.4328 2 2 4 5 8
178.......................................................... 2,924 3.1211 1 2 3 4 5
179.......................................................... 14,542 5.8548 2 3 5 7 11
180.......................................................... 92,648 5.3227 2 3 4 7 10
181.......................................................... 26,045 3.3267 1 2 3 4 6
182.......................................................... 293,770 4.4295 1 2 3 5 8
183.......................................................... 87,104 2.8668 1 1 2 4 5
184.......................................................... 81 3.2840 1 2 2 4 6
185.......................................................... 5,754 4.4944 1 2 3 5 9
186.......................................................... 4 2.0000 1 1 1 3 3
187.......................................................... 634 4.1514 1 2 3 5 8

[[Page 47660]]

188.......................................................... 91,501 5.5437 1 2 4 7 11
189.......................................................... 13,270 3.0916 1 1 2 4 6
190.......................................................... 70 4.3286 1 2 3 5 8
191.......................................................... 10,475 12.7179 3 6 9 16 26
192.......................................................... 1,329 5.6764 1 3 5 7 10
193.......................................................... 4,535 12.0485 5 7 10 15 22
194.......................................................... 524 6.6660 3 4 6 8 11
195.......................................................... 3,262 10.6125 4 6 9 13 19
196.......................................................... 703 5.7070 2 4 5 7 9
197.......................................................... 17,409 9.1025 3 5 7 11 17
198.......................................................... 4,664 4.3216 2 3 4 6 7
199.......................................................... 1,430 9.5203 2 4 7 13 19
200.......................................................... 942 9.7187 1 4 7 13 20
201.......................................................... 2,684 13.7299 3 6 10 18 28
202.......................................................... 27,484 6.1745 2 3 5 8 12
203.......................................................... 31,852 6.4862 2 3 5 8 13
204.......................................................... 73,333 5.5299 2 3 4 7 11
205.......................................................... 31,719 5.9002 2 3 4 7 12
206.......................................................... 2,095 3.8788 1 2 3 5 8
207.......................................................... 35,947 5.2368 1 2 4 7 10
208.......................................................... 9,830 2.9347 1 1 2 4 6
209.......................................................... 464,512 4.5650 3 3 4 5 7
210.......................................................... 129,184 6.6984 3 4 6 8 11
211.......................................................... 26,872 4.6683 3 3 4 5 7
212.......................................................... 10 2.9000 1 1 3 4 4
213.......................................................... 10,326 9.1100 2 4 7 12 18
216.......................................................... 17,774 5.7605 1 1 3 8 14
217.......................................................... 17,790 12.4693 3 5 9 15 26
218.......................................................... 29,029 5.4549 2 3 4 7 10
219.......................................................... 21,589 3.1095 1 2 3 4 5
220.......................................................... 4 2.7500 2 2 3 3 3
223.......................................................... 13,562 3.2145 1 1 2 4 6
224.......................................................... 11,013 1.8900 1 1 1 2 3
225.......................................................... 6,609 5.1607 1 2 4 7 11
226.......................................................... 6,717 6.3484 1 2 4 8 13
227.......................................................... 5,138 2.6086 1 1 2 3 5
228.......................................................... 2,665 4.1403 1 1 3 5 9
229.......................................................... 1,217 2.5094 1 1 2 3 5
230.......................................................... 2,591 5.5832 1 2 4 7 12
232.......................................................... 736 2.8139 1 1 1 3 6
233.......................................................... 15,214 6.6706 1 2 5 9 14
234.......................................................... 7,745 2.7898 1 1 2 4 6
235.......................................................... 5,010 4.6415 1 2 4 6 9
236.......................................................... 42,665 4.4765 1 3 4 5 8
237.......................................................... 2,035 3.6644 1 2 3 4 7
238.......................................................... 9,940 8.3339 3 4 6 10 16
239.......................................................... 43,175 6.0614 2 3 5 7 11
240.......................................................... 12,753 6.6181 2 3 5 8 13
241.......................................................... 2,717 3.7004 1 2 3 5 7
242.......................................................... 2,758 6.6164 2 3 5 8 13
243.......................................................... 102,299 4.5163 1 2 4 6 8
244.......................................................... 15,863 4.4900 1 2 4 6 8
245.......................................................... 5,870 3.1295 1 1 3 4 6
246.......................................................... 1,437 3.5783 1 2 3 4 7
247.......................................................... 21,831 3.3168 1 2 3 4 6
248.......................................................... 15,210 4.8406 1 3 4 6 9
249.......................................................... 14,161 3.8764 1 1 3 5 8
250.......................................................... 4,194 3.8884 1 2 3 5 7
251.......................................................... 2,168 2.7495 1 1 3 3 5
252.......................................................... 1 1.0000 1 1 1 1 1
253.......................................................... 25,052 4.5304 2 3 4 5 8
254.......................................................... 10,503 3.0475 1 2 3 4 5
255.......................................................... 1 7.0000 7 7 7 7 7
256.......................................................... 7,214 5.0349 1 2 4 6 10
257.......................................................... 13,587 2.6109 1 1 2 3 5
258.......................................................... 12,118 1.7490 1 1 1 2 3
259.......................................................... 2,910 2.7680 1 1 1 3 7
260.......................................................... 3,001 1.4045 1 1 1 1 2
261.......................................................... 1,630 2.2092 1 1 1 2 4
262.......................................................... 641 4.8222 1 2 4 7 10

[[Page 47661]]

263.......................................................... 23,953 10.7683 3 5 8 13 21
264.......................................................... 3,948 6.2497 2 3 5 8 12
265.......................................................... 4,335 6.6046 1 2 4 8 14
266.......................................................... 2,335 3.1764 1 1 2 4 7
267.......................................................... 272 4.1838 1 1 3 5 10
268.......................................................... 1,038 3.5308 1 1 2 4 7
269.......................................................... 10,761 8.3312 2 4 6 11 16
270.......................................................... 2,661 3.8200 1 1 3 5 8
271.......................................................... 21,218 6.8298 2 3 5 8 13
272.......................................................... 5,964 5.8273 2 3 4 7 11
273.......................................................... 1,358 3.6406 1 2 3 5 7
274.......................................................... 2,303 6.2731 2 3 5 8 12
275.......................................................... 228 3.2500 1 1 2 4 7
276.......................................................... 1,451 4.4590 1 2 4 6 8
277.......................................................... 113,037 5.5031 2 3 5 7 10
278.......................................................... 34,072 4.0544 2 2 3 5 7
279.......................................................... 8 4.3750 1 1 5 6 6
280.......................................................... 19,468 4.0057 1 2 3 5 7
281.......................................................... 7,192 2.8411 1 1 2 4 5
283.......................................................... 6,300 4.5775 1 2 3 6 9
284.......................................................... 1,847 3.0238 1 1 2 4 6
285.......................................................... 7,696 10.0444 3 5 8 12 19
286.......................................................... 2,715 5.4748 2 2 4 6 10
287.......................................................... 6,162 9.9081 3 5 7 12 19
288.......................................................... 10,604 4.1167 2 2 3 4 7
289.......................................................... 6,923 2.5524 1 1 1 2 5
290.......................................................... 10,937 2.1306 1 1 1 2 4
291.......................................................... 67 2.7761 1 1 1 2 4
292.......................................................... 7,377 10.0538 2 4 8 13 20
293.......................................................... 370 4.4568 1 2 3 6 9
294.......................................................... 99,631 4.2903 1 2 3 5 8
295.......................................................... 4,143 3.6667 1 2 3 4 7
296.......................................................... 256,039 4.7212 1 2 4 6 9
297.......................................................... 45,622 3.0707 1 2 3 4 6
298.......................................................... 86 3.9302 1 1 2 4 7
299.......................................................... 1,497 5.1670 1 2 4 6 10
300.......................................................... 21,447 5.8676 2 3 5 7 11
301.......................................................... 3,916 3.4068 1 2 3 4 6
302.......................................................... 9,903 8.1703 4 5 6 9 14
303.......................................................... 23,854 7.3928 3 4 6 9 14
304.......................................................... 13,932 8.4913 2 3 6 11 18
305.......................................................... 3,110 3.2077 1 2 3 4 6
306.......................................................... 6,364 5.4788 1 2 3 8 13
307.......................................................... 2,075 2.0733 1 1 2 2 3
308.......................................................... 7,123 6.1189 1 2 4 8 14
309.......................................................... 3,585 2.0006 1 1 1 2 4
310.......................................................... 26,164 4.5252 1 2 3 6 10
311.......................................................... 6,530 1.8778 1 1 1 2 3
312.......................................................... 1,464 4.8347 1 1 3 6 11
313.......................................................... 514 2.2082 1 1 2 3 4
314.......................................................... 1 2.0000 2 2 2 2 2
315.......................................................... 36,882 6.7594 1 1 4 9 16
316.......................................................... 182,009 6.2874 2 3 5 8 12
317.......................................................... 2,798 3.4578 1 1 2 4 7
318.......................................................... 5,961 5.7412 1 2 4 7 11
319.......................................................... 388 2.7784 1 1 2 3 6
320.......................................................... 219,838 5.0956 2 3 4 6 9
321.......................................................... 31,579 3.5951 1 2 3 4 6
322.......................................................... 65 3.4462 2 2 3 4 6
323.......................................................... 20,616 3.0939 1 1 2 4 6
324.......................................................... 5,451 1.8835 1 1 1 2 3
325.......................................................... 9,685 3.6823 1 2 3 5 7
326.......................................................... 2,596 2.6221 1 1 2 3 5
327.......................................................... 5 2.6000 1 1 2 3 5
328.......................................................... 611 3.4583 1 1 3 5 7
329.......................................................... 72 1.8333 1 1 1 2 3
331.......................................................... 55,177 5.4326 1 2 4 7 11
332.......................................................... 4,439 3.1246 1 1 2 4 6
333.......................................................... 260 5.3923 1 2 3 6 13
334.......................................................... 9,878 4.2963 2 2 3 5 7

[[Page 47662]]

335.......................................................... 12,049 2.6821 1 2 3 3 4
336.......................................................... 31,389 3.2999 1 2 2 4 7
337.......................................................... 25,268 1.9183 1 1 2 2 3
338.......................................................... 653 6.1884 1 2 3 9 14
339.......................................................... 1,259 5.1096 1 1 3 7 11
340.......................................................... 2 5.0000 4 4 6 6 6
341.......................................................... 3,196 3.1621 1 1 2 3 7
342.......................................................... 566 3.4223 1 2 2 4 7
344.......................................................... 2,702 2.7028 1 1 1 2 6
345.......................................................... 1,465 4.8007 1 1 3 6 11
346.......................................................... 3,993 5.7250 1 3 4 7 11
347.......................................................... 250 3.0640 1 1 2 4 7
348.......................................................... 4,202 4.0888 1 2 3 5 8
349.......................................................... 579 2.3523 1 1 2 3 4
350.......................................................... 7,188 4.4509 2 2 4 5 8
352.......................................................... 984 4.0061 1 2 3 5 8
353.......................................................... 2,745 6.3100 2 3 4 7 12
354.......................................................... 7,648 5.6951 2 3 4 6 10
355.......................................................... 4,958 3.0621 2 2 3 4 4
356.......................................................... 24,123 1.9262 1 1 2 2 3
357.......................................................... 5,589 8.1313 3 4 6 10 15
358.......................................................... 20,933 3.9643 2 2 3 4 7
359.......................................................... 28,972 2.4053 1 2 2 3 4
360.......................................................... 14,861 2.5888 1 1 2 3 4
361.......................................................... 276 3.0072 1 1 2 3 7
362.......................................................... 2 1.0000 1 1 1 1 1
363.......................................................... 2,144 3.7733 1 2 2 4 8
364.......................................................... 1,464 4.1858 1 2 3 5 9
365.......................................................... 1,628 7.7279 2 3 5 9 17
366.......................................................... 4,822 6.4942 1 3 5 8 13
367.......................................................... 459 2.9891 1 1 2 4 6
368.......................................................... 3,941 6.6420 2 3 5 8 13
369.......................................................... 3,645 3.2483 1 1 2 4 6
370.......................................................... 1,892 5.1723 2 3 4 5 8
371.......................................................... 2,309 3.4171 2 3 3 4 5
372.......................................................... 1,179 3.1688 2 2 2 3 5
373.......................................................... 4,967 2.2350 1 2 2 3 3
374.......................................................... 160 2.7688 2 2 2 3 5
375.......................................................... 6 4.0000 1 2 2 6 6
376.......................................................... 403 3.3945 1 2 2 4 7
377.......................................................... 78 4.5000 1 1 3 4 8
378.......................................................... 197 2.3147 1 1 2 3 4
379.......................................................... 511 2.8043 1 1 2 3 6
380.......................................................... 93 2.0860 1 1 1 2 4
381.......................................................... 217 2.2396 1 1 1 2 4
382.......................................................... 43 1.4419 1 1 1 2 2
383.......................................................... 2,515 3.6509 1 1 2 4 7
384.......................................................... 134 2.5522 1 1 1 3 5
385.......................................................... 1 1.0000 1 1 1 1 1
389.......................................................... 2 87.5000 21 21 154 154 154
390.......................................................... 2 2.5000 1 1 4 4 4
392.......................................................... 2,223 9.1939 2 4 6 11 19
393.......................................................... 1 4.0000 4 4 4 4 4
394.......................................................... 2,840 7.3718 1 2 5 9 16
395.......................................................... 116,839 4.2599 1 2 3 5 8
396.......................................................... 10 4.2000 1 2 2 3 6
397.......................................................... 18,586 5.1464 1 2 4 6 10
398.......................................................... 18,416 5.7084 2 3 4 7 11
399.......................................................... 1,659 3.3207 1 2 3 4 6
401.......................................................... 6,364 11.0506 2 5 9 14 22
402.......................................................... 1,414 4.0304 1 1 3 5 9
403.......................................................... 32,036 7.9373 2 3 6 10 16
404.......................................................... 3,825 4.1485 1 2 3 5 8
406.......................................................... 2,235 9.8868 2 4 7 12 21
407.......................................................... 589 3.8200 1 2 3 5 7
408.......................................................... 2,183 8.2171 1 2 5 10 19
409.......................................................... 1,818 5.7948 1 3 4 6 12
410.......................................................... 28,563 3.8313 1 2 3 5 6
411.......................................................... 12 3.2500 1 2 2 4 4
412.......................................................... 12 2.7500 1 1 1 3 4

[[Page 47663]]

413.......................................................... 5,229 6.7569 2 3 5 9 13
414.......................................................... 576 4.0260 1 2 3 5 8
415.......................................................... 51,153 14.0354 4 6 11 18 28
416.......................................................... 240,311 7.3872 2 3 6 9 14
417.......................................................... 22 4.0455 1 2 3 5 7
418.......................................................... 28,788 6.1952 2 3 5 8 12
419.......................................................... 16,399 4.3887 1 2 3 5 8
420.......................................................... 2,961 3.3810 1 2 3 4 6
421.......................................................... 11,952 4.0628 1 2 3 5 7
422.......................................................... 53 3.7358 1 1 2 5 7
423.......................................................... 8,704 8.2135 2 3 6 10 17
424.......................................................... 1,078 12.4017 2 4 8 14 22
425.......................................................... 14,887 3.4519 1 1 3 4 7
426.......................................................... 4,353 4.1358 1 2 3 5 8
427.......................................................... 1,519 4.7110 1 2 3 5 9
428.......................................................... 777 7.2844 1 2 5 8 15
429.......................................................... 25,617 5.4610 2 3 4 6 10
430.......................................................... 71,987 7.6793 2 3 6 9 15
431.......................................................... 309 5.8576 1 2 4 7 12
432.......................................................... 422 4.2583 1 2 3 5 8
433.......................................................... 5,227 2.9629 1 1 2 3 6
439.......................................................... 1,756 8.8844 1 3 5 10 19
440.......................................................... 5,670 8.8106 2 3 6 10 18
441.......................................................... 786 3.3804 1 1 2 4 7
442.......................................................... 18,167 8.6812 2 3 6 11 18
443.......................................................... 3,422 3.3928 1 1 3 4 7
444.......................................................... 5,949 4.0309 1 2 3 5 8
445.......................................................... 2,376 2.8283 1 1 2 4 5
447.......................................................... 6,296 2.5681 1 1 2 3 5
448.......................................................... 1 2.0000 2 2 2 2 2
449.......................................................... 39,204 3.6748 1 1 3 4 7
450.......................................................... 7,880 1.9868 1 1 1 2 4
451.......................................................... 3 1.6667 1 1 1 3 3
452.......................................................... 27,882 4.9010 1 2 3 6 10
453.......................................................... 5,499 2.7978 1 1 2 3 5
454.......................................................... 3,874 4.1033 1 2 3 5 8
455.......................................................... 855 2.2187 1 1 2 3 4
461.......................................................... 2,752 5.1286 1 1 3 6 12
462.......................................................... 7,839 10.2341 4 6 8 13 19
463.......................................................... 31,249 3.8966 1 2 3 5 7
464.......................................................... 7,700 2.9153 1 1 2 4 5
465.......................................................... 226 3.7566 1 1 2 5 8
466.......................................................... 1,429 5.2645 1 1 2 5 10
467.......................................................... 1,023 2.6755 1 1 2 3 5
468.......................................................... 50,812 12.8282 3 6 10 16 25
471.......................................................... 15,754 5.0523 3 3 4 5 8
473.......................................................... 8,839 12.4395 2 3 7 18 32
475.......................................................... 117,173 11.0464 2 5 9 15 22
476.......................................................... 3,040 10.4967 2 4 9 14 21
477.......................................................... 29,601 8.5271 1 3 6 11 18
478.......................................................... 114,427 7.0983 1 2 5 9 15
479.......................................................... 24,838 2.7842 1 1 2 4 6
480.......................................................... 823 17.9380 7 8 13 22 36
481.......................................................... 1,099 21.7543 9 16 20 25 35
482.......................................................... 5,100 11.5082 4 6 9 14 21
484.......................................................... 468 12.7906 2 6 10 17 25
485.......................................................... 3,476 9.6530 4 5 7 12 18
486.......................................................... 2,662 12.3681 2 5 10 16 25
487.......................................................... 4,804 7.0760 1 3 5 9 14
488.......................................................... 798 16.3972 4 7 13 22 35
489.......................................................... 13,587 8.3522 2 3 6 10 17
490.......................................................... 5,255 5.3753 1 2 4 7 11
491.......................................................... 19,972 3.1398 1 2 3 3 5
492.......................................................... 4,033 13.6677 3 5 6 23 31
493.......................................................... 61,926 6.0526 1 3 5 8 12
494.......................................................... 25,786 2.6794 1 1 2 4 5
495.......................................................... 315 17.4127 8 9 13 20 31
496.......................................................... 3,319 8.9708 3 4 6 11 18
497.......................................................... 29,820 6.0519 3 4 5 7 10
498.......................................................... 19,770 3.7891 2 3 3 5 6

[[Page 47664]]

499.......................................................... 35,931 4.3194 1 2 3 5 9
500.......................................................... 48,926 2.2388 1 1 2 3 4
501.......................................................... 3,144 9.9078 4 5 8 13 18
502.......................................................... 721 5.7406 2 3 5 7 9
503.......................................................... 5,983 3.8369 1 2 3 5 7
504.......................................................... 189 27.2116 8 16 23 36 49
505.......................................................... 181 4.6354 1 1 1 6 11
506.......................................................... 1,010 15.8822 3 7 13 21 33
507.......................................................... 311 8.4662 1 3 7 11 18
508.......................................................... 645 7.2341 1 3 5 9 16
509.......................................................... 171 5.1345 1 2 3 6 11
510.......................................................... 1,770 6.4068 1 2 4 8 14
511.......................................................... 640 4.0531 1 1 2 4 8
512.......................................................... 539 12.7737 7 8 10 13 23
513.......................................................... 233 9.9356 5 7 8 12 16
515.......................................................... 27,658 4.2880 1 1 2 6 11
516.......................................................... 38,925 4.7852 2 2 4 6 9
517.......................................................... 66,832 2.5758 1 1 1 3 6
518.......................................................... 41,407 3.4769 1 1 2 4 8
519.......................................................... 11,642 4.8104 1 1 3 6 11
520.......................................................... 15,531 2.0012 1 1 1 2 4
521.......................................................... 32,416 5.4724 2 3 4 7 11
522.......................................................... 5,684 9.3895 3 4 7 12 19
523.......................................................... 16,002 3.8933 1 2 3 5 7
524.......................................................... 119,564 3.1912 1 2 3 4 6
525.......................................................... 323 13.2477 1 3 8 15 31
526.......................................................... 56,224 4.3526 1 2 3 5 8
527.......................................................... 194,348 2.2279 1 1 1 2 5
528.......................................................... 1,777 17.1486 6 10 15 22 30
529.......................................................... 4,046 7.9983 1 2 5 10 18
530.......................................................... 2,370 3.1224 1 1 2 4 6
531.......................................................... 4,846 9.4191 2 4 7 12 20
532.......................................................... 2,659 3.7131 1 1 3 5 8
533.......................................................... 47,840 3.7569 1 1 2 4 9
534.......................................................... 45,532 1.7911 1 1 1 2 3
535.......................................................... 13,099 8.2594 1 3 7 11 17
536.......................................................... 19,770 5.4062 1 2 4 7 12
537.......................................................... 8,711 6.7751 1 3 5 8 14
538.......................................................... 5,655 2.8233 1 1 2 3 6
539.......................................................... 5,041 10.8242 2 4 7 14 23
540.......................................................... 1,518 3.5870 1 1 3 4 7
541.......................................................... 22,675 43.1644 17 25 36 52 77
542.......................................................... 24,573 32.6658 12 18 27 40 58
543.......................................................... 5,471 12.0068 2 5 10 16 24
-------------
12,216,080
--------------------------------------------------------------------------------------------------------------------------------------------------------

Table 7B.--Medicare Prospective Payment System Selected Percentile Lengths-of-Stay
[FY 2004 MedPAR Update March 2005 GROUPER V23.0]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number Arithmetic 10th 25th 50th 75th 90th
DRG discharges Mean LOS percentile percentile percentile percentile percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1............................................................ 23,407 9.8451 3 5 8 13 19
2............................................................ 10,422 4.5659 1 2 4 6 9
3............................................................ 4 9.5 1 1 8 14 15
6............................................................ 413 3.0363 1 1 2 4 7
7............................................................ 15,520 9.3891 2 4 7 12 19
8............................................................ 3,497 2.9548 1 1 2 4 7
9............................................................ 1,970 6.2162 1 3 4 7 12
10........................................................... 19,633 6.0172 2 3 5 8 12
11........................................................... 3,284 3.7643 1 2 3 5 8
12........................................................... 54,743 5.3802 2 3 4 6 10
13........................................................... 7,425 4.9494 2 3 4 6 8
14........................................................... 235,884 5.6478 2 3 4 7 11
15........................................................... 76,495 4.5219 1 2 4 6 8
16........................................................... 16,366 6.3522 2 3 5 8 12
17........................................................... 3,008 3.2134 1 2 2 4 6
18........................................................... 33,343 5.2655 2 3 4 7 10

[[Page 47665]]

19........................................................... 8,614 3.4418 1 2 3 4 6
20........................................................... 6,591 9.849 3 5 8 13 19
21........................................................... 2,218 6.312 2 3 5 8 13
22........................................................... 3,333 5.2187 2 2 4 7 10
23........................................................... 10,801 3.8931 1 2 3 5 7
24........................................................... 64,424 4.7297 1 2 4 6 9
25........................................................... 28,333 3.1286 1 2 3 4 6
26........................................................... 18 6.2778 1 2 3 4 8
27........................................................... 5,462 5.1531 1 1 3 6 11
28........................................................... 17,714 5.749 1 3 4 7 12
29........................................................... 6,347 3.3198 1 1 3 4 6
30........................................................... 1 19 19 19 19 19 19
31........................................................... 5,190 3.9726 1 2 3 5 8
32........................................................... 2,029 2.3967 1 1 2 3 5
34........................................................... 26,697 4.7673 1 2 4 6 9
35........................................................... 7,689 3.0061 1 1 3 4 6
36........................................................... 1,477 1.6019 1 1 1 1 3
37........................................................... 1,253 4.1564 1 1 3 5 9
38........................................................... 56 3.5179 1 1 2 4 6
39........................................................... 449 2.3742 1 1 1 2 5
40........................................................... 1,395 4.1004 1 1 4 5 8
42........................................................... 1,156 2.7578 1 1 2 4 6
43........................................................... 125 3.144 1 1 2 4 6
44........................................................... 1,171 4.7976 2 3 4 6 8
45........................................................... 2,819 3.0816 1 2 2 4 6
46........................................................... 3,837 4.178 1 2 3 5 8
47........................................................... 1,346 2.8886 1 1 2 4 5
49........................................................... 2,491 4.3826 1 2 3 5 8
50........................................................... 2,183 1.814 1 1 1 2 3
51........................................................... 191 2.7539 1 1 1 3 6
52........................................................... 333 1.9129 1 1 1 2 3
53........................................................... 2,259 3.9354 1 1 2 5 9
54........................................................... 1 7 7 7 7 7 7
55........................................................... 1,367 3.1207 1 1 2 4 7
56........................................................... 447 2.5682 1 1 1 3 6
57........................................................... 920 3.5989 1 1 2 4 8
59........................................................... 105 2.5905 1 1 1 3 6
60........................................................... 9 3 1 1 2 4 4
61........................................................... 222 5.3694 1 1 3 7 12
63........................................................... 2,902 4.501 1 2 3 5 9
64........................................................... 3,370 6.0576 1 2 4 8 13
65........................................................... 41,607 2.7731 1 1 2 3 5
66........................................................... 8,052 3.1333 1 1 2 4 6
67........................................................... 420 3.681 1 2 3 4 7
68........................................................... 17,478 3.9693 1 2 3 5 7
69........................................................... 4,764 3.0246 1 2 3 4 5
70........................................................... 26 2.3462 1 2 2 3 3
71........................................................... 68 4 1 2 3 5 7
72........................................................... 1,073 3.4418 1 2 3 4 7
73........................................................... 9,574 4.4027 1 2 3 6 9
74........................................................... 4 2.5 2 2 2 3 3
75........................................................... 45,259 9.8105 3 5 7 12 20
76........................................................... 47,648 10.8335 3 5 8 13 21
77........................................................... 2,142 4.6438 1 2 4 6 9
78........................................................... 45,896 6.2537 2 4 6 8 10
79........................................................... 171,506 8.1955 3 4 7 10 15
80........................................................... 7,514 5.383 2 3 4 7 10
81........................................................... 5 9.8 3 3 11 13 14
82........................................................... 65,516 6.6893 2 3 5 9 13
83........................................................... 7,121 5.2219 2 3 4 7 10
84........................................................... 1,472 3.1413 1 2 3 4 6
85........................................................... 22,034 6.2247 2 3 5 8 12
86........................................................... 1,824 3.6151 1 2 3 5 7
87........................................................... 83,132 6.4294 2 3 5 8 12
88........................................................... 415,743 4.9005 2 3 4 6 9
89........................................................... 554,672 5.6426 2 3 5 7 10
90........................................................... 44,466 3.8085 2 2 3 5 7
91........................................................... 48 4.3542 1 2 3 5 9
92........................................................... 16,675 5.9867 2 3 5 8 11
93........................................................... 1,522 3.8371 1 2 3 5 7

[[Page 47666]]

94........................................................... 13,468 6.1288 2 3 5 8 12
95........................................................... 1,622 3.6245 1 2 3 5 7
96........................................................... 60,100 4.3643 2 2 4 5 8
97........................................................... 26,493 3.385 1 2 3 4 6
98........................................................... 9 2.5556 1 2 3 3 3
99........................................................... 21,768 3.1137 1 1 2 4 6
100.......................................................... 6,922 2.1108 1 1 2 3 4
101.......................................................... 23,407 4.2505 1 2 3 5 8
102.......................................................... 5,200 2.4892 1 1 2 3 5
103.......................................................... 755 37.6159 8 12 23 48 79
104.......................................................... 21,072 14.4891 6 8 12 18 25
105.......................................................... 31,848 9.94 4 6 8 12 18
106.......................................................... 3,544 11.2015 5 7 9 13 19
108.......................................................... 9,311 10.8565 4 6 9 13 20
110.......................................................... 56,311 8.3074 1 3 6 10 17
111.......................................................... 10,039 3.4017 1 1 3 5 7
113.......................................................... 37,476 12.6142 4 6 10 16 24
114.......................................................... 8,583 8.462 2 4 7 11 16
117.......................................................... 5,173 4.2295 1 1 2 5 10
118.......................................................... 7,652 3.0387 1 1 2 4 7
119.......................................................... 998 5.492 1 1 3 7 13
120.......................................................... 36,527 9.0471 1 3 6 12 20
121.......................................................... 160,170 6.2471 2 3 5 8 12
122.......................................................... 62,110 3.383 1 2 3 4 6
123.......................................................... 33,796 4.8114 1 1 3 6 11
124.......................................................... 131,668 4.3935 1 2 3 6 9
125.......................................................... 96,650 2.7212 1 1 2 3 5
126.......................................................... 5,867 11.3414 3 6 9 14 21
127.......................................................... 699,142 5.1265 2 3 4 6 10
128.......................................................... 5,201 5.165 2 3 5 6 9
129.......................................................... 3,781 2.6006 1 1 1 3 6
130.......................................................... 89,660 5.4256 1 3 5 7 10
131.......................................................... 23,937 3.8036 1 2 4 5 7
132.......................................................... 117,968 2.8045 1 1 2 3 5
133.......................................................... 7,335 2.1793 1 1 2 3 4
134.......................................................... 42,681 3.1055 1 2 2 4 6
135.......................................................... 7,482 4.2926 1 2 3 5 8
136.......................................................... 1,136 2.7509 1 1 2 3 5
138.......................................................... 208,165 3.914 1 2 3 5 7
139.......................................................... 78,938 2.4356 1 1 2 3 5
140.......................................................... 38,463 2.4369 1 1 2 3 5
141.......................................................... 122,656 3.4603 1 2 3 4 6
142.......................................................... 52,441 2.4785 1 1 2 3 5
143.......................................................... 250,910 2.0938 1 1 2 3 4
144.......................................................... 100,597 5.6989 1 2 4 7 12
145.......................................................... 6,201 2.6093 1 1 2 3 5
146.......................................................... 10,816 9.8879 5 6 8 12 17
147.......................................................... 2,652 5.8111 3 4 6 7 9
148.......................................................... 136,377 12.094 5 7 9 15 22
149.......................................................... 20,001 5.9437 3 4 6 7 9
150.......................................................... 22,841 10.8905 4 6 9 14 20
151.......................................................... 5,383 5.1274 1 2 5 7 10
152.......................................................... 5,039 8.0367 3 5 7 9 14
153.......................................................... 2,103 4.9719 2 3 5 6 8
154.......................................................... 28,663 13.0553 3 6 10 16 25
155.......................................................... 6,182 4.1349 1 2 3 6 8
156.......................................................... 6 24.1667 1 5 9 27 27
157.......................................................... 8,313 5.7218 1 2 4 7 12
158.......................................................... 4,127 2.6067 1 1 2 3 5
159.......................................................... 19,282 5.1208 1 2 4 7 10
160.......................................................... 12,052 2.6618 1 1 2 3 5
161.......................................................... 10,467 4.3978 1 2 3 6 9
162.......................................................... 5,523 2.0802 1 1 1 3 4
163.......................................................... 10 2.9 1 1 2 3 6
164.......................................................... 5,991 7.9806 3 5 7 10 14
165.......................................................... 2,536 4.2039 2 3 4 5 7
166.......................................................... 4,978 4.5026 1 2 3 5 9
167.......................................................... 4,677 2.2153 1 1 2 3 4
168.......................................................... 1,565 4.8907 1 2 3 6 10
169.......................................................... 778 2.2969 1 1 2 3 5

[[Page 47667]]

170.......................................................... 17,581 10.7952 2 5 8 14 22
171.......................................................... 1,493 4.1025 1 2 3 5 8
172.......................................................... 33,087 6.8372 2 3 5 9 14
173.......................................................... 2,404 3.5815 1 1 3 5 7
174.......................................................... 269,113 4.7025 2 3 4 6 9
175.......................................................... 32,790 2.8894 1 2 2 4 5
176.......................................................... 14,625 5.1424 2 3 4 6 10
177.......................................................... 8,605 4.4335 2 2 4 5 8
178.......................................................... 2,922 3.1181 1 2 3 4 5
179.......................................................... 14,542 5.8548 2 3 5 7 11
180.......................................................... 92,667 5.3223 2 3 4 7 10
181.......................................................... 26,026 3.3268 1 2 3 4 6
182.......................................................... 293,882 4.4288 1 2 3 5 8
183.......................................................... 86,992 2.8669 1 1 2 4 5
184.......................................................... 81 3.284 1 2 2 4 6
185.......................................................... 5,754 4.4944 1 2 3 5 9
186.......................................................... 4 2 1 1 1 3 3
187.......................................................... 634 4.1514 1 2 3 5 8
188.......................................................... 91,507 5.5436 1 2 4 7 11
189.......................................................... 13,264 3.0913 1 1 2 4 6
190.......................................................... 70 4.3286 1 2 3 5 8
191.......................................................... 10,476 12.7174 3 6 9 16 26
192.......................................................... 1,328 5.6755 1 3 5 7 10
193.......................................................... 4,536 12.0476 5 7 10 15 22
194.......................................................... 523 6.6635 3 4 6 8 11
195.......................................................... 3,262 10.6125 4 6 9 13 19
196.......................................................... 703 5.707 2 4 5 7 9
197.......................................................... 17,419 9.0995 3 5 7 11 17
198.......................................................... 4,653 4.3215 2 3 4 6 7
199.......................................................... 1,430 9.5203 2 4 7 13 19
200.......................................................... 942 9.7187 1 4 7 13 20
201.......................................................... 2,684 13.7299 3 6 10 18 28
202.......................................................... 27,484 6.1745 2 3 5 8 12
203.......................................................... 31,852 6.4862 2 3 5 8 13
204.......................................................... 73,333 5.5299 2 3 4 7 11
205.......................................................... 31,724 5.8998 2 3 4 7 12
206.......................................................... 2,090 3.8804 1 2 3 5 8
207.......................................................... 35,951 5.2367 1 2 4 7 10
208.......................................................... 9,826 2.9341 1 1 2 4 6
210.......................................................... 129,253 6.6973 3 4 6 8 11
211.......................................................... 26,803 4.6683 3 3 4 5 7
212.......................................................... 10 2.9 1 1 3 4 4
213.......................................................... 10,326 9.11 2 4 7 12 18
216.......................................................... 17,774 5.7605 1 1 3 8 14
217.......................................................... 17,790 12.4693 3 5 9 15 26
218.......................................................... 29,060 5.4537 2 3 4 7 10
219.......................................................... 21,558 3.1077 1 2 3 4 5
220.......................................................... 4 2.75 2 2 3 3 3
223.......................................................... 13,578 3.2155 1 1 2 4 6
224.......................................................... 10,998 1.8869 1 1 1 2 3
225.......................................................... 6,609 5.1607 1 2 4 7 11
226.......................................................... 6,725 6.3486 1 2 4 8 13
227.......................................................... 5,130 2.6025 1 1 2 3 5
228.......................................................... 2,665 4.1403 1 1 3 5 9
229.......................................................... 1,217 2.5094 1 1 2 3 5
230.......................................................... 2,591 5.5832 1 2 4 7 12
232.......................................................... 735 2.815 1 1 1 3 6
233.......................................................... 15,221 6.6695 1 2 5 9 14
234.......................................................... 7,738 2.7886 1 1 2 4 6
235.......................................................... 5,010 4.6415 1 2 4 6 9
236.......................................................... 42,665 4.4765 1 3 4 5 8
237.......................................................... 2,035 3.6644 1 2 3 4 7
238.......................................................... 9,940 8.3339 3 4 6 10 16
239.......................................................... 43,175 6.0614 2 3 5 7 11
240.......................................................... 12,757 6.6172 2 3 5 8 13
241.......................................................... 2,713 3.7003 1 2 3 5 7
242.......................................................... 2,758 6.6164 2 3 5 8 13
243.......................................................... 102,299 4.5163 1 2 4 6 8
244.......................................................... 15,871 4.4895 1 2 4 6 8
245.......................................................... 5,862 3.129 1 1 3 4 6

[[Page 47668]]

246.......................................................... 1,437 3.5783 1 2 3 4 7
247.......................................................... 21,831 3.3168 1 2 3 4 6
248.......................................................... 15,210 4.8406 1 3 4 6 9
249.......................................................... 14,161 3.8764 1 1 3 5 8
250.......................................................... 4,199 3.8876 1 2 3 5 7
251.......................................................... 2,163 2.7485 1 1 3 3 5
252.......................................................... 1 1 1 1 1 1 1
253.......................................................... 25,073 4.5295 2 3 4 5 8
254.......................................................... 10,482 3.0467 1 2 3 4 5
255.......................................................... 1 7 7 7 7 7 7
256.......................................................... 7,214 5.0349 1 2 4 6 10
257.......................................................... 13,593 2.6106 1 1 2 3 5
258.......................................................... 12,112 1.7488 1 1 1 2 3
259.......................................................... 2,912 2.7679 1 1 1 3 7
260.......................................................... 2,999 1.4038 1 1 1 1 2
261.......................................................... 1,630 2.2092 1 1 1 2 4
262.......................................................... 641 4.8222 1 2 4 7 10
263.......................................................... 23,959 10.7669 3 5 8 13 21
264.......................................................... 3,942 6.2511 2 3 5 8 12
265.......................................................... 4,339 6.6036 1 2 4 8 14
266.......................................................... 2,331 3.1725 1 1 2 4 7
267.......................................................... 272 4.1838 1 1 3 5 10
268.......................................................... 1,038 3.5308 1 1 2 4 7
269.......................................................... 10,763 8.3298 2 4 6 11 16
270.......................................................... 2,658 3.8209 1 1 3 5 8
271.......................................................... 21,218 6.8298 2 3 5 8 13
272.......................................................... 5,966 5.8265 2 3 4 7 11
273.......................................................... 1,356 3.6409 1 2 3 5 7
274.......................................................... 2,304 6.2708 2 3 5 8 12
275.......................................................... 227 3.2599 1 1 2 4 7
276.......................................................... 1,451 4.459 1 2 4 6 8
277.......................................................... 113,079 5.5031 2 3 5 7 10
278.......................................................... 34,030 4.0527 2 2 3 5 7
279.......................................................... 8 4.375 1 1 5 6 6
280.......................................................... 19,491 4.0045 1 2 3 5 7
281.......................................................... 7,169 2.8407 1 1 2 4 5
283.......................................................... 6,303 4.5766 1 2 3 6 9
284.......................................................... 1,844 3.0244 1 1 2 4 6
285.......................................................... 7,696 10.0444 3 5 8 12 19
286.......................................................... 2,715 5.4748 2 2 4 6 10
287.......................................................... 6,162 9.9081 3 5 7 12 19
288.......................................................... 10,604 4.1167 2 2 3 4 7
289.......................................................... 6,923 2.5524 1 1 1 2 5
290.......................................................... 10,937 2.1306 1 1 1 2 4
291.......................................................... 67 2.7761 1 1 1 2 4
292.......................................................... 7,378 10.0529 2 4 8 13 20
293.......................................................... 369 4.4607 1 2 3 6 9
294.......................................................... 99,631 4.2903 1 2 3 5 8
295.......................................................... 4,143 3.6667 1 2 3 4 7
296.......................................................... 256,121 4.7208 1 2 4 6 9
297.......................................................... 45,540 3.0703 1 2 3 4 6
298.......................................................... 86 3.9302 1 1 2 4 7
299.......................................................... 1,497 5.167 1 2 4 6 10
300.......................................................... 21,452 5.8669 2 3 5 7 11
301.......................................................... 3,911 3.4076 1 2 3 4 6
302.......................................................... 9,903 8.1703 4 5 6 9 14
303.......................................................... 23,854 7.3928 3 4 6 9 14
304.......................................................... 13,937 8.4896 2 3 6 11 18
305.......................................................... 3,105 3.2068 1 2 3 4 6
306.......................................................... 6,364 5.4788 1 2 3 8 13
307.......................................................... 2,075 2.0733 1 1 2 2 3
308.......................................................... 7,124 6.1186 1 2 4 8 14
309.......................................................... 3,584 2 1 1 1 2 4
310.......................................................... 26,169 4.5248 1 2 3 6 10
311.......................................................... 6,525 1.8775 1 1 1 2 3
312.......................................................... 1,464 4.8347 1 1 3 6 11
313.......................................................... 514 2.2082 1 1 2 3 4
314.......................................................... 1 2 2 2 2 2 2
315.......................................................... 36,882 6.7594 1 1 4 9 16
316.......................................................... 182,009 6.2874 2 3 5 8 12

[[Page 47669]]

317.......................................................... 2,798 3.4578 1 1 2 4 7
318.......................................................... 5,962 5.7404 1 2 4 7 11
319.......................................................... 387 2.7829 1 1 2 3 6
320.......................................................... 219,971 5.0946 2 3 4 6 9
321.......................................................... 31,446 3.5956 1 2 3 4 6
322.......................................................... 65 3.4462 2 2 3 4 6
323.......................................................... 20,619 3.0937 1 1 2 4 6
324.......................................................... 5,448 1.8834 1 1 1 2 3
325.......................................................... 9,686 3.6822 1 2 3 5 7
326.......................................................... 2,595 2.622 1 1 2 3 5
327.......................................................... 5 2.6 1 1 2 3 5
328.......................................................... 611 3.4583 1 1 3 5 7
329.......................................................... 72 1.8333 1 1 1 2 3
331.......................................................... 55,181 5.4324 1 2 4 7 11
332.......................................................... 4,435 3.1256 1 1 2 4 6
333.......................................................... 260 5.3923 1 2 3 6 13
334.......................................................... 9,887 4.2956 2 2 3 5 7
335.......................................................... 12,040 2.6815 1 2 3 3 4
336.......................................................... 31,395 3.2997 1 2 2 4 7
337.......................................................... 25,262 1.9182 1 1 2 2 3
338.......................................................... 653 6.1884 1 2 3 9 14
339.......................................................... 1,259 5.1096 1 1 3 7 11
340.......................................................... 2 5 4 4 6 6 6
341.......................................................... 3,196 3.1621 1 1 2 3 7
342.......................................................... 566 3.4223 1 2 2 4 7
344.......................................................... 2,702 2.7028 1 1 1 2 6
345.......................................................... 1,465 4.8007 1 1 3 6 11
346.......................................................... 3,993 5.725 1 3 4 7 11
347.......................................................... 250 3.064 1 1 2 4 7
348.......................................................... 4,202 4.0888 1 2 3 5 8
349.......................................................... 579 2.3523 1 1 2 3 4
350.......................................................... 7,188 4.4509 2 2 4 5 8
352.......................................................... 984 4.0061 1 2 3 5 8
353.......................................................... 2,745 6.31 2 3 4 7 12
354.......................................................... 7,655 5.6933 2 3 4 6 10
355.......................................................... 4,951 3.0612 2 2 3 4 4
356.......................................................... 24,123 1.9262 1 1 2 2 3
357.......................................................... 5,589 8.1313 3 4 6 10 15
358.......................................................... 20,954 3.9633 2 2 3 4 7
359.......................................................... 28,951 2.4049 1 2 2 3 4
360.......................................................... 14,861 2.5888 1 1 2 3 4
361.......................................................... 276 3.0072 1 1 2 3 7
362.......................................................... 2 1 1 1 1 1 1
363.......................................................... 2,144 3.7733 1 2 2 4 8
364.......................................................... 1,464 4.1858 1 2 3 5 9
365.......................................................... 1,628 7.7279 2 3 5 9 17
366.......................................................... 4,822 6.4942 1 3 5 8 13
367.......................................................... 459 2.9891 1 1 2 4 6
368.......................................................... 3,941 6.642 2 3 5 8 13
369.......................................................... 3,645 3.2483 1 1 2 4 6
370.......................................................... 1,892 5.1723 2 3 4 5 8
371.......................................................... 2,309 3.4171 2 3 3 4 5
372.......................................................... 1,179 3.1688 2 2 2 3 5
373.......................................................... 4,967 2.235 1 2 2 3 3
374.......................................................... 160 2.7688 2 2 2 3 5
375.......................................................... 5 4.6 2 2 3 6 10
376.......................................................... 403 3.3945 1 2 2 4 7
377.......................................................... 78 4.5 1 1 3 4 8
378.......................................................... 197 2.3147 1 1 2 3 4
379.......................................................... 511 2.8043 1 1 2 3 6
380.......................................................... 93 2.086 1 1 1 2 4
381.......................................................... 217 2.2396 1 1 1 2 4
382.......................................................... 43 1.4419 1 1 1 2 2
383.......................................................... 2,515 3.6509 1 1 2 4 7
384.......................................................... 134 2.5522 1 1 1 3 5
385.......................................................... 1 1 1 1 1 1 1
389.......................................................... 2 87.5 21 21 154 154 154
390.......................................................... 2 2.5 1 1 4 4 4
392.......................................................... 2,223 9.1939 2 4 6 11 19
393.......................................................... 1 4 4 4 4 4 4

[[Page 47670]]

394.......................................................... 2,840 7.3718 1 2 5 9 16
395.......................................................... 116,839 4.2599 1 2 3 5 8
396.......................................................... 10 4.2 1 2 2 3 6
397.......................................................... 18,586 5.1464 1 2 4 6 10
398.......................................................... 18,422 5.7074 2 3 4 7 11
399.......................................................... 1,653 3.323 1 2 3 4 6
401.......................................................... 6,366 11.0485 2 5 9 14 22
402.......................................................... 1,412 4.0297 1 1 3 5 9
403.......................................................... 32,042 7.9368 2 3 6 10 16
404.......................................................... 3,819 4.1464 1 2 3 5 8
406.......................................................... 2,236 9.8837 2 4 7 12 20
407.......................................................... 588 3.8214 1 2 3 5 7
408.......................................................... 2,183 8.2171 1 2 5 10 19
409.......................................................... 1,818 5.7948 1 3 4 6 12
410.......................................................... 28,563 3.8313 1 2 3 5 6
411.......................................................... 12 3.25 1 2 2 4 4
412.......................................................... 12 2.75 1 1 1 3 4
413.......................................................... 5,230 6.7558 2 3 5 9 13
414.......................................................... 575 4.0313 1 2 3 5 8
415.......................................................... 51,152 14.0356 4 6 11 18 28
416.......................................................... 240,311 7.3872 2 3 6 9 14
417.......................................................... 22 4.0455 1 2 3 5 7
418.......................................................... 28,788 6.1952 2 3 5 8 12
419.......................................................... 16,428 4.389 1 2 3 5 8
420.......................................................... 2,932 3.3697 1 2 3 4 6
421.......................................................... 11,952 4.0628 1 2 3 5 7
422.......................................................... 53 3.7358 1 1 2 5 7
423.......................................................... 8,704 8.2135 2 3 6 10 17
424.......................................................... 1,078 12.4017 2 4 8 14 22
425.......................................................... 14,887 3.4519 1 1 3 4 7
426.......................................................... 4,353 4.1358 1 2 3 5 8
427.......................................................... 1,519 4.711 1 2 3 5 9
428.......................................................... 777 7.2844 1 2 5 8 15
429.......................................................... 25,617 5.461 2 3 4 6 10
430.......................................................... 71,987 7.6793 2 3 6 9 15
431.......................................................... 309 5.8576 1 2 4 7 12
432.......................................................... 4.2583 1 2 3 5 8
433.......................................................... 5,227 2.9629 1 1 2 3 6
439.......................................................... 1,756 8.8844 1 3 5 10 19
440.......................................................... 5,670 8.8106 2 3 6 10 18
441.......................................................... 786 3.3804 1 1 2 4 7
442.......................................................... 18,171 8.68 2 3 6 11 18
443.......................................................... 3,416 3.3929 1 1 3 4 7
444.......................................................... 5,955 4.0316 1 2 3 5 8
445.......................................................... 2,370 2.8236 1 1 2 4 5
447.......................................................... 6,296 2.5681 1 1 2 3 5
448.......................................................... 1 2 2 2 2 2 2
449.......................................................... 39,246 3.6741 1 1 3 4 7
450.......................................................... 7,838 1.9815 1 1 1 2 4
451.......................................................... 3 1.6667 1 1 1 3 3
452.......................................................... 27,889 4.9002 1 2 3 6 10
453.......................................................... 5,492 2.799 1 1 2 3 5
454.......................................................... 3,876 4.1019 1 2 3 5 8
455.......................................................... 853 2.2204 1 1 2 3 4
461.......................................................... 2,752 5.1286 1 1 3 6 12
462.......................................................... 7,839 10.2341 4 6 8 13 19
463.......................................................... 31,272 3.8962 1 2 3 5 7
464.......................................................... 7,677 2.9139 1 1 2 4 5
465.......................................................... 226 3.7566 1 1 2 5 8
466.......................................................... 1,429 5.2645 1 1 2 5 10
467.......................................................... 1,023 2.6755 1 1 2 3 5
468.......................................................... 50,777 12.8319 3 6 10 16 25
471.......................................................... 15,754 5.0523 3 3 4 5 8
473.......................................................... 8,839 12.4395 2 3 7 18 32
475.......................................................... 117,173 11.0464 2 5 9 15 22
476.......................................................... 3,040 10.4967 2 4 9 14 21
477.......................................................... 29,602 8.5325 1 3 6 11 18
479.......................................................... 24,830 2.7834 1 1 2 4 6
480.......................................................... 823 17.938 7 8 13 22 36
481.......................................................... 1,099 21.7543 9 16 20 25 35

[[Page 47671]]

482.......................................................... 5,211 11.4558 4 6 9 14 21
484.......................................................... 468 12.7906 2 6 10 17 25
485.......................................................... 3,476 9.653 4 5 7 12 18
486.......................................................... 2,662 12.3681 2 5 10 16 25
487.......................................................... 4,804 7.076 1 3 5 9 14
488.......................................................... 798 16.3972 4 7 13 22 35
489.......................................................... 13,587 8.3522 2 3 6 10 17
490.......................................................... 5,255 5.3753 1 2 4 7 11
491.......................................................... 19,972 3.1398 1 2 3 3 5
492.......................................................... 4,033 13.6677 3 5 6 23 31
493.......................................................... 61,968 6.0511 1 3 5 8 12
494.......................................................... 25,744 2.6775 1 1 2 4 5
495.......................................................... 312 17.3173 8 9 13 19 31
496.......................................................... 3,542 8.7572 3 4 6 10 18
497.......................................................... 27,884 5.8094 3 3 5 7 9
498.......................................................... 19,238 3.7597 2 3 3 5 6
499.......................................................... 35,954 4.3187 1 2 3 5 9
500.......................................................... 48,903 2.2383 1 1 2 3 4
501.......................................................... 3,144 9.9078 4 5 8 13 18
502.......................................................... 721 5.7406 2 3 5 7 9
503.......................................................... 5,983 3.8369 1 2 3 5 7
504.......................................................... 189 27.2116 8 16 23 36 49
505.......................................................... 181 4.6354 1 1 1 6 11
506.......................................................... 1,010 15.8822 3 7 13 21 33
507.......................................................... 311 8.4662 1 3 7 11 18
508.......................................................... 645 7.2341 1 3 5 9 16
509.......................................................... 171 5.1345 1 2 3 6 11
510.......................................................... 1,774 6.3968 1 2 4 8 14
511.......................................................... 636 4.066 1 1 2 5 8
512.......................................................... 539 12.7737 7 8 10 13 23
513.......................................................... 233 9.9356 5 7 8 12 16
515.......................................................... 44,944 4.3382 1 1 2 6 10
518.......................................................... 25,988 2.4905 1 1 1 3 5
519.......................................................... 11,650 4.8095 1 1 3 6 11
520.......................................................... 15,523 2.0005 1 1 1 2 4
521.......................................................... 32,428 5.4713 2 3 4 7 11
522.......................................................... 5,684 9.3895 3 4 7 12 19
523.......................................................... 15,979 3.8937 1 2 3 5 7
524.......................................................... 119,564 3.1912 1 2 3 4 6
525.......................................................... 314 13.242 1 3 8 15 29
528.......................................................... 1,777 17.1486 6 10 15 22 30
529.......................................................... 4,046 7.9983 1 2 5 10 18
530.......................................................... 2,370 3.1224 1 1 2 4 6
531.......................................................... 4,846 9.4191 2 4 7 12 20
532.......................................................... 2,659 3.7131 1 1 3 5 8
533.......................................................... 47,870 3.7563 1 1 2 4 9
534.......................................................... 45,500 1.7902 1 1 1 2 3
535.......................................................... 7,459 10.273 3 5 8 13 20
536.......................................................... 8,124 7.64 2 4 6 9 14
537.......................................................... 8,715 6.7733 1 3 5 8 14
538.......................................................... 5,651 2.8234 1 1 2 3 6
539.......................................................... 5,041 10.8242 2 4 7 14 23
540.......................................................... 1,518 3.587 1 1 3 4 7
541.......................................................... 22,715 43.1055 17 24 35 52 77
542.......................................................... 24,492 32.7431 12 18 27 40 58
543.......................................................... 5,471 12.0068 2 5 10 16 24
544.......................................................... 421,851 4.5075 3 3 4 5 7
545.......................................................... 42,661 5.1333 3 3 4 6 8
546.......................................................... 2,245 8.8272 3 4 7 11 17
547.......................................................... 35,664 12.0587 6 8 10 14 20
548.......................................................... 34,868 8.8612 5 6 8 10 14
549.......................................................... 14,483 10.1284 5 6 8 12 17
550.......................................................... 36,445 6.7982 4 5 6 8 10
551.......................................................... 56,978 6.359 1 2 5 8 13
552.......................................................... 84,699 3.5196 1 1 3 5 7
553.......................................................... 38,754 9.4977 2 4 7 12 20
554.......................................................... 75,681 5.8694 1 2 4 8 13
555.......................................................... 72,121 4.6626 1 2 3 6 9
556.......................................................... 49,952 2.0677 1 1 1 2 4
557.......................................................... 95,324 4.0908 1 2 3 5 8

[[Page 47672]]

558.......................................................... 155,257 1.854 1 1 1 2 4
559.......................................................... 2,258 7.1165 3 4 6 9 13
-------------
12,215,613
--------------------------------------------------------------------------------------------------------------------------------------------------------

Table 8A.--Statewide Average Operating Cost-to-Charge Ratios--July 2005
------------------------------------------------------------------------
State Urban Rural
------------------------------------------------------------------------
Alabama........................................... 0.271 0.344
Alaska............................................ 0.454 0.678
Arizona........................................... 0.292 0.391
Arkansas.......................................... 0.348 0.38
California........................................ 0.247 0.349
Colorado.......................................... 0.326 0.475
Connecticut....................................... 0.442 0.52
Delaware.......................................... 0.529 0.509
District of Columbia.............................. 0.377 .........
Florida........................................... 0.256 0.294
Georgia........................................... 0.367 0.418
Hawaii............................................ 0.396 0.44
Idaho............................................. 0.481 0.532
Illinois.......................................... 0.333 0.432
Indiana........................................... 0.437 0.469
Iowa.............................................. 0.393 0.486
Kansas............................................ 0.304 0.473
Kentucky.......................................... 0.391 0.4
Louisiana......................................... 0.31 0.378
Maine............................................. 0.504 0.489
Maryland.......................................... 0.762 0.884
Massachusetts..................................... 0.484 .........
Michigan.......................................... 0.386 0.486
Minnesota......................................... 0.404 0.531
Mississippi....................................... 0.349 0.389
Missouri.......................................... 0.342 0.406
Montana........................................... 0.437 0.485
Nebraska.......................................... 0.356 0.494
Nevada............................................ 0.249 0.494
New Hampshire..................................... 0.464 0.5
New Jersey........................................ 0.201 .........
New Mexico........................................ 0.411 0.407
New York.......................................... 0.374 0.529
North Carolina.................................... 0.45 0.439
North Dakota...................................... 0.418 0.469
Ohio.............................................. 0.39 0.548
Oklahoma.......................................... 0.328 0.43
Oregon............................................ 0.487 0.471
Pennsylvania...................................... 0.293 0.46
Puerto Rico....................................... 0.444 .........
Rhode Island...................................... 0.439 .........
South Carolina.................................... 0.31 0.34
South Dakota...................................... 0.382 0.485
Tennessee......................................... 0.331 0.397
Texas............................................. 0.294 0.377
Utah.............................................. 0.433 0.583
Vermont........................................... 0.577 0.621
Virginia.......................................... 0.385 0.383
Washington........................................ 0.444 0.494
West Virginia..................................... 0.49 0.476
Wisconsin......................................... 0.45 0.493
Wyoming........................................... 0.442 0.615
------------------------------------------------------------------------

Table 8B.--Statewide Average Capital Cost-to-Charge Ratios--July 2005
------------------------------------------------------------------------
State Ratio
------------------------------------------------------------------------
Alabama...................................................... 0.026
Alaska....................................................... 0.044
Arizona...................................................... 0.028
Arkansas..................................................... 0.029
California................................................... 0.018
Colorado..................................................... 0.03
Connecticut.................................................. 0.033
Delaware..................................................... 0.042
District of Columbia......................................... 0.027
Florida...................................................... 0.026
Georgia...................................................... 0.034
Hawaii....................................................... 0.034
Idaho........................................................ 0.038
Illinois..................................................... 0.029
Indiana...................................................... 0.04
Iowa......................................................... 0.031
Kansas....................................................... 0.032
Kentucky..................................................... 0.032
Louisiana.................................................... 0.032
Maine........................................................ 0.036
Maryland..................................................... 0.013
Massachusetts................................................ 0.037
Michigan..................................................... 0.034
Minnesota.................................................... 0.034
Mississippi.................................................. 0.032
Missouri..................................................... 0.029
Montana...................................................... 0.039
Nebraska..................................................... 0.039
Nevada....................................................... 0.02
New Hampshire................................................ 0.039
New Jersey................................................... 0.015
New Mexico................................................... 0.034
New York..................................................... 0.033
North Carolina............................................... 0.038
North Dakota................................................. 0.042
Ohio......................................................... 0.032
Oklahoma..................................................... 0.031
Oregon....................................................... 0.036
Pennsylvania................................................. 0.025
Puerto Rico.................................................. 0.033
Rhode Island................................................. 0.022
South Carolina............................................... 0.03
South Dakota................................................. 0.039
Tennessee.................................................... 0.033
Texas........................................................ 0.028
Utah......................................................... 0.039
Vermont...................................................... 0.045
Virginia..................................................... 0.039
Washington................................................... 0.036
West Virginia................................................ 0.034
Wisconsin.................................................... 0.038
Wyoming...................................................... 0.046
------------------------------------------------------------------------

Table 9A.--Hospital Reclassifications and Redesignations by Individual
Hospital and CBSA--FY 2006
------------------------------------------------------------------------
Geographic Reclassified
Provider No. CBSA CBSA Lugar
------------------------------------------------------------------------
010008............... 01 33860
010012............... 01 16860
010022............... 01 40660 Lugar
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
010164............... 01 11500 Lugar
030007............... 03 22380
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 26
040069............... 04 32820
040072............... 04 30780
040076............... 04 26300 Lugar
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
050054............... 40140 42044
050065............... 42044 31084
050069............... 42044 31084
050071............... 41940 36084
050073............... 46700 36084
050076............... 41884 36084
050089............... 40140 31084
050090............... 42220 41884
050099............... 40140 31084
050102............... 40140 42044
050118............... 44700 33700
050129............... 40140 31084

[[Page 47673]]

050136............... 42220 41884
050140............... 40140 31084
050150............... 05 40900
050168............... 42044 31084
050173............... 42044 31084
050174............... 42220 41884
050193............... 42044 31084
050224............... 42044 31084
050226............... 42044 31084
050228............... 41884 36084
050230............... 42044 31084
050243............... 40140 42044
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
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
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
060027............... 14500 19740
060044............... 06 19740
060049............... 06 22660
060096............... 06 19740
060103............... 14500 19740
070003............... 07 25540 Lugar
070015............... 25540 35644
070021............... 07 25540 Lugar
070033............... 14860 35644
080004............... 20100 48864
080007............... 08 36140
100022............... 33124 22744
100023............... 10 36740
100024............... 10 33124
100045............... 19660 36740
100049............... 10 29460
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
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 10
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
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
130018............... 13 38540
130049............... 17660 44060
130067............... 13 26820 Lugar
140012............... 14 16974
140015............... 14 41180
140032............... 14 41180
140034............... 14 41180
140040............... 14 37900
140043............... 14 40420
140046............... 14 41180
140058............... 14 41180
140061............... 14 41180
140064............... 14 37900
140093............... 19180 16580
140110............... 14 16974
140143............... 14 37900
140160............... 14 40420
140161............... 14 16974
140164............... 14 41180
140189............... 14 16580
140233............... 40420 16974
140234............... 14 37900
140236............... 14 28100 Lugar
140291............... 29404 16974
150002............... 23844 16974
150004............... 23844 16974
150006............... 33140 43780
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
150113............... 11300 26900
150125............... 23844 16974
150126............... 23844 16974
150132............... 23844 16974
150133............... 15 23060
150146............... 15 23060
150147............... 23844 16974
160001............... 16 11180
160016............... 16 19780
160026............... 16 11180 Lugar
160057............... 16 26980
160080............... 16 40420
160089............... 16 19780
160147............... 16 19780
170006............... 17 27900
170010............... 17 46140
170012............... 17 48620
170013............... 17 48620
170020............... 17 48620
170022............... 17 28140
170023............... 17 48620
170033............... 17 48620
170058............... 17 28140
170068............... 17 111100
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

[[Page 47674]]

180044............... 18 26580
180048............... 18 31140
180066............... 18 34980
180069............... 18 26580
180075............... 18 14540 Lugar
180078............... 18 26580
180080............... 18 30460
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
190106............... 19 10780
190131............... 12940 35380
190155............... 19 12940 Lugar
190164............... 19 10780
190191............... 19 12940
190223............... 19 12940 Lugar
200002............... 20 38860
200020............... 38860 40484
200024............... 30340 38860
200034............... 30340 38860
200039............... 20 38860
200050............... 20 12620
200063............... 20 38860
220001............... 49340 14484
220003............... 49340 14484
220010............... 21604 14484
220019............... 49340 14484
220025............... 49340 14484
220028............... 49340 14484
220029............... 21604 14484
220033............... 21604 14484
220035............... 21604 14484
220058............... 49340 14484
220060............... 14484 12700
220062............... 49340 14484
220077............... 44140 25540
220080............... 21604 14484
220090............... 49340 14484
220095............... 49340 14484
220163............... 49340 14484
220174............... 21604 14484
230022............... 23 11460
230030............... 23 40980
230035............... 23 24340 Lugar
230037............... 23 11460
230047............... 47644 19804
230054............... 23 24580
230069............... 47644 22420
230077............... 40980 22420
230080............... 23 40980
230093............... 23 24340
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
240013............... 24 33460
240018............... 24 33460
240030............... 24 41060
240031............... 41060 33460
240036............... 41060 33460
240052............... 24 22020
240064............... 24 20260
240069............... 24 40340
240071............... 24 40340
240075............... 24 41060
240088............... 24 41060
240093............... 24 33460
240105............... 24 40340 Lugar
240150............... 24 40340 Lugar
240152............... 24 33460
240187............... 24 33460
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
260017............... 26 41180
260022............... 26 16
260025............... 26 41180
260047............... 27620 17860
260049............... 26 44180 Lugar
260064............... 26 17860
260074............... 26 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
300005............... 30 31700
300011............... 31700 15764
300012............... 31700 15764
300019............... 30 15764
300020............... 31700 15764
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
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

[[Page 47675]]

340068............... 34 48900
340069............... 39580 20500
340071............... 34 39580 Lugar
340073............... 39580 20500
340109............... 34 47260
340114............... 39580 20500
340115............... 34 20500
340124............... 34 39580 Lugar
340126............... 34 39580
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
360095............... 36 30620
360096............... 36 49660 Lugar
360107............... 36 17460
360112............... 45780 11460
360121............... 36 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
380027............... 38 21660
380050............... 38 32780
390006............... 39 25420
390013............... 39 25420
390030............... 39 10900
390031............... 39 39740 Lugar
390048............... 39 25420
390052............... 39 11020
390065............... 39 47894
390066............... 30140 25420
390071............... 39 48700 Lugar
390079............... 39 13780
390086............... 39 44300
390091............... 39 49660
390093............... 39 38300
390110............... 27780 38300
390113............... 39 49660
390133............... 10900 37964
390138............... 39 47894
390150............... 39 38300 Lugar
390151............... 39 47894
390224............... 39 13780 Lugar
390246............... 39 48700
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
450073............... 45 10180
450080............... 45 30980
450087............... 23104 19124
450098............... 45 30980
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

[[Page 47676]]

490013............... 49 31340
490018............... 49 16820
490047............... 49 25500 Lugar
490079............... 49 49180
490092............... 49 40060
490105............... 49 28700
490106............... 49 16820
490109............... 47260 40060
500002............... 50 28420
500003............... 34580 42644
500016............... 48300 42644
500031............... 50 36500
500039............... 14740 42644
500041............... 31020 38900
500072............... 50 42644
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--FY 2006
----------------------------------------------------------------------------------------------------------------
Wage index CBSA
Provider No. Note Geographic Sec. 508 Own wage index
CBSA reclassification
----------------------------------------------------------------------------------------------------------------
010150................................... ................... 01 17980
020008................................... ................... 02 ................ 1.2828
050494................................... ................... 05 42220
050549................................... ................... 37100 42220
060057................................... ................... 06 19740
060075................................... ................... 06 ................ 1.1697
070001................................... ................... 35300 35004
070005................................... ................... 35300 35004
070006................................... * 14860 35644
070010................................... ................... 14860 35644
070016................................... ................... 35300 35004
070017................................... ................... 35300 35004
070018................................... * 14860 35644
070019................................... ................... 35300 35004
070022................................... ................... 35300 35004
070028................................... ................... 14860 35644
070031................................... ................... 35300 35004
070034................................... * 14860 35644
070036................................... ................... 25540 ................ 1.2913
070039................................... ................... 35300 35004
120025................................... ................... 12 26180
150034................................... ................... 23844 16974
160040................................... ................... 47940 16300
160064................................... ................... 16 ................ 1.0218
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

[[Page 47677]]

230072................................... ................... 26100 28020
230089................................... ................... 19804 11460
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
250078................................... * 25620 25060
250122................................... ................... 25 25060
270002................................... * 27 33540
270012................................... * 24500 33540
270021................................... ................... 27 13740
270023................................... ................... 33540 13740
270032................................... ................... 27 13740
270050................................... ................... 27 13740
270057................................... ................... 27 13740
270084................................... * 27 33540
310021................................... ................... 45940 35644
310028................................... ................... 35084 35644
310050................................... ................... 35084 35644
310051................................... ................... 35084 35644
310060................................... ................... 10900 35644
310115................................... ................... 10900 35644
310120................................... ................... 35084 35644
330023................................... * 39100 35644
330049................................... ................... 39100 35644
330067................................... * 39100 35644
330106................................... ................... 35004 ................ 1.4804
330126................................... ................... 39100 35644
330135................................... ................... 39100 35644
330205................................... ................... 39100 35644
330209................................... ................... 39100 35004
330264................................... ................... 39100 35004
340002................................... ................... 11700 16740
350002................................... ................... 13900 22020
350003................................... ................... 35 22020
350006................................... ................... 35 22020
350010................................... ................... 35 22020
350014................................... ................... 35 22020
350015................................... ................... 13900 22020
350017................................... ................... 35 22020
350019................................... * 24220 22020
350030................................... ................... 35 22020
350061................................... ................... 35 22020
380090................................... ................... 38 ................ 1.2303
390001................................... ................... 42540 10900
390003................................... ................... 39 10900
390054................................... ................... 42540 29540
390072................................... ................... 39 10900
390095................................... ................... 42540 10900
390109................................... ................... 42540 10900
390119................................... ................... 42540 10900
390137................................... ................... 42540 10900

[[Page 47678]]

390169................................... ................... 42540 10900
390185................................... ................... 42540 29540
390192................................... ................... 42540 10900
390237................................... ................... 42540 10900
390270................................... ................... 42540 29540
410010................................... ................... 39300 ................ 1.1734
430005................................... ................... 43 39660
430008................................... * 43 43620
430013................................... * 43 43620
430015................................... ................... 43 43620
430031................................... * 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
530008................................... * 53 16220
530010................................... * 53 16220
530015................................... ................... 53 ................ 0.9887
----------------------------------------------------------------------------------------------------------------
*These hospitals are assigned a wage index value under a special exceptions policy (see FY 2005 IPPS final
rule, 69 FR 49105).

Table 9C.--Hospitals Redesignated As Rural under Section 1886(d)(8)(E)of
the Act--FY 2006
------------------------------------------------------------------------
Geographic Redesignated
Provider No. CBSA rural area
------------------------------------------------------------------------
040075.................................. 22220 04
050192.................................. 23420 05
050469.................................. 40140 05
050528.................................. 32900 05
050618.................................. 40140 05
070004.................................. 25540 07
100048.................................. 37860 10
100134.................................. 27260 10
140167.................................. 00014 14
150051.................................. 14020 15
170137.................................. 29940 17
190048.................................. 26380 19
230042.................................. 26100 23
230078.................................. 35660 23
260006.................................. 41140 26
260195.................................. 44180 26
330268.................................. 10580 33
370054.................................. 36420 37
380040.................................. 13460 38
390181.................................. 00039 39
390183.................................. 00039 39
440135.................................. 34980 44
450052.................................. 00045 45
450078.................................. 10180 45
450243.................................. 10180 45
450276.................................. 48660 45
450348.................................. 00045 45
500122.................................. 00050 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)--JULY 2005 \1\
------------------------------------------------------------------------
Number of
DRG Cases Threshold
------------------------------------------------------------------------
1....................................... 23,405 $50,112
2....................................... 10,422 $34,822
3....................................... 4 $45,382
6....................................... 413 $15,921
7....................................... 15,520 $38,797
8....................................... 3,497 $28,679
9....................................... 1,970 $23,976
10...................................... 19,629 $23,222
11...................................... 3,284 $17,958
12...................................... 54,701 $17,426
13...................................... 7,421 $16,770
14...................................... 235,814 $23,807
15...................................... 76,451 $18,831
16...................................... 16,361 $24,322
17...................................... 3,005 $14,704
18...................................... 33,326 $19,739
19...................................... 8,606 $14,443
20...................................... 6,590 $38,390
21...................................... 2,218 $25,462
22...................................... 3,332 $21,992
23...................................... 10,796 $15,560
24...................................... 64,403 $19,693
25...................................... 28,327 $12,640
26...................................... 18 $22,199
27...................................... 5,461 $23,116
28...................................... 17,707 $23,770
29...................................... 6,341 $14,627
31...................................... 5,188 $19,178
32...................................... 2,029 $12,777
34...................................... 26,693 $19,711
35...................................... 7,684 $12,809
36...................................... 1,474 $14,633
37...................................... 1,252 $22,719
38...................................... 56 $14,203
39...................................... 449 $14,256
40...................................... 1,394 $19,743
42...................................... 1,155 $16,308
43...................................... 125 $11,917
44...................................... 1,170 $13,746
45...................................... 2,817 $15,155
46...................................... 3,835 $15,193
47...................................... 1,346 $10,774
49...................................... 2,490 $29,091
50...................................... 2,176 $17,333
51...................................... 191 $18,125
52...................................... 332 $16,799
53...................................... 2,257 $24,659
55...................................... 1,367 $18,802

[[Page 47679]]

56...................................... 447 $17,749
57...................................... 920 $20,414
59...................................... 105 $15,664
60...................................... 9 $15,242
61...................................... 222 $24,062
63...................................... 2,902 $24,985
64...................................... 3,369 $21,134
65...................................... 41,598 $12,272
66...................................... 8,051 $11,767
67...................................... 420 $15,477
68...................................... 17,469 $13,293
69...................................... 4,762 $9,900
70...................................... 26 $8,627
71...................................... 68 $15,085
72...................................... 1,073 $15,217
73...................................... 9,571 $17,094
74...................................... 4 $7,591
75...................................... 45,250 $45,002
76...................................... 47,634 $40,725
77...................................... 2,142 $24,059
78...................................... 45,875 $24,834
79...................................... 171,419 $27,473
80...................................... 7,512 $17,867
81...................................... 5 $28,450
82...................................... 65,487 $24,675
83...................................... 7,120 $19,618
84...................................... 1,472 $11,829
85...................................... 22,028 $23,434
86...................................... 1,824 $14,267
87...................................... 83,068 $24,812
88...................................... 415,631 $17,720
89...................................... 554,469 $20,598
90...................................... 44,452 $12,328
91...................................... 48 $16,648
92...................................... 16,675 $23,136
93...................................... 1,522 $14,651
94...................................... 13,466 $22,215
95...................................... 1,621 $12,301
96...................................... 60,087 $14,799
97...................................... 26,487 $10,920
98...................................... 9 $8,159
99...................................... 21,760 $14,405
100..................................... 6,914 $11,047
101..................................... 23,399 $17,489
102..................................... 5,199 $11,159
103..................................... 755 $213,786
104..................................... 21,060 $114,683
105..................................... 31,833 $86,722
106..................................... 3,543 $105,479
108..................................... 9,310 $83,192
110..................................... 56,310 $55,494
111..................................... 10,039 $41,761
113..................................... 37,457 $41,919
114..................................... 8,582 $28,228
117..................................... 5,172 $23,613
118..................................... 7,643 $30,997
119..................................... 998 $23,563
120..................................... 36,523 $33,864
121..................................... 160,146 $27,836
122..................................... 62,100 $19,640
123..................................... 33,782 $24,266
124..................................... 131,638 $27,647
125..................................... 96,574 $22,049
126..................................... 5,866 $39,226
127..................................... 698,888 $20,488
128..................................... 5,197 $13,933
129..................................... 3,774 $20,262
130..................................... 89,628 $18,627
131..................................... 23,926 $11,214
132..................................... 117,924 $12,607
133..................................... 7,325 $10,996
134..................................... 42,673 $12,392
135..................................... 7,482 $17,703
136..................................... 1,136 $12,755
138..................................... 208,101 $16,588
139..................................... 78,893 $10,661
140..................................... 38,450 $10,389
141..................................... 122,639 $15,323
142..................................... 52,421 $12,025
143..................................... 250,830 $11,593
144..................................... 100,553 $22,549
145..................................... 6,198 $11,859
146..................................... 10,813 $41,925
147..................................... 2,652 $29,209
148..................................... 136,334 $48,373
149..................................... 19,988 $28,480
150..................................... 22,833 $42,103
151..................................... 5,382 $25,607
152..................................... 5,039 $31,655
153..................................... 2,102 $21,743
154..................................... 28,654 $52,974
155..................................... 6,182 $25,854
156..................................... 6 $49,288
157..................................... 8,312 $24,166
158..................................... 4,126 $13,492
159..................................... 19,277 $26,228
160..................................... 12,043 $17,157
161..................................... 10,464 $23,437
162..................................... 5,515 $13,832
163..................................... 10 $14,000
164..................................... 5,991 $36,827
165..................................... 2,534 $23,727
166..................................... 4,976 $27,347
167..................................... 4,668 $17,898
168..................................... 1,565 $23,385
169..................................... 776 $14,845
170..................................... 17,580 $41,447
171..................................... 1,492 $24,444
172..................................... 33,073 $24,521
173..................................... 2,401 $15,446
174..................................... 268,990 $20,257
175..................................... 32,775 $11,560
176..................................... 14,617 $22,349
177..................................... 8,603 $18,603
178..................................... 2,920 $14,351
179..................................... 14,538 $21,599
180..................................... 92,638 $19,327
181..................................... 26,020 $11,449
182..................................... 293,794 $16,910
183..................................... 86,966 $12,054
184..................................... 81 $10,486
185..................................... 5,753 $17,250
186..................................... 4 $6,238
187..................................... 634 $16,858
188..................................... 91,481 $21,540
189..................................... 13,256 $12,410
190..................................... 70 $12,478
191..................................... 10,469 $51,233
192..................................... 1,328 $30,378
193..................................... 4,532 $47,362
194..................................... 523 $29,931
195..................................... 3,262 $46,669
196..................................... 703 $30,967
197..................................... 17,408 $38,874
198..................................... 4,645 $23,923
199..................................... 1,430 $35,852
200..................................... 942 $36,898
201..................................... 2,684 $48,681
202..................................... 27,457 $23,443
203..................................... 31,842 $24,227
204..................................... 73,292 $21,594
205..................................... 31,701 $21,723
206..................................... 2,087 $14,915
207..................................... 35,943 $22,789
208..................................... 9,819 $14,213
210..................................... 129,152 $33,582
211..................................... 26,760 $24,523
212..................................... 10 $26,859
213..................................... 10,325 $31,192
216..................................... 17,773 $33,187
217..................................... 17,785 $39,754
218..................................... 29,053 $29,997
219..................................... 21,541 $20,902
220..................................... 4 $28,868
223..................................... 13,572 $22,491
224..................................... 10,977 $16,523
225..................................... 6,608 $23,901
226..................................... 6,725 $26,967
227..................................... 5,124 $16,694
228..................................... 2,665 $23,174
229..................................... 1,216 $14,213
230..................................... 2,590 $24,625
232..................................... 733 $19,423
233..................................... 15,220 $32,286
234..................................... 7,736 $25,343
235..................................... 5,006 $14,886
236..................................... 42,644 $14,237
237..................................... 2,034 $12,297
238..................................... 9,936 $24,709
239..................................... 43,167 $21,069
240..................................... 12,749 $22,928
241..................................... 2,711 $13,362
242..................................... 2,758 $21,468
243..................................... 102,278 $15,522
244..................................... 15,860 $14,400
245..................................... 5,857 $9,430
246..................................... 1,437 $12,113
247..................................... 21,824 $11,771
248..................................... 15,208 $17,231
249..................................... 14,157 $13,978

[[Page 47680]]

250..................................... 4,195 $13,885
251..................................... 2,162 $9,734
253..................................... 25,058 $15,138
254..................................... 10,478 $9,255
256..................................... 7,212 $16,727
257..................................... 13,582 $17,867
258..................................... 12,093 $14,253
259..................................... 2,908 $19,367
260..................................... 2,991 $14,161
261..................................... 1,630 $19,578
262..................................... 641 $19,774
263..................................... 23,955 $30,672
264..................................... 3,942 $20,869
265..................................... 4,338 $26,784
266..................................... 2,331 $17,512
267..................................... 272 $18,006
268..................................... 1,038 $22,965
269..................................... 10,762 $28,834
270..................................... 2,658 $16,899
271..................................... 21,209 $19,563
272..................................... 5,962 $19,175
273..................................... 1,356 $11,513
274..................................... 2,304 $21,476
275..................................... 227 $11,209
276..................................... 1,450 $13,973
277..................................... 113,024 $17,133
278..................................... 34,015 $10,875
279..................................... 8 $16,892
280..................................... 19,484 $14,549
281..................................... 7,168 $10,009
283..................................... 6,300 $14,577
284..................................... 1,840 $9,181
285..................................... 7,694 $32,910
286..................................... 2,714 $32,554
287..................................... 6,159 $29,259
288..................................... 10,593 $34,864
289..................................... 6,917 $18,263
290..................................... 10,909 $17,602
291..................................... 67 $18,276
292..................................... 7,378 $38,188
293..................................... 368 $24,998
294..................................... 99,610 $15,030
295..................................... 4,138 $14,600
296..................................... 256,061 $16,155
297..................................... 45,533 $9,891
298..................................... 86 $10,485
299..................................... 1,497 $19,326
300..................................... 21,444 $21,582
301..................................... 3,908 $12,527
302..................................... 9,900 $49,840
303..................................... 23,847 $36,195
304..................................... 13,937 $35,431
305..................................... 3,103 $23,608
306..................................... 6,363 $23,807
307..................................... 2,074 $12,380
308..................................... 7,123 $27,016
309..................................... 3,582 $18,603
310..................................... 26,165 $23,337
311..................................... 6,522 $12,993
312..................................... 1,464 $22,392
313..................................... 513 $14,111
315..................................... 36,881 $32,144
316..................................... 181,946 $22,863
317..................................... 2,793 $16,038
318..................................... 5,961 $21,867
319..................................... 386 $13,276
320..................................... 219,905 $17,094
321..................................... 31,443 $11,415
322..................................... 65 $11,006
323..................................... 20,612 $16,786
324..................................... 5,447 $10,404
325..................................... 9,685 $13,024
326..................................... 2,595 $9,061
327..................................... 5 $5,735
328..................................... 611 $14,623
329..................................... 71 $10,100
331..................................... 55,165 $20,706
332..................................... 4,433 $12,522
333..................................... 259 $18,296
334..................................... 9,884 $28,157
335..................................... 12,033 $21,864
336..................................... 31,389 $16,654
337..................................... 25,251 $11,414
338..................................... 653 $24,778
339..................................... 1,259 $22,426
340..................................... 2 $18,747
341..................................... 3,196 $23,840
342..................................... 565 $17,333
344..................................... 2,702 $24,952
345..................................... 1,465 $21,814
346..................................... 3,991 $20,384
347..................................... 250 $12,534
348..................................... 4,202 $14,652
349..................................... 579 $8,745
350..................................... 7,188 $14,636
352..................................... 984 $14,886
353..................................... 2,736 $29,499
354..................................... 7,651 $27,759
355..................................... 4,945 $17,497
356..................................... 24,093 $14,919
357..................................... 5,584 $35,120
358..................................... 20,938 $22,649
359..................................... 28,904 $15,871
360..................................... 14,850 $17,215
361..................................... 276 $22,374
362..................................... 2 $11,740
363..................................... 2,143 $19,913
364..................................... 1,464 $17,689
365..................................... 1,628 $30,015
366..................................... 4,820 $22,232
367..................................... 459 $11,968
368..................................... 3,939 $22,092
369..................................... 3,643 $12,841
370..................................... 1,888 $17,385
371..................................... 2,304 $11,896
372..................................... 1,177 $9,775
373..................................... 4,955 $7,031
374..................................... 160 $13,121
375..................................... 5 $22,537
376..................................... 403 $10,215
377..................................... 78 $23,287
378..................................... 196 $15,726
379..................................... 510 $7,170
380..................................... 93 $7,850
381..................................... 217 $12,532
382..................................... 43 $4,116
383..................................... 2,514 $9,798
384..................................... 134 $6,368
389..................................... 2 $193,336
390..................................... 2 $20,529
392..................................... 2,223 $42,569
394..................................... 2,839 $28,560
395..................................... 116,763 $16,487
396..................................... 10 $14,834
397..................................... 18,541 $21,173
398..................................... 18,411 $22,559
399..................................... 1,648 $13,702
401..................................... 6,365 $40,602
402..................................... 1,412 $23,453
403..................................... 32,022 $27,810
404..................................... 3,817 $18,926
406..................................... 2,235 $39,723
407..................................... 587 $24,616
408..................................... 2,183 $30,932
409..................................... 1,817 $22,452
410..................................... 28,552 $22,154
411..................................... 12 $7,098
412..................................... 12 $16,529
413..................................... 5,226 $23,470
414..................................... 574 $16,033
415..................................... 51,145 $48,904
416..................................... 240,228 $26,693
417..................................... 22 $17,612
418..................................... 28,775 $20,650
419..................................... 16,423 $17,053
420..................................... 2,930 $12,337
421..................................... 11,946 $14,869
422..................................... 53 $10,931
423..................................... 8,701 $26,984
424..................................... 1,078 $33,194
425..................................... 14,886 $12,559
426..................................... 4,353 $9,541
427..................................... 1,519 $10,475
428..................................... 776 $13,581
429..................................... 25,609 $15,540
430..................................... 71,973 $12,801
431..................................... 309 $10,477
432..................................... 422 $12,749
433..................................... 5,225 $5,600
439..................................... 1,756 $27,865
440..................................... 5,669 $27,803
441..................................... 786 $18,799
442..................................... 18,168 $34,984
443..................................... 3,415 $20,268
444..................................... 5,954 $14,880
445..................................... 2,369 $10,345
447..................................... 6,294 $10,673
449..................................... 39,238 $16,570
450..................................... 7,826 $8,664
451..................................... 3 $5,773

[[Page 47681]]

452..................................... 27,878 $20,075
453..................................... 5,492 $10,737
454..................................... 3,876 $15,906
455..................................... 853 $9,747
461..................................... 2,752 $24,473
462..................................... 7,828 $16,918
463..................................... 31,267 $13,853
464..................................... 7,673 $10,274
465..................................... 226 $12,400
466..................................... 1,429 $13,649
467..................................... 1,023 $9,734
468..................................... 50,764 $52,876
470..................................... 502 $64,232
471..................................... 15,627 $52,323
473..................................... 8,835 $35,986
475..................................... 117,155 $48,272
476..................................... 3,038 $34,031
477..................................... 29,597 $30,919
479..................................... 24,817 $28,352
480..................................... 821 $117,571
481..................................... 1,098 $82,815
482..................................... 5,206 $46,279
484..................................... 468 $72,010
485..................................... 3,471 $48,251
486..................................... 2,662 $63,364
487..................................... 4,802 $29,883
488..................................... 798 $55,257
489..................................... 13,579 $26,429
490..................................... 5,254 $20,265
491..................................... 19,917 $32,894
492..................................... 4,032 $41,888
493..................................... 61,952 $31,960
494..................................... 25,682 $20,733
495..................................... 311 $106,522
496..................................... 3,537 $87,344
497..................................... 27,848 $55,870
498..................................... 19,209 $46,173
499..................................... 35,943 $26,528
500..................................... 48,831 $18,113
501..................................... 3,143 $40,031
502..................................... 721 $27,568
503..................................... 5,980 $24,309
504..................................... 189 $134,049
505..................................... 181 $24,546
506..................................... 1,010 $48,681
507..................................... 311 $29,068
508..................................... 645 $21,865
509..................................... 171 $14,860
510..................................... 1,774 $20,128
511..................................... 636 $12,654
512..................................... 539 $78,167
513..................................... 233 $94,790
515..................................... 44,891 $85,654
518..................................... 25,965 $31,491
519..................................... 11,647 $40,559
520..................................... 15,488 $32,459
521..................................... 32,428 $13,578
522..................................... 5,680 $9,558
523..................................... 15,979 $7,628
524..................................... 119,534 $14,814
525..................................... 314 $134,845
528..................................... 1,777 $99,303
529..................................... 4,046 $35,002
530..................................... 2,369 $24,213
531..................................... 4,846 $42,213
532..................................... 2,659 $26,414
533..................................... 47,837 $28,289
534..................................... 45,427 $20,389
535..................................... 7,457 $120,243
536..................................... 8,117 $105,754
537..................................... 8,715 $30,405
538..................................... 5,648 $19,992
539..................................... 5,040 $41,927
540..................................... 1,517 $24,005
541..................................... 22,708 $240,567
542..................................... 24,483 $153,747
543..................................... 5,468 $59,942
544..................................... 420,959 $36,819
545..................................... 42,611 $41,350
546..................................... 2,241 $74,614
547..................................... 35,636 $90,627
548..................................... 34,824 $74,108
549..................................... 14,479 $74,286
550..................................... 36,399 $58,866
551..................................... 56,969 $49,706
552..................................... 84,578 $38,275
553..................................... 38,749 $44,392
554..................................... 75,669 $34,300
555..................................... 72,073 $40,910
556..................................... 49,856 $35,707
557..................................... 95,205 $48,043
558..................................... 154,831 $40,079
559..................................... 2,258 $37,803
------------------------------------------------------------------------
\1\ Cases taken from the FY 2004 MedPAR file; DRGs are from GROUPER
Version 23.0.

Table 11.--FY 2006 LTC-DRGs, Relative Weights, Geometric Average Length
of Stay, and 5/6ths of the Geometric Average Length of Stay
------------------------------------------------------------------------
5/6th of
Geometric the
Relative average geometric
LTC-DRG Description weight length of average
stay length of
stay
------------------------------------------------------------------------
1.............. \5\ CRANIOTOMY 1.7034 38.5 32.1
AGE >17 W CC.
2.............. \7\ CRANIOTOMY 1.7034 38.5 32.1
AGE > 17 W/O CC.
3.............. \7\ CRANIOTOMY 1.7034 38.5 32.1
AGE 0-17.
6.............. \7\ CARPAL 0.4499 19.0 15.8
TUNNEL RELEASE.
7.............. PERIPH & CRANIAL 1.3984 37.7 31.4
NERVE & OTHER
NERV SYST PROC
W CC.
8.............. \3\ PERIPH & 0.7637 24.8 20.7
CRANIAL NERVE &
OTHER NERV SYST
PROC W/O CC.
9.............. SPINAL DISORDERS 0.9720 33.7 28.1
& INJURIES.
10............. NERVOUS SYSTEM 0.7554 24.5 20.4
NEOPLASMS W CC.
11............. \2\ NERVOUS 0.5837 21.3 17.8
SYSTEM
NEOPLASMS W/O
CC.
12............. DEGENERATIVE 0.6851 25.5 21.3
NERVOUS SYSTEM
DISORDERS.
13............. MULTIPLE 0.6531 23.1 19.3
SCLEROSIS &
CEREBELLAR
ATAXIA.
14............. INTERCRANIAL 0.7783 26.0 21.7
HEMORRHAGE OR
STROKE WITH
INFARCT.
15............. NONSPECIFIC CVA 0.7314 26.8 22.3
& PRECEREBRAL
OCCULUSION
WITHOUT INFARCT.
16............. NONSPECIFIC 0.7471 23.5 19.6
CEREBROVASCULAR
DISORDERS W CC.
17............. \1\NONSPECIFIC 0.4499 19.0 15.8
CEREBROVASCULAR
DISORDERS W/O
CC.
18............. CRANIAL & 0.7197 23.6 19.7
PERIPHERAL
NERVE DISORDERS
W CC.
19............. CRANIAL & 0.4773 21.2 17.7
PERIPHERAL
NERVE DISORDERS
W/O CC.
20............. NERVOUS SYSTEM 1.0277 27.2 22.7
INFECTION
EXCEPT VIRAL
MENINGITIS.

[[Page 47682]]

21............. \3\ VIRAL 0.7637 24.8 20.7
MENINGITIS.
22............. \4\ HYPERTENSIVE 1.1820 29.6 24.7
ENCEPHALOPATHY.
23............. NONTRAUMATIC 0.8054 25.4 21.2
STUPOR & COMA.
24............. SEIZURE & 0.6251 22.6 18.8
HEADACHE AGE
>17 W CC.
25............. \1\ SEIZURE & 0.4499 19.0 15.8
HEADACHE AGE
>17 W/O CC.
26............. \7\ SEIZURE & 0.4499 19.0 15.8
HEADACHE AGE 0-
17.
27............. TRAUMATIC STUPOR 0.9444 27.1 22.6
& COMA, COMA >1
HR.
28............. TRAUMATIC STUPOR 0.8890 30.2 25.2
& COMA, COMA <1
HR AGE >17 W CC.
29............. \2\ TRAUMATIC 0.5837 21.3 17.8
STUPOR & COMA,
COMA <1 HR AGE
>17 W/O CC.
30............. \7\ TRAUMATIC 0.5837 21.3 17.8
STUPOR & COMA,
COMA <1 HR AGE
0-17.
31............. \3\ CONCUSSION 0.7637 24.8 20.7
AGE >17 W CC.
32............. \7\ CONCUSSION 0.4499 19.0 15.8
AGE >17 W/O CC.
33............. \7\ CONCUSSION 0.4499 19.0 15.8
AGE 0-17.
34............. OTHER DISORDERS 0.8004 25.3 21.1
OF NERVOUS
SYSTEM W CC.
35............. OTHER DISORDERS 0.5698 24.2 20.2
OF NERVOUS
SYSTEM W/O CC.
36............. \7\ RETINAL 1.1820 29.6 24.7
PROCEDURES.
37............. \7\ ORBITAL 1.1820 29.6 24.7
PROCEDURES.
38............. \7\ PRIMARY IRIS 1.1820 29.6 24.7
PROCEDURES.
39............. \7\ LENS 1.1820 29.6 24.7
PROCEDURES WITH
OR WITHOUT
VITRECTOMY.
40............. \4\ EXTRAOCULAR 1.1820 29.6 24.7
PROCEDURES
EXCEPT ORBIT
AGE >17.
41............. \7\ EXTRAOCULAR 1.1820 29.6 24.7
PROCEDURES
EXCEPT ORBIT
AGE 0-17.
42............. \7\ INTRAOCULAR 1.1820 29.6 24.7
PROCEDURES
EXCEPT RETINA,
IRIS & LENS.
43............. \7\ HYPHEMA..... 1.1820 29.6 24.7
44............. \2\ ACUTE MAJOR 0.5837 21.3 17.8
EYE INFECTIONS.
45............. \7\ NEUROLOGICAL 1.1820 29.6 24.7
EYE DISORDERS.
46............. \2\ OTHER 0.5837 21.3 17.8
DISORDERS OF
THE EYE AGE >17
W CC.
47............. \7\ OTHER 1.1820 29.6 24.7
DISORDERS OF
THE EYE AGE >17
W/O CC.
48............. \7\ OTHER 1.1820 29.6 24.7
DISORDERS OF
THE EYE AGE 0-
17.
49............. \7\ MAJOR HEAD & 1.1820 29.6 24.7
NECK PROCEDURES.
50............. S7 1.1820 29.6 24.7
IALOADENECTOMY.
51............. \7\ SALIVARY 1.1820 29.6 24.7
GLAND
PROCEDURES
EXCEPT
SIALOADENECTOMY.
52............. \7\ CLEFT LIP & 1.1820 29.6 24.7
PALATE REPAIR.
53............. \7\ SINUS & 1.1820 29.6 24.7
MASTOID
PROCEDURES AGE
>17.
54............. \7\ SINUS & 1.1820 29.6 24.7
MASTOID
PROCEDURES AGE
0-17.
55............. \7\ 1.1820 29.6 24.7
MISCELLANEOUS
EAR, NOSE,
MOUTH & THROAT
PROCEDURES.
56............. \7\ RHINOPLASTY. 1.1820 29.6 24.7
57............. \7\ T&A PROC, 0.4499 19.0 15.8
EXCEPT
TONSILLECTOMY &/
OR
ADENOIDECTOMY
ONLY, AGE >17.
58............. \7\ T&A PROC, 0.4499 19.0 15.8
EXCEPT
TONSILLECTOMY &/
OR
ADENOIDECTOMY
ONLY, AGE 0-17.
59............. \7\ 0.4499 19.0 15.8
TONSILLECTOMY &/
OR
ADENOIDECTOMY
ONLY, AGE >17.
60............. \7\ 0.4499 19.0 15.8
TONSILLECTOMY &/
OR
ADENOIDECTOMY
ONLY, AGE 0-17.
61............. \3\ MYRINGOTOMY 0.7637 24.8 20.7
W TUBE
INSERTION AGE
>17.
62............. \7\ MYRINGOTOMY 0.4499 19.0 15.8
W TUBE
INSERTION AGE 0-
17.
63............. \4\ OTHER EAR, 1.1820 29.6 24.7
NOSE, MOUTH &
THROAT O.R.
PROCEDURES.
64............. EAR, NOSE, MOUTH 1.1480 26.2 21.8
& THROAT
MALIGNANCY.
65............. \1\ 0.4499 19.0 15.8
DYSEQUILIBRIUM.
66............. \7\ EPISTAXIS... 0.4499 19.0 15.8
67............. \3\ EPIGLOTTITIS 0.7637 24.8 20.7
68............. OTITIS MEDIA & 0.5111 18.0 15
URI AGE >17
W CC.
69............. \1\ OTITIS MEDIA 0.4499 19.0 15.8
& URI AGE
>17 W/O CC.
70............. \7\ OTITIS MEDIA 0.4499 19.0 15.8
& URI AGE 0-17.
71............. \7\ 0.5837 21.3 17.8
LARYNGOTRACHEIT
IS.
72............. \7\ NASAL TRAUMA 0.7637 24.8 20.7
& DEFORMITY.
73............. OTHER EAR, NOSE, 0.7535 21.9 18.3
MOUTH & THROAT
DIAGNOSES AGE
>17.
74............. \7\ OTHER EAR, 0.4499 19.0 15.8
NOSE, MOUTH &
THROAT
DIAGNOSES AGE 0-
17.
75............. \5\ MAJOR CHEST 1.7034 38.5 32.1
PROCEDURES.
76............. OTHER RESP 2.5523 43.9 36.6
SYSTEM O.R.
PROCEDURES W CC.
77............. \5\ OTHER RESP 1.7034 38.5 32.1
SYSTEM O.R.
PROCEDURES W/O
CC.
78............. PULMONARY 0.6900 21.9 18.3
EMBOLISM.
79............. RESPIRATORY 0.8280 22.9 19.1
INFECTIONS &
INFLAMMATIONS
AGE >17 W CC.
80............. RESPIRATORY 0.5986 21.7 18.1
INFECTIONS &
INFLAMMATIONS
AGE >17 W/O CC.
81............. \7\ RESPIRATORY 0.4499 19.0 15.8
INFECTIONS &
INFLAMMATIONS
AGE 0-17.
82............. RESPIRATORY 0.7174 20.1 16.8
NEOPLASMS.
83............. \2\ MAJOR CHEST 0.5837 21.3 17.8
TRAUMA W CC.
84............. \7\ MAJOR CHEST 0.5837 21.3 17.8
TRAUMA W/O CC.
85............. PLEURAL EFFUSION 0.7264 21.2 17.7
W CC.
86............. \1\ PLEURAL 0.4499 19.0 15.8
EFFUSION W/O CC.

[[Page 47683]]

87............. PULMONARY EDEMA 1.0816 25.4 21.2
& RESPIRATORY
FAILURE.
88............. CHRONIC 0.6585 19.6 16.3
OBSTRUCTIVE
PULMONARY
DISEASE.
89............. SIMPLE PNEUMONIA 0.6987 20.8 17.3
& PLEURISY AGE
>17 W CC.
90............. SIMPLE PNEUMONIA 0.4970 17.8 14.8
& PLEURISY AGE
>17 W/O CC.
91............. \7\ SIMPLE 0.4499 19.0 15.8
PNEUMONIA &
PLEURISY AGE 0-
17.
92............. INTERSTITIAL 0.6704 20.2 16.8
LUNG DISEASE W
CC.
93............. \2\ INTERSTITIAL 0.5837 21.3 17.8
LUNG DISEASE W/
O CC.
94............. PNEUMOTHORAX W 0.5880 17.0 14.2
CC.
95............. \1\ PNEUMOTHORAX 0.4499 19.0 15.8
W/O CC.
96............. BRONCHITIS & 0.6417 19.4 16.2
ASTHMA AGE >17
W CC.
97............. \2\ BRONCHITIS & 0.5837 21.3 17.8
ASTHMA AGE >17
W/O CC.
98............. \7\ BRONCHITIS & 0.5837 21.3 17.8
ASTHMA AGE 0-17.
99............. RESPIRATORY 0.9219 23.2 19.3
SIGNS &
SYMPTOMS W CC.
100............ \3\ RESPIRATORY 0.7637 24.8 20.7
SIGNS &
SYMPTOMS W/O CC.
101............ OTHER 0.8147 21.1 17.6
RESPIRATORY
SYSTEM
DIAGNOSES W CC.
102............ \1\ OTHER 0.4499 19.0 15.8
RESPIRATORY
SYSTEM
DIAGNOSES W/O
CC.
103............ \6\ HEART 0.0000 0.0 0
TRANSPLANT OR
IMPLANT OF
HEART ASSIST
SYSTEM.
104............ \7\ CARDIAC 0.7637 24.8 20.7
VALVE & OTHER
MAJOR
CARDIOTHORACIC
PROC W CARDIAC
CATH.
105............ \7\ CARDIAC 0.7637 24.8 20.7
VALVE & OTHER
MAJOR
CARDIOTHORACIC
PROC W/O
CARDIAC CATH.
106............ \7\ CORONARY 0.7637 24.8 20.7
BYPASS W PTCA.
108............ \7\ OTHER 0.7637 24.8 20.7
CARDIOTHORACIC
PROCEDURES.
110............ \3\ MAJOR 0.7637 24.8 20.7
CARDIOVASCULAR
PROCEDURES W CC.
111............ \7\ MAJOR 0.7637 24.8 20.7
CARDIOVASCULAR
PROCEDURES W/O
CC.
113............ AMPUTATION FOR 1.4887 39.3 32.8
CIRC SYSTEM
DISORDERS
EXCEPT UPPER
LIMB & TOE.
114............ UPPER LIMB & TOE 1.2389 33.2 27.7
AMPUTATION FOR
CIRC SYSTEM
DISORDERS.
117............ \4\ CARDIAC 1.1820 29.6 24.7
PACEMAKER
REVISION EXCEPT
DEVICE
REPLACEMENT.
118............ \4\ CARDIAC 1.1820 29.6 24.7
PACEMAKER
DEVICE
REPLACEMENT.
119............ \3\ VEIN 0.7637 24.8 20.7
LIGATION &
STRIPPING.
120............ OTHER 1.0979 31.7 26.4
CIRCULATORY
SYSTEM O.R.
PROCEDURES.
121............ CIRCULATORY 0.8429 23.2 19.3
DISORDERS W AMI
& MAJOR COMP,
DISCHARGED
ALIVE.
122............ \2\ CIRCULATORY 0.5837 21.3 17.8
DISORDERS W AMI
W/O MAJOR COMP,
DISCHARGED
ALIVE.
123............ CIRCULATORY 1.1811 20.4 17
DISORDERS W
AMI, EXPIRED.
124............ \4\ CIRCULATORY 1.1820 29.6 24.7
DISORDERS
EXCEPT AMI, W
CARD CATH &
COMPLEX DIAG.
125............ \3\ CIRCULATORY 0.7637 24.8 20.7
DISORDERS
EXCEPT AMI, W
CARD CATH W/O
COMPLEX DIAG.
126............ ACUTE & SUBACUTE 0.8386 25.3 21.1
ENDOCARDITIS.
127............ HEART FAILURE & 0.6857 21.2 17.7
SHOCK.
128............ \2\ DEEP VEIN 0.5837 21.3 17.8
THROMBOPHLEBITI
S.
129............ \7\ CARDIAC 0.7637 24.8 20.7
ARREST,
UNEXPLAINED.
130............ PERIPHERAL 0.6741 23.2 19.3
VASCULAR
DISORDERS W CC.
131............ PERIPHERAL 0.4675 20.4 17
VASCULAR
DISORDERS W/O
CC.
132............ ATHEROSCLEROSIS 0.6565 21.8 18.2
W CC.
133............ \1\ 0.4499 19.0 15.8
ATHEROSCLEROSIS
W/O CC.
134............ HYPERTENSION.... 0.6354 24.8 20.7
135............ CARDIAC 0.7211 23.7 19.8
CONGENITAL &
VALVULAR
DISORDERS AGE
>17 W CC.
136............ \2\ CARDIAC 0.5837 21.3 17.8
CONGENITAL &
VALVULAR
DISORDERS AGE
>17 W/O CC.
137............ \7\ CARDIAC 0.5837 21.3 17.8
CONGENITAL &
VALVULAR
DISORDERS AGE 0-
17.
138............ CARDIAC 0.6201 20.5 17.1
ARRHYTHMIA &
CONDUCTION
DISORDERS W CC.
139............ \2\ CARDIAC 0.5837 21.3 17.8
ARRHYTHMIA &
CONDUCTION
DISORDERS W/O
CC.
140............ \1\ ANGINA 0.4499 19.0 15.8
PECTORIS.
141............ \8\ SYNCOPE & 0.4271 18.3 15.3
COLLAPSE W CC.
142............ \8\ SYNCOPE & 0.4271 18.3 15.3
COLLAPSE W/O CC.
143............ \1\ CHEST PAIN.. 0.4499 19.0 15.8
144............ OTHER 0.7413 21.7 18.1
CIRCULATORY
SYSTEM
DIAGNOSES W CC.
145............ OTHER 0.4568 18.2 15.2
CIRCULATORY
SYSTEM
DIAGNOSES W/O
CC.
146............ \7\ RECTAL 1.7034 38.5 32.1
RESECTION W CC.
147............ \7\ RECTAL 1.7034 38.5 32.1
RESECTION W/O
CC.
148............ MAJOR SMALL & 1.8616 40.9 34.1
LARGE BOWEL
PROCEDURES W CC.
149............ \7\ MAJOR SMALL 0.7637 24.8 20.7
& LARGE BOWEL
PROCEDURES W/O
CC.
150............ \4\ PERITONEAL 1.1820 29.6 24.7
ADHESIOLYSIS W
CC.
151............ \2\ PERITONEAL 0.5837 21.3 17.8
ADHESIOLYSIS W/
O CC.
152............ \3\ MINOR SMALL 0.7637 24.8 20.7
& LARGE BOWEL
PROCEDURES W CC.
153............ \7\ MINOR SMALL 0.7637 24.8 20.7
& LARGE BOWEL
PROCEDURES W/O
CC.
154............ \5\ STOMACH, 1.7034 38.5 32.1
ESOPHAGEAL &
DUODENAL
PROCEDURES AGE
>17 W CC.
155............ \7\ STOMACH, 1.7034 38.5 32.1
ESOPHAGEAL &
DUODENAL
PROCEDURES AGE
>17 W/O CC.
156............ \7\ STOMACH, 1.7034 38.5 32.1
ESOPHAGEAL &
DUODENAL
PROCEDURES AGE
0-17.

[[Page 47684]]

157............ \4\ ANAL & 1.1820 29.6 24.7
STOMAL
PROCEDURES W CC.
158............ \7\ ANAL & 1.1820 29.6 24.7
STOMAL
PROCEDURES W/O
CC.
159............ \7\ HERNIA 0.7637 24.8 20.7
PROCEDURES
EXCEPT INGUINAL
& FEMORAL AGE
>17 W CC.
160............ \7\ HERNIA 0.7637 24.8 20.7
PROCEDURES
EXCEPT INGUINAL
& FEMORAL AGE
>17 W/O CC.
161............ \5\ INGUINAL & 1.7034 38.5 32.1
FEMORAL HERNIA
PROCEDURES AGE
>17 W CC.
162............ \7\ INGUINAL & 0.7637 24.8 20.7
FEMORAL HERNIA
PROCEDURES AGE
>17 W/O CC.
163............ \7\ HERNIA 0.7637 24.8 20.7
PROCEDURES AGE
0-17.
164............ \1\ APPENDECTOMY 1.7034 38.5 32.1
W COMPLICATED
PRINCIPAL DIAG
W CC.
165............ \7\ APPENDECTOMY 1.7034 38.5 32.1
W COMPLICATED
PRINCIPAL DIAG
W/O CC.
166............ \7\ APPENDECTOMY 1.7034 38.5 32.1
W/O COMPLICATED
PRINCIPAL DIAG
W CC.
167............ \7\ APPENDECTOMY 1.7034 38.5 32.1
W/O COMPLICATED
PRINCIPAL DIAG
W/O CC.
168............ \4\ MOUTH 1.1820 29.6 24.7
PROCEDURES W CC.
169............ \7\ MOUTH 0.7637 24.8 20.7
PROCEDURES W/O
CC.
170............ OTHER DIGESTIVE 1.6271 35.9 29.9
SYSTEM O.R.
PROCEDURES W CC.
171............ \1\ OTHER 0.4499 19.0 15.8
DIGESTIVE
SYSTEM O.R.
PROCEDURES W/O
CC.
172............ DIGESTIVE 0.8553 21.8 18.2
MALIGNANCY W CC.
173............ \2\ DIGESTIVE 0.5837 21.3 17.8
MALIGNANCY W/O
CC.
174............ G.I. HEMORRHAGE 0.7119 22.2 18.5
W CC.
175............ \1\ G.I. 0.4499 19.0 15.8
HEMORRHAGE W/O
CC.
176............ COMPLICATED 0.8426 21.5 17.9
PEPTIC ULCER.
177............ \3\ 0.7637 24.8 20.7
UNCOMPLICATED
PEPTIC ULCER W
CC.
178............ \3\ 0.7637 24.8 20.7
UNCOMPLICATED
PEPTIC ULCER W/
O CC.
179............ INFLAMMATORY 0.9675 24.0 20
BOWEL DISEASE.
180............ G.I. OBSTRUCTION 0.9375 23.5 19.6
W CC.
181............ \3\ G.I. 0.7637 24.8 20.7
OBSTRUCTION W/O
CC.
182............ ESOPHAGITIS, 0.7745 22.6 18.8
GASTROENT &
MISC DIGEST
DISORDERS AGE
>17 W CC.
183............ ESOPHAGITIS, 0.3870 16.8 14
GASTROENT &
MISC DIGEST
DISORDERS AGE
>17 W/O CC.
184............ \7\ ESOPHAGITIS, 0.4499 19.0 15.8
GASTROENT &
MISC DIGEST
DISORDERS AGE 0-
17.
185............ \3\ DENTAL & 0.7637 24.8 20.7
ORAL DIS EXCEPT
EXTRACTIONS &
RESTORATIONS,
AGE >17.
186............ \7\ DENTAL & 0.7637 24.8 20.7
ORAL DIS EXCEPT
EXTRACTIONS &
RESTORATIONS,
AGE 0-17.
187............ \7\ DENTAL 0.7637 24.8 20.7
EXTRACTIONS &
RESTORATIONS.
188............ OTHER DIGESTIVE 0.9952 24.0 20
SYSTEM
DIAGNOSES AGE
>17 W CC.
189............ OTHER DIGESTIVE 0.4707 18.2 15.2
SYSTEM
DIAGNOSES AGE
>17 W/O CC.
190............ \7\ OTHER 0.4499 19.0 15.8
DIGESTIVE
SYSTEM
DIAGNOSES AGE 0-
17.
191............ \4\ PANCREAS, 1.1820 29.6 24.7
LIVER & SHUNT
PROCEDURES W CC.
192............ \7\ PANCREAS, 1.1820 29.6 24.7
LIVER & SHUNT
PROCEDURES W/O
CC.
193............ \3\ BILIARY 0.7637 24.8 20.7
TRACT PROC
EXCEPT ONLY
CHOLECYST W OR
W/O C.D.E. W CC.
194............ \7\ BILIARY 0.7637 24.8 20.7
TRACT PROC
EXCEPT ONLY
CHOLECYST W OR
W/O C.D.E. W/O
CC.
195............ \3\ 0.7637 24.8 20.7
CHOLECYSTECTOMY
W C.D.E. W CC.
196............ \7\ 0.7637 24.8 20.7
CHOLECYSTECTOMY
W C.D.E. W/O CC.
197............ \3\ 0.7637 24.8 20.7
CHOLECYSTECTOMY
EXCEPT BY
LAPAROSCOPE W/O
C.D.E. W CC.
198............ \7\ 0.7637 24.8 20.7
CHOLECYSTECTOMY
EXCEPT BY
LAPAROSCOPE W/O
C.D.E. W/O CC.
199............ \7\ 1.7034 38.5 32.1
HEPATOBILIARY
DIAGNOSTIC
PROCEDURE FOR
MALIGNANCY.
200............ \5\ 1.7034 38.5 32.1
HEPATOBILIARY
DIAGNOSTIC
PROCEDURE FOR
NON-MALIGNANCY.
201............ OTHER 2.0371 36.1 30.1
HEPATOBILIARY
OR PANCREAS
O.R. PROCEDURES.
202............ CIRRHOSIS & 0.6610 20.6 17.2
ALCOHOLIC
HEPATITIS.
203............ MALIGNANCY OF 0.7896 19.5 16.3
HEPATOBILIARY
SYSTEM OR
PANCREAS.
204............ DISORDERS OF 0.9441 22.7 18.9
PANCREAS EXCEPT
MALIGNANCY.
205............ DISORDERS OF 0.6642 20.5 17.1
LIVER EXCEPT
MALIG,CIRR,ALC
HEPA W CC.
206............ \2\ DISORDERS OF 0.5837 21.3 17.8
LIVER EXCEPT
MALIG,CIRR,ALC
HEPA W/O CC.
207............ DISORDERS OF THE 0.7570 21.5 17.9
BILIARY TRACT W
CC.
208............ \2\ DISORDERS OF 0.5837 21.3 17.8
THE BILIARY
TRACT W/O CC.
210............ \5\ HIP & FEMUR 1.7034 38.5 32.1
PROCEDURES
EXCEPT MAJOR
JOINT AGE >17 W
CC.
211............ \4\ HIP & FEMUR 1.1820 29.6 24.7
PROCEDURES
EXCEPT MAJOR
JOINT AGE >17 W/
O CC.
212............ \7\ HIP & FEMUR 1.7034 38.5 32.1
PROCEDURES
EXCEPT MAJOR
JOINT AGE 0-17.
213............ AMPUTATION FOR 1.1948 34.0 28.3
MUSCULOSKELETAL
SYSTEM & CONN
TISSUE
DISORDERS.
216............ \4\ BIOPSIES OF 1.1820 29.6 24.7
MUSCULOSKELETAL
SYSTEM &
CONNECTIVE
TISSUE.
217............ WND DEBRID & SKN 1.2927 38.0 31.7
GRFT EXCEPT
HAND,FOR
MUSCSKELET &
CONN TISS DIS.
218............ \5\ LOWER EXTREM 1.7034 38.5 32.1
& HUMER PROC
EXCEPT
HIP,FOOT,FEMUR
AGE >17 W CC.
219............ \1\ LOWER EXTREM 0.4499 19.0 15.8
& HUMER PROC
EXCEPT
HIP,FOOT,FEMUR
AGE >17 W/O CC.
220............ \7\ LOWER EXTREM 1.7034 38.5 32.1
& HUMER PROC
EXCEPT
HIP,FOOT,FEMUR
AGE 0-17.
223............ \3\ MAJOR 0.7637 24.8 20.7
SHOULDER/ELBOW
PROC, OR OTHER
UPPER EXTREMITY
PROC W CC.
224............ \7\ 0.7637 24.8 20.7
SHOULDER,ELBOW
OR FOREARM
PROC,EXC MAJOR
JOINT PROC, W/O
CC.
225............ FOOT PROCEDURES. 0.9869 28.4 23.7
226............ SOFT TISSUE 0.9443 29.5 24.6
PROCEDURES W CC.
227............ \3\ SOFT TISSUE 0.7637 24.8 20.7
PROCEDURES W/O
CC.

[[Page 47685]]

228............ \4\ MAJOR THUMB 1.1820 29.6 24.7
OR JOINT
PROC,OR OTH
HAND OR WRIST
PROC W CC.
229............ \7\ HAND OR 0.4499 19.0 15.8
WRIST PROC,
EXCEPT MAJOR
JOINT PROC, W/O
CC.
230............ \5\ LOCAL 1.7034 38.5 32.1
EXCISION &
REMOVAL OF INT
FIX DEVICES OF
HIP & FEMUR.
232............ \7\ ARTHROSCOPY. 0.4499 19.0 15.8
233............ OTHER 1.3522 34.6 28.8
MUSCULOSKELET
SYS & CONN TISS
O.R. PROC W CC.
234............ \7\ OTHER 0.4499 19.0 15.8
MUSCULOSKELET
SYS & CONN TISS
O.R. PROC W/O
CC.
235............ \3\ FRACTURES OF 0.7637 24.8 20.7
FEMUR.
236............ FRACTURES OF HIP 0.6531 25.2 21
& PELVIS.
237............ \1\ SPRAINS, 0.4499 19.0 15.8
STRAINS, &
DISLOCATIONS OF
HIP, PELVIS &
THIGH.
238............ OSTEOMYELITIS... 0.8278 28.3 23.6
239............ PATHOLOGICAL 0.6935 23.6 19.7
FRACTURES &
MUSCULOSKELETAL
& CONN TISS
MALIGNANCY.
240............ CONNECTIVE 0.7310 24.8 20.7
TISSUE
DISORDERS W CC.
241............ \1\ CONNECTIVE 0.4499 19.0 15.8
TISSUE
DISORDERS W/O
CC.
242............ SEPTIC ARTHRITIS 0.7864 26.5 22.1
243............ MEDICAL BACK 0.6061 23.4 19.5
PROBLEMS.
244............ BONE DISEASES & 0.5259 22.2 18.5
SPECIFIC
ARTHROPATHIES W
CC.
245............ BONE DISEASES & 0.4635 20.4 17
SPECIFIC
ARTHROPATHIES W/
O CC.
246............ \1\ NON-SPECIFIC 0.4499 19.0 15.8
ARTHROPATHIES.
247............ SIGNS & SYMPTOMS 0.5548 21.9 18.3
OF
MUSCULOSKELETAL
SYSTEM & CONN
TISSUE.
248............ TENDONITIS, 0.6574 22.6 18.8
MYOSITIS &
BURSITIS.
249............ AFTERCARE, 0.6577 24.7 20.6
MUSCULOSKELETAL
SYSTEM &
CONNECTIVE
TISSUE.
250............ \2\ FX, SPRN, 0.5837 21.3 17.8
STRN & DISL OF
FOREARM, HAND,
FOOT AGE >17 W
CC.
251............ \1\ FX, SPRN, 0.4499 19.0 15.8
STRN & DISL OF
FOREARM, HAND,
FOOT AGE >17 W/
O CC.
252............ \7\ FX, SPRN, 0.7637 24.8 20.7
STRN & DISL OF
FOREARM, HAND,
FOOT AGE 0-17.
253............ FX, SPRN, STRN & 0.6802 26.3 21.9
DISL OF
UPARM,LOWLEG EX
FOOT AGE >17 W
CC.
254............ \2\ FX, SPRN, 0.5837 21.3 17.8
STRN & DISL OF
UPARM,LOWLEG EX
FOOT AGE >17 W/
O CC.
255............ \7\ FX, SPRN, 0.7637 24.8 20.7
STRN & DISL OF
UPARM,LOWLEG EX
FOOT AGE 0-17.
256............ OTHER 0.7924 25.3 21.1
MUSCULOSKELETAL
SYSTEM &
CONNECTIVE
TISSUE
DIAGNOSES.
257............ \7\ TOTAL 0.7637 24.8 20.7
MASTECTOMY FOR
MALIGNANCY W CC.
258............ \7\ TOTAL 0.7637 24.8 20.7
MASTECTOMY FOR
MALIGNANCY W/O
CC.
259............ \2\ SUBTOTAL 0.5837 21.3 17.8
MASTECTOMY FOR
MALIGNANCY W CC.
260............ \7\ SUBTOTAL 0.7637 24.8 20.7
MASTECTOMY FOR
MALIGNANCY W/O
CC.
261............ \7\ BREAST PROC 0.7637 24.8 20.7
FOR NON-
MALIGNANCY
EXCEPT BIOPSY &
LOCAL EXCISION.
262............ \1\ BREAST 0.4499 19.0 15.8
BIOPSY & LOCAL
EXCISION FOR
NON-MALIGNANCY.
263............ SKIN GRAFT &/OR 1.3222 39.5 32.9
DEBRID FOR SKN
ULCER OR
CELLULITIS W CC.
264............ SKIN GRAFT &/OR 0.9584 32.0 26.7
DEBRID FOR SKN
ULCER OR
CELLULITIS W/O
CC.
265............ SKIN GRAFT &/OR 1.0398 33.1 27.6
DEBRID EXCEPT
FOR SKIN ULCER
OR CELLULITIS W
CC.
266............ \3\ SKIN GRAFT &/ 0.7637 24.8 20.7
OR DEBRID
EXCEPT FOR SKIN
ULCER OR
CELLULITIS W/O
CC.
267............ \7\ PERIANAL & 0.7637 24.8 20.7
PILONIDAL
PROCEDURES.
268............ \5\ SKIN, 1.7034 38.5 32.1
SUBCUTANEOUS
TISSUE & BREAST
PLASTIC
PROCEDURES.
269............ OTHER SKIN, 1.3037 36.1 30.1
SUBCUT TISS &
BREAST PROC W
CC.
270............ \3\ OTHER SKIN, 0.7637 24.8 20.7
SUBCUT TISS &
BREAST PROC W/O
CC.
271............ SKIN ULCERS..... 0.8720 27.7 23.1
272............ MAJOR SKIN 0.7420 22.6 18.8
DISORDERS W CC.
273............ \1\ MAJOR SKIN 0.4499 19.0 15.8
DISORDERS W/O
CC.
274............ \3\ MALIGNANT 0.7637 24.8 20.7
BREAST
DISORDERS W CC.
275............ \7\ MALIGNANT 0.7637 24.8 20.7
BREAST
DISORDERS W/O
CC.
276............ \2\ NON-MALIGANT 0.5837 21.3 17.8
BREAST
DISORDERS.
277............ CELLULITIS AGE 0.6264 21.0 17.5
>17 W CC.
278............ CELLULITIS AGE 0.4420 17.8 14.8
>17 W/O CC.
279............ \7\ CELLULITIS 0.4499 19.0 15.8
AGE 0-17.
280............ TRAUMA TO THE 0.6698 24.3 20.3
SKIN, SUBCUT
TISS & BREAST
AGE >17 W CC.
281............ \1\ TRAUMA TO 0.4499 19.0 15.8
THE SKIN,
SUBCUT TISS &
BREAST AGE >17
W/O CC.
282............ \7\ TRAUMA TO 0.4499 19.0 15.8
THE SKIN,
SUBCUT TISS &
BREAST AGE 0-17.
283............ MINOR SKIN 0.6935 23.9 19.9
DISORDERS W CC.
284............ \1\ MINOR SKIN 0.4499 19.0 15.8
DISORDERS W/O
CC.
285............ AMPUTAT OF LOWER 1.3501 35.6 29.7
LIMB FOR
ENDOCRINE,NUTRI
T,& METABOL
DISORDERS.
286............ \7\ ADRENAL & 1.7034 38.5 32.1
PITUITARY
PROCEDURES.
287............ SKIN GRAFTS & 1.1387 33.9 28.3
WOUND DEBRID
FOR ENDOC,
NUTRIT & METAB
DISORDERS.
288............ \4\ O.R. 1.1820 29.6 24.7
PROCEDURES FOR
OBESITY.
289............ \7\ PARATHYROID 1.1820 29.6 24.7
PROCEDURES.
290............ \5\ THYROID 1.7034 38.5 32.1
PROCEDURES.
291............ \7\ THYROGLOSSAL 1.1820 29.6 24.7
PROCEDURES.
292............ OTHER ENDOCRINE, 1.3409 31.7 26.4
NUTRIT & METAB
O.R. PROC W CC.
293............ \2\ OTHER 0.5837 21.3 17.8
ENDOCRINE,
NUTRIT & METAB
O.R. PROC W/O
CC.
294............ DIABETES AGE >35 0.7293 25.0 20.8

[[Page 47686]]

295............ \3\ DIABETES AGE 0.7637 24.8 20.7
0-35.
296............ NUTRITIONAL & 0.7212 23.1 19.3
MISC METABOLIC
DISORDERS AGE
>17 W CC.
297............ NUTRITIONAL & 0.5227 18.4 15.3
MISC METABOLIC
DISORDERS AGE
>17 W/O CC.
298............ \7\ NUTRITIONAL 0.5837 21.3 17.8
& MISC
METABOLIC
DISORDERS AGE 0-
17.
299............ \4\ INBORN 1.1820 29.6 24.7
ERRORS OF
METABOLISM.
300............ ENDOCRINE 0.6376 21.2 17.7
DISORDERS W CC.
301............ \1\ ENDOCRINE 0.4499 19.0 15.8
DISORDERS W/O
CC.
302............ \6\ KIDNEY 0.0000 0.0 0
TRANSPLANT.
303............ \4\ 1.1820 29.6 24.7
KIDNEY,URETER &
MAJOR BLADDER
PROCEDURES FOR
NEOPLASM.
304............ \5\ 1.7034 38.5 32.1
KIDNEY,URETER &
MAJOR BLADDER
PROC FOR NON-
NEOPL W CC.
305............ \1\ 0.4499 19.0 15.8
KIDNEY,URETER &
MAJOR BLADDER
PROC FOR NON-
NEOPL W/O CC.
306............ \2\ 0.5837 21.3 17.8
PROSTATECTOMY W
CC.
307............ \7\ 0.5837 21.3 17.8
PROSTATECTOMY W/
O CC.
308............ \3\ MINOR 0.7637 24.8 20.7
BLADDER
PROCEDURES W CC.
309............ \7\ MINOR 0.7637 24.8 20.7
BLADDER
PROCEDURES W/O
CC.
310............ \4\ 1.1820 29.6 24.7
TRANSURETHRAL
PROCEDURES W CC.
311............ \7\ 1.1820 29.6 24.7
TRANSURETHRAL
PROCEDURES W/O
CC.
312............ \1\ URETHRAL 0.4499 19.0 15.8
PROCEDURES, AGE
>17 W CC.
313............ \7\ URETHRAL 0.4499 19.0 15.8
PROCEDURES, AGE
>17 W/O CC.
314............ \7\ URETHRAL 0.4499 19.0 15.8
PROCEDURES, AGE
0-17.
315............ OTHER KIDNEY & 1.4055 31.6 26.3
URINARY TRACT
O.R. PROCEDURES.
316............ RENAL FAILURE... 0.8219 22.7 18.9
317............ ADMIT FOR RENAL 0.9852 25.2 21
DIALYSIS.
318............ KIDNEY & URINARY 0.7586 20.2 16.8
TRACT NEOPLASMS
W CC.
319............ \1\ KIDNEY & 0.4499 19.0 15.8
URINARY TRACT
NEOPLASMS W/O
CC.
320............ KIDNEY & URINARY 0.6179 22.2 18.5
TRACT
INFECTIONS AGE
>17 W CC.
321............ KIDNEY & URINARY 0.4792 19.0 15.8
TRACT
INFECTIONS AGE
>17 W/O CC.
322............ \7\ KIDNEY & 0.4499 19.0 15.8
URINARY TRACT
INFECTIONS AGE
0-17.
323............ \4\ URINARY 1.1820 29.6 24.7
STONES W CC, &/
OR ESW
LITHOTRIPSY.
324............ \7\ URINARY 0.4499 19.0 15.8
STONES W/O CC.
325............ \2\ KIDNEY & 0.5837 21.3 17.8
URINARY TRACT
SIGNS &
SYMPTOMS AGE
>17 W CC.
326............ \7\ KIDNEY & 0.4499 19.0 15.8
URINARY TRACT
SIGNS &
SYMPTOMS AGE
>17 W/O CC.
327............ \7\ KIDNEY & 0.4499 19.0 15.8
URINARY TRACT
SIGNS &
SYMPTOMS AGE 0-
17.
328............ \1\ URETHRAL 0.4499 19.0 15.8
STRICTURE AGE
>17 W CC.
329............ \7\ URETHRAL 0.4499 19.0 15.8
STRICTURE AGE
>17 W/O CC.
330............ \7\ URETHRAL 0.4499 19.0 15.8
STRICTURE AGE 0-
17.
331............ OTHER KIDNEY & 0.8010 23.1 19.3
URINARY TRACT
DIAGNOSES AGE
>17 W CC.
332............ \2\ OTHER KIDNEY 0.5837 21.3 17.8
& URINARY TRACT
DIAGNOSES AGE
>17 W/O CC.
333............ \7\ OTHER KIDNEY 0.5837 21.3 17.8
& URINARY TRACT
DIAGNOSES AGE 0-
17.
334............ \2\ MAJOR MALE 0.5837 21.3 17.8
PELVIC
PROCEDURES W CC.
335............ \7\ MAJOR MALE 1.7034 38.5 32.1
PELVIC
PROCEDURES W/O
CC.
336............ \2\ 0.5837 21.3 17.8
TRANSURETHRAL
PROSTATECTOMY W
CC.
337............ \7\ 0.5837 21.3 17.8
TRANSURETHRAL
PROSTATECTOMY W/
O CC.
338............ \7\ TESTES 0.5837 21.3 17.8
PROCEDURES, FOR
MALIGNANCY.
339............ \4\ TESTES 1.1820 29.6 24.7
PROCEDURES, NON-
MALIGNANCY AGE
>17.
340............ \7\ TESTES 1.1820 29.6 24.7
PROCEDURES, NON-
MALIGNANCY AGE
0-17.
341............ \4\ PENIS 1.1820 29.6 24.7
PROCEDURES.
342............ \7\ CIRCUMCISION 1.1820 29.6 24.7
AGE >17.
343............ \7\ CIRCUMCISION 1.1820 29.6 24.7
AGE 0-17.
344............ \1\ OTHER MALE 0.4499 19.0 15.8
REPRODUCTIVE
SYSTEM O.R.
PROCEDURES FOR
MALIGNANCY.
345............ \5\ OTHER MALE 1.7034 38.5 32.1
REPRODUCTIVE
SYSTEM O.R.
PROC EXCEPT FOR
MALIGNANCY.
346............ MALIGNANCY, MALE 0.6060 20.6 17.2
REPRODUCTIVE
SYSTEM, W CC.
347............ \2\ MALIGNANCY, 0.5837 21.3 17.8
MALE
REPRODUCTIVE
SYSTEM, W/O CC.
348............ \2\ BENIGN 0.5837 21.3 17.8
PROSTATIC
HYPERTROPHY W
CC.
349............ \7\ BENIGN 1.1820 29.6 24.7
PROSTATIC
HYPERTROPHY W/O
CC.
350............ INFLAMMATION OF 0.6798 21.9 18.3
THE MALE
REPRODUCTIVE
SYSTEM.
351............ \7\ 1.1820 29.6 24.7
STERILIZATION,
MALE.
352............ OTHER MALE 0.6375 23.4 19.5
REPRODUCTIVE
SYSTEM
DIAGNOSES.
353............ \7\ PELVIC 1.1820 29.6 24.7
EVISCERATION,
RADICAL
HYSTERECTOMY &
RADICAL
VULVECTOMY.
354............ \7\ 1.1820 29.6 24.7
UTERINE,ADNEXA
PROC FOR NON-
OVARIAN/ADNEXAL
MALIG W CC.
355............ \7\ UTERINE, 1.1820 29.6 24.7
ADNEXA PROC FOR
NON-OVARIAN/
ADNEXAL MALIG W/
O CC.
356............ \7\ FEMALE 1.1820 29.6 24.7
REPRODUCTIVE
SYSTEM
RECONSTRUCTIVE
PROCEDURES.
357............ \7\ UTERINE & 1.1820 29.6 24.7
ADNEXA PROC FOR
OVARIAN OR
ADNEXAL
MALIGNANCY.
358............ \7\ UTERINE & 1.1820 29.6 24.7
ADNEXA PROC FOR
NON-MALIGNANCY
W CC.
359............ \7\ UTERINE & 1.1820 29.6 24.7
ADNEXA PROC FOR
NON-MALIGNANCY
W/O CC.
360............ \4\ VAGINA, 1.1820 29.6 24.7
CERVIX & VULVA
PROCEDURES.

[[Page 47687]]

361............ \7\ LAPAROSCOPY 0.7637 24.8 20.7
& INCISIONAL
TUBAL
INTERRUPTION.
362............ \7\ ENDOSCOPIC 0.7637 24.8 20.7
TUBAL
INTERRUPTION.
363............ \7\ D&C, 0.7637 24.8 20.7
CONIZATION &
RADIO-IMPLANT,
FOR MALIGNANCY.
364............ \5\ D&C, 1.7034 38.5 32.1
CONIZATION
EXCEPT FOR
MALIGNANCY.
365............ \5\ OTHER FEMALE 1.7034 38.5 32.1
REPRODUCTIVE
SYSTEM O.R.
PROCEDURES.
366............ MALIGNANCY, 0.7072 20.3 16.9
FEMALE
REPRODUCTIVE
SYSTEM W CC.
367............ \7\ MALIGNANCY, 0.7637 24.8 20.7
FEMALE
REPRODUCTIVE
SYSTEM W/O CC.
368............ INFECTIONS, 0.6416 20.7 17.3
FEMALE
REPRODUCTIVE
SYSTEM.
369............ \3\ MENSTRUAL & 0.7637 24.8 20.7
OTHER FEMALE
REPRODUCTIVE
SYSTEM
DISORDERS.
370............ \7\ CESAREAN 0.7637 24.8 20.7
SECTION W CC.
371............ \7\ CESAREAN 0.5837 21.3 17.8
SECTION W/O CC.
372............ \7\ VAGINAL 0.7637 24.8 20.7
DELIVERY W
COMPLICATING
DIAGNOSES.
373............ \7\ VAGINAL 0.7637 24.8 20.7
DELIVERY W/O
COMPLICATING
DIAGNOSES.
374............ \7\ VAGINAL 0.7637 24.8 20.7
DELIVERY W
STERILIZATION &/
OR D&C.
375............ \7\ VAGINAL 0.7637 24.8 20.7
DELIVERY W O.R.
PROC EXCEPT
STERIL &/OR D&C.
376............ \7\ POSTPARTUM & 0.7637 24.8 20.7
POST ABORTION
DIAGNOSES W/O
O.R. PROCEDURE.
377............ \7\ POSTPARTUM & 0.7637 24.8 20.7
POST ABORTION
DIAGNOSES W
O.R. PROCEDURE.
378............ \7\ ECTOPIC 0.7637 24.8 20.7
PREGNANCY.
379............ \7\ THREATENED 0.7637 24.8 20.7
ABORTION.
380............ \7\ ABORTION W/O 0.7637 24.8 20.7
D&C.
381............ \7\ ABORTION W 0.7637 24.8 20.7
D&C, ASPIRATION
CURETTAGE OR
HYSTEROTOMY.
382............ \7\ FALSE LABOR. 0.7637 24.8 20.7
383............ \7\ OTHER 0.7637 24.8 20.7
ANTEPARTUM
DIAGNOSES W
MEDICAL
COMPLICATIONS.
384............ \7\ OTHER 0.7637 24.8 20.7
ANTEPARTUM
DIAGNOSES W/O
MEDICAL
COMPLICATIONS.
385............ \7\ NEONATES, 0.7637 24.8 20.7
DIED OR
TRANSFERRED TO
ANOTHER ACUTE
CARE FACILITY.
386............ \7\ EXTREME 1.1820 29.6 24.7
IMMATURITY.
387............ \7\ PREMATURITY 1.1820 29.6 24.7
W MAJOR
PROBLEMS.
388............ \7\ PREMATURITY 0.7637 24.8 20.7
W/O MAJOR
PROBLEMS.
389............ \7\ FULL TERM 1.1820 29.6 24.7
NEONATE W MAJOR
PROBLEMS.
390............ \7\ NEONATE W 1.1820 29.6 24.7
OTHER
SIGNIFICANT
PROBLEMS.
391............ \7\ NORMAL 0.7637 24.8 20.7
NEWBORN.
392............ \7\ SPLENECTOMY 0.7637 24.8 20.7
AGE >17.
393............ \7\ SPLENECTOMY 0.7637 24.8 20.7
AGE 0-17.
394............ \5\ OTHER O.R. 1.7034 38.5 32.1
PROCEDURES OF
THE BLOOD AND
BLOOD FORMING
ORGANS.
395............ RED BLOOD CELL 0.6581 22.0 18.3
DISORDERS AGE
>17.
396............ \7\ RED BLOOD 0.5837 21.3 17.8
CELL DISORDERS
AGE 0-17.
397............ COAGULATION 0.8675 22.9 19.1
DISORDERS.
398............ RETICULOENDOTHEL 0.8240 23.7 19.8
IAL & IMMUNITY
DISORDERS W CC.
399............ \2\ 0.5837 21.3 17.8
RETICULOENDOTHE
LIAL & IMMUNITY
DISORDERS W/O
CC.
401............ \5\ LYMPHOMA & 1.7034 38.5 32.1
NON-ACUTE
LEUKEMIA W
OTHER O.R. PROC
W CC.
402............ \7\ LYMPHOMA & 0.5837 21.3 17.8
NON-ACUTE
LEUKEMIA W
OTHER O.R. PROC
W/O CC.
403............ LYMPHOMA & NON- 0.8757 21.3 17.8
ACUTE LEUKEMIA
W CC.
404............ \2\ LYMPHOMA & 0.5837 21.3 17.8
NON-ACUTE
LEUKEMIA W/O CC.
405............ \7\ ACUTE 0.5837 21.3 17.8
LEUKEMIA W/O
MAJOR O.R.
PROCEDURE AGE 0-
17.
406............ \4\ MYELOPROLIF 1.1820 29.6 24.7
DISORD OR
POORLY DIFF
NEOPL W MAJ
O.R.PROC DW CC.
407............ \7\ MYELOPROLIF 1.1820 29.6 24.7
DISORD OR
POORLY DIFF
NEOPL W MAJ
O.R.PROC W/O CC.
408............ \4\ MYELOPROLIF 1.1820 29.6 24.7
DISORD OR
POORLY DIFF
NEOPL W OTHER
O.R.PROC.
409............ RADIOTHERAPY.... 0.8642 23.5 19.6
410............ CHEMOTHERAPY W/O 1.1684 26.4 22
ACUTE LEUKEMIA
AS SECONDARY
DIAGNOSIS.
411............ \7\ HISTORY OF 0.7637 24.8 20.7
MALIGNANCY W/O
ENDOSCOPY.
412............ \7\ HISTORY OF 0.7637 24.8 20.7
MALIGNANCY W
ENDOSCOPY.
413............ OTHER 0.8920 20.5 17.1
MYELOPROLIF DIS
OR POORLY DIFF
NEOPL DIAG W CC.
414............ \7\ OTHER 0.5837 21.3 17.8
MYELOPROLIF DIS
OR POORLY DIFF
NEOPL DIAG W/O
CC.
415............ O.R. PROCEDURE 1.4251 35.6 29.7
FOR INFECTIOUS
& PARASITIC
DISEASES.
416............ SEPTICEMIA AGE 0.8241 23.5 19.6
>17.
417............ \7\ SEPTICEMIA 0.7637 24.8 20.7
AGE 0-17.
418............ POSTOPERATIVE & 0.8252 24.7 20.6
POST-TRAUMATIC
INFECTIONS.
419............ \4\ FEVER OF 1.1820 29.6 24.7
UNKNOWN ORIGIN
AGE >17 W CC.
420............ \7\ FEVER OF 1.1820 29.6 24.7
UNKNOWN ORIGIN
AGE >17 W/O CC.
421............ VIRAL ILLNESS 0.9441 27.3 22.8
AGE >17.
422............ \7\ VIRAL 1.1820 29.6 24.7
ILLNESS & FEVER
OF UNKNOWN
ORIGIN AGE 0-17.
423............ OTHER INFECTIOUS 0.9505 21.8 18.2
& PARASITIC
DISEASES
DIAGNOSES.
424............ \3\ O.R. 0.7637 24.8 20.7
PROCEDURE W
PRINCIPAL
DIAGNOSES OF
MENTAL ILLNESS.
425............ \2\ ACUTE 0.5837 21.3 17.8
ADJUSTMENT
REACTION &
PSYCHOLOGICAL
DYSFUNCTION.
426............ DEPRESSIVE 0.4113 20.7 17.3
NEUROSES.
427............ NEUROSES EXCEPT 0.4653 23.8 19.8
DEPRESSIVE.
428............ \1\ DISORDERS OF 0.4499 19.0 15.8
PERSONALITY &
IMPULSE CONTROL.

[[Page 47688]]

429............ ORGANIC 0.5813 26.8 22.3
DISTURBANCES &
MENTAL
RETARDATION.
430............ PSYCHOSES....... 0.4330 24.2 20.2
431............ \1\ CHILDHOOD 0.4499 19.0 15.8
MENTAL
DISORDERS.
432............ \2\ OTHER MENTAL 0.5837 21.3 17.8
DISORDER
DIAGNOSES.
433............ \2\ ALCOHOL/DRUG 0.5837 21.3 17.8
ABUSE OR
DEPENDENCE,
LEFT AMA.
439............ SKIN GRAFTS FOR 1.3677 35.6 29.7
INJURIES.
440............ WOUND 1.3442 36.1 30.1
DEBRIDEMENTS
FOR INJURIES.
441............ \1\ HAND 0.4499 19.0 15.8
PROCEDURES FOR
INJURIES.
442............ OTHER O.R. 1.3937 33.4 27.8
PROCEDURES FOR
INJURIES W CC.
443............ \3\ OTHER O.R. 0.7637 24.8 20.7
PROCEDURES FOR
INJURIES W/O CC.
444............ TRAUMATIC INJURY 0.7584 26.3 21.9
AGE >17 W CC.
445............ \1\ TRAUMATIC 0.4499 19.0 15.8
INJURY AGE >17
W/O CC.
446............ \7\ TRAUMATIC 0.4499 19.0 15.8
INJURY AGE 0-17.
447............ \2\ ALLERGIC 0.5837 21.3 17.8
REACTIONS AGE
>17.
448............ \7\ ALLERGIC 0.5837 21.3 17.8
REACTIONS AGE 0-
17.
449............ \3\ POISONING & 0.7637 24.8 20.7
TOXIC EFFECTS
OF DRUGS AGE
>17 W CC.
450............ \7\ POISONING & 0.7637 24.8 20.7
TOXIC EFFECTS
OF DRUGS AGE
>17 W/O CC.
451............ \7\ POISONING & 0.7637 24.8 20.7
TOXIC EFFECTS
OF DRUGS AGE 0-
17.
452............ COMPLICATIONS OF 0.9265 25.3 21.1
TREATMENT W CC.
453............ COMPLICATIONS OF 0.5871 23.8 19.8
TREATMENT W/O
CC.
454............ \3\ OTHER 0.7637 24.8 20.7
INJURY,
POISONING &
TOXIC EFFECT
DIAG W CC.
455............ \7\ OTHER 0.7637 24.8 20.7
INJURY,
POISONING &
TOXIC EFFECT
DIAG W/O CC.
461............ O.R. PROC W 1.2245 34.0 28.3
DIAGNOSES OF
OTHER CONTACT W
HEALTH SERVICES.
462............ REHABILITATION.. 0.5787 22.4 18.7
463............ SIGNS & SYMPTOMS 0.6258 23.8 19.8
W CC.
464............ SIGNS & SYMPTOMS 0.5554 24.1 20.1
W/O CC.
465............ AFTERCARE W 0.6958 21.9 18.3
HISTORY OF
MALIGNANCY AS
SECONDARY
DIAGNOSIS.
466............ AFTERCARE W/O 0.6667 21.9 18.3
HISTORY OF
MALIGNANCY AS
SECONDARY
DIAGNOSIS.
467............ \3\ OTHER 0.7637 24.8 20.7
FACTORS
INFLUENCING
HEALTH STATUS.
468............ EXTENSIVE O.R. 2.1478 40.2 33.5
PROCEDURE
UNRELATED TO
PRINCIPAL
DIAGNOSIS.
469............ \6\ PRINCIPAL 0.0000 0.0 0
DIAGNOSIS
INVALID AS
DISCHARGE
DIAGNOSIS.
470............ \6\ UNGROUPABLE. 0.0000 0.0 0
471............ \5\ BILATERAL OR 1.7034 38.5 32.1
MULTIPLE MAJOR
JOINT PROCS OF
LOWER EXTREMITY.
473............ ACUTE LEUKEMIA W/ 0.8537 20.0 16.7
O MAJOR O.R.
PROCEDURE AGE
>17.
475............ RESPIRATORY 2.0831 34.6 28.8
SYSTEM
DIAGNOSIS WITH
VENTILATOR
SUPPORT.
476............ \4\ PROSTATIC 1.1820 29.6 24.7
O.R. PROCEDURE
UNRELATED TO
PRINCIPAL
DIAGNOSIS.
477............ NON-EXTENSIVE 1.5836 35.3 29.4
O.R. PROCEDURE
UNRELATED TO
PRINCIPAL
DIAGNOSIS.
479............ \7\ OTHER 0.7637 24.8 20.7
VASCULAR
PROCEDURES W/O
CC.
480............ \6\ LIVER 0.0000 0.0 0
TRANSPLANT.
481............ \7\ BONE MARROW 1.7034 38.5 32.1
TRANSPLANT.
482............ \5\ TRACHEOSTOMY 1.7034 38.5 32.1
FOR FACE,MOUTH
& NECK
DIAGNOSES.
484............ \2\ CRANIOTOMY 0.5837 21.3 17.8
FOR MULTIPLE
SIGNIFICANT
TRAUMA.
485............ \7\ LIMB 1.1820 29.6 24.7
REATTACHMENT,
HIP AND FEMUR
PROC FOR
MULTIPLE
SIGNIFICANT TR.
486............ \5\ OTHER O.R. 1.7034 38.5 32.1
PROCEDURES FOR
MULTIPLE
SIGNIFICANT
TRAUMA.
487............ OTHER MULTIPLE 0.8992 26.0 21.7
SIGNIFICANT
TRAUMA.
488............ \5\ HIV W 1.7034 38.5 32.1
EXTENSIVE O.R.
PROCEDURE.
489............ HIV W MAJOR 0.8535 21.4 17.8
RELATED
CONDITION.
490............ HIV W OR W/O 0.4919 16.6 13.8
OTHER RELATED
CONDITION.
491............ \5\ MAJOR JOINT 1.7034 38.5 32.1
& LIMB
REATTACHMENT
PROCEDURES OF
UPPER EXTREMITY.
492............ \7\ CHEMOTHERAPY 1.1820 29.6 24.7
W ACUTE
LEUKEMIA AS
SECONDARY
DIAGNOSIS.
493............ \5\ LAPAROSCOPIC 1.7034 38.5 32.1
CHOLECYSTECTOMY
W/O C.D.E. W CC.
494............ \7\ LAPAROSCOPIC 1.7034 38.5 32.1
CHOLECYSTECTOMY
W/O C.D.E. W/O
CC.
495............ \6\ LUNG 0.0000 0.0 0
TRANSPLANT.
496............ \7\ COMBINED 1.1820 29.6 24.7
ANTERIOR/
POSTERIOR
SPINAL FUSION.
497............ \4\ SPINAL 1.1820 29.6 24.7
FUSION W CC.
498............ \7\ SPINAL 1.1820 29.6 24.7
FUSION W/O CC.
499............ \5\ BACK & NECK 1.7034 38.5 32.1
PROCEDURES
EXCEPT SPINAL
FUSION W CC.
500............ \4\ BACK & NECK 1.1820 29.6 24.7
PROCEDURES
EXCEPT SPINAL
FUSION W/O CC.
501............ \5\ KNEE 1.7034 38.5 32.1
PROCEDURES W
PDX OF
INFECTION W CC.
502............ \4\ KNEE 1.1820 29.6 24.7
PROCEDURES W
PDX OF
INFECTION W/O
CC.
503............ \2\ KNEE 0.5837 21.3 17.8
PROCEDURES W/O
PDX OF
INFECTION.
504............ \7\ EXTENSIVE 1.7034 38.5 32.1
BURN OR FULL
THICKNESS BURNS
WITH MECH VENT
96+ HOURS WITH
SKIN GRAFT.
505............ \4\ EXTENSIVE 1.1820 29.6 24.7
BURN OR FULL
THICKNESS BURNS
WITH MECH VENT
96+ HOURS
WITHOUT SKIN
GRAFT.
506............ \4\ FULL 1.1820 29.6 24.7
THICKNESS BURN
W SKIN GRAFT OR
INHAL INJ W CC
OR SIG TRAUMA.

[[Page 47689]]

507............ \3\ FULL 0.7637 24.8 20.7
THICKNESS BURN
W SKIN GRFT OR
INHAL INJ W/O
CC OR SIG
TRAUMA.
508............ FULL THICKNESS 0.8367 29.4 24.5
BURN W/O SKIN
GRFT OR INHAL
INJ W CC OR SIG
TRAUMA.
509............ \1\ FULL 0.4499 19.0 15.8
THICKNESS BURN
W/O SKIN GRFT
OR INH INJ W/O
CC OR SIG
TRAUMA.
510............ NON-EXTENSIVE 0.7709 24.6 20.5
BURNS W CC OR
SIGNIFICANT
TRAUMA.
511............ \1\ NON- 0.4499 19.0 15.8
EXTENSIVE BURNS
W/O CC OR
SIGNIFICANT
TRAUMA.
512............ \6\ SIMULTANEOUS 0.0000 0.0 0
PANCREAS/KIDNEY
TRANSPLANT.
513............ \6\ PANCREAS 0.0000 0.0 0
TRANSPLANT.
515............ \5\ CARDIAC 1.7034 38.5 32.1
DEFIBRILATOR
IMPLANT W/O
CARDIAC CATH.
518............ \7\ PERCUTANEOUS 0.7637 24.8 20.7
CARDIVASCULAR
PROC W/O
CORONARY ARTERY
STENT OR AMI.
519............ \5\ CERVICAL 1.7034 38.5 32.1
SPINAL FUSION W
CC.
520............ \7\ CERVICAL 1.1820 29.6 24.7
SPINAL FUSION W/
O CC.
521............ ALCOHOL/DRUG 0.4457 19.4 16.2
ABUSE OR
DEPENDENCE W CC.
522............ \7\ ALCOHOL/DRUG 0.4499 19.0 15.8
ABUSE OR
DEPENDENCE W
REHABILITATION
THERAPY W/O CC.
523............ \7\ ALCOHOL/DRUG 0.4499 19.0 15.8
ABUSE OR
DEPENDENCE W/O
REHABILITATION
THERAPY W/O CC.
524............ TRANSIENT 0.5043 21.1 17.6
ISCHEMIA.
525............ \7\ OTHER HEART 1.7034 38.5 32.1
ASSIST SYSTEM
IMPLANT.
528............ \7\ INTRACRANIAL 1.7034 38.5 32.1
VASCULAR PROC W
PDX HEMORRHAGE.
529............ \5\ VENTRICULAR 1.7034 38.5 32.1
SHUNT
PROCEDURES W CC.
530............ \7\ VENTRICULAR 1.7034 38.5 32.1
SHUNT
PROCEDURES W/O
CC.
531............ \3\ SPINAL 0.7637 24.8 20.7
PROCEDURES WITH
CC.
532............ \3\ SPINAL 0.7637 24.8 20.7
PROCEDURES
WITHOUT CC.
533............ \5\ EXTRACRANIAL 1.7034 38.5 32.1
VASCULAR
PROCEDURES WITH
CC.
534............ \7\ EXTRACRANIAL 1.1820 29.6 24.7
VASCULAR
PROCEDURES
WITHOUT CC.
535............ \7\ CARDIAC 1.7034 38.5 32.1
DEFIB IMPLANT W
CARDIAC CATH W
AMI/HF/SHOCK.
536............ \7\ CARDIAC 1.7034 38.5 32.1
DEFIB IMPLANT W
CARDIAC CATH W/
O AMI/HF/SHOCK.
537............ LOCAL EXCISION 1.1615 34.7 28.9
AND REMOVAL OF
INTERNAL
FIXATION
DEVICES EXCEPT
HIP AND FEMUR
WITH CC.
538............ \7\ LOCAL 1.1820 29.6 24.7
EXCISION AND
REMOVAL OF
INTERNAL
FIXATION
DEVICES EXCEPT
HIP AND FEMUR
WITHOUT CC.
539............ \4\ LYMPHOMA AND 1.1820 29.6 24.7
LEUKEMIA WITH
MAJOR O.R.
PROCEDURE WITH
CC.
540............ \7\ LYMPHOMA AND 0.5837 21.3 17.8
LEUKEMIA WITH
MAJOR O.R.
PROCEDURE
WITHOUT CC.
541............ ECMO OR TRACH W 4.2287 65.6 54.7
MECH VENT 96+
HRS OR PDX
EXCEPT
FACE,MOUTH &
NECK DIAG WITH
MAJOR OR.
542............ TRACH W MECH 3.1869 48.2 40.2
VENT 96+ HRS OR
PDX EXCEPT
FACE,MOUTH &
NECK DIAG
WITHOUT MAJOR
OR.
543............ \5\ CRANIOTOMY W 1.7034 38.5 32.1
IMPLANT OF
CHEMO AGENT OR
ACUTE COMPLEX
CNS PDX.
544............ \5\ MAJOR JOINT 1.7034 38.5 32.1
REPLACEMENT OR
REATTACHMENT OF
LOWER EXTREMITY.
545............ \5\ REVISION OF 1.7034 38.5 32.1
HIP OR KNEE
REPLACEMENT.
546............ \7\ SPINAL 1.7034 38.5 32.1
FUSION EXCEPT
CERVICAL WITH
CURVATURE OF
SPINE OR
MALIGNANCY.
547............ \7\ CORONARY 1.7034 38.5 32.1
BYPASS WITH
CARDIAC CATH
WITH MAJOR CV
DIAGNOSIS.
548............ \7\ CORONARY 1.7034 38.5 32.1
BYPASS WITH
CARDIAC CATH
WITHOUT MAJOR
CV DIAGNOSIS.
549............ \7\ CORONARY 1.7034 38.5 32.1
BYPASS WITHOUT
CARDIAC CATH
WITH MAJOR CV
DIAGNOSIS.
550............ \7\ CORONARY 1.7034 38.5 32.1
BYPASS WITHOUT
CARDIAC CATH
WITHOUT MAJOR
CV DIAGNOSIS.
551............ \4\ PERMANENT 1.1820 29.6 24.7
CARDIAC
PACEMAKER
IMPLANT WITH
MAJOR CV
DIAGNOSIS OR
AICD LEAD OR
GNRTR.
552............ \4\ OTHER 1.1820 29.6 24.7
PERMANENT
CARDIAC
PACEMAKER
IMPLANT WITHOUT
MAJOR CV
DIAGNOSIS.
553............ \8\ OTHER 1.3255 30.6 25.5
VASCULAR
PROCEDURES WITH
CC WITH MAJOR
CV DIAGNOSIS.
554............ \8\ OTHER 1.3255 30.6 25.5
VASCULAR
PROCEDURES WITH
CC WITHOUT
MAJOR CV
DIAGNOSIS.
555............ \4\ PERCUTANEOUS 1.1820 29.6 24.7
CARDIOVASCULAR
PROC WITH MAJOR
CV DIAGNOSIS.
556............ \8\ PERCUTANEOUS 1.1820 29.6 24.7
CARDIOVASCULAR
PROC WITH NON-
DRUG-ELUTING
STENT WITHOUT
MAJOR CV
DIAGNOSIS.
557............ \8\ PERCUTANEOUS 1.1820 29.6 24.7
CARDIOVASCULAR
PROC WITH DRUG-
ELUTING STENT
WITH MAJOR CV
DIAGNOSIS.
558............ \7\ PERCUTANEOUS 1.1820 29.6 24.7
CARDIOVASCULAR
PROC WITH DRUG-
ELUTING STENT
WITHOUT MAJOR
CV DIAGNOSIS.
559............ \7\ ACUTE 0.7637 24.8 20.7
ISCHEMIC STROKE
WITH USE OF
THROMBOLYTIC
AGENT.
------------------------------------------------------------------------
\1\ Relative weights for these LTC-DRGs were determined by assigning
these cases to low-volume quintile 1.
\2\ Relative weights for these LTC-DRGs were determined by assigning
these cases to low-volume quintile 2.
\3\ Relative weights for these LTC-DRGs were determined by assigning
these cases to low-volume quintile 3.
\4\ Relative weights for these LTC-DRGs were determined by assigning
these cases to low-volume quintile 4.
\5\ Relative weights for these LTC-DRGs were determined by assigning
these cases to low-volume quintile 5.

[[Page 47690]]

\6\ Relative weights for these LTC-DRGs were assigned a value of 0.0000.

\7\ Relative weights for these LTC-DRGs were determined by assigning
these cases to the appropriate low-volume quintile because there are
no LTCH cases in the FY 2004 MedPAR file.
\8\ Relative weights for these LTC-DRGs were determined after adjusting
to account for nonmonotonicity (see step 5 above).

Appendix A--Regulatory Analysis of Impacts

I. Background and Summary

We have examined the impacts of this final rule as required by
Executive Order 12866 (September 1993, Regulatory Planning and
Review) and the Regulatory Flexibility Act (RFA) (September 19,
1980, Pub. L. 96-354), section 1102(b) of the Social Security Act,
the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and
Executive Order 13132.
Executive Order 12866 directs agencies to assess all costs and
benefits of available regulatory alternatives and, if regulation is
necessary, to select regulatory approaches that maximize net
benefits (including potential economic, environmental, public health
and safety effects, distributive impacts, and equity). A regulatory
impact analysis (RIA) must be prepared for major rules with
economically significant effects ($100 million or more in any 1
year).
We have determined that this final rule is a major rule as
defined in 5 U.S.C. 804(2). We estimate that the total impact of the
changes for FY 2006 operating and capital payments compared to FY
2005 operating and capital payments to be approximately a $3.33
billion increase. This amount does not reflect changes in hospital
admissions or case-mix intensity, which would also affect overall
payment changes.
The RFA requires agencies to analyze options for regulatory
relief of small businesses. For purposes of the RFA, small entities
include small businesses, nonprofit organizations, and government
agencies. Most hospitals and most other providers and suppliers are
small entities, either by nonprofit status or by having revenues of
$5 million to $25 million in any 1 year. For purposes of the RFA,
all hospitals and other providers and suppliers are considered to be
small entities. Individuals and States are not included in the
definition of a small entity.
In addition, section 1102(b) of the Act requires us to prepare a
regulatory impact analysis for any 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
604 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 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 final rule that has been preceded by a
proposed rule that may result in an expenditure in any one year by
State, local, or tribal governments, in the aggregate, or by the
private sector, of $110 million. This final rule will not mandate
any requirements for State, local, or tribal governments.
Executive Order 13132 establishes certain requirements that an
agency must meet when it promulgates a proposed rule (and subsequent
final rule) that imposes substantial direct requirement costs on
State and local governments, preempts State law, or otherwise has
Federalism implications. We have reviewed this final rule in light
of Executive Order 13132 and have determined that it will not have
any negative impact on the rights, roles, and responsibilities of
State, local, or tribal governments.
In accordance with the provisions of Executive Order 12866, this
final rule was reviewed by the Office of Management and Budget.
The following analysis, in conjunction with the remainder of
this document, demonstrates that this final rule is consistent with
the regulatory philosophy and principles identified in Executive
Order 12866, the RFA, and section 1102(b) of the Act. The final rule
will affect payments to a substantial number of small rural
hospitals, as well as other classes of hospitals, and the effects on
some hospitals may be significant.

II. Objectives

The primary objective of the IPPS is to create incentives for
hospitals to operate efficiently and minimize unnecessary costs
while at the same time ensuring that payments are sufficient to
adequately compensate hospitals for their legitimate costs. In
addition, we share national goals of preserving the Medicare Trust
Fund.
We believe the changes in this final rule will further each of
these goals while maintaining the financial viability of the
hospital industry and ensuring access to high quality health care
for Medicare beneficiaries. We expect that these changes will ensure
that the outcomes of this payment system are reasonable and
equitable while avoiding or minimizing unintended adverse
consequences.

III. Limitations of Our Analysis

The following quantitative analysis presents the projected
effects of our policy changes, as well as statutory changes
effective for FY 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, in the FY
2006 IPPS proposed rule, we solicited comments and information about
the anticipated effects of the changes on hospitals and our
methodology for estimating them. Any comments that we received in
response to the FY 2006 IPPS proposed rule are addressed below under
the appropriate heading 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 34 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 July 2005, there are 3,744 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 1,123
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 1,150 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 policy changes on these hospitals are
discussed below.

V. Impact on Excluded Hospitals and Hospital Units

As of July 2005, there were 1,150 specialty hospitals excluded
from the IPPS. Of these 1,150 specialty hospitals, 469 psychiatric
hospitals, 81 children's, 11 cancer hospitals, and 12 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--216
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 1,330 psychiatric units (paid on a blend of the IPF PPS
per diem payment and the TEFRA reasonable cost-based payment) and
1,010 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.

[[Page 47691]]

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 fully on a reasonable
cost basis are subject to TEFRA limits for FY 2006. For these
hospitals (cancer and children's hospitals and RNHCIs), the update
is the percentage increase in the FY 2006 IPPS operating market
basket of 3.7 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 2006, the IRF PPS is based on 100 percent of the
adjusted Federal IRF prospective payment amount, updated annually.
Therefore, these hospitals are not impacted by this final rule.
Effective for cost reporting periods beginning on or after
October 1, 2002, LTCHs are paid under a LTCH PPS, based on a Federal
prospective payment amount that is updated annually. Existing 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, an
existing 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 target amount by
the excluded hospital market basket percentage increase, which is
3.8 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 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 will be, we updated the IPF's TEFRA target amount by the
excluded hospital market basket percentage increase of 3.8 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 final 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 3.5 percent
increase), we estimate the total impact of the changes for FY 2006
operating and capital payments compared to FY 2005 operating and
capital payments to be approximately a $3.33 billion increase. This
amount does not reflect changes in hospital admissions or case-mix
intensity, which would also affect overall payment changes.
We have prepared separate impact analyses of the changes to each
system. This section deals with changes to the operating prospective
payment system. Our payment simulation model relies on the most
recent available data to enable us to estimate the impacts on
payments per case of certain changes we are making in this final
rule. However, there are other changes for which we do not have data
available that would allow us to estimate the payment impacts using
this model. For those changes, we have attempted to predict the
payment impacts of those changes based upon our experience and other
more limited data.
The data used in developing the quantitative analyses of changes
in payments per case presented below are taken from the FY 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 policy changes, and we do not adjust for future
changes in such variables as admissions, lengths of stay, or case-
mix. Second, due to the interdependent nature of the IPPS payment
components, it is very difficult to precisely quantify the impact
associated with each change. Third, we draw upon various sources for
the data used to categorize hospitals in the tables. In some cases,
particularly the number of beds, there is a fair degree of variation
in the data from different sources. We have attempted to construct
these variables with the best available source overall. However, for
individual hospitals, some miscategorizations are possible.
Using cases from the March 2005 update of 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 FY 2006 changes to the
capital IPPS are discussed in section VIII of this Appendix.
The 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 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 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 wage and recalibration budget
neutrality factors, including the rebased labor share for both the
national and Puerto Rico standardized amounts.
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 FY 2006 policies
and MMA-imposed changes relative to payments based on FY 2005
policies.
To illustrate the impacts of the FY 2006 changes, our analysis
begins with a FY 2006 baseline simulation model using: The update of
3.7 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

[[Page 47692]]

not submit quality data. At the time this impact was prepared, the
quality data were still under review. Since early results indicated
that very few providers would fail the quality edits, for purposes
of the FY 2006 simulations in this impact analysis, we have assumed
that all hospitals will qualify for the full update. Subsequent
analysis of the quality data indicate that 2.0 percent of hospitals
will fail the quality edits and the impact of this finding is
discussed in section C of this addendum.
Each policy change is then added incrementally to this baseline
model, finally arriving at an FY 2006 model incorporating all of the
changes. This allows us to isolate the effects of each 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 3.7 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 3.3 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 3.7 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 payments during FY 2005 will be 4.1 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 final
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 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 3,744 hospitals included in the
analysis. There are 153 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 2,616
hospitals located in urban areas included in our analysis. Among
these, there are 1,440 hospitals located in large urban areas
(populations over 1 million), and 1,176 hospitals in other urban
areas (populations of 1 million or fewer). In addition, there are
1,128 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 2,651,
1,451, 1,200, and 1,093, respectively.
The next three groupings examine the impacts of the 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
2,661 nonteaching hospitals in our analysis, 845 teaching hospitals
with fewer than 100 residents, and 238 teaching hospitals with 100
or more residents.
In the DSH categories, hospitals are grouped according to their
DSH payment status, and whether they are considered urban or rural
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 changes on rural
hospitals by special payment groups (sole community hospitals
(SCHs), rural referral centers (RRCs), and Medicare dependent
hospitals (MDHs)), as well as rural hospitals not receiving a
special payment designation. There were 136 RRCs, 389 SCHs, 146
MDHs, and 77 hospitals that are both SCHs and RRCs.
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 reports, 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.
BILLING CODE 4120-01-P

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[GRAPHIC] [TIFF OMITTED] TR12AU05.005

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[GRAPHIC] [TIFF OMITTED] TR12AU05.006

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[GRAPHIC] [TIFF OMITTED] TR12AU05.008

[[Page 47697]]

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

In Column 2 of Table I, we present the effects of the expansion
of the postacute care transfer policy, as discussed in section V.A.
of the preamble to this final rule. We compared aggregate payments
using the FY 2005 DRG relative weights (GROUPER version 22.0) and
the 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 making are estimated to result in a 0.9 percent decrease in
payments to hospitals overall. We estimate the total savings at
approximately $780 million in FY 2006.
To simulate the impact of this final 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 postacute care
transfer policy and the second was based on the expanded postacute
care transfer policy discussed in the preamble to this final 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 postacute care 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 postacute care 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 postacute care 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 12 DRGs
(including 210 and 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 13 special payment DRGs:
Accordingly, these cases 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 change to the
postacute care transfer policy.
This expansion of the policy has a -0.9 percent payment impact
overall among both urban and rural hospitals. There is only small
variation among all of the hospital categories from the -0.9 percent
impact. The areas that are most dramatically affected are urban
areas, with urban New England experiencing a 1.6 percent decline in
payments and the East North Central experiencing a 1.1 percent
decline. Although none of the rural regions show an increase in
payments, all 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 affected by this
policy.

D. Impact of the 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 final rule. Section 1886(d)(4)(C)(i) of the
Act requires us annually to make appropriate classification changes
and to recalibrate the DRG weights in order to reflect changes in
treatment patterns, technology, and any other factors that may
change the relative use of hospital resources.
We compared aggregate payments using the FY 2005 DRG relative
weights (GROUPER version 22.0) to aggregate payments using the 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 budget neutrality factor of
1.002271 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 making include--
The creation of several new DRGs designed to better
reflect severity among cardiac DRG cases,
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 DRG 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 or secondary diagnosis codes
for curvature of the spine and the principal diagnosis code for
malignancy from DRGs 497 and 498 to new DRG 546 (Spinal Fusions
Except Cervical with Curvature of the Spine or Malignancy);
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); and
Creating a new DRG 559 (Acute Ischemic Stroke With Use
of Thrombolytic Agent) that identifies embolic stroke combined with
tPA treatment.
Of the changes described above, the most significant change we
are making results from our focused review of the cardiovascular
DRGs for FY 2006. The approach we are adopting provides a sound
analytical basis for replacing 9 cardiovascular DRGs that account
for nearly 700,000 cases with 12 new DRGs that better recognize
severity of illness. These nine DRGs are commonly billed by
specialty hospitals. While these changes do not appear to have a
significant impact among any of the categories of hospitals listed
below, we believe the changes will address a portion of the
inappropriately higher payments that are accruing to specialty
hospitals under the current DRG system. We have analyzed a sample of
specialty hospitals and found that the effect of the DRG changes
alone may decrease the case-mix index (and the resulting payments)
by an average 1 percent. While we expect to complete a comprehensive
analysis of the MedPAC recommendations over the next year and will
consider making further changes to the DRG system for FY 2007, the
changes we are making to the cardiovascular DRGs for FY 2006
represent an excellent interim step for beginning the improvements
to the DRG system.
In the aggregate, these changes will have no impact on overall
payments to hospitals. On average, the impacts of these changes on
any particular hospital group are very small, with urban hospitals
experiencing a 0.1 percent increase and rural hospitals experiencing
a 0.1 percent decrease. The largest impact is a 0.3 percent increase
among urban hospitals in New England. This impact is in part due to
the residual effects of the change to the postacute care transfer
policy on the relative weights. Including a DRG in the postacute
care transfer policy 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 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 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

[[Page 47698]]

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 0.2
percent decrease for all hospitals and for hospitals in urban areas.
This decrease is due to both fluctuations in the wage data itself
and full implementation of the new labor market areas in FY 2006.
Hospitals that experienced a decline in the wage index due to the
new labor market areas received a transition blended wage index in
FY 2006. The labor market transition is no longer in effect for FY
2006 resulting in a payment reduction for hospitals that benefited
in FY 2005 from the transition. Among regions, the largest increase
is in the rural New England region, which is experiencing a 1.3
percent increase. The largest decline from updating the wage data is
seen in the urban Puerto Rico region (a 1.2 percent decrease).
In looking at the wage data itself, the national average hourly
wage increased 6.2 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 6.2 increase in average hourly wage. Of
the 3,681 hospitals with wage data for both FYs 2005 and 2006,
1,647, or 44.7 percent, also experienced an average hourly wage
increase of 6.2 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, 56
will experience an increase of between 5 percent and 10 percent and
20 will experience an increase of more than 10 percent. A total of
35 rural hospitals will experience increases greater than 5 percent,
but none will experience increases of greater than 10 percent. On
the negative side, 46 urban hospitals will experience decreases in
their wage index values of at least 5 percent, but less than 10
percent. Fifteen 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.

------------------------------------------------------------------------
Number of
hospitals
Percentage change in area wage index values -----------------
Urban Rural
------------------------------------------------------------------------
Increase more than 10 percent......................... 20 0
Increase more than 5 percent and less than 10 percent. 56 35
Increase or decrease less than 5 percent.............. 2,375 1,102
Decrease more than 5 percent and less than 10 percent. 46 12
Decrease more than 10 percent......................... 15 0
------------------------------------------------------------------------

F. Impact of Change in Treatment of Section 1886(d)(8)(E) Wage Data
(Column 5)

For the FY 2006 wage index, we are leaving 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 moving 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 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. Rural hospitals
in the Mountain region are shown to experience a 0.3 percent
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 0.9 percent
increase.

G. Combined Impact of 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 final rule,
in determining the budget neutrality factor, we compared simulated
aggregate payments using the FY 2005 DRG relative weights, the
blended wage index, and labor share percentage to simulated
aggregate payments using the FY 2006 DRG relative weights and wage
index and the rebased labor share percentage (69.7 percent for the
national rate, 58.7 percent for the Puerto Rico specific rate).
We computed a wage and DRG recalibration budget neutrality
factor of 1.002271. 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 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 0.4 and 1.0 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 1.5 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 0.998859 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 basis 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' wage index area assignments.
By February 28 of each year, the MGCRB makes reclassification
determinations that will be effective for the next fiscal year,
which begins on October 1. The MGCRB may approve a hospital's
reclassification request for the purpose of using another area's
wage index value. The FY 2006 wage index values incorporate all of
the MGCRB's

[[Page 47699]]

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, or a request
by a hospital to withdraw its application.
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 0.992521 to ensure that the effects of
reclassification are budget neutral. (See section II.A.4.b. of the
Addendum to this final rule.)
As a group, rural hospitals benefit from geographic
reclassification. We estimate that their payments will rise 2.1
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 region. 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
2.6 percent.
Urban hospitals reclassified for FY 2006 are expected to receive
an increase of 2.8 percent, while rural reclassified hospitals are
expected to benefit from the MGCRB changes with a 3.8 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 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, 308 counties and 592 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 final rule for FY 2006
(including statutory changes), to our estimate of payments per case
in FY 2005. This column includes all of the policy changes. 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
3.5 percent. This increase includes the effects of the 3.7 percent
market basket update. It also reflects the 1.0 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 (4.1 percent), as
described in the introduction to this Appendix and the Addendum to
this final rule. As a result, payments are projected to be 1.0
percentage point lower in FY 2005 than originally estimated,
resulting in a 1.0 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 1.3 percent are primarily attributable to the impact of expanding
the postacute care transfer policy (-0.9 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 final rule we are revising 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.
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
will increase by 3.5 percent. Hospitals in urban areas will
experience a 3.5 percent increase in payments per case compared to
FY 2005. Hospitals in rural areas, meanwhile, will experience a 3.3
percent payment increase. Hospitals in large urban areas will
experience a 3.4 percent increase in payments and hospitals in other
urban areas will experience a 3.6 percent increase in payments.
Among urban census divisions, the largest payment increase will
be 5.1 percent in the Pacific region. Hospitals in the West South
Central region will experience the next largest overall increase of
3.9 percent. The smallest urban increase would occur in the New
England region, with an increase of 2.3 percent.
Among rural regions in Column 10, no hospital category will
experience overall payment decreases. The Pacific and New England
regions will benefit the most, with 4.3 and 4.7 percent increases,
respectively. The smallest increase will occur in the South Atlantic
and East North Central regions, with 2.0 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) will experience payment increases of 3.8
percent, 3.2 percent, and 3.5 percent, respectively.
Urban hospitals reclassified for FY 2006 are anticipated to
receive an increase of 4.2 percent, while rural reclassified
hospitals are expected to benefit from reclassification with a 3.3
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 2.5 percent.

L. Impact Analysis of Table II

Table II presents the projected impact of the 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.

[[Page 47700]]

Table II.--Impact Analysis of Changes for FY 2006 Operating Prospective
Payment System
[Payments per case]
------------------------------------------------------------------------
Average Average
Number FY 2005 FY 2006 All FY
of payment payment 2006
hospitals per case per case changes
\1\ \1\
(1) (2) (3) (4)
-----------------------------
All hospitals............... 3,744 8,257 8,542 3.5

By Geographic Location
Urban hospitals............. 2,616 8,580 8,878 3.5
Large urban areas 1,440 8,961 9,267 3.4
(populations over 1
million)...................
Other urban areas 1,176 8,123 8,412 3.6
(populations of 1 million
or fewer)..................
Rural hospitals............. 1,128 6,534 6,750 3.3
Bed Size (Urban):
0-99 beds............... 676 6,480 6,726 3.8
100-199 beds............ 884 7,187 7,439 3.5
200-299 beds............ 485 8,127 8,417 3.6
300-499 beds............ 410 9,075 9,380 3.4
500 or more beds........ 161 10,866 11,238 3.4
Bed Size (Rural):
0-49 beds............... 452 5,629 5,814 3.3
50-99 beds.............. 379 6,021 6,214 3.2
100-149 beds............ 188 6,490 6,706 3.3
150-199 beds............ 61 7,703 7,931 3.0
200 or more beds........ 48 7,788 8,079 3.7
Urban by Region:
New England............. 129 9,225 9,437 2.3
Middle Atlantic......... 368 9,342 9,626 3.0
South Atlantic.......... 396 8,148 8,430 3.5
East North Central...... 405 8,251 8,491 2.9
East South Central...... 171 7,809 8,101 3.7
West North Central...... 159 8,653 8,925 3.1
West South Central...... 370 8,115 8,432 3.9
Mountain................ 146 8,455 8,770 3.7
Pacific................. 420 10,089 10,603 5.1
Puerto Rico............. 52 3,998 4,118 3.0
Rural by Region:
New England............. 25 8,397 8,787 4.7
Middle Atlantic......... 73 6,200 6,460 4.2
South Atlantic.......... 180 6,419 6,593 2.7
East North Central...... 145 6,474 6,651 2.7
East South Central...... 197 5,807 6,019 3.7
West North Central...... 160 6,889 7,110 3.2
West South Central...... 210 6,149 6,348 3.2
Mountain................ 87 7,399 7,658 3.5
Pacific................. 51 9,904 10,328 4.3

By Payment Classification

Urban hospitals............. 2,651 8,544 8,840 3.5
Large urban areas 1,451 8,940 9,245 3.4
(populations over 1
million)...................
Other urban areas 1,200 8,070 8,355 3.5
(populations of 1 million
or fewer)..................
Rural areas................. 1,093 6,675 6,898 3.3
Teaching Status:
Non-teaching............ 2,661 6,958 7,216 3.7
Fewer than 100 Residents 845 8,379 8,665 3.4
100 or more Residents... 238 12,175 12,544 3.0
Urban DSH:
Non-DSH................. 1,026 7,462 7,715 3.4
100 or more beds........ 1,505 9,035 9,350 3.5
Less than 100 beds...... 350 5,945 6,181 4.0
Rural DSH:
SCH..................... 404 6,941 7,201 3.7
RRC..................... 182 7,278 7,499 3.0
Other Rural:
100 or more beds.... 63 5,580 5,743 2.9
Less than 100 beds.. 214 4,904 5,044 2.9
Urban Teaching and DSH:
Both teaching and DSH... 811 9,971 10,301 3.3
Teaching and no DSH..... 207 8,424 8,683 3.1
No teaching and DSH..... 1,044 7,271 7,554 3.9
No teaching and no DSH.. 589 6,893 7,143 3.6
Rural Hospital Types:

[[Page 47701]]

Non special status 334 5,149 5,305 3.0
hospitals..............
RRC..................... 136 6,754 6,943 2.8
SCH..................... 389 7,548 7,837 3.8
MDH..................... 146 4,824 4,980 3.2
SCH and RRC............. 77 8,467 8,760 3.5
Type of Ownership:
Voluntary............... 2,217 8,374 8,655 3.4
Proprietary............. 857 7,545 7,819 3.6
Government.............. 670 8,481 8,803 3.8
Medicare Utilization as a
Percent of Inpatient Days:
0-25.................... 280 11,238 11,670 3.8
25-50................... 1,427 9,272 9,595 3.5
50-65................... 1,534 7,326 7,573 3.4
Over 65................. 403 6,555 6,759 3.1

Hospitals Reclassified by
the Medicare Geographic
Classification Review Board

FY 2005 Reclassifications:
All Urban Reclassified 263 8,522 8,882 4.2
Hospitals..............
Urban Nonreclassified 2,329 8,576 8,867 3.4
Hospitals..............
All Reclassified Rural 355 7,052 7,284 3.3
Hospitals..............
Rural Nonreclassified 702 6,066 6,274 3.4
Hospitals..............
Other Reclassified 64 5,717 5,857 2.5
Hospitals (Section
1886(d)(8)(E)).........
Other Reclassified 31 10,164 10,481 3.1
Hospitals (Section
1886(d)(8)(B)).........
------------------------------------------------------------------------
\1\ These payment amounts per case do not reflect any estimates of
annual case-mix increase.

VII. Impact of Other Policy Changes

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

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

In section II.D. of the preamble of this final rule, we discuss
the changes in the LTC-DRG relative weights for FY 2006, which is
based on the version 23.0 of the CMS GROUPER (including the changes
in the classifications, relative weights and geometric mean length
of stay for each LTC-DRG). As also discussed in that same section of
this final rule, currently, there is no statutory or regulatory
requirement that the annual update to the LTC-DRG classifications
and relative weights be done in a budget neutral manner. As
discussed above in section II.D.4. of the preamble to this final
rule, the LTCH PPS is still in the midst of a transition from a
reasonable cost-based payment system to fully Federal PPS payments,
during which time LTCH coding and data are still in flux. The LTCH
PPS was implemented for cost reporting periods beginning on or after
October 1, 2002 (FY 2003). Therefore, the FY 2004 MedPAR data used
to compute the FY 2006 LTC-DRG relative weights are based on LTCH
claims data taken from only the first full year of the LTCH PPS.
Based on LTCH cases in the March 2005 update of the FY 2004 MedPAR
files, we estimate that the changes to the LTC-DRG classifications
and relative weights for FY 2006 will result in an aggregate
decrease in LTCH PPS payments of approximately 4.2 percent.
When we compared the Grouper version 22 (FY 2005) LTC-DRG
relative weights to the Grouper version 23 (FY 2006) LTC-DRG
relative weights, we found that approximately 71 percent of the LTC-
DRGs had higher relative weights under version 22. We also found
that the Grouper version 22 LTC-DRG relative weights were, on
average, approximately 15 percent higher than the Grouper 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 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 typical when
moving from a reasonable cost-based payment system to a PPS. The
impact of including additional cases with relatively lower charges
into LTC-DRGs that had a relatively higher relative weight in the
Grouper version 22.0 (FY 2005) is a decrease in the average relative
weight for those LTC-DRGs in the GROUPER version 23.0.
As noted above in section II.D.4 of the preamble of this final
rule, LTCHs are a specialized provider type that typically do not
treat a broad spectrum of patients in their facilities with many
different diagnoses. While there are 526 valid Grouper version 23
LTC-DRGs, 196 LTC-DRGs have no LTCH cases. In addition, another 171
LTC-DRGs are categorized as ``low volume'' (that is, have less than
25 cases annually). Consequently, only about 159 LTC-DRGs are used
by most LTCHs on a ``regular basis'' (that is, nationally LTCHs
discharge, in total, average 25 or more of these cases annually). Of
these 159 LTC-DRGs that are used on a ``regular basis,'' we found
that approximately 80 percent of the LTC-DRGs had higher relative
weights under Grouper version 22 in comparison to Grouper version
23. About 33 percent of the159 LTC-DRGs that are used on a ``regular
basis'' (53 LTC-DRGs) will experience a decrease in the average
charge per case as compared to the average charge per case in that
DRG based on FY 2003 data, which generally results in a lower
relative weight. We also found that there has been an increase of
approximately 16 percent in the average LTCH charge across all LTC-
DRGs from FY 2003 to FY 2004. In addition, about 42 percent of the
159 LTC-DRGs that are used on a ``regular basis'' (66 LTC-DRGs) will
experience an increase in the average charge that is less than the
increase in the overall average charge across all LTC-DRGs (about 16
percent, as noted above). Accordingly, those LTC-DRGs will also have
a reduction in their relative weight as compared to the relative
weight in FY 2005. For those LTC-DRGs in which the average charge
within the LTC-DRG increase is less than 16 percent, the relative
weights for those LTC-DRGs will decrease because the average

[[Page 47702]]

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 changes in the LTC-DRG
relative weights, which include a significant number of LTC-DRGs
with lower relative weights, will result in approximately a 4.2
percent decrease in aggregate LTCH PPS payments.

B. Impact of 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 final rule).
However, we are still providing an estimate of the payment increases
here, as they will have an impact on total payments made in FY 2006.
New technology add-on payments are limited to the lower 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 final
rule, we are approving two of the new technology applications,
Restore[supreg] Rechargable Implantable Neurostimulator and GORE
TAG, that were filed for FY 2006. Additionally, we are continuing to
make add-on payments in FY 2006 for an FY 2005 new technology:
Kinetra^TM implants. We estimate these approvals will
increase overall FY 2006 payments by $6.01 million, $16.61 million
and $12.82 million, respectively. The total increase in payments for
these three new technologies, approximately $35.5 million, 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 final 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 as 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. of the preamble to this final rule. The final date for
submission of quality data for purposes of receiving the full market
basket update in FY 2006 was 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 final rule, we are providing additional
validation criteria to ensure that the quality data being sent to
CMS are accurate. The requirement of 5 charts per hospital will
result in approximately 19,000 charts per quarter total submitted to
the agency. We reimburse hospitals for the cost of sending charts to
the CDAC at the rate of 12 cents per page for copying and
approximately $4.00 per chart for postage. Our experience shows that
the average chart received at the CDAC is approximately 140 pages.
Thus, the agency will have expenditures of approximately $380,000
per quarter to collect the charts. Given that we reimburse for the
data collection effort, we believe that a requirement for five
charts per hospital per quarter represents a minimal burden to the
participating hospital. Based on test applications of these
validation criteria to quality data that have been submitted thus
far, we currently estimate that approximately 2 percent of hospitals
will fail the edits and receive the reduced market basket update to
the standardized amount. We estimate reduced market basket payments
of approximately $8 million for FY 2006.

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

In section V.E. of the preamble to this final rule, we discussed
our 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 continuing
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 eight 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 $1.49 million.

E. Impact of 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 final rule, we discuss
the incorporation into regulations of 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 addition to the
regulations clarifies the established policy for computing an IME
FTE resident cap for these hospitals. Because this is a
clarification of existing policy and codification of 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 final rule, we present
our policy 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
convert to rural status solely to gain a higher IME FTE cap in the
absence of this policy 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.

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

In section V.H.2. of the preamble of this final 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 providing that, for reclassification
applications submitted for FY 2006 (that is, applications received
by September 1, 2004), for FY 2007 (that is, applications received
by September 1, 2005, and for FY 2008 (that is, applications
received by September 1, 2006), we will allow a campus or campuses
of a multicampus hospital system to seek geographic reclassification
to the labor market area where the other campus(es) is located on
the basis of the average hourly

[[Page 47703]]

wage data submitted for the entire hospital system. This policy will
only affect those multicampus hospitals that are located in more
than one labor market area that seek to reclassify to allow the
entire hospital system to be paid using a single wage index. We
estimate there are less than 10 multicampus hospital systems
nationwide that will seek to reclassify under the revised
regulation. This provision 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 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 final rule, we discuss
our 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 providing 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 final rule, we have estimated
the impact of this 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 0.50 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 final rule, we discuss
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 revising 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 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 final 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 final 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 final rule.

I. Impact of Policy on Provider-Based Status of Facilities and
Organizations Under Medicare--Location Requirements for Off-Campus
Facilities: Application to Certain Neonatal Intensive Care Units

In section V.J.2. of the preamble to this final rule, we discuss
the change to the provider-based regulations regarding the location
requirements for off-campus facilities as they relate to neonatal
intensive care units (NICUs). In accordance with this final rule,
NICUs meeting other applicable requirements will be considered to be
qualified provider-based entities if they are located within a 100-
mile radius of the children's hospitals which is the potential main
provider and at least 35 miles from the nearest other NICU. We
estimate that there will be fewer than five NICUs nationwide that
will be able to meet the provider-based status as a result of this
change. Given the specialized nature of the care provided and their
rural location, we expect that these types of units will not treat
any Medicare patients, though some of their patients may qualify for
Medicaid. As a result, we believe that this change will have no
impact on Medicare. The Medicaid impact, on a national basis, will
be very small.

J. Impact of Policy on CAH Relocation Provisions

In section VII.B.3. of the preamble to this final rule, we
discuss the 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 revising the regulations to allow some flexibility for those
CAHs previously designated as necessary providers to replace their
facilities. For the reasons explained more fully in section VII.B.3,
we have decided to permit a necessary provider CAH to relocate its
facility and begin providing services at a new location, provided
the necessary provider will be essentially the same facility in its
new location.
The Health Resources Services Administration (HRSA) estimates
that these necessary provider CAH facility replacements will take
place at the rate of 5 facilities per year, nationwide, over the
next 10 years. The average cost of construction of a new 25-bed CAH
is approximately $25 million. Given a depreciation schedule based on
a 25 year useful life and Medicare utilization of approximately 50
percent, the additional annual capital costs for 5 CAH facility
replacements would be $2.5 million. However, the actual cost to the
program would be further reduced since those CAH are currently being
reimbursed for their existing capital costs and their increased
operating costs that are associated with operating an aged facility.
Accordingly, the budgetary impact for the 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 change is
estimated at between $200,000 and $400,000 per CAH.
Comment: One commenter stated that our estimated cost of $25 to
$35 million is not a realistic estimate. One example given was a
hospital in Oklahoma with 15 beds and 2 complete surgical suites.
The commenter indicated that the cost for building the new facility
and buying equipment was $7.5 million.
Response: We appreciate the commenter's information and
considered it in developing the cost estimate for the final rule.
However, as acknowledged by the commenter, the $7.5 million figure
represents a single instance of construction at a single location
and related to a facility having only 15 beds. In contrast, our
estimate of $25 to $35 million is intended to be national in scope
and assumes the new facility will have 25 beds, as do the vast
majority of facilities now operating as CAHs. Therefore, we made no
change in our cost estimates based on this comment.

VIII. Impact of 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 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 final rule, with the 10-year transition period
ending with hospital cost reporting periods beginning on or after
October 1, 2001 (FY

[[Page 47704]]

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 +
Disproportionate Share (DSH) Adjustment Factor + Indirect Medical
Education (IME) Adjustment Factor, if applicable).
In addition, hospitals may also receive outlier payments for
those cases that qualify under the threshold established for each
fiscal year.
The data used in developing the impact analysis presented below
are taken from the March 2005 update of the FY 2004 MedPAR file and
the March 2005 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 March 2005 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 March 2005 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 final
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 will
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 FY 2006 update is 0.8 percent (see
section III.A.1.a. of the Addendum to this final rule).
In addition to the FY 2006 update factor, the FY 2006
capital Federal rate was calculated based on a GAF/DRG budget
neutrality factor of 1.0008, an outlier adjustment factor of 0.9515,
and a (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 March 2005 update of the FY 2004
MedPAR file, the March 2005 update to the Provider-Specific File,
and the most recent cost report data from the March 2005 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 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 0.8 percent update to the capital Federal
rate, a 0.0 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 2.4 percent in FY 2006. In
addition to the 0.8 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 2.5 percent increase in IPPS
capital payments per case, while rural hospitals are only expected
to experience a 1.8 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 1.0 percent (Middle Atlantic rural)
to a maximum increase of 4.5 percent (New England rural). The
relatively small increase in projected capital payments per
discharge for hospitals located in the Middle Atlantic region is
largely attributable to the change in the GAF value (that is, the
GAF 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 New England rural region is largely due to the changes in the
GAF values (that is, the GAFs for most of these hospitals for FY
2006 are higher than the average of the GAFs for FY 2005) and an
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 0.3 percent. This
lower than average increase in payment per case for hospitals
located in Puerto Rico is largely due to the changes in the GAF
values (that is, the GAFs for most of these hospitals for FY 2006
are lower 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 (2.6 percent).
Similarly, payments to voluntary and proprietary hospitals are
expected to increase 2.4 percent and 2.3 percent, respectively. As
noted above, this slightly larger projected increase in capital
payments per case for government hospitals is mostly due to a
smaller than average decrease in the 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
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 2.7

[[Page 47705]]

percent increase in payments. Payments to nonreclassified hospitals
in FY 2006 are expected to increase 2.4 percent. Hospitals
reclassified during both FY 2005 and FY 2006 are projected to
experience an increase in payments of 1.9 percent. Hospitals
reclassified during FY 2006 only are projected to receive an
increase in payments of 4.5 percent. This relatively large increase
is primarily due to the changes in the GAF values (that is, the GAFs
for most of these hospitals for FY 2006 are higher than the average
of the GAFs for FY 2005).

Table III.--Comparison of Total Payments per Case
[FY 2005 payments compared to FY 2006 payments]
------------------------------------------------------------------------
Average Average
Number of FY 2005 FY 2006
hospitals payments/ payments/ Change
case case
------------------------------------------------------------------------
By Geographic Location ......... ......... ......... .........
-----------------------------
All hospitals............... 3,744 723 741 2.4
Large urban areas 1,440 807 827 2.5
(populations over 1
million)...................
Other urban areas 1,176 715 732 2.4
(populations of 1 million
of fewer)..................
Rural areas................. 1,128 501 510 1.8
Urban hospitals............. 2,616 765 784 2.5
0-99 beds............... 676 587 600 2.2
100-199 beds............ 884 649 664 2.3
200-299 beds............ 485 723 740 2.3
300-499 beds............ 410 805 824 2.3
500 or more beds........ 161 961 991 3.1
Rural hospitals............. 1,128 501 510 1.8
0-49 beds............... 452 414 420 1.3
50-99 beds.............. 379 463 471 1.8
100-149 beds............ 188 506 515 1.9
150-199 beds............ 61 562 572 1.8
200 or more beds........ 48 626 640 2.3

By Region

Urban by Region............. 2,616 765 784 2.5
New England............. 129 831 849 2.1
Middle Atlantic......... 368 832 854 2.6
South Atlantic.......... 396 734 751 2.2
East North Central...... 405 757 771 2.0
East South Central...... 171 689 706 2.4
West North Central...... 159 760 775 2.0
West South Central...... 370 712 730 2.5
Mountain................ 146 767 786 2.5
Pacific................. 420 864 898 4.0
Puerto Rico............. 52 338 339 0.3
Rural by Region............. 1,128 501 510 1.8
New England............. 25 647 676 4.5
Middle Atlantic......... 73 512 517 1.0
South Atlantic.......... 180 491 500 1.7
East North Central...... 145 532 540 1.5
East South Central...... 197 460 470 2.2
West North Central...... 160 526 532 1.3
West South Central...... 210 454 461 1.7
Mountain................ 87 520 532 2.4
Pacific................. 51 591 612 3.6

By Payment Classification

All hospitals............... 3,744 723 741 2.4
Large urban areas 1,451 806 826 2.6
(populations over 1
million)...................
Other urban areas 1,200 713 730 2.4
(populations of 1 million
of fewer)..................
Rural areas................. 1,093 502 511 1.9
Teaching Status:
Non-teaching............ 2,661 605 618 2.2
Fewer than 100 Residents 845 743 760 2.2
100 or more Residents... 238 1,062 1,094 3.0
Urban DSH:
100 or more beds.... 1,505 790 811 2.6
Less than 100 beds.. 350 521 535 2.6
Rural DSH:
Sole Community (SCH/ 404 452 459 1.7
EACH)..............
Referral Center (RRC/ 182 559 572 2.2
EACH)..............
Other Rural:
100 or more beds 63 471 478 1.6
Less than 100 214 416 421 1.2
beds...........
Urban teaching and DSH:
Both teaching and DSH... 811 870 893 2.7

[[Page 47706]]

Teaching and no DSH..... 207 793 810 2.1
No teaching and DSH..... 1,044 641 656 2.4
No teaching and no DSH.. 589 664 678 2.2
Rural Hospital Types:
Non special status 334 441 448 1.5
hospitals..............
RRC/EACH................ 136 570 582 2.1
SCH/EACH................ 389 470 479 1.8
Medicare-dependent 146 418 424 1.4
hospitals (MDH)........
SCH, RRC and EACH....... 77 570 582 2.0

Hospitals Reclassified by
the Medicare Geographic
Classification Review Board

Reclassification Status
During FY2005 and FY2006:
Reclassified During Both 418 632 644 1.9
FY2005 and FY2006......
Reclassified During 198 705 736 4.5
FY2006 Only........
Reclassified During 134 678 695 2.5
FY2005 Only........
FY2006
Reclassifications:
All Reclassified 618 655 673 2.7
Hospitals..........
All Nonreclassified 3,031 740 757 2.4
Hospitals..........
All Urban 263 759 782 3.0
Reclassified
Hospitals..........
Urban 2,329 766 785 2.4
Nonreclassified
Hospitals..........
All Reclassified 355 545 558 2.3
Rural Hospitals....
Rural 702 453 459 1.4
Nonreclassified
Hospitals..........
Other Reclassified 71 501 502 0.2
Hospitals (Section
1886(D)(8)(B)).........

Type of Ownership

Voluntary............... 2,189 743 760 2.4
Proprietary............. 806 654 669 2.3
Government.............. 669 696 715 2.6
Medicare Utilization as a
Percent of Inpatient Days:.
0-25.................... 280 918 947 3.2
25-50................... 1,427 811 834 2.7
50-65................... 1,534 644 658 2.0
Over 65................. 403 587 597 1.6
------------------------------------------------------------------------

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

I. Background

Section 1886(e)(4)(A) of the Act requires that the Secretary,
taking into consideration the recommendations of the Medicare
Payment Advisory Commission (MedPAC), recommend update factors for
inpatient hospital services for each fiscal year that take into
account the amounts necessary for the efficient and effective
delivery of medically appropriate and necessary care of high
quality. Under section 1886(e)(5)(B) of the Act, we are required to
publish update factors recommended by the Secretary in the final
rule.
Consistent with section 1886(e)(5)(B) of the Act, in this final
rule, we are publishing our final recommendations for updating
hospitals payments for FY 2006. In accordance with sections
1886(d)(3)(A) and 1886(b)(3)(B)(i)(XIX) of the Act, we are updating
the standardized amount for FY 2006 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 basket percentage increase less 0.4 percentage
points. 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).
Based on the Office of the Actuary's revised and rebased fourth
quarter 2004 forecast of the FY 2006 market basket increase of 3.7
percent, the update to the standardized amounts for hospitals
subject to the acute inpatient prospective payment system is 3.7
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, and 3.3 percent for hospitals that do not
provide the required quality data. The update to the hospital
specific rate applicable to SCHs and MDHs is also 3.7 percent. In
the proposed rule, the most recent estimate of the market basket
increase was 3.2 percent. Accordingly, we proposed an update factor
of 3.2 percent for hospitals that submitted quality data and 2.8
percent for hospitals that did not provide the required quality
data.
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, children's
hospitals, and RNHCIs 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 final rule, we have used the estimated FY
2006 IPPS operating market basket percentage increase (3.7 percent)
to

[[Page 47707]]

update the target limits for children's hospitals, cancer hospitals,
and RNHCIs.
As described in greater detail below, under their respective
PPSs, existing LTCHs and existing IPFs are/or will soon be 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 final rule, we are
rebasing the market basket used to determine the reasonable cost-
based payment amount for LTCHs and IPFs. We are providing 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 3.8 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).) An existing 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 will be determined by updating the LTCH's TEFRA
limit by the current estimate of the FY 2002-based excluded hospital
market basket (or 3.8 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, existing 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 will be determined by updating the IPF's TEFRA
limit by the current estimate of the FY 2002-based excluded hospital
market basket (or 3.8 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).)

II. Secretary's Final Recommendation for Updating the Prospective
Payment System Standardized Amount

In recommending an update, the Secretary takes into account the
factors in the update framework, as well as other factors, such as
the recommendations of MedPAC, the long-term solvency of the
Medicare Trust funds and the capacity of the hospital industry to
continually provide access to high quality care to Medicare
beneficiaries through adequate payment to health care providers.
In the proposed rule, we proposed to recommend an update of 3.2
percent, which reflected the CMS Office of the Actuary's most recent
forecast of the FY 2006 market basket increase. We did not receive
any public comments regarding this issue. In this final rule, we are
recommending an update for IPPS hospitals based on the forecasted
market basket increase. However, the Office of the Actuary's most
recent (second quarter) 2005 forecast of the FY 2006 market basket
increase is 3.7 percent. Thus, the Secretary's final recommendation
for the update to the IPPS standardized amount for all hospitals is
3.7 percentage points for hospitals that provide the required
quality data. The update to the hospital-specific rate applicable to
SCHs and MDHs is also 3.7 percent (or consistent with current law,
the market basket percentage increase).

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

We did not receive any comments concerning our proposed
recommendations for updating the rate-of-increase for FY 2006 for
cancer hospitals, RNHCIs, and children's hospitals. Our final
recommendation does not differ from the proposed recommendation.
However, the fourth quarter forecast of the market basket percentage
increase is 3.7 for these excluded hospitals and hospital units (up
from 3.2 percent estimated in the proposed rule). Thus, the
Secretary's final recommendation is that the update to the target
limits for cancer hospitals, RNHCIs, and children's hospitals is 3.7
percent.
Further, we did not receive any comments concerning our proposed
recommendations for the update factor for LTCHs for 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, we are recommending a final
update factor of 3.8 percent (up from the estimated 3.4 percent in
the proposed rule) for the portion of the payment that is based on
reasonable costs, subject to the TEFRA limits, consistent with our
determination in section IV. of the preamble of this final rule. For
the Federal portion of this same blended payment amount, we are
recommending a final update of 3.4 percent (up from the estimated
3.1 percent in the proposed rule and consistent with determination
in the FY 2006 LTGH PPS final rule (70 FR 24180)).
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 a final update of
zero for IPFs (69 FR 66922). Finally, for the IRF PPS, we proposed
an update of 3.1 percent in the FY 2006 IPPS proposed rule. In the
FY 2006 IRF PPS proposed rule (70 FR 24180), which was published
after the issuance of the FY 2006 IPPS proposed rule, we proposed an
update for the IRF PPS payments of 3.1 percent. Accordingly, we are
finalizing our recommendation of an update of 3.1 percent for IRF
PPS.

IV. Secretary's Final Recommendation for Updating the Capital
Prospective Payment Amounts

Because the operating and capital prospective payment systems
remain separate, we are continuing to use separate updates for
operating and capital payments. The final update to the capital
payment rates is discussed in section III. of the Addendum to this
final rule.

[FR Doc. 05-15406 Filed 8-1-05; 4:16 pm]
BILLING CODE 4120-01-P