[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]



[[Page 47277]]

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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  

[[Page 47278]]


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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

    This Federal Register document is also available from the Federal 
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password required).

Acronyms

AAOS American Association of Orthopedic Surgeons
ACGME Accreditation Council on Graduate Medical Education
AHIMA American Health Information Management Association
AHA American Hospital Association
AICD Automatic 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:

----------------------------------------------------------------------------------------------------------------
                                                                     Number of    Average length      Average
                               DRG                                     cases          of stay         charges
----------------------------------------------------------------------------------------------------------------
515.............................................................          25,236            4.32      $83,659.76
535.............................................................          12,118            8.27      113,175.43
536.............................................................          18,305            5.39       94,453.62
----------------------------------------------------------------------------------------------------------------

    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:

----------------------------------------------------------------------------------------------------------------
                                                                     Number of    Average length-     Average
                               DRG                                     cases          of-stay         charges
----------------------------------------------------------------------------------------------------------------
535--Cardiac Catheterization Without Code 37.26.................           5,060           10.63     $127,130.79
535--With Code 37.26 Only Without Cardiac Catheterization.......           5,264            5.61       98,900.13
535--With Cardiac Catheterization and Code 37.26................           1,794            9.44      115,701.09
536--Cardiac Catheterization Without Code 37.26.................           4,799            8.11      110,493.86
536--With Code 37.26 Only Without Cardiac Catheterization.......          10,829            3.85       85,390.88
536--With Cardiac Catheterization and Code 37.26................           2,677            6.76      102,359.21
----------------------------------------------------------------------------------------------------------------

    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:

----------------------------------------------------------------------------------------------------------------
                                                                     Number of    Average length      Average
                               DRG                                     cases          of stay         charges
----------------------------------------------------------------------------------------------------------------
DRG 108 With Code 35.52 Reported................................             523            2.69         $29,231
DRG 108--All cases..............................................           5,293           10.1           76,274
DRG 518--All cases..............................................          39,553            4.3           31,955
----------------------------------------------------------------------------------------------------------------

    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:

----------------------------------------------------------------------------------------------------------------
                                                                     Number of    Average length-     Average
                               DRG                                     cases          of-stay         charges
----------------------------------------------------------------------------------------------------------------
DRG 108 With Code 35.52 Reported................................             872            2.42         $29,579
DRG 108--All cases..............................................           8,264            9.81          81,323
DRG 518--All cases..............................................          38,624            3.49          27,591
----------------------------------------------------------------------------------------------------------------

    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:

----------------------------------------------------------------------------------------------------------------
                                                                     Number of    Average length      Average
                               DRG                                     cases          of stay         charges
----------------------------------------------------------------------------------------------------------------
DRG 533--All cases..............................................          44,677            3.73         $24,464
DRG 533 with codes 39.50 and 39.90 reported.....................           1,586            3.13          29,737
DRG 534--All cases..............................................          42,493            1.79          15,873
DRG 534 with codes 39.50 and 39.90 reported.....................           1,397            1.54          22,002
----------------------------------------------------------------------------------------------------------------

    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 CorCapTM 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' CorCapTM 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 
CorCapTM 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)
    INFUSETM 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 SoletraTM, also manufactured by 
Medtronic): one for the right side of the brain (to control symptoms on 
the left side of the body), the other for the left side of the brain 
(to control symptoms on the right side of the body). Additional 
procedures were required to create pockets in the chest cavity to place 
the two generators required to run the individual leads. The 
Kinetra[supreg] neurostimulator generator, implanted in the pectoral 
area, is designed to eliminate the need for two devices by 
accommodating two leads that are placed in both the left and right 
sides of the brain to deliver the necessary impulses. The manufacturer 
argued that the development of a single neurostimulator that treats 
bilateral symptoms provides a less invasive treatment option for 
patients, and simpler implantation, 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 
SoletraTM, the predecessor technology used to treat this 
condition, as a proxy for Kinetra[supreg]. The preexisting technology 
provided the closest means to track cases that have actually used 
similar technology and served to identify the need and use of the new 
device. The manufacturer informed us that the cost of the 
Kinetra[supreg] device is twice the price of a single 
SoletraTM device. Because most patients would receive two 
SoletraTM devices if the Kinetra[supreg] device is not 
implanted,

[[Page 47346]]

we believed data regarding the cost of SoletraTM would give 
a good measure of the actual costs that would be incurred. Medtronic 
submitted data for 104 cases that involved the SoletraTM 
device (26 cases in DRG 1 (Craniotomy Age > 17 With CC), and 78 cases 
in DRG 2 (Craniotomy Age > 17 Without CC)). These cases were identified 
from the FY 2002 MedPAR file using procedure codes 02.93 (Implantation, 
intracranial neurostimulator) and 86.09 (Other incision of skin and 
subcutaneous tissue). In the analysis presented by the applicant, the 
mean standardized charges for cases involving SoletraTM in 
DRGs 1 and 2 were $69,018 and $44,779, respectively. The mean 
standardized charge for these SoletraTM cases according to 
Medtronic's data was $50,839.
    Last year, we used the same procedure codes to identify 187 cases 
involving the SoletraTM device in DRGs 1 and 2 in the FY 
2003 MedPAR file. Similar to the Medtronic data, 53 of the cases were 
found in DRG 1, and 134 cases were found in DRG 2. The average 
standardized charges for these cases in DRGs 1 and 2 were $51,163 and 
$44,874, respectively. Therefore, the case-weighted average 
standardized charges for cases that included implantation of the 
SoletraTM 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 
SoletraTM 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. AquadexTM System 100 Fluid 
Removal System (System 100)
    CHF Solutions, Inc. resubmitted an application (previously 
submitted for consideration for FY 2005) for the approval of the System 
100 for new technology add-on payments for FY 2006. The System 100 is 
designed to remove excess fluid (primarily excess water) from patients 
suffering from severe fluid overload through the process of 
ultrafiltration. Fluid retention, sometimes to an extreme degree, is a 
common problem for patients with chronic congestive heart failure. This 
technology removes excess fluid without causing hemodynamic 
instability. It also avoids the inherent nephrotoxicity and 
tachyphylaxis associated with aggressive diuretic therapy, the mainstay 
of current therapy for fluid overload in congestive heart failure.
    The System 100 consists of: (1) An S-100 console; (2) a UF 500 
blood circuit; (3) an extended length catheter (ELC); and (4) a 
catheter extension tubing. The System 100 is designed to monitor the 
extracorporeal blood circuit and to alert the user to abnormal 
conditions. Vascular access is established via the peripheral venous 
system, and up to 4 liters of excess fluid can be removed in an 8-hour 
period.
    On June 3, 2002, FDA approved the System 100 for use with 
peripheral venous access. On November 20, 2003, FDA approved the System 
100 for expanded use with central venous access and catheter extension 
use for infusion or withdrawal circuit line with other commercially 
applicable venous catheters. According to the applicant, although the 
FDA first approved System 100 in June 2002, it was not used by 
hospitals until August 2002 because of the substantial amount of time 
necessary to market and sell the device to hospitals. The applicant 
presented data and evidence demonstrating that the System 100 was not 
marketed until August 2002.
    We note the applicant submitted an application for FY 2005 and was 
denied new technology add-on payments. Our review indicated that the 
applicant did not present sufficient objective clinical evidence to 
determine that the System 100 meets the substantial clinical 
improvement criterion (such as a large prospective, randomized clinical 
trial) even though it is indicated for use in patients with congestive 
heart failure, a common condition in the Medicare population. However, 
for FY 2006, we 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 SpineTM 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 SpineTM 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 RenewTM 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 RenewTM SCS because 
``RenewTM 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 RenewTM 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 RenewTM 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 
RenewTM 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 RenewTM 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 RenewTM device because 
RenewTM 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. WingspanTM Stent System With GatewayTM PTA 
Balloon Catheter
    Boston Scientific submitted an application for the 
WingspanTM Stent System with GatewayTM 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 WingspanTM 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 WingspanTM is 
the first commercially available PTA/stent system designed specifically 
for the intracranial vasculature. However, because the 
WingspanTM 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 
WingspanTM 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 WingspanTM, 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 WingspanTM 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.

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    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
ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½
Forecast:
    FY 2005.............................             4.2             4.2
    FY 2006.............................             3.7             3.8
    FY 2007.............................             3.1             3.4
ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½
------------------------------------------------------------------------
 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
ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½
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
ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½
------------------------------------------------------------------------
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
ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½
--------------------------------------------------------------------------------------------------------------------------------------------------------
 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\
---------------------------------------------------------------------------

    \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
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[[Page 47642]]

 
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[[Page 47643]]

 
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[[Page 47644]]

 
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[[Page 47645]]

 
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[[Page 47646]]

 
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[[Page 47647]]

 
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[[Page 47648]]

 
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  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.
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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: 
KinetraTM 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