[Federal Register Volume 72, Number 85 (Thursday, May 3, 2007)]
[Proposed Rules]
[Pages 24680-25135]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 07-1920]



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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 411, 412, 413, and 489



Medicare Program; Proposed Changes to the Hospital Inpatient 
Prospective Payment Systems and Fiscal Year 2008 Rates; Proposed Rule

  Federal Register / Vol. 72, No. 85 / Thursday, May 3, 2007 / Proposed 
Rules  

[[Page 24680]]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 411, 412, 413, and 489

[CMS-1533-P]
RIN 0938-AO70


Medicare Program; Proposed Changes to the Hospital Inpatient 
Prospective Payment Systems and Fiscal Year 2008 Rates

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

ACTION: Proposed rule.

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SUMMARY: We are proposing to revise the Medicare hospital inpatient 
prospective payment systems (IPPS) for operating and capital-related 
costs to implement changes arising from our continuing experience with 
these systems, and to implement certain provisions made by the Deficit 
Reduction Act of 2005 (Pub. L. 109-171), the Medicare Improvements and 
Extension Act under Division B, Title I of the Tax Relief and Health 
Care Act of 2006 (Pub. L. 109-432), and the Pandemic and All-Hazards 
Preparedness Act (Pub. L. 109-417). In addition, in the Addendum to 
this proposed rule, we describe the proposed changes to the amounts and 
factors used to determine the rates for Medicare hospital inpatient 
services for operating costs and capital-related costs. We also are 
setting forth proposed rate-of-increase limits for certain 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 or that have a 
portion of a prospective payment system payment based on reasonable 
cost principles. These proposed changes would be applicable to 
discharges occurring on or after October 1, 2007.
    In this proposed rule, we discuss our proposals to further refine 
the diagnosis-related group (DRG) system under the IPPS to better 
recognize severity of illness among patients--for FY 2008, we are 
proposing to adopt a Medicare Severity DRG (MS-DRG) classification 
system for the IPPS. We are also proposing to use the structure of the 
proposed MS-DRG system for the LTCH prospective payment system 
(referred to as MS-LTC-DRGs) for FY 2008.
    Among the other policy changes that we are proposing to make are 
changes related to: Limited revisions of the reclassification of cases 
to proposed MS-DRGs, the proposed relative weights for the proposed MS-
LTC-DRGs; the wage data, including the occupational mix data, used to 
compute the wage index; applications for new technologies and medical 
services add-on payments; payments to hospitals for the indirect costs 
of graduate medical education; submission of hospital quality data; 
provisions governing application of sanctions relating to the Emergency 
Medical Treatment and Labor Act of 1986 (EMTALA); provisions governing 
disclosure of physician ownership in hospitals and patient safety 
measures; and provisions relating to services furnished to 
beneficiaries in custody of penal authorities.

DATES: To be assured consideration, comments must be received at one of 
the addresses provided below, no later than 5 p.m. on June 12, 2007.

ADDRESSES: In commenting, please refer to file code CMS-1533-P. Because 
of staff and resource limitations, we cannot accept comments by 
facsimile (FAX) transmission.
    You may submit comments in one of three ways (no duplicates, 
please):
    1. Electronically. You may submit electronic comments on specific 
issues in this regulation to http://www.cms.hhs.gov/eRulemaking. Click 
on the link ``Submit electronic comments on CMS regulations with an 
open comment period''. (Attachments should be in Microsoft Word, 
WordPerfect, or Excel; however, we prefer Microsoft Word.)
    2. By regular mail. You may mail written comments (one original and 
two copies) to the following address ONLY: Centers for Medicare & 
Medicaid Services, Department of Health and Human Services, Attention: 
CMS-1533-P, P.O. Box 8011, Baltimore, MD 21244-1850.
    Please allow sufficient time for mailed comments to be received 
before the close of the comment period.
    3. By express or overnight mail. You may send written comments (one 
original and two copies) to the following address ONLY: Centers for 
Medicare & Medicaid Services, Department of Health and Human Services, 
Attention: CMS-1533-P, Mail Stop C4-26-05, 7500 Security Boulevard, 
Baltimore, MD 21244-1850.
    4. By hand or courier. If you prefer, you may deliver (by hand or 
courier) your written comments (one original and two copies) before the 
close of the comment period to one of the following addresses. If you 
intend to deliver your comments to the Baltimore address, please call 
telephone number (410) 786-7195 in advance to schedule your arrival 
with one of our staff members. Room 445-G, Hubert H. Humphrey Building, 
200 Independence Avenue, SW., Washington, DC 20201, or 7500 Security 
Boulevard, Baltimore, MD 21244-1850.
    (Because access to the interior of the Hubert H. Humphrey Building 
is not readily available to persons without Federal Government 
identification, commenters are encouraged to leave their comments in 
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain proof of filing by 
stamping in and retaining an extra copy of the comments being filed.)
    Comments mailed to the addresses indicated as appropriate for hand 
or courier delivery may be delayed and received after the comment 
period.
    Submission of comments on paperwork requirements. You may submit 
comments on this document's paperwork requirements by mailing your 
comments to the addresses provided at the end of the ``Collection of 
Information Requirements'' section in this document.
    For information on viewing public comments, see the beginning of 
the SUPPLEMENTARY INFORMATION section.

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, and Hospital Geographic Reclassifications 
Issues
Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded 
Hospitals, Graduate Medical Education, Critical Access Hospitals, and 
Long-Term Care (LTC)-DRG Issues
Siddhartha Mazumdar, (410) 786-6673, Rural Community Hospital 
Demonstration Issues
Sheila Blackstock, (410) 786-3502, Quality Data for Annual Payment 
Update Issues
Thomas Valuck, (410) 786-7479, Hospital Value-Based Purchasing Issues
Jacqueline Proctor, (410) 786-8852, Disclosure of Physician Ownership 
in Hospitals and Patient Safety Measures Issues
Fred Grabau, (410) 786-0206, Services to Beneficiaries in Custody of 
Penal Authorities Issues

SUPPLEMENTARY INFORMATION:
    Submitting Comments: We welcome comments from the public on all 
issues set forth in this rule to assist us in fully considering issues 
and developing policies. You can assist us by referencing the file code 
CMS-1533-P

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and the specific ``issue identifier'' that precedes the section on 
which you choose to comment.
    Inspection of Public Comments: All comments received before the 
close of the comment period are available for viewing by the public, 
including any personally identifiable or confidential business 
information that is included in a comment. We post all comments 
received before the close of the comment period on the following Web 
site as soon as possible after they have been received: http://www.cms.hhs.gov/eRulemaking. Click on the link ``Electronic Comments on 
CMS Regulations'' on that Web site to view public comments.
    Comments received timely will also be available for public 
inspection as they are received, generally beginning approximately 3 
weeks after publication of a document, at the headquarters of the 
Centers for Medicare & Medicaid Services, 7500 Security Boulevard, 
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30 
a.m. to 4 p.m. To schedule an appointment to view public comments, 
phone 1-800-743-3951.

Electronic Access

    This Federal Register document is also available from the Federal 
Register online database through GPO Access, a service of the U.S. 
Government Printing Office. Free public access is available on a Wide 
Area Information Server (WAIS) through the Internet and via 
asynchronous dial-in. Internet users can access the database by using 
the World Wide Web; the Superintendent of Documents' home page address 
is http://www.gpoaccess.gov/, by using local WAIS client software, or 
by telnet to swais.access.gpo.gov, then login as guest (no password 
required). Dial-in users should use communications software and modem 
to call (202) 512-1661; type swais, then login as guest (no password 
required).

Acronyms

AHA American Hospital Association
AHIMA American Health Information Management Association
AHRQ Agency for Health Care Research and Quality
AMI Acute myocardial infarction
AOA American Osteopathic Association
APR DRG All Patient Refined Diagnosis Related Group System
ASC Ambulatory surgical center
ASP Average sales price
AWP Average wholesale price
BBA Balanced Budget Act of 1997, Pub. L. 105-33
BBRA Medicare, Medicaid, and SCHIP [State Children's Health 
Insurance Program] Balanced Budget Refinement Act of 1999, Pub. L. 
106-113
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
CART CMS Abstraction & Reporting Tool
CBSAs Core-based statistical areas
CC Complication or comorbidity
CCR Cost-to-charge ratio
CDAC Clinical Data Abstraction Center
CIPI Capital input price index
CPI Consumer price index
CMI Case-mix index
CMS Centers for Medicare & Medicaid Services
CMSA Consolidated Metropolitan Statistical Area
COBRA Consolidated Omnibus Reconciliation Act of 1985, Pub. L. 99-
272
CPI Consumer price index
CY Calendar year
DRA Deficit Reduction Act of 2005, Pub. L. 109-171
DRG Diagnosis-related group
DSH Disproportionate share hospital
ECI Employment cost index
EMR Electronic medical record
EMTALA Emergency Medical Treatment and Labor Act of 1986, Pub. L. 
99-272
FDA Food and Drug Administration
FFY Federal fiscal year
FIPS Federal information processing standards
FQHC Federally qualified health center
FTE Full-time equivalent
FY Fiscal year
GAAP Generally Accepted Accounting Principles
GAF Geographic Adjustment Factor
GME Graduate medical education
HCAHPS Hospital Consumer Assessment of Healthcare Providers and 
Systems
HCFA Health Care Financing Administration
HCRIS Hospital Cost Report Information System
HHA Home health agency
HHS Department of Health and Human Services
HIC Health insurance card
HIPAA Health Insurance Portability and Accountability Act of 1996, 
Pub. L. 104-191
HIPC Health Information Policy Council
HIS Health information system
HIT Health information technology
HMO Health maintenance organization
HSA Health savings account
HSCRC Maryland Health Services Cost Review Commission
HSRV Hospital-specific relative value
HSRVcc Hospital-specific relative value cost center
HQA Hospital Quality Alliance
HQI Hospital Quality Initiative
ICD-9-CM International Classification of Diseases, Ninth Revision, 
Clinical Modification
ICD-10-PCS International Classification of Diseases, Tenth Edition, 
Procedure Coding System
IHS Indian Health Service
IME Indirect medical education
IOM Institute of Medicine
IPF Inpatient psychiatric facility
IPPS Acute care hospital inpatient prospective payment system
IRF Inpatient rehabilitation facility
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
MAC Medicare Administrative Contractor
MCC Major complication or comorbidity
MCE Medicare Code Editor
MCO Managed care organization
MCV Major cardiovascular condition
MDC Major diagnostic category
MDH Medicare-dependent, small rural hospital
MedPAC Medicare Payment Advisory Commission
MedPAR Medicare Provider Analysis and Review File
MEI Medicare Economic Index
MGCRB Medicare Geographic Classification Review Board
MIEA-TRHCA Medicare Improvements and Extension Act, Division B of 
the Tax Relief and Health Care Act of 2006, Pub. L. 109-432
MMA Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003, Pub. L. 108-173
MPN Medicare provider number
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
NCQA National Committee for Quality Assurance
NCVHS National Committee on Vital and Health Statistics
NECMA New England County Metropolitan Areas
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
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)
QIG Quality Improvement Group, CMS
QIO Quality Improvement Organization
RHC Rural health clinic
RHQDAPU Reporting hospital quality data for annual payment update
RNHCI Religious nonmedical health care institution

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RRC Rural referral center
RUCAs Rural-urban commuting area codes
RY Rate year
SAF Standard Analytic File
SCH Sole community hospital
SFY State fiscal year
SIC Standard Industrial Classification
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
VBP Value-based purchasing

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. Inpatient Rehabilitation Facilities (IRFs)
    b. Long-Term Care Hospitals (LTCHs)
    c. Inpatient Psychiatric Facilities (IPFs)
    3. Critical Access Hospitals (CAHs)
    4. Payments for Graduate Medical Education (GME)
    B. Provisions of the Deficit Reduction Act of 2005 (DRA)
    C. Provisions of the Medicare Improvements and Extension Act 
Under Division B of the Tax Relief and Health Care Act of 2006
    D. Provisions of the Pandemic and All-Hazards Preparedness Act
    E. Major Contents of this Proposed Rule
    1. Proposed DRG Reclassifications and Recalibrations of Relative 
Weights
    2. Proposed Changes to the Hospital Wage Index
    3. Other Decisions and Proposed Changes to the IPPS for 
Operating Costs and GME Costs
    4. Proposed Changes to the IPPS for Capital-Related Costs
    5. Proposed Changes to the Payment Rate for Excluded Hospitals 
and Hospital Units: Rate-of-Increase Percentages
    6. Services Furnished to Beneficiaries in Custody of Penal 
Authorities
    7. Determining Proposed Prospective Payment Operating and 
Capital Rates and Rate-of-Increase Limits
    8. Impact Analysis
    9. Recommendation of Update Factors for Operating Cost Rates of 
Payment for Inpatient Hospital Services
    10. Discussion of Medicare Payment Advisory Commission 
Recommendations
II. Proposed Changes to DRG Classifications and Relative Weights
    A. Background
    B. DRG Reclassifications
    1. General
    2. Yearly Review for Making DRG Changes
    C. MedPAC Recommendations for Revisions to the IPPS DRG System
    D. Refinement of DRGs Based on Severity of Illness
    1. Evaluation of Alternative Severity-Adjusted DRG Systems
    a. Overview of Alternative DRG Classification Systems
    b. Comparative Performance in Explaining Variation in Resource 
Use
    c. Payment Accuracy and Case-Mix Impact
    d. Issues for Future Consideration
    2. Development of Proposed Medicare Severity DRGs (MS-DRGs)
    a. Comprehensive Review of the CC List
    b. Chronic Diagnosis Codes
    c. Acute Diagnosis Codes
    d. Prior Research on Subdivisions of CCs Into Multiple 
Categories
    e. Proposed Medicare Severity DRGs (MS-DRGs)
    3. Dividing Proposed MS-DRGs on the Basis of the CCs and MCCs
    4. Conclusion
    5. Impact of the Proposed MS-DRGs
    6. Changes to Case-Mix Index (CMI) from the Proposed MS-DRGs
    7. Effect of the Proposed MS-DRGs on the Outlier Threshold
    8. Effect of the Proposed MS-DRGs on the Postacute Care Transfer 
Policy
    E. Refinement of the Relative Weight Calculation
    1. Summary of RTI's Report on Charge Compression
    2. RTI Recommendations
    a. Short-Term Recommendations
    b. Medium-Term Recommendations
    c. Long-Term Recommendations
    F. Hospital-Acquired Conditions, Including Infections
    1. General
    2. Legislative Requirements
    3. Public Input
    4. Collaborative Effort
    5. Criteria for Selection of the Hospital-Acquired Conditions
    6. Proposed Selection of Hospital-Acquired Conditions
    7. Other Issues
    G. Proposed Changes to the Specific DRG Classifications
    1. Pre-MDC: Intestinal Transplantations
    2. MDC 1 (Diseases and Disorders of the Nervous System)
    a. Implantable Neurostimulators
    b. Intracranial Stents
    3. MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth, and 
Throat)--Cochler Implants
    4. MDC 8 (Diseases and Disorders of the Musculoskeletal System 
and Connective Tissue)
    a. Hip and Knee Replacements
    b. Spinal Fusions
    c. Spinal Disc Devices
    d. Other Spinal DRGs
    5. MDC 17 (Myeloproliferative Diseases and Disorders, Poorly 
Differentiated Neoplasm): Endoscopic Procedures
    6. Medicare Code Editor (MCE) Changes
    a. Non-Covered Procedure Edit: Code 00.62 (Percutaneous 
Angioplasty or Atherectomy of Intracranial Vessel(s))
    b. Non-Specific Principal Diagnosis Edit 7 and Non-Specific O.R. 
Procedures Edit 10
    c. Limited Coverage Edit 17
    7. Surgical Hierarchies
    8. CC Exclusion List Proposed for FY 2008
    a. Background
    b. Proposed CC Exclusions List for FY 2008
    9. Review of Procedure Codes in CMS DRGs 468, 476, and 477
    a. Moving Procedure Codes From CMS DRG 468 (Proposed MS-DRGs 981 
Through 983) or CMS DRG 477 (Proposed MS-DRGs 987 Through 989) to 
MDCs
    b. Reassignment of Procedures Among CMS DRGs 468, 476, and 477 
(Proposed MS-DRG 981 Through 983, 984 Through 986, and 987 Through 
989)
    c. Adding Diagnosis or Procedure Codes to MDCs
    10. Changes to the ICD-9-CM Coding System
    11. Other Issues
    a. Seizures and Headaches
    b. Devices That Are Replaced Without Cost or Where Credit for a 
Replaced Device Is Furnished to the Hospital
    H. Recalibration of DRG Weights
    I. Proposed MS-LTC-DRG Reclassifications and Relative Weights 
for LTCHs for FY 2008
    1. Background
    2. Proposed Changes in the LTC-DRG Classifications
    a. Background
    b. Patient Classifications Into DRGs
    3. Development of the Proposed FY 2008 MS-LTC-DRG Relative 
Weights
    a. General Overview of Development of the Proposed MS-LTC-DRG 
Relative Weights
    b. Data
    c. Hospital-Specific Relative Value Methodology
    d. Proposed Treatment of Severity Levels in Developing Relative 
Weights
    e. Proposed Low-Volume MS-LTC-DRGs
    4. Steps for Determining the Proposed FY 2008 MS-LTC-DRG 
Relative Weights
    J. Proposed Add-On Payments for New Services and Technologies
    1. Background
    2. Public Input Before Publication of a Notice of Proposed 
Rulemaking on Add-On Payments
    3. FY 2008 Status of Technologies Approved for FY 2007 Add-On 
Payments
    a. Endovascular Graft Repair of the Thoracic Aorta
    b. Restore[reg] Rechargeable Implantable 
Neurostimulators
    c. X STOP Interspinous Process Decompression System
    4. FY 2008 Application for New Technology Add-On Payments
    5. Technical Correction
III. Proposed Changes to the Hospital Wage Index
    A. Background
    B. Core-Based Statistical Areas for the Hospital Wage Index
    C. Proposed Occupational Mix Adjustment to the Proposed FY 2008 
Wage Index
    1. Development of Data for the Proposed FY 2008 Occupational Mix 
Adjustment
    2. Timeline for the Collection, Review, and Correction of the 
Occupational Mix Data
    3. Calculation of the Proposed Occupational Mix Adjustment for 
FY 2008
    4. Proposed 2007-2008 Occupational Mix Survey for the FY 2010 
Wage Index
    D. Worksheet S-3 Wage Data for the Proposed FY 2008 Wage Index
    1. Included Categories of Costs

[[Page 24683]]

    2. Contract Labor for Indirect Patient Care Services
    3. Excluded Categories of Costs
    4. Use of Wage Index Data by Providers Other Than Acute Care 
Hospitals Under the IPPS
    E. Verification of Worksheet S-3 Wage Data
    F. Wage Index for Multicampus Hospitals
    G. Computation of the Proposed FY 2008 Unadjusted Wage Index
    1. Method for Computing the Proposed FY 2008 Unadjusted Wage 
Index
    2. Expiration of the Imputed Floor
    3. CAHs Reverting Back to IPPS Hospitals and Raising the Rural 
Floor
    4. Application of Rural Floor Budget Neutrality
    H. Analysis and Implementation of the Proposed Occupational Mix 
Adjustment and the Proposed FY 2008 Occupational Mix Adjusted Wage 
Index
    I. Revisions to the Proposed Wage Index Based on Hospital 
Redesignations
    1. General
    2. Effects of Reclassification/Redesignation
    3. FY 2008 MGCRB Reclassifications
    4. Hospitals That Applied for Reclassification Effective in FY 
2008 and Reinstating Reclassifications in FY 2008
    5. Clarification of Policy on Reinstating Reclassifications
    6. ``Fallback'' Reclassifications
    7. Geographic Reclassification Issues for Multicampus Hospitals
    8. Redesignations of Hospitals under Section 1886(d)(8)(B) of 
the Act
    9. Reclassifications Under Section 1886(d)(8)(B) of the Act
    10. New England Deemed Counties
    11. Reclassifications under Section 508 of Pub. L. 108-173
    12. Other Issues
    J. Proposed FY 2008 Wage Index Adjustment Based on Commuting 
Patterns of Hospital Employees
    K. Process for Requests for Wage Index Data Corrections
    L. Labor-Related Share for the Proposed Wage Index for FY 2008
    M. Wage Index Study Required Under Pub. L. 109-432
    N. Proxy for the Hospital Market Basket
IV. Other Decisions and Proposed Changes to the IPPS for Operating 
Costs and GME Costs
    A. Reporting of Hospital Quality Data for Annual Hospital 
Payment Update
    1. Background
    2. FY 2008 Quality Measures
    3. New Quality Measures and Data Submission Requirements for FY 
2009 and Subsequent Years
    a. Proposed New Quality Measures for FY 2009 and Subsequent 
Years
    b. Data Submission
    4. Retiring or Modifying RHQDAPU Program Quality Measures
    5. Procedures for the RHQDAPU Program for FY 2008 and FY 2009
    a. Procedures for Participating in the RHQDAPU Program
    b. Chart Validation Requirements
    c. Data Validation and Attestation
    d. Public Display
    e. Reconsideration and Appeal Procedures
    f. RHQDAPU Program Withdrawal Requirements
    6. Electronic Medical Records
    7. New Hospitals
    B. Development of the Medicare Hospital Value-Based Purchasing 
Plan
    C. Rural Referral Centers (RRCs)
    1. Proposed Annual Update of RRC Status Criteria
    a. Case-Mix Index
    b. Discharges
    2. Acquired Rural Status of RRCs
    D. Indirect Medical Education (IME) Adjustment
    1. Background
    2. IME Adjustment Factor for FY 2008
    3. Time Spent by Residents on Vacation or Sick Leave and in 
Orientation
    a. Background
    b. Vacation and Sick Leave Time
    c. Orientation Activities
    d. Proposed Regulation Changes
    E. Hospital Emergency Services Under EMTALA
    1. Background
    2. Recent Legislation Affecting EMTALA Implementation
    a. Secretary's Authority to Waive Requirements During National 
Emergencies
    b. Provisions of the Pandemic and All-Hazards Preparedness Act
    c. Proposed Revisions to the EMTALA Regulations
    F. Disclosure of Physician Ownership in Hospitals and Patient 
Safety Measures
    1. Disclosure of Physician Ownership in Hospitals
    2. Patient Safety Measures
    G. Rural Community Hospital Demonstration Program
V. Proposed Changes to the IPPS for Capital-Related Costs
    A. Background
    B. Proposed Policy Change
VI. Proposed Changes for Hospitals and Hospital Units Excluded From 
the IPPS
    A. Payments to Existing and New Excluded Hospitals and Hospital 
Units
    B. Separate PPS for IRFs
    C. Separate PPS for LTCHs
    D. Separate PPS for IPFs
    E. Determining Proposed LTCH Cost-to-Charge Ratios (CCRs) Under 
the LTCH PPS
VII. Services Furnished to Beneficiaries in Custody of Penal 
Authorities
VIII. MedPAC Recommendations
IX. Other Required Information
    A. Requests for Data From the Public
    B. Collection of Information Requirements
    C. Response to Public Comments

Regulation Text

Addendum--Proposed Schedule of Standardized Amounts, Update Factors, 
and Rate-of-Increase Percentages Effective With Cost Reporting Periods 
Beginning On or After October 1, 2007

I. Summary and Background
II. Proposed Changes to the Prospective Payment Rates for Hospital 
Inpatient Operating Costs for FY 2008
    A. Calculation of the Proposed Adjusted Standardized Amount
    1. Standardization of Base-Year Costs or Target Amounts
    2. Computing the Proposed Average Standardized Amount
    3. Updating the Proposed Average Standardized Amount
    4. Other Adjustments to the Average Standardized Amount
    a. Proposed Recalibration of DRG Weights and Updated Wage 
Index--Budget Neutrality Adjustment
    b. Reclassified Hospitals--Budget Neutrality Adjustment
    c. Case-Mix Budget Neutrality Adjustment
    d. Outliers
    e. Proposed Rural Community Hospital Demonstration Program 
Adjustment (Section 410A of Pub. L. 108-173)
    5. Proposed FY 2008 Standardized Amount
    B. Proposed Adjustments for Area Wage Levels and Cost-of-Living
    1. Proposed Adjustment for Area Wage Levels
    2. Proposed Adjustment for Cost-of-Living in Alaska and Hawaii
    C. Proposed DRG Relative Weights
    D. Calculation of the Proposed Prospective Payment Rates for FY 
2008
    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, FY 1996, and FY 2002 Hospital-
Specific Rates for FY 2008
    3. General Formula for Calculation of Proposed Prospective 
Payment Rates for Hospitals Located in Puerto Rico Beginning On or 
After October 1, 2007 and Before October 1, 2008
    a. Puerto Rico Rate
    b. National Rate
III. Proposed Changes to Payment Rates for Acute Care Hospital 
Inpatient Capital-Related Costs for FY 2008
    A. Determination of Proposed Federal Hospital Inpatient Capital-
Related Prospective Payment Rate Update
    1. Projected Capital Standard Federal Rate Update
    a. Description of the Update Framework
    b. Comparison of CMS and MedPAC Update Recommendation
    2. Proposed Outlier Payment Adjustment Factor
    3. Proposed Budget Neutrality Adjustment Factor for Changes in 
DRG Classifications and Weights and the GAF
    4. Proposed Exceptions Payment Adjustment Factor
    5. Proposed Capital Standard Federal Rate for FY 2008
    6. Proposed Special Capital Rate for Puerto Rico Hospitals
    B. Calculation of the Proposed Inpatient Capital-Related 
Prospective Payments for FY 2008
    C. Capital Input Price Index
    1. Background
    2. Forecast of the CIPI for FY 2008
IV. Proposed Changes to Payment Rates for Excluded Hospitals and 
Hospital Units: Rate-of-Increase Percentages
    A. Payments to Existing Excluded Hospitals and Units
    B. New Excluded Hospitals and Units

[[Page 24684]]

V. 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 2006; Hospital Wage Indexes for Federal Fiscal 
Year 2008; Hospital Average Hourly Wages for Federal Fiscal Years 
2006 (2002 Wage Data), 2007 (2003 Wage Data), and 2008 (2004 Wage 
Data); and 3-Year Average of Hospital Average Hourly Wages
    Table 3A--FY 2008 and 3-Year Average Hourly Wage for Urban Areas 
by CBSA
    Table 3B--FY 2008 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--FY 2008
    Table 4B--Wage Index and Capital Geographic Adjustment Factor 
(GAF) for Rural Areas by CBSA--FY 2008
    Table 4C--Wage Index and Capital Geographic Adjustment Factor 
(GAF) for Hospitals That Are Reclassified by CBSA--FY 2008
    Table 4F--Puerto Rico Wage Index and Capital Geographic 
Adjustment Factor (GAF) by CBSA--FY 2008
    Table 4J--Out-Migration Wage Adjustment--FY 2008
    Table 5--List of Proposed Medicare Severity Diagnosis-Related 
Groups (MS-DRGs), Relative Weighting Factors, and Geometric and 
Arithmetic Mean Length of Stay
    Table 6A--New Diagnosis Codes
    Table 6B--New Procedure Codes
    Table 6C--Invalid Diagnosis Codes
    Table 6D--Invalid Procedure Codes
    Table 6E--Revised Diagnosis Code Titles
    Table 6F--Revised Procedure Code Titles
    Table 6G--Additions to the CC Exclusion List (Available only 
through the Internet on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/)
    Table 6H--Deletions from the CC Exclusion List (Available only 
through the Internet on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS/)
    Table 6I--Complete List of Complication and Comorbidity (CC) 
Exclusions (Available only through the Internet on the CMS Web site 
at: http://www.cms.hhs.gov/AcuteInpatientPPS/)
    Table 6J--Major Complication and Comorbidity (MCC) List
    Table 6K--Complications and Comorbidity (CC) List
    Table 7A--Medicare Prospective Payment System Selected 
Percentile Lengths of Stay: FY 2006 MedPAR Update--December 2006 
GROUPER V24.0 CMS-DRGs
    Table 7B--Medicare Prospective Payment System Selected 
Percentile Lengths of Stay: FY 2006 MedPAR Update--December 2006 
GROUPER V25.0 CMS DRGs
    Table 8A--Proposed Statewide Average Operating Cost-to-Charge 
Ratios--March 2007
    Table 8B--Proposed Statewide Average Capital Cost-to-Charge 
Ratios--March 2007
    Table 8C--Proposed Statewide Average Total Cost-to-Charge Ratios 
for LTCHs--March 2007
    Table 9A--Hospital Reclassifications and Redesignations--FY 2008
    Table 9C--Hospitals Redesignated as Rural under Section 
1886(d)(8)(E) of the Act--FY 2008
    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 Proposed Medicare Severity Diagnosis-
Related Groups (MS-DRGs)--March 2007
    Table 11--Proposed FY 2008 MS-LTC-DRGs, Relative Weights, 
Geometric Average Length of Stay, and 5/6ths of the Geometric 
Average Length of Stay

Appendix A--Regulatory Impact Analysis

I. Overall Impact
II. Objectives
III. Limitations on Our Analysis
IV. Hospitals Included In and Excluded From the IPPS
V. Effects on Excluded Hospitals and Hospital Units
VI. Quantitative Effects of the Proposed Policy Changes Under the 
IPPS for Operating Costs
    A. Basis and Methodology of Estimates
    B. Analysis of Table I
    C. Effects of the Proposed Changes to the DRG Reclassifications 
and Relative Cost-Based Weights (Column 2)
    D. Effects of Proposed Wage Index Changes (Column 3)
    E. Combined Effects of Proposed DRG and Wage Index Changes 
(Column 4)
    F. Effects of the Expiration of the 3-Year Provision Allowing 
Urban Hospitals That Were Converted to Rural as a Result of the FY 
2005 Labor Market Area Changes to Maintain the Wage Index of the 
Urban Labor Market Area in Which They Were Formerly Located (Column 
5)
    G. Effects of MGCRB Reclassifications (Column 6)
    H. Effects of the Adjustment to the Application of the Rural 
Floor (Column 7)
    I. Effects of Expiration of the Imputed Rural Floor (Column 8)
    J. Effects of the Expiration of Section 508 of Pub. L. 108-173 
(Column 9)
    K. Effects of the Proposed Wage Index Adjustment for Out-
Migration (Column 10)
    L. Effects of All Proposed Changes With CMI Adjustment Prior to 
Assumed Growth (Column 11)
    M. Effects of All Proposed Changes With CMI Adjustment and 
Assumed Growth (Column 12)
    N. Effects of Proposed Policy on Payment Adjustment for Low-
Volume Hospitals
    O. Impact Analysis of Table II
VII. Effects of Other Proposed Policy Changes
    A. Effects of Proposed Policy on Hospital-Acquired Conditions, 
Including Infections
    B. Effects of Proposed MS-LTC-DRG Reclassifications and Relative 
Weights for LTCHs
    C. Effects of Proposed New Technology Add-On Payments
    D. Effects of Requirements for Hospital Reporting of Quality 
Data for Annual Hospital Payment Update
    E. Effects of Proposed Policy on Cancellation of Classification 
of Acquired Rural Status and Rural Referral Centers
    F. Effects of Proposed Policy Change on Payment for Indirect 
Graduate Medical Education
    G. Effects of Proposed Policy Changes Relating to Emergency 
Services Under EMTALA
    H. Effects of Proposed Policy on Disclosure of Physician 
Ownership in Hospitals and Patient Safety Measures
    I. Effects of Implementation of Rural Community Hospital 
Demonstration Program
    J. Effects of Proposed Policy Changes on Services Furnished to 
Beneficiaries in Custody of Penal Authorities
VIII. Effects of Proposed Changes in the Capital IPPS
    A. General Considerations
    B. Results
IX. Alternatives Considered
X. Overall Conclusion
XI. Accounting Statement
XII. Executive Order 12866

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

I. Background
II. Inpatient Hospital Update for FY 2008
III. Secretary's Recommendation
IV. MedPAC Recommendation for Assessing Payment Adequacy and 
Updating Payments in Traditional Medicare

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

[[Page 24685]]

predetermined, specific rates for each hospital discharge. Discharges 
are classified according to a list of diagnosis-related groups (DRGs).
    The base payment rate is comprised of a standardized amount that is 
divided into a labor-related share and a nonlabor-related share. The 
labor-related share is adjusted by the wage index applicable to the 
area where the hospital is located; and if the hospital is located in 
Alaska or Hawaii, the nonlabor-related share is adjusted by a cost-of-
living adjustment factor. This base payment rate is multiplied by the 
DRG relative weight.
    If the hospital treats a high percentage of low-income patients, it 
receives a percentage add-on payment applied to the DRG-adjusted base 
payment rate. This add-on payment, known as the disproportionate share 
hospital (DSH) adjustment, provides for a percentage increase in 
Medicare payments to hospitals that qualify under either of two 
statutory formulas designed to identify hospitals that serve a 
disproportionate share of low-income patients. For qualifying 
hospitals, the amount of this adjustment may vary based on the outcome 
of the statutory calculations.
    If the hospital is an approved teaching hospital, it receives a 
percentage add-on payment for each case paid under the IPPS, known as 
the indirect medical education (IME) adjustment. This percentage 
varies, depending on the ratio of residents to beds.
    Additional payments may be made for cases that involve new 
technologies 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, FY 1996, or FY 2002) 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. (Until FY 2007, 
an MDH has received the IPPS rate plus 50 percent of the difference 
between the IPPS rate and its hospital-specific rate 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. As discussed below, for discharges occurring on or after 
October 1, 2007, but before October 1, 2011, an MDH will receive the 
IPPS rate plus 75 percent of the difference between the IPPS rate and 
its hospital-specific rate, if the hospital-specific rate is higher 
than the IPPS rate.)
    Section 1886(g) of the Act requires the Secretary to pay for the 
capital-related costs of inpatient hospital services ``in accordance 
with a prospective payment system established by the Secretary.'' The 
basic methodology for determining capital prospective payments is set 
forth in our regulations at 42 CFR 412.308 and 412.312. Under the 
capital IPPS, payments are adjusted by the same DRG for the case as 
they are under the operating IPPS. Capital IPPS payments are also 
adjusted for IME and DSH, similar to the adjustments made under the 
operating IPPS. In addition, hospitals may receive outlier payments 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: rehabilitation hospitals and units; 
long-term care hospitals (LTCHs); psychiatric hospitals and units; 
children's hospitals; and cancer hospitals. Religious nonmedical health 
care institutions (RNHCIs) are also excluded from the IPPS. 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)), LTCHs, and psychiatric hospitals and 
units (referred to as inpatient psychiatric facilities (IPFs)), as 
discussed below. Children's hospitals, cancer hospitals, and RNHCIs 
continue to be paid solely under a reasonable cost-based system.
    The existing regulations governing payments to excluded hospitals 
and hospital units are located in 42 CFR parts 412 and 413.
a. Inpatient Rehabilitation Facilities (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. IRFs subject to the blend were 
also permitted to elect payment based on 100 percent of the Federal 
rate. The existing regulations governing payments under the IRF PPS are 
located in 42 CFR part 412, subpart P.
b. Long-Term Care Hospitals (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, the LTCH PPS was effective 
for a LTCH's first cost reporting period beginning on or after October 
1, 2002. LTCHs that do not meet the definition of ``new'' under Sec.  
412.23(e)(4) are paid, during a 5-year transition period, a LTCH 
prospective payment that is comprised of an increasing proportion of 
the LTCH Federal rate and a decreasing proportion based on reasonable 
cost principles. Those LTCHs that did not meet the definition of 
``new'' could elect to be paid based on 100 percent of the Federal 
prospective payment rate instead of a blended payment in any year 
during the 5-year transition. For cost reporting periods beginning on 
or after October 1, 2006, all LTCHs are paid 100 percent of the Federal 
rate. The existing regulations governing payment under the LTCH PPS are 
located in 42 CFR part 412, subpart O.
c. Inpatient Psychiatric Facilities (IPFs)
    Under the authority of sections 124(a) and (c) of Pub. L. 106-113, 
inpatient

[[Page 24686]]

psychiatric facilities (IPFs) (formerly psychiatric hospitals and 
psychiatric units of acute care hospitals) are paid under the 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. 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. 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. Provisions of the Deficit Reduction Act of 2005 (DRA)

    The Deficit Reduction Act of 2005 (DRA), Pub. L. 109-171, made a 
number of changes to the Act relating to prospective payments to 
hospitals and other providers for inpatient services. This proposed 
rule would implement amendments made by (1) section 5001(a), which, 
effective for FY 2007 and subsequent years, expands the requirements 
for hospital quality data reporting; and (2) section 5001(c), which 
requires the Secretary to select, by October 1, 2007, at least two 
hospital-acquired conditions that meet certain specified criteria that 
will be subject to a quality adjustment in DRG payments during FY 2008.
    In this proposed rule, we also discuss our development of a plan to 
implement, beginning with FY 2009, a value-based purchasing plan for 
section 1886(d) hospitals, in accordance with the requirements of 
section 5001(b) of Pub. L. 109-171.

C. Provisions of the Medicare Improvements and Extension Act Under 
Division B of the Tax Relief and Health Care Act of 2006

    In this proposed rule, we discuss the provisions of section 
106(b)(1) of the Medicare Improvements and Extensions Act under 
Division B, Title I of the Tax Relief and Health Care Act of 2006 
(MIEA-TRHCA), Pub. L. 109-432, which requires MedPAC to submit to 
Congress, not later than June 30, 2007, a report on the Medicare wage 
index classification system applied under the Medicare Prospective 
Payment System. Section 106(b) of the MIEA-TRHCA requires the report to 
include any alternatives that MedPAC recommends to the method to 
compute the wage index under section 1886(d)(3)(E) of the Act.
    In addition, we discuss the provisions of section 106(b)(2) of the 
MIEA-TRHCA, which instructs the Secretary of Health and Human Services, 
taking into account MedPAC's recommendations on the Medicare wage index 
classification system, to include in the FY 2009 IPPS proposed rule one 
or more proposals to revise the wage index adjustment applied under 
section 1886(d)(3)(E) of the Act for purposes of the IPPS.
    We note that we published a notice in the Federal Register on March 
23, 2007 (72 FR 13799) that addressed the provisions of section 106(a) 
of the MIEA-TRHCA relating to the extension of geographic 
reclassifications of hospitals under section 508 of Pub. L. 108-173 
(that expired on March 31, 2007) through September 30, 2007.

D. Provisions of the Pandemic and All-Hazards Preparedness Act

    On December 19, 2006, Congress enacted the Pandemic and All-Hazards 
Preparedness Act, Pub. L. 109-417. Section 302(b) of Pub. L. 109-417 
makes two specific changes that affect EMTALA implementation in 
emergency areas during an emergency period. Specifically section 
302(b)(1)(A) of Pub. L. 109-417 amended section 1135(b)(3)(B) of the 
Act to state that sanctions may be waived for the direction or 
relocation of an individual for screening where, in the case of a 
public health emergency that involves a pandemic infections disease, 
that direction or relocation occurs pursuant to a State pandemic 
preparedness plan. In addition, sections 302(b)(1)(B) and (b)(1)(C) of 
Pub. L. 109-417 amended section 1135(b)(3)(B) of the Act to state that, 
if a public health emergency involves a pandemic infectious disease 
(such as pandemic influenza), the duration of a waiver or modification 
under section 1135(b)(3) of the Act (relating to EMTALA) shall be 
determined in accordance with section 1135(e) of the Act as that 
subsection applies to public health emergencies.
    In this proposed rule, we are proposing to make changes to the 
EMTALA regulations to conform them to the sanction waiver provisions of 
section 302(b) of Pub. L. 109-417.

E. Major Contents of This Proposed Rule

    In this proposed rule, we are setting forth proposed changes to the 
Medicare IPPS for operating costs and for capital-related costs in FY 
2008. We also are setting forth proposed changes relating to payments 
for IME costs and payments to certain hospitals and units that continue 
to be excluded from the IPPS and paid on a reasonable cost basis. The 
changes being proposed would be effective for discharges occurring on 
or after October 1, 2007, unless otherwise noted.
    The following is a summary of the major changes that we are 
proposing to make:
1. Proposed DRG Reclassifications and Recalibrations of Relative 
Weights
    We are proposing to adopt a Medicare Severity DRG (MS-DRG) 
classification system for the IPPS to better recognize severity of 
illness. We present the methodology we used to establish the proposed 
MS-DRGs and discuss our efforts to further analyze alternative 
severity-adjusted DRG systems and to refine the relative weight 
calculations for DRGs.
    We present a proposed listing and discussion of hospital-acquired 
conditions, including infections, which we have evaluated and are 
considering for selection to be subject to the statutorily required 
quality adjustment in DRG payments for FY 2008.
    We are proposing limited annual revisions to the DRG classification 
system in the following areas: intestinal transplants, 
neurostimulators, intracranial stents, cochlear implants, knee and hip 
replacements, spinal fusions and spinal disc devices, and endoscopic 
procedures.
    We are presenting our reevaluation of certain FY 2007 applicants 
for add-on payments for high-cost new medical services and 
technologies, and our analysis of the FY 2008 applicant

[[Page 24687]]

(including public input, as directed by Pub. L. 108-173, obtained in a 
town hall meeting).
    We are proposing the annual update of the long-term care diagnosis-
related group (LTC-DRG) classifications and relative weights for use 
under the LTCH PPS for FY 2008. We are proposing that the LTC-DRGs 
would be revised to mirror the proposed MS-DRGs for the IPPS.
2. Proposed Changes to the Hospital Wage Index
    In section III. of the preamble to this proposed rule, we are 
proposing revisions to the wage index and the annual update of the wage 
data. Specific issues addressed include the following:
     The FY 2008 wage index update, using wage data from cost 
reporting periods that began during FY 2004.
     Analysis and implementation of the proposed FY 2008 
occupational mix adjustment to the wage index.
     Proposed changes relating to expiration of the imputed 
floor for the wage index and application of budget neutrality for the 
rural floor.
     Proposed changes in determining the wage index for 
multicampus hospitals.
     The proposed revisions to the wage index based on hospital 
redesignations and reclassifications, including reclassifications for 
multicampus hospitals.
     The proposed adjustment to the wage index for FY 2008 
based on commuting patterns of hospital employees who reside in a 
county and work in a different area with a higher wage index.
     The timetable for reviewing and verifying the wage data 
that will be in effect for the proposed FY 2008 wage index.
     The labor-related share for the FY 2008 wage index, 
including the labor-related share for Puerto Rico.
3. Other Decisions and Proposed Changes to the IPPS for Operating Costs 
and GME Costs
    In section IV. of the preamble to this proposed rule, we discuss a 
number of provisions of the regulations in 42 CFR Parts 412, 413, and 
489, including the following:
     The reporting of hospital quality data as a condition for 
receiving the full annual payment update increase.
     Development of the Medicare value-based purchasing plan 
and scheduled ``listening sessions.''
     The proposed updated national and regional case-mix values 
and discharges for purposes of determining RRC status and a proposed 
policy change relating to the acquired rural status of RRCs.
     The statutorily-required IME adjustment factor for FY 2008 
and a proposed policy change relating to determining counts of 
residents on vacation or sick leave and in orientation for IME and 
direct GME purposes.
     Proposed changes relating to waiver of sanctions for 
requirements for emergency services for hospitals under EMTALA during 
national emergency.
     Proposed policy changes relating to disclosure to patients 
of physician ownership of hospitals and patient safety measures.
     Discussion of the fourth year of implementation of the 
Rural Community Hospital Demonstration Program.
4. Proposed Changes to the IPPS for Capital-Related Costs
    In section V. of the preamble to this proposed rule, we discuss the 
payment policy requirements for capital-related costs and capital 
payments to hospitals and propose changes relating to adjustments to 
the Federal capital rate to address continuous large positive margins.
5. Proposed Changes to the Payment Rates for Excluded Hospitals and 
Hospital Units: Rate-of-Increase Percentages
    In section VI. of the preamble to this proposed rule, we discuss 
payments to excluded hospitals and hospital units, and proposed changes 
for determining LTCH CCRs under the LTCH PPS.
6. Services Furnished to Beneficiaries in Custody of Penal Authorities
    In section VII. of the preamble to this proposed rule, we clarify 
when individuals are considered to be in ``custody'' for purposes of 
Medicare payment for services furnished to beneficiaries who are under 
penal authorities.
7. Determining Proposed Prospective Payment Operating and Capital Rates 
and Rate-of-Increase Limits
    In the Addendum to this proposed rule, we set forth proposed 
changes to the amounts and factors for determining the FY 2008 
prospective payment rates for operating costs and capital-related 
costs. We also establish the proposed threshold amounts for outlier 
cases. In addition, we address the proposed update factors for 
determining the rate-of-increase limits for cost reporting periods 
beginning in FY 2008 for hospitals and hospital units excluded from the 
PPS.
8. Impact Analysis
    In Appendix A of this proposed rule, we set forth an analysis of 
the impact that the proposed changes would have on affected hospitals.
9. Recommendation of Update Factors for Operating Cost Rates of Payment 
for Inpatient Hospital Services
    In Appendix B of this proposed rule, as required by sections 
1886(e)(4) and (e)(5) of the Act, we provided our recommendations of 
the appropriate percentage changes for FY 2008 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.
10. Discussion of Medicare Payment Advisory Commission Recommendations
    Under section 1805(b) of the Act, 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 2007 recommendation concerning hospital inpatient 
payment policies addressed the update factor for inpatient hospital 
operating costs and capital-related costs under the IPPS and for 
hospitals and distinct part hospital units excluded from the IPPS. This 
recommendation is addressed in Appendix B of this proposed rule. For 
further information relating specifically to the MedPAC March 2007 
reports or to obtain a copy of the reports, contact MedPAC at (202) 
220-3700 or visit MedPAC's Web site at: http://www.medpac.gov.

II. Proposed Changes to DRG Classifications and Relative Weights

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

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

[[Page 24688]]

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.

B. DRG Reclassifications

1. General
    As discussed in the preamble to the FY 2007 IPPS final rule (71 FR 
47881 through 47971), we are focusing our efforts in FY 2008 on making 
significant reforms to the IPPS consistent with the recommendations 
made by MedPAC in its ``Report to the Congress, Physician-Owned 
Specialty Hospitals'' in March 2005. MedPAC recommended that the 
Secretary refine the entire DRG system by taking into account severity 
of illness and applying hospital-specific relative value (HSRV) weights 
to DRGs.\1\ We began this reform process by adopting cost-based weights 
over a 3-year transition period beginning in FY 2007 and making interim 
changes to the DRG system for FY 2007 by creating 20 new CMS DRGs and 
modifying 32 others across 13 different clinical areas involving nearly 
1.7 million cases. As described below in more detail, these refinements 
are intermediate steps towards comprehensive reform of both the 
relative weights and the DRG system that is occurring as we undertake 
further study.
---------------------------------------------------------------------------

    \1\ Medicare Payment Advisory Commission: Report to the 
Congress, Physician-Owned Specialty Hospitals, March 2005, page 
viii.
---------------------------------------------------------------------------

    Currently, cases are classified into CMS 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 2007, cases are 
assigned to one of 538 DRGs in 25 MDCs. 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 2007, 
there are 9 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 transplants, lung transplants, simultaneous pancreas/kidney 
transplants, pancreas transplants, and

[[Page 24689]]

for tracheostomies. Cases are assigned to these DRGs before they are 
classified to an MDC. The table below lists the nine current pre-MDCs.

               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..............  ECMO or Tracheostomy with Mechanical Ventilation
                        96+ Hours or Principal Diagnosis Except for
                        Face, Mouth, and Neck Diagnosis with Major O.R.
DRG 542..............  Tracheostomy with Mechanical Ventilation 96+
                        Hours or Principal Diagnosis Except for Face,
                        Mouth, and Neck Diagnosis without Major O.R.
------------------------------------------------------------------------

    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. Because 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 (0 to 17 years of age 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 
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. An example is 
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 
diagnosis class 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 CC. A 
substantial CC 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 CC would consistently 
affect the consumption of hospital resources.
    A patient's diagnosis, procedure, discharge status, and demographic 
information is entered 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 payment 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 FY 2000 
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 date 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 this IPPS proposed rule for FY 2008, we are proposing to adopt 
significant changes to the current DRGs. As described in detail below, 
we are proposing significant improvement in the DRG system to recognize 
severity of illness and resource usage by proposing to adopt Medicare 
Severity DRGs (MS-DRGs). The changes we are proposing in this proposed 
rule would be reflected in the FY 2008 GROUPER, Version 25.0, and would 
be effective for discharges occurring on or after October 1, 2007. 
Unless otherwise noted in this proposed rule, our DRG analysis is based 
on data from the December 2006 update of the FY 2006 MedPAR file, which 
contains hospital bills received through December 31, 2006, for 
discharges occurring in FY 2006.
2. Yearly Review for Making DRG Changes
    Many of the changes to the DRG classifications we make annually 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 annual 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

[[Page 24690]]

the DRG recalibration process, concerns about DRG classification issues 
should be brought to our attention no later than early December in 
order to be considered and possibly included in the next annual 
proposed rule updating the IPPS.
    The actual process of forming the DRGs was, and will likely 
continue to be, highly iterative, involving a combination of 
statistical results from test data combined with clinical judgment. We 
describe in detail below the process we used to develop the proposed 
MS-DRGs. In addition, in deciding whether to make further modification 
to the proposed MS-DRGs for particular circumstances brought to our 
attention, we would 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 proposed 
MS-DRG. We would 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 clinically distinct or 
similar to other patients in the MS-DRG. In evaluating resource costs, 
we would consider both the absolute and percentage differences in 
average charges between the cases we would select for review and the 
remainder of cases in the MS-DRG. We also would consider variation in 
charges within these groups; that is, whether observed average 
differences were consistent across patients or attributable to cases 
that were extreme in terms of charges or length of stay, or both. 
Further, we also would consider the number of patients who will have a 
given set of characteristics and generally would prefer not to create a 
new DRG unless it would include a substantial number of cases.

C. MedPAC Recommendations for Revisions to the IPPS DRG System

    In the FY 2006 and FY 2007 IPPS final rules, we discussed a number 
of recommendations made by MedPAC regarding revisions to the DRG system 
used under the IPPS (70 FR 47473 through 47482 and 71 FR 47881 through 
47939).
    In Recommendations 1-3 in the 2005 Report to Congress on Physician-
Owned Specialty Hospitals, MedPAC recommended that CMS:
     Refine the current DRGs to more fully capture differences 
in severity of illness among patients.
     Base the DRG relative weights on the estimated cost of 
providing care.
     Base the weights on the national average of the hospital-
specific relative values (HSRVs) for each DRG (using hospital-specific 
costs to derive the HSRVs).
     Adjust the DRG relative weights to account for differences 
in the prevalence of high-cost outlier cases.
     Implement the case-mix measurement and outlier policies 
over a transitional period.
    As we noted in the FY 2006 IPPS final rule, we had insufficient 
time to complete a thorough evaluation of these recommendations for 
full implementation in FY 2006. However, we did adopt severity-weighted 
cardiac DRGs in FY 2006 to address public comments on this issue and 
the specific concerns of MedPAC regarding cardiac surgery DRGs. We also 
indicated that we planned to further consider all of MedPAC's 
recommendations and thoroughly analyze options and their impacts on the 
various types of hospitals in the FY 2007 IPPS proposed rule.
    For FY 2007, we began this process. In the FY 2007 IPPS proposed 
rule, we proposed to adopt Consolidated Severity DRGs (CS DRGs) for FY 
2008 (if not earlier). However, based on public comments received on 
the FY 2007 IPPS proposed rule, we decided not to adopt the CS DRGs. 
Rather, we decided to make interim changes to the existing DRGs for FY 
2007 by creating 20 new DRGs involving 13 different clinical areas that 
would significantly improve the CMS DRG system's recognition of 
severity of illness. We also modified 32 DRGs to better capture 
differences in severity. The new and revised DRGs were selected from 40 
existing CMS DRGs that contain 1,666,476 cases and represent a number 
of body systems. In creating these 20 new DRGs, we deleted 8 and 
modified 32 existing DRGs. We indicated that these interim steps for FY 
2007 were being taken as a prelude to more comprehensive changes to 
better account for severity in the DRG system by FY 2008. In the FY 
2007 IPPS final rule, we indicated our intent to pursue further DRG 
reform through two initiatives. First, we announced that we were in the 
process of engaging a contractor to assist us with evaluating 
alternative DRG systems that were raised as potential alternatives to 
the CS DRGs in the public comments. Second, we indicated our intent to 
review over 13,000 ICD-9-CM diagnosis codes as part of making further 
refinements to the current CMS DRGs to better recognize severity of 
illness based on the work that CMS (then HCFA) did in the mid-1990's to 
adopt severity DRGs. We describe in detail below the progress we have 
made on these two initiatives, our proposed actions for FY 2008, and 
our plans for continued analysis of reform of the DRG system for FY 
2009. We note that revising the DRGs to better recognize severity of 
illness has implications for the outlier threshold, the application of 
the postacute care transfer policy, the measurement of real case-mix 
versus apparent case-mix, and the IME and the DSH adjustments. We 
discuss these implications in more detail in the following sections.
    In the FY 2007 IPPS proposed rule, we discussed MedPAC's 
recommendations to move to a cost-based HSRV weighting methodology 
beginning with the FY 2007 IPPS proposed rule. Although we proposed to 
adopt HSRV weights for FY 2007, we decided not to adopt the proposed 
methodology in the final rule after considering the public comments. 
Instead, in the FY 2007 IPPS final rule, we adopted a cost-based 
weighting methodology without the hospital-specific portion of the 
methodology. The cost weights are being adopted over a 3-year 
transition period in 1/3 increments between FY 2007 and FY 2009. In 
addition, in the FY 2007 IPPS final rule, we indicated our intent to 
further study the hospital-specific methodology as well as other issues 
brought to our attention with respect to the cost weights. There was 
significant concern in the public comments that we account for charge 
compression or the practice of applying a higher charge markup over 
costs to lower cost than higher cost items and services, if we are to 
develop relative weights based on cost. Further, public commenters 
expressed concern about potential inconsistencies between how costs and 
charges are reported on the Medicare cost reports and charges on the 
Medicare claims. In the FY 2007 IPPS final rule, we used costs and 
charges from the cost report to determine departmental level cost-to-
charge ratios (CCRs) to apply to charges on the Medicare claims to 
determine the cost weights. The commenters were concerned about 
potential distortions to the cost weights that would result from 
inconsistent reporting between the cost reports and the Medicare 
claims. After publication of the FY 2007 IPPS final rule, we entered 
into a contract with RTI International to study both charge compression 
and to what extent our methodology for calculating DRG relative weights 
is affected by inconsistencies between how hospitals report costs and 
charges on the cost report and how hospitals report charges on 
individual claims. Further, as part of its study of alternative DRG 
systems, the

[[Page 24691]]

RAND Corporation is analyzing the HSRV cost-weighting methodology.
    As we present below, we believe that revisions to the DRG system to 
better recognize severity of illness and changes to the relative 
weights based on costs rather than charges are improving the accuracy 
of the payment rates in the IPPS. We agree with MedPAC that these 
refinements should be pursued. Although we continue to caution that any 
system that groups cases will always present some opportunities for 
providers to specialize in cases they believe to have higher margins, 
we believe that the changes we have adopted and the continuing reforms 
we are proposing to adopt for FY 2008 will improve payment accuracy and 
reduce financial incentives to create specialty hospitals.

D. Refinement of DRGs Based on Severity of Illness

    (If you choose to comment on issues in this section, please include 
the caption ``DRG Reform and Proposed MS-DRGs'' at the beginning of 
your comment.)
    For purposes of the following discussions, the term ``CMS DRGs'' 
means the DRG system we currently use under the IPPS; the term 
``Medicare-Severity DRGs (MS-DRGs)'' means the revisions that we are 
proposing to make to the current CMS DRGs to better recognize severity 
of illness and resource use based on case complexity. Although we have 
found the terms ``CMS DRGs'' and ``MS-DRGs'' useful to distinguish the 
current DRG system from the DRGs that we are proposing to adopt for FY 
2008, we are interested in public comments on how to best refer to both 
the current DRGs and the proposed DRGs to avoid confusion and improve 
clarity.
1. Evaluation of Alternative Severity-Adjusted DRG Systems
    In the FY 2007 IPPS final rule, we stated our intent to engage a 
contractor to assist us with an evaluation of alternative DRG systems 
that may better recognize severity than the current CMS DRGs. We noted 
it was possible that some of the alternative systems would better 
recognize severity of illness and are based on the current CMS DRGs. We 
further stated that if we were to develop a clinical severity concept 
using the current CMS DRGs as the starting point, it was possible that 
several of the issues raised by commenters (in response to the CS DRGs, 
which, in the FY 2007 IPPS proposed rule, we proposed to adopt for FY 
2008 or earlier) would no longer be a concern. We noted that if we were 
to propose adoption of severity DRGs for FY 2008, we would consider the 
issues raised by commenters on last year's proposed rule as we 
continued to make further refinements to account for complexity as well 
as severity to better reflect relative resource use. We stated that we 
believed it was likely that at least one of several alternative 
severity-adjusted DRG systems suggested for review (or potentially a 
system we would develop ourselves) would be suitable to achieve our 
goal of improving payment accuracy beginning in FY 2008.
    On September 1, 2006, we awarded a contract to the RAND Corporation 
to perform an evaluation of alternative severity-adjusted DRG 
classification systems. RAND is evaluating several alternative DRG 
systems based on how well they are suited to classifying and making 
payments for inpatient hospital services provided to Medicare patients. 
Each system is being assessed on its ability to differentiate among 
severity of illness. A final report is due on or before September 1, 
2007.
    RAND's draft interim report focused on the following criteria:
     Severity-adjusted DRG classification systems: --How well 
does each classification system explain variation in resource use? --
How would the classification system affect a hospital's patient mix? --
Are the groupings manageable, administratively feasible and 
understandable?
     Payment accuracy--What are the payment implications of 
selected models?
    In response to our request, several vendors of DRG systems 
submitted their products for evaluation. The following products are 
currently being evaluated by RAND:

3M/Health Information Systems (HIS)

     CMS DRGs modified for AP-DRG Logic (CMS + AP-DRGs)
     Consolidated Severity-Adjusted DRGs (CS DRGs)

Health Systems Consultants (HSC)

     Refined DRGs (HSC-DRGs)

HSS/Ingenix

     All-Payer Severity DRGs with Medicare modifications (MM-
APS-DRGs)

Solucient

     Solucient Refined DRGs (Sol-DRGs)
    Vendors submitted their commercial (off-the-shelf) software to RAND 
in late September 2006. The five systems were compared to the CMS DRGs 
that were in effect as of October 1, 2006 (FY 2007). RAND assigned FY 
2004 and FY 2005 Medicare discharges from acute care hospitals to the 
FY 2007 CMS DRGs and to each of the alternative severity-adjusted DRG 
systems. RAND's initial analysis provided an overview of each 
alternative DRG classification system, their comparative performance in 
explaining variation in resource use, differences in DRG grouping 
logic, and case-mix change.
    A Technical Expert Panel comprised of individuals representing 
academic institutions, hospital associations, and MedPAC was formed in 
October 2006. The members received the preliminary draft report of 
RAND's alternative severity-adjusted DRG systems evaluation in early 
January 2007. The panel met with RAND and CMS on January 18, 2007, to 
discuss the preliminary draft report and to provide additional 
comments. RAND incorporated items raised by the panel into its 
preliminary draft report and submitted a revised interim report to CMS 
in mid-March 2007. CMS posted RAND's interim report on the CMS Web site 
in late March 2007. Interested individuals can view RAND's interim 
report on the CMS Web site at: http://www.cms.hhs.gov/Reports/downloads/Wynn0307.pdf.
    At this time, RAND has not completed its final evaluation. RAND's 
interim report reflects its preliminary evaluation of the alternative 
DRG systems using the criteria described above. In the project's second 
phase, RAND will continue to evaluate alternative DRG systems as well 
as to compare performance using HSRVs. As RAND has not completed its 
evaluation of alternative DRG systems, we are not ready at this time to 
propose use of one of the alternative DRG systems being evaluated for 
Medicare in FY 2008. Further, even if RAND had completed its 
evaluation, we would need to explore whether any transition issues 
would need to be resolved before we are ready to propose adopting an 
alternative DRG system. Among other issues, we would need to evaluate 
the legal and contractual issues associated with adopting a proprietary 
DRG product. Although vendors for four of the five systems have 
indicated a willingness to make their products available in the public 
domain, we believe it is likely there would need to be some discussion 
as to whether there would be any limitations (such as the source code 
as well as the DRG logic) on the availability of the DRG systems to 
hospitals or competing vendors. Further, we would need to resolve 
contractual issues for updates and maintenance of an alternative DRG 
system and consider how they interact with our current ongoing contract 
to maintain the CMS DRGs. There may be further system conversion issues 
that we have not yet considered. The RAND

[[Page 24692]]

contract will be complete by September 1, 2007. Once RAND completes its 
work, we believe we will be in a better position to evaluate whether it 
would be appropriate to propose to adopt one of the five alternative 
DRG systems for purposes of the IPPS.
    As discussed later in this proposed rule, we are proposing to adopt 
MS-DRGs beginning with FY 2008. The MS-DRGs are the result of 
modifications to the CMS DRGs to better account for severity. While we 
are proposing to implement the MS-DRGs on October 1, 2007, we believe 
the MS-DRGs should be evaluated by RAND. We have instructed RAND to 
evaluate the proposed MS-DRGs using the same criteria that it is 
applying to the other DRG systems. As described below, we believe the 
proposed MS-DRGs represent a substantial improvement in the recognition 
of severity of illness and resource consumption. For this reason, we 
are proposing to adopt MS-DRGs for FY 2008.
    As stated earlier, a final report is expected from RAND by 
September 1, 2007. This report will include further analysis of the 
five alternative DRG systems and the additional evaluation of the MS-
DRGs. We look forward to reviewing RAND's final report that will 
provide a comprehensive evaluation of each severity DRG system that has 
been examined. We anticipate that after this process is completed, we 
will have the necessary information to decide our next steps in the 
reform of the IPPS. Meanwhile, we are proposing to adopt the MS-DRGs 
for FY 2008 and are providing the following update on RAND's progress 
in evaluating alternative DRG systems.
    We invite public comment regarding RAND's preliminary analysis of 
each vendor-supplied alternative severity-adjusted DRG system described 
below.
a. Overview of Alternative DRG Classification Systems
    Analysis of how each of the five severity-adjusted DRG systems 
performs began by using the current CMS DRGs as a baseline. Two of the 
five systems (CS DRGs and MM-APS-DRGs) are derivatives of all-patient 
severity-adjusted DRG systems that have been modified by their 
developers for the Medicare population and two of the systems (HSC-DRGs 
and Sol-DRGs) are all-patient systems that incorporate severity levels 
into the CMS DRGs. The CMS-AP-DRGs are a combination of CMS DRGs and a 
modification for the Medicare population of the major CC severity 
groupings used in the AP-DRG system. (The AP-DRG system was developed 
by 3M/HIS specifically for the State of New York to capture the non-
Medicare population.)
    Table A below shows how each of the five alternative severity-
adjusted systems classifies patients into base DRGs and their 
corresponding severity levels.

                                                   Table A.--Logic of CMS and Alternative DRG Systems
--------------------------------------------------------------------------------------------------------------------------------------------------------
     Classification element             CMS DRG           CMS+AP-DRG            HSC-DRG            Sol--DRG           MM-APS-DRG          Con-APR-DRG
--------------------------------------------------------------------------------------------------------------------------------------------------------
Number of MDCs..................  25................  25................  25................  25................  25................  25
Number of Pre-MDC base DRGs.....  9.................  9.................  9.................  9.................  9.................  7
Number of base DRGs.............  379...............  379...............  215 ADRGs.........  248 ADRGs.........  361...............  379
Total number of Pre-MDC DRGs....  9.................  9.................  30................  27................  27................  9
Total number of DRGs............  538...............  602...............  1,274.............  1,261.............  915...............  859
Number of CC (severity)           2.................  3.................  3 (medical) or 4    3 (medical) or 4    3.................  4
 subclasses.                                                               (surgical).         (surgical).
CC subclasses...................  With CC without CC  Without CC With CC  No CC, Class C CC,  Minor/no            Without CC, with    Minor, moderate,
                                   for selected base   for selected base   Class B CC, Class   substantial CCs,    CC with MCC with    major, severe
                                   DRGs.               DRGs and With MCC   A CC (surgical      moderate CCs,       some collapsing     with some
                                                       across DRGs         only).              MCCs,               at base DRG level.  collapsing at DRG
                                                       within MDC.                             catastrophic CCs                        level.
                                                                                               (surgical only).
Multiple CCs recognized.........  No................  No................  No................  No................  Yes (in             Yes.
                                                                                                                   computation of
                                                                                                                   weights.
CC assignment specific to base    Mostly no.........  Mostly no.........  Mostly no.........  Mostly no.........  No................  Yes.
 DRG.
Logic of CC subdivision.........  Presence/absence..  Presence/absence..  Presence/absence..  Presence/absence..  Presence/absence..  18-step process.
Logic of MDC assignment.........  Principal           Principal           Principal           Principal           Principal           Principal
                                   diagnosis.          diagnosis.          diagnosis.          diagnosis.          diagnosis.          diagnosis with
                                                                                                                                       rerouting.
Death used in DRG assignment....  Yes (in selected    Yes (in selected    Yes (includes       Yes (includes       Yes (in selected    No.
                                   DRGs).              DRGs).              ``early death''     ``early death''     DRGs).
                                                                           DRGs).              DRGs).
Complications of care are CCs...  Yes...............  Yes...............  Yes...............  Yes...............  Yes, when           Few.
                                                                                                                   recognized as a
                                                                                                                   CC No, when CC
                                                                                                                   represents ``poor
                                                                                                                   medical care''.
--------------------------------------------------------------------------------------------------------------------------------------------------------

    RAND's preliminary evaluation of the logic for each system 
demonstrated the following:
     Four systems add severity levels to the base CMS DRGs; the 
CS DRGs add severity levels to base APR-DRGs, which are comparable but 
not identical to the base CMS DRGs. Both the CS DRGs and MM-APS-DRGs 
collapse some base DRGs with low Medicare volume.

[[Page 24693]]

     The HSC-DRGs and the Sol-DRGs use uniform severity levels 
for each base DRG (three for medical and four for surgical). The 
general structure of the MM-APS-DRG logic includes three severity 
levels for each base DRG, but some severity levels for the same base 
DRG are consolidated to address Medicare low-volume DRGs and 
monotonicity issues. Monotonicity is when the average costs for a 
severity group consistently rise as the severity level of the group 
increases. For example, in a monotonic system, if within a base DRG 
there are three severity groups and level 1 severity is less than level 
2 severity and level 2 severity is less than level 3 severity, the 
average costs for a level 3 case would be greater than the average 
costs for a level 2 case, which would be greater than the average costs 
for a level 1 case. The general structure of the CS DRGs includes four 
severity levels for each base DRG. However, severity level 
consolidations occur to address Medicare low-volume DRGs and 
monotonicity. The CS DRGs consolidate both adjacent severity levels for 
the same base DRG and the same severity level across multiple base DRGs 
(especially for severity level 4).
     Under the CMS+AP-DRGs and MM-APS-DRGs, each diagnosis is 
assigned a uniform CC-severity level across all base DRGs (other than 
CCs on the exclusion list for specific principal diagnoses). The 
remaining systems assign diagnoses to CC-severity level classifications 
by groups of DRGs.
     Under the grouping logic used by all systems other than 
the CS DRGs, each discharge is assigned to the highest severity level 
of any secondary diagnosis. The CS DRGs adjust the initial severity 
level assignment based on other factors, including the presence of 
additional CCs. None of the other systems adjust the severity level 
classification for additional factors or CCs. However, the MM-APS-DRG 
system handles additional CCs through an enhanced relative weight.
     The HSC-DRGs and the Sol-DRGs have a medical ``early 
death'' DRG within each MDC.
     The CS DRGs do not use death in the grouping logic. In 
addition, most complications of care do not affect the DRG assignment.
b. Comparative Performance in Explaining Variation in Resource Use
    In evaluating the comparative performance of each alternative DRG 
system, RAND used MedPAR data from FY 2004 and FY 2005. RAND excluded 
data from CAHs, Indian Health Service (IHS) hospitals, and hospitals 
that have all-inclusive rate charging practices. Consistent with CMS 
practice, RAND did not exclude data from Maryland hospitals, which 
operate under an IPPS waiver. Records that failed edits for data 
consistency or that had missing variables that were needed to determine 
standardized costs were also excluded.
    RAND reported that evaluation of each alternative severity-adjusted 
DRG system is a complex process due to differences in how each of the 
severity levels are applied, the number of severity-adjusted DRGs in 
each system, and the average number of discharges assigned to each DRG. 
In addition, the manner in which the DRGs for patients 0-17 years of 
age are assigned in the severity-adjusted systems affects the number of 
low-volume DRGs using Medicare discharges.
    Low-volume, severity-adjusted DRGs can affect the relative 
performance of a classification system. However, the percentage of 
Medicare discharges assigned to these DRGs is small--approximately 0.7 
percent in the HSC-DRG and Sol-DRG systems compared to 0.1 percent in 
the CMS DRGs.
    In determining how much within-DRG variation exists for each 
alternative severity-adjusted DRG system, RAND calculated the mean 
standardized cost, standard deviation, and coefficient of variation for 
each DRG among the systems. The coefficient of variation (CV) is the 
standard deviation divided by the mean. The CV allowed RAND to compare 
the variation of populations that contain significantly different mean 
values. Preliminary results of the comparison demonstrate that all five 
severity-adjusted systems reduce the amount of variation within DRGs. 
The HSC-DRGs and Sol-DRGs have a slightly higher proportion of patients 
assigned to DRGs with a CV<76 percent but also have a higher proportion 
of patients assigned to DRGs with a CV>=100 percent. The CS DRGs had a 
slightly lower percentage of patients assigned to DRGs with a CV<76 
percent than the other severity-adjusted systems. The MM-APS-DRGs, CS 
DRGs, and CMS+AP-DRGs all have fewer than 2 percent of patients 
assigned to DRGs with a CV>=100 percent.
    RAND utilized a general linear regression model to evaluate how 
well each severity-adjusted DRG system explains variation in costs per 
case. The initial results demonstrate that all five severity-adjusted 
DRG systems predict cost better than the CMS DRGs. The CS DRGs have 
higher adjusted R\2\ values (explanatory power) than the other 
severity-adjusted systems in nearly every MDC. In general, the adjusted 
R\2\ value for the CS DRGs is 0.4458, a 13-percent improvement over the 
adjusted R\2\ value for the CMS DRGs. The HSC-DRGs demonstrate an 11-
percent improvement, while the adjusted R\2\ values for the MM-APS-DRGs 
and Sol-DRGs are 10.0 percent and 9.7 percent higher respectively, than 
the CMS DRG R\2\ value. The CMS+AP-DRGs show the smallest improvement, 
nearly 8 percent.
    Another aspect of RAND's evaluation was to identify the validity of 
each alternative DRG system as a measurement for resource costs. For a 
base DRG, the severity levels should be monotonic; that is, the mean 
cost per discharge should increase simultaneously with an increase in 
the severity level. A distinction between patient groups and varying 
treatment costs should be accomplished by the severity levels. RAND 
studied the percentage differences and absolute differences in cost 
between the severity levels within the base DRGs for each system under 
evaluation. For the two systems (CMS+AP-DRGs and CS DRGs) that include 
several base DRGs, RAND assigned those discharges to the lower severity 
level base DRG. Following that methodology, RAND was able to calculate 
how much more costly the discharges assigned to the consolidated or 
lower severity levels were than the discharges in the base DRG assigned 
to the next higher severity level. Preliminary results demonstrate 
that, overall, monotonicity is not a factor across the alternative DRG 
systems. There are only a small percentage of discharges that are 
assigned to nonmonotonic DRGs. When a DRG is nonmonotonic, the mean 
cost in the higher severity level is less than the mean cost in the 
lower severity level.
    Using the data from severity of illness levels 1 through 3 (except 
for the MM-APS-DRGs, which do not have a severity of illness level 3), 
RAND calculated the discharge-weighted mean cost difference between 
severity levels and the mean ratio of the cost per discharge for the 
higher severity level to the adjacent lower severity level. The 
greatest cost discrimination was present in the higher severity levels 
versus the lower severity levels across all the systems. The mean cost 
difference between severity of illness level 1 and severity of illness 
level 0 was reported to be less than $2,000 for all the severity-
adjusted systems. The CMS+AP DRGs have the least amount of cost 
discrimination between severity levels ($2,117), while the MM-APS-DRG 
system has the highest mean cost difference ($2,385). The remaining 
systems demonstrated equivalent percentage cost differences between the

[[Page 24694]]

severity levels as shown in Table B below.
BILLING CODE 4120-01-P 
[GRAPHIC] [TIFF OMITTED] TP03MY07.000

BILLING CODE 4120-01-C
    In examining whether each of the alternative DRG systems provided 
stability in the relative weights from year to year, RAND compared the 
relative weights derived from the MedPAR data in FY 2004 to the 
relative weights data from FY 2005. RAND's preliminary results 
demonstrate that generally, across all the systems, only a small 
percentage of DRGs had greater than a 5 percent change in relative 
weights. The HSC-DRGs and Sol-DRGs had a higher proportion of DRGs with 
a greater than 5 percent change in relative weights than the other 
systems. Fewer than 10 percent of the DRGs in the remaining systems had 
relative weight changes greater than 10 percent. In addition to 
differences in the number of DRGs and the methodology of assigning the 
severity levels, RAND noted additional factors that may affect the 
comparative performance of each alternative severity-adjusted DRG 
system. For further details and discussion, we encourage readers to 
view RAND's full interim report on the CMS Web site at: http://www.cms.hhs.gov/Reports/downloads/Wynn0307.pdf.
c. Payment Accuracy and Case-Mix Impact
    Similar to how CMS established the relative weights in the FY 2007 
IPPS final rule, RAND used standardized costs as determined by the 
national CCR and the FY 2005 MedPAR data to construct relative weights 
for each of the DRG systems being evaluated. RAND analyzed the effect 
of variations in the

[[Page 24695]]

explanatory power on the distribution of Medicare payments for each 
system under evaluation. The preliminary findings indicate payment 
accuracy is improved by each severity-adjusted system by redistributing 
payment from lower-cost discharges to higher-cost discharges. However, 
the total payment redistribution across systems differs and reflects 
the payment impact of improved explanatory power. Although these 
findings are estimates, the percent of total payment redistributed was 
the least under the CMS+AP-DRGs (7.1 percent) and the most under the CS 
DRGs (11.9 percent).
    Table C shows changes in case-mix index (CMI) by hospital category 
across alternative severity-adjusted DRG systems. Preliminary results 
demonstrate that under the severity-adjusted systems, urban hospitals 
have a higher average CMI than under the CMS DRGs, and rural hospitals 
have a lower CMI. The analysis suggests that any system adopted to 
better recognize severity of illness with a budget neutrality 
constraint will result in payment redistribution that can be expected 
to benefit urban hospitals at the expense of rural hospitals. This 
impact occurs because patients treated in urban hospitals are generally 
more severely ill than patients in rural hospitals and the CMS DRGs are 
not currently recognizing the full extent of these differences. For 
purposes of the study, RAND assumed no behavioral changes in coding 
practice or the types of patients treated.
    The shift in case-mix (CMI) is greatest with the CS DRGs. The CMI 
for rural hospitals is 2.4 percent lower than under the CMS DRGs. The 
CMI for large urban (hospitals located in CBSAs with greater than 1 
million population) and other urban hospitals is 0.6 percent and 0.1 
percent higher, respectively, for the CS DRGs. The CMI generally 
increases for larger hospitals and decreases for smaller hospitals. 
Under the CMS+AP-DRG, HSC-DRG, and Sol-DRG systems, greater than 70 
percent of hospitals would experience less than a 2.5 percent change in 
their CMI. Under the MM-APS-DRG and Con-APR-DRG systems, 65 and 45 
percent of hospitals, respectively, would experience less than a 2.5 
percent change. The percentage of hospitals experiencing less than a 5 
percent change is significant across all of the CMS-based DRG systems.
    Teaching hospitals commonly treat a higher number of complex cases. 
However, depending on the severity-adjusted DRG system being analyzed, 
the impact will vary. In the CMS+AP-DRG, HSC-DRG, and MM-APS-DRG 
systems, facilities with large teaching programs (100 or more 
residents) demonstrated a larger increase than those facilities with 
smaller teaching programs. Under the Sol-DRG system, facilities with 
large teaching programs would experience a 0.1 percent increase, while 
facilities with the smaller teaching programs would experience a 0.2 
percent increase. The CS DRGs showed similar results for hospitals with 
large teaching programs, but hospitals with the smaller teaching 
programs would experience an increase of 0.7 percent, relative to the 
CMS DRGs. RAND found that CMI would decline for nonteaching hospitals 
from severity adjusted DRGs, from a 0.2 percent decrease under the HSC-
DRGs and Sol-DRGs compared to a 0.5 percent decrease under the CS DRGs.

                                       Table C.--CMI Change in Alternative DRG Systems Relative to the CMS DRG CMI
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                           Percentage change from CMS-DRG-CMI
                                                                N            N        CMS  DRG ---------------------------------------------------------
                                                            hospitals    discharges     CMI     CMS + AP-
                                                                                                   DRG      HSC-DRG    Sol-DRG   MM-APS-DRG  Con-APR-DRG
--------------------------------------------------------------------------------------------------------------------------------------------------------
ALL......................................................        3,890   12,165,763       1.00        0.0        0.0        0.0         0.0         0.0
By Geographic Location:
    Large urban areas (pop>1 million)....................        1,485    5,715,356       1.02        0.5        0.4        0.3         0.6         0.6
    Other urban areas (pop<1 million)....................        1,186    4,578,447       1.04       -0.2       -0.2       -0.1        -0.2         0.1
    Rural hospitals......................................        1,219    1,871,960       0.84       -1.3       -0.9       -1.0        -1.4        -2.4
Bed Size (Urban):
    0-99 beds............................................          685      611,139       0.91       -1.0       -1.1       -1.1        -1.3        -1.6
    100-199 beds.........................................          875    2,346,922       0.93        0.0        0.1        0.0         0.1         0.0
    200-299 beds.........................................          511    2,446,737       1.00        0.1        0.2        0.3         0.3         0.6
    300-499 beds.........................................          433    2,965,216       1.08        0.3        0.3        0.3         0.4         0.8
    500 or more beds.....................................          167    1,923,789       1.17        0.6        0.3        0.2         0.4         0.4
Bed Size (Rural):
    0-49 beds............................................          543      330,242       0.73       -2.5       -2.1       -2.2        -2.7        -5.0
    50-99 beds...........................................          398      595,599       0.80       -1.4       -1.0       -1.1        -1.6        -2.7
    100-149 beds.........................................          160      415,367       0.85       -1.1       -0.7       -0.8        -1.2        -2.0
    150-199 beds.........................................           69      260,910       0.91       -0.8       -0.6       -0.7        -0.8        -1.5
    200 or more beds.....................................           49      269,842       0.99       -0.6       -0.1       -0.1        -0.6        -0.5
Urban by Region:
    New England..........................................          129      541,471       0.99        0.1       -0.2       -0.5        -0.5        -0.6
    Middle Atlantic......................................          370    1,621,488       1.00        0.0       -0.4       -0.5        -0.3        -1.5
    South Atlantic.......................................          432    2,208,336       1.04        0.5        0.7        0.7         0.7         1.4
    East North Central...................................          410    1,856,164       1.03        0.6        0.7        0.6         0.8         1.5
    East South Central...................................          168      696,943       1.06       -0.2       -0.2       -0.2        -0.2        -0.3
    West North Central...................................          164      657,322       1.08       -0.3       -0.3        0.0        -0.3         0.3
    West South Central...................................          369    1,115,411       1.05        0.1        0.0        0.1         0.3         0.5
    Mountain.............................................          153      465,093       1.08        0.4        0.2        0.5         0.4         1.0
    Pacific..............................................          423    1,016,135       1.03        0.0       -0.2       -0.1        -0.1         0.2
    Puerto Rico..........................................           53      115,440       0.87       -1.1       -1.4       -0.1        -1.2        -5.1
Rural by Region:
    New England..........................................           34       49,842       0.90       -0.6       -0.6       -0.5        -1.1        -0.6
    Middle Atlantic......................................           68      139,639       0.85       -1.1       -0.7       -0.7        -1.3        -1.5
    South Atlantic.......................................          191      409,116       0.82       -0.8       -0.4       -0.5        -0.9        -1.8
    East North Central...................................          163      290,069       0.87       -1.1       -0.7       -0.9        -1.3        -1.8
    East South Central...................................          201      328,326       0.82       -1.5       -0.9       -1.1        -1.4        -3.2

[[Page 24696]]

 
    West North Central...................................          184      240,449       0.87       -1.6       -1.2       -1.1        -1.8        -2.5
    West South Central...................................          227      266,419       0.80       -2.1       -1.8       -1.9        -2.0        -4.3
    Mountain.............................................           91       80,219       0.85       -1.2       -1.0       -0.4        -1.3        -1.2
    Pacific..............................................           60       67,881       0.86       -0.9       -1.0       -1.1        -1.4        -1.6
Teaching Status:
    Non-teaching.........................................        2,791    6,115,193       0.92       -0.4       -0.2       -0.2        -0.4        -0.5
    Fewer than 100 Residents.............................          853    4,061,451       1.04        0.1        0.2        0.2         0.2         0.7
    100 or more Residents................................          246    1,989,119       1.16        0.8        0.3        0.1         0.5         0.0
Urban DSH:
    Non-DSH..............................................          778    2,574,640       1.02       -0.1        0.0        0.1        -0.2         0.5
    100 or more beds.....................................        1,541    7,378,095       1.05        0.3        0.2        0.2         0.4         0.4
    Less than 100 beds...................................          352      341,068       0.82       -0.9       -0.8       -1.0        -1.1        -2.0
Rural DSH:
    Non-DSH..............................................          238      300,747       0.87       -1.4       -1.0       -0.9        -1.7        -1.9
    SCH..................................................          402      599,823       0.83       -1.3       -1.0       -1.0        -1.4        -2.4
    RRC..................................................          132      466,395       0.92       -0.8       -0.3       -0.5        -0.7        -1.4
Other Rural:
    100 or more beds.....................................           60      135,146       0.80       -0.9       -0.8       -1.2        -1.3        -2.0
    Less than 100 beds...................................          387      369,849       0.74       -2.1       -1.6       -1.7        -2.2        -4.3
Urban teaching and DSH:
    Both teaching and DSH................................          829    4,705,476       1.09        0.5        0.3        0.3         0.5         0.5
    Teaching and no DSH..................................          204    1,108,092       1.06        0.0        0.1        0.0        -0.1         0.4
    No teaching and DSH..................................        1,064    3,013,687       0.95       -0.1        0.1        0.0         0.1         0.1
    No teaching and no DSH...............................          574    1,466,548       1.00       -0.2       -0.1        0.1        -0.3         0.5
Rural Hospital Types:
    RRC..................................................          145      519,808       0.92       -0.8       -0.4       -0.5        -0.7        -1.4
    SCH..................................................          423      457,119       0.79       -1.6       -1.2       -1.2        -1.7        -3.0
    MDH..................................................          180      164,453       0.75       -2.1       -1.7       -1.7        -2.3        -4.1
    SCH and RRC..........................................           76      266,027       0.92       -0.9       -0.7       -0.7        -1.1        -1.3
    MDH and RRC..........................................            8       19,746       0.85       -1.4       -0.6       -0.8        -1.6        -1.9
    Other Rural..........................................          387      444,807       0.77       -1.6       -1.2       -1.4        -1.8        -3.3
--------------------------------------------------------------------------------------------------------------------------------------------------------

    RAND also noted that changes in coding patterns or behaviors could 
improve payments with each severity adjusted DRG system. Increases in 
CMI after adopting the system could be the result of improved coding 
rather than increases in actual patient severity. Although the State of 
Maryland's experience using the APR-DRG system is an indicator, coding 
behaviors are expected to vary under alternative systems according to 
RAND. Therefore, the risk of case-mix growth due to improved 
documentation and coding exists with any system. However, RAND advises 
that the amount of risk can be assessed based on the logic of the DRG 
system and result in anticipated changes in coding behavior. RAND found 
that the CMS+AP-DRG system may have the lowest risk of case-mix 
increase, while the CS DRGs present the greatest risk. The remaining 
systems under evaluation demonstrated equivalent risk, based on the DRG 
logic and other features specific to each system.
    In section II.D.2.c. of the preamble of this proposed rule, the CMI 
impact under the proposed MS-DRGs using the State of Maryland's 
experience and data is described in detail. RAND's final report will 
include a comparison of the CMI impact under the proposed MS-DRG system 
with the CMI impact of the other alternative severity-adjusted DRG 
systems.
d. Other Issues for Consideration
    RAND was asked to examine whether each of the alternative severity-
adjusted DRG systems under evaluation appear to contain logic that is 
manageable, administratively feasible, and understandable. Although its 
evaluation is not yet complete, RAND's preliminary results describe the 
extent to which those features are present in the grouping logic of 
each system. A brief summary of these findings and other discussion 
points follow. For more complete details of the grouping logic for each 
system evaluated, we encourage readers to review RAND's interim report 
at the following Web site: http://www.cms.hhs.gov/Reports/downloads/Wynn0307.pdf.
    To increase and promote understanding of a DRG classification 
system, the grouping logic should include a uniform structure. With the 
exception of the CS DRGs, RAND found that there is uniformity in the 
hierarchical structure for assigning discharges to MDCs, DRGs, and 
severity levels for each system evaluated. The CS DRGs utilize a 
complex rerouting logic and severity of illness level assignment. 
However, the result is a higher explanatory power that accounts for 
limitations in the current system. Therefore, due to the complexities 
associated with that system, it may not easily be understood. However, 
if the results yield clinically coherent groups of patients with 
comparable costs, RAND concluded that the system may be worth exploring 
further. The HSC-DRG and Sol-DRG grouping logic uses a standard number 
of severity levels for each base DRG, although the result is an 
increase in the number of low-volume DRGs. The standard severity level 
structure provides increased understanding, although as mentioned 
previously, low-volume, severity-adjusted DRGs can affect the relative 
performance of a classification system. The MM-APS-DRGs and CS DRGs use 
standard DRG severity levels. However, the method of collapsing DRGs 
varies due to the modifications made for Medicare use. By only 
collapsing DRGs to determine relative weights, RAND

[[Page 24697]]

notes it is possible to preserve the underlying DRG structure, which 
perhaps would lead to a more understandable system.
    As stated earlier, there are also several transition issues that 
require attention when evaluating alternative severity-adjusted DRG 
systems. In determining how manageable, administratively feasible, and 
understandable the systems being evaluated are, consideration should be 
given to how they crosswalk or map to the current CMS DRGs. Because 
four of the systems under evaluation are based on the underlying CMS 
DRG grouping logic to establish their base DRGs (CMS+AP-DRGs, HSC-DRGs, 
Sol-DRGs, and MM-APS-DRGs), the CMS DRGs are able to crosswalk smoothly 
to these severity-adjusted DRGs. Conversely, crosswalking in reverse or 
backward mapping from the CMS+AP DRGs to the CMS DRGs is problematic 
due to the discharges in one severity level of the CMS+AP-DRG system 
compared to several base CMS DRGs. As expected, the CS DRGs do not 
crosswalk easily to the CMS DRGs due to the complex grouping logic. The 
MM-APS-DRGs pose unique complications as well due to the large number 
(over 1,000) of DRGs.
    System updates are another important factor that may have serious 
implications. All of the DRG systems RAND evaluated were reported to 
make annual updates to reflect ICD-9-CM coding changes. However, the CC 
severity level assignments for each system have not routinely been 
reviewed and revised. The review of the CC exclusion list and severity 
level assignments should be reviewed where appropriate to reflect 
current patterns of care, according to RAND.
    Accessibility to each of the severity-adjusted DRG system's logic 
and software is also a concern. Each system RAND analyzed is currently 
maintained as a proprietary product. In general, all of the vendors 
indicated a willingness to place their product in the public domain, 
under certain terms. As such, we believe it is likely there would need 
to be discussion as to whether there would be any limitations (such as 
the source code as well as the DRG logic) on the availability of the 
DRG systems to hospitals or competing vendors. The intent of each 
vendor to provide public access to its grouper logic and software is 
described in further detail in RAND's interim report.
    The RAND contract will be complete by September 1, 2007. The final 
report will include evaluation of the proposed MS-DRGs, with further 
analysis of the five alternative severity-adjusted DRG classification 
systems. RAND will also study various approaches to estimating costs 
and developing relative weights, as well as the payment impacts of 
alternative methodologies. Again, we invite public comment on RAND's 
preliminary analysis of the alternative severity-adjusted DRG systems. 
The interim report can be viewed on the CMS Web site at: http://www.cms.hhs.gov/Reports/downloads/Wynn0307.pdf.
2. Development of Proposed Medicare Severity DRGs (MS-DRGs)
    As discussed previously, we are committed to continuing our efforts 
of making refinements to the current CMS DRGs to better recognize 
severity of illness. In the FY 2007 final rule, we stated that we had 
begun a comprehensive review of over 13,000 diagnosis codes to 
determine which codes should be classified as CCs when present as a 
secondary diagnosis. We stated that we would also build on the severity 
DRG work we performed in the mid-1990's. We received a number of public 
comments on last year's proposed rule that supported the refinement of 
the current CMS DRGs so that they better capture severity.
    We also committed to performing a more broad based analysis of the 
entire DRG system to better recognize severity of illness. As a result 
of this broad based analysis, we developed the proposed MS-DRGs. The 
proposed MS-DRGs represent a comprehensive approach to applying a 
severity of illness stratification for Medicare patients throughout the 
DRGs. As discussed in section II.D.5. of the preamble of this proposed 
rule, the proposed MS-DRGs maintain the significant advancements in 
identifying medical technology made to the DRGs in past years. At the 
same time, they greatly improve our ability to identify groups of 
patients with varying levels of severity using secondary diagnoses. 
Further, they improve our ability to assign patients to different DRG 
severity levels based on resource use that is independent of the 
patient's secondary diagnosis--referred to in this discussion as 
``complexity.'' We are proposing to adopt the MS-DRGs for FY 2008 and 
submit the system to RAND as part of its evaluation of alternative DRG 
systems. We encourage comments on both our proposed methodology as well 
as on the resulting proposed DRG structure.
a. Comprehensive Review of the CC List
    Our efforts to better recognize severity of illness began with a 
comprehensive review of the CC list. Currently, 115 DRGs are split 
based on the presence or absence of a CC. For these DRGs, the presence 
of a CC assigns the discharge to a higher weighted DRG. The list of 
diagnoses designated as a CC was initially created at Yale University 
in 1980-1981 as part of the project to develop an ICD-9-CM version of 
the DRGs. The researchers at Yale University developed the ICD-9-CM 
DRGs using national hospital data with diagnoses and procedures coded 
in ICD-9-CM from the second half of 1979. Because hospitals only began 
reporting ICD-9-CM codes in 1979, discharge abstracts at that time were 
much less likely to fully report all secondary diagnoses. As a result, 
the Yale University researchers developed a liberal definition of a CC 
as any secondary diagnosis that ``would cause an increase in length of 
stay by at least 1 day in at least 75 percent of the patients.'' 
Because of the likely underreporting of secondary diagnoses in the 1979 
data, the Yale University researchers also used age as a surrogate for 
identifying patients with a CC. The original version of the ICD-9-CM 
DRGs assigned patients to a CC DRG if they had a secondary diagnosis on 
the CC list or if the patient was 70 years or older.
    With the implementation of the IPPS in FY 1984, the coding of 
secondary diagnoses by hospitals dramatically improved. During the 
first 4 years of the IPPS, the CC definition included the age 70 
criterion. With the improved coding and reporting of diagnoses 
associated with the implementation of the IPPS, the use of age as a 
surrogate for CCs was no longer necessary. Thus, beginning in FY 1988, 
the age 70 criterion was removed from the CC definition and a CC DRG 
was defined exclusively by the presence of a secondary diagnosis on the 
CC list.
    Except for new diagnosis codes that were added to ICD-9-CM after FY 
1984 (for example, HIV), the CC list of diagnoses currently used in the 
CMS DRGs is virtually identical to the CC list created at Yale 
University. However, there have been dramatic changes not only in the 
accuracy and completeness of the coding of secondary diagnoses but also 
in the characteristics of patients admitted to hospitals and the 
practice patterns within hospitals as well.
    Since the implementation of the IPPS, Medicare average length of 
stay has dropped dramatically from 9.8 days in 1983 to 5.7 days in 
2005. The economic incentives inherent in DRGs motivated a change in 
practice patterns to discharge patients earlier from the hospital. 
These changes were facilitated by the increased availability of 
postacute care services, such as nursing homes and home health 
services, which

[[Page 24698]]

allowed problems previously requiring continued hospitalization to be 
effectively treated outside the acute care hospital. Furthermore, there 
has also been a dramatic shift to outpatient surgery that avoids costly 
inpatient stays. Many surgical procedures formerly performed in the 
hospital are now routinely performed on an outpatient basis. As a 
result, patients admitted to the hospital today are on average more 
likely to have a CC than when the IPPS was implemented. The net effect 
of better coding of secondary diagnoses, reductions in hospital length 
of stay, increased availability of postacute care services, and the 
shift to outpatient care is that most patients (nearly 80 percent) 
admitted to a hospital now have a CC. As a result of the changes that 
have occurred during the 22 years since the implementation of the IPPS, 
the CC list as currently defined has lost much of its power to 
discriminate hospital resource use.
    Currently, 115 CMS DRGs have a CC subdivision. Up until FY 2002, 
the number of DRGs with a CC subdivision remained essentially unchanged 
from the original FY 1984 version of the DRGs. As a means of improving 
the payment accuracy of the DRGs, beginning with the FY 2002 DRG 
update, each base CMS DRG without a CC subdivision was evaluated to 
determine if a CC subdivision was warranted. Over the past five DRG 
updates, only seven base CMS DRGs have had a CC subdivision added. The 
primary constraint preventing a significant increase in the number of 
base CMS DRGs with a CC subdivision is the low number of patients that 
would be assigned to the non-CC group. Thus, the expansion of the 
number of CMS DRGs subdivided based on a CC is constrained because the 
vast majority of patients would be assigned to the CC group and few 
patients would be assigned to the non-CC group. To remedy these 
problems, we reviewed each of the 13,549 secondary diagnosis codes to 
evaluate their assignment as a CC or non-CC using statistical 
information from the Medicare claims data and applying medical judgment 
based on current clinical practice. We refer to this list in this 
section as the ``revised CC list.''
    The need for a revised CC list prompted a reexamination of the 
secondary diagnoses that qualify as a CC. Our intent was to better 
distinguish cases that are likely to result in increased hospital 
resource use based on secondary diagnosis. Using a combination of 
mathematical data and the judgment of our medical officers, we included 
the condition on the CC list if it could demonstrate that its presence 
would lead to substantially increased hospital resource use.
    Diagnoses may require increased hospital resource use because of a 
need for such services as:
     Intensive monitoring (for example, an intensive care unit 
(ICU) stay).
     Expensive and technically complex services (for example, 
heart transplant).
     Extensive care requiring a greater number of caregivers 
(for example, nursing care for a quadriplegic). There are 3,326 
diagnosis codes on the current CC list. Our 2006 review of the CC list 
reduced the number of diagnosis codes on the CC list to 2,583. Based on 
the current CC list, 77.6 percent of patients have at least one CC 
present. Based on the revised CC list from our 2007 review, the percent 
of patients having at least one CC present would be reduced to 41.24 
percent.
b. Chronic Diagnosis Codes
    The 1979 data used in the original formation of the CC list often 
did not have the manifestations of a chronic disease fully coded. As a 
result, the CC list included many chronic diseases with a broad range 
of manifestations. Such chronic illness diagnoses usually do not cause 
a significant increase in hospital resource use unless there is an 
acute exacerbation present or there is a significant deterioration in 
the underlying chronic condition. Therefore, in the revised CC list, we 
removed chronic diseases without a significant acute manifestation. 
Recognition of the impact of the chronic disease is accomplished by 
separately coding the acute manifestation. For example, the mitral 
valve disease codes (codes 396.0 through 396.9) are assigned to the 
current CC list. However, unless the mitral valve abnormalities are 
associated with other diagnoses indicating acute deterioration, such as 
acute congestive heart failure, acute pulmonary edema, or respiratory 
failure, they would not be expected to significantly increase hospital 
resource use. Therefore, the revised CC list did not include the mitral 
valve codes. Recognition of the contribution of mitral valve disease to 
the complexity of hospital care would be accomplished by separately 
coding those diseases on the CC list that are associated with an acute 
exacerbation or deterioration of the mitral valve disease.
    The revised CC list applied the criterion that chronic diagnoses 
having a broad range of manifestations are not assigned to the CC list 
as long as there are codes available that allow the acute 
manifestations of the disease to be coded separately. For some 
diseases, there are ICD-9-CM codes that explicitly include a 
specification of the acute exacerbation of the underlying disease. For 
example, for congestive heart failure, the following codes specify an 
acute exacerbation of the congestive heart failure:

 428.21, Acute systolic heart failure
 428.41, Acute systolic and diastolic heart failure
 428.43, Acute on chronic systolic heart failure
 428.31, Acute diastolic heart failure
 428.33, Acute on chronic diastolic heart failure

    These congestive heart failure codes are included on the revised CC 
List. However, the following congestive heart failure codes do not 
indicate an acute exacerbation and are not included in the revised CC 
list:

 428.0, Congestive heart failure not otherwise specified
 428.1, Left heart failure
 428.20, Systolic heart failure not otherwise specified
 428.22, Chronic systolic heart failure
 428.32, Chronic diastolic heart failure
 428.40, Systolic and diastolic heart failure
 428.9, Heart failure not otherwise specified

    As a result of this approach, most chronic diseases were not 
assigned to the revised CC list. In general, a significant acute 
manifestation of the chronic disease must be present and coded for the 
patient to be assigned a CC. We made exceptions for diagnosis codes 
that indicate a chronic disease in which the underlying illness has 
reached an advanced stage or is associated with systemic physiologic 
decompensation and debility. The presence of such advanced chronic 
diseases, even in the absence of a separately coded acute 
manifestation, significantly adds to the treatment complexity of the 
patient. Thus, the presence of the advanced chronic disease inherently 
makes the reason for admission more difficult to treat. For example, 
under the revised CC list, stage IV, V, or end-stage chronic renal 
failure (codes 585.4 through 585.6) are designated as a CC, but stage I 
through III chronic renal failure (codes 585.1 through 585.3) are not. 
For obesity, a body mass index over 35 (codes V85.35 through V85.4) is 
a CC, but a body mass index between 19 and 35 is not. End-stage renal 
failure and extreme obesity are examples of chronic diseases for which 
the advanced stage of the disease is clearly specified.
    However, for most major chronic diseases, the stage of the disease 
is not clearly specified in the code. These

[[Page 24699]]

codes were evaluated based on the consistency and intensity of the 
physiologic decompensation and debility associated with the chronic 
disease. For example, quadriplegia (codes 344.00 through 344.09) 
requires extensive care with a substantial increase in nursing services 
and more intensive monitoring. Therefore, quadriplegia is considered a 
CC in the revised CC list.
c. Acute Diagnosis Codes
    Examples of acute diseases included on the revised CC list included 
acute myocardial infarction (AMI), cerebrovascular accident (CVA) or 
stroke, acute respiratory failure, acute renal failure, pneumonia and 
septicemia. These six diseases are representative of the types of 
illnesses we included on the revised CC list. Other acute diseases were 
designated as a CC if their impact on hospital resource use would be 
expected to be comparable to these representative acute diseases. For 
example, acute endocarditis was included on the CC list but urinary 
tract infection was not.
    The revised CC list is essentially comprised of significant acute 
disease, acute exacerbations of significant chronic diseases, advanced 
or end stage chronic diseases and chronic diseases associated with 
extensive debility. Compared to the existing CC list, the revised CC 
list requires a secondary diagnosis to have a consistently greater 
impact on hospital resource.
    The following Table D compares the current CC list and the revised 
CC list. There are 3,326 diagnosis codes on the current CC list. The CC 
revisions reduce the number of diagnosis codes on the CC list to 2,583. 
Based on the current CC list, 77.6 percent of patients have at least 
one CC present, using FY 2006 MedPAR data. Based on the revised CC 
list, the percent of patients having at least one CC present is reduced 
to 40.34 percent. The revised CC list increases the difference in 
average charges between patients with and without a CC by 56 percent 
($15,236 versus $9,743).

       Table D.--Comparison of Current CC List and Revised CC List
------------------------------------------------------------------------
                                            Current CC      Revised CC
                                               list            list
------------------------------------------------------------------------
Codes designated as a CC................        3,326           2,583
Percent of patients with one or more CCs           77.66           40.34
Percent of patients with no CC..........           22.34           59.66
Average charge of patients with one or        $24,538         $31,451
 more CCs...............................
Average charge of patients with no CCs..      $14,795         $16,215
------------------------------------------------------------------------

    The analysis above suggests that merely reviewing and updating the 
CC list can lead to significant improvements in the ability of the CMS 
DRGs to recognize severity of illness. Although we could potentially 
adopt this one change to better recognize severity of illness in the 
CMS DRGs, we have undertaken additional analyses that further refine 
secondary diagnoses into MCCs, CCs and non-CCs as described below.
d. Prior Research on Subdivision of CCs into Multiple Categories
(1) Refined DRGs
    During the mid-1980s, CMS (then HCFA) funded a project at Yale 
University to revise the use of CCs in the CMS DRGs. The Yale 
University project mapped all secondary diagnoses that were considered 
a CC in the CMS DRGs into 136 secondary diagnosis groups, each of which 
was assigned a CC complexity level. For surgical patients, each of the 
136 secondary diagnosis groups was assigned to 1 of 4 CC complexity 
levels (non-CC, moderate CC, MCC, and catastrophic CC). For medical 
patients, each of the 136 secondary diagnosis groups was assigned to 1 
of 3 CC complexity levels (non-CC, moderate/MCC, and catastrophic CC). 
All age subdivisions and CC subdivisions in the DRGs were eliminated 
and replaced by the four CC subgroups for surgical patients, or the 
three CC subgroups for medical patients. The Yale University project 
did not reevaluate the categorization of secondary diagnosis as a CC 
versus a non-CC. Only the diagnoses on the standard CC list were used 
to create the moderate, major, and catastrophic subgroups. All 
secondary diagnoses in a secondary diagnosis group were assigned the 
same level, and a patient was assigned to the subgroup corresponding to 
the highest level secondary diagnosis. The number of secondary 
diagnoses had no effect on the subgroup assigned to the patient (that 
is, multiple secondary diagnoses at one level did not cause a patient 
to be assigned to a higher subgroup). The DRG system developed by the 
Yale University project demonstrated that a subdivision of the CCs into 
multiple subclasses would improve the predictability of hospital costs.
(2) 1994 Severity DRGs
    We also examined the work we performed in the mid-1990's to revise 
the CMS DRGs to better capture severity. In 1993, we reevaluated the 
use of CCs within the CMS DRGs. The reevaluation excluded the CMS DRGs 
associated with pregnancy, newborn, and pediatric patients (MDCs 14 and 
15 and DRGs defined based on age 0-17). The major CC list from the AP-
DRGs that are used for Medicaid payment by New York and other States 
was used to identify an initial list of MCCs. Using Medicare data, we 
reevaluated the categorization of each secondary diagnosis as a non-CC, 
CC, or an MCC. The end result was that 111 diagnoses that were non-CCs 
in the standard CMS DRGs were made a CC, 220 diagnoses that were a CC 
were made a non-CC, and 395 CCs were considered an MCC.
    All CC splits in the CMS DRGs were eliminated, and an additional 24 
DRGs were merged together. The resulting base CMS DRGs were then 
subdivided into three, two, or no subgroups based on an analysis of 
Medicare data. The result was 84 DRGs with no subgroups, 124 DRGs with 
two subgroups, and 85 DRGs with three subgroups. An additional 63 
pregnancy, newborn, and pediatric DRGs not evaluated resulted in a 
total of 652 DRGs.
    A patient was assigned to the CC subgroup corresponding to the 
highest level secondary diagnosis. Multiple secondary diagnoses at one 
level did not cause a patient to be assigned to a higher subgroup. The 
categorization of a diagnosis as non-CC, CC, or MCC was uniform across 
the CMS DRGs, and there were no modifications for specific DRGs. As 
part of the FY 1995 IPPS proposed rule, we made a complete file of the 
revised DRG descriptions available to the public. However, we never 
adopted the revised DRGs (55 FR 27756).
e. Proposed Medicare Severity DRGs (MS-DRGs)
    We had several options in developing a refinement to the current 
CMS DRGs to better recognize increased resource use due to severity of 
illness. One

[[Page 24700]]

option would involve simply taking the work performed in 1994 and then 
updating it with all the code changes that have taken place since then. 
We were reluctant to do this because of changes in medical practices as 
well as the substantial change in ICD-9-CM codes since that time. 
Another option would be to build on current CMS DRGs which include a 
number of advancements that better identify medical practices and 
technologies. Many commenters on the FY 2007 IPPS proposed rule urged 
us to take the latter approach because they believed the current base 
CMS DRGs clearly differentiate between the complexities of varying 
surgical procedures and medical devices. Therefore, we chose the option 
of developing a new severity DRG system based on the current CMS DRGs.
    The development of the 1994 Severity DRGs involved three steps:
     Consolidation of existing DRGs into base DRGs.
     Categorization of each diagnosis as an MCC, CC, or non-CC.
     Subdivision of each base DRG into subclasses based on CCs.
    We reviewed and revised each of the three steps and applied them to 
our current CMS DRGs to develop DRGs that better identify severity of 
illness among Medicare patients. We refer to this proposed system as 
the Medicare Severity DRGs (MS-DRGs). The purpose of the proposed MS-
DRGs is to more accurately stratify groups of Medicare patients with 
varying levels of severity.
(1) Consolidation of Existing CMS DRGs Into Proposed Base MS-DRGs
    The first step in our process was the consolidation of existing CMS 
DRGs into new proposed base MS-DRGs. We combined together the 115 pairs 
of CMS DRGs that are subdivided based on the presence of a CC. We 
further consolidated the CMS DRGs that are split on the basis of a 
major cardiovascular condition, AMI with and without major complication 
(CMS DRGs 121 and 122), and cardiac catheterization with and without 
complex diagnoses (CMS DRGs 124 and 125). We also consolidated the 
three pairs of burn CMS DRGs that were defined based on the presence of 
a CC or a significant trauma (CMS DRGs 506 and 507; 508 and 509; and 
510 and 511). Next, we consolidated the 43 pediatric CMS DRGs that are 
defined based on age less than or equal to 17. These pediatric CMS DRGs 
contain a very low volume of Medicare patients. As shown in Table 10 of 
the FY 2007 IPPS final rule (71 FR 48318), only two of these pediatric 
CMS DRGs contained more than 100 patients (CMS DRGs 298 and 333). 
Seventeen of these pediatric DRGs had no patients (CMS DRGs 30, 33, 41, 
48, 54, 58, 137, 252, 255, 282, 330, 340, 343, 393, 405, 446, and 448). 
As we have stated frequently, our primary focus in maintaining the CMS 
DRGs is to serve the Medicare population. We do not have the data or 
the expertise to maintain the DRGs in clinical areas that are not 
relevant to the Medicare population. We continue to encourage users of 
the CMS DRGs (or MS-DRGs if adopted) to make relevant adaptations if 
they are being used for a non-Medicare patient population.
    In addition to the pediatric CMS DRGs defined by the age of the 
patient, there are a number of CMS DRGs that relate primarily to the 
pediatric or adult population that have very low volume in the Medicare 
population, such as male sterilization, tubal interruptions, 
circumcisions, tonsillectomies, and myringotomies. These CMS DRGs were 
consolidated into the most clinically similar proposed MS-DRG.
    Over the past two decades, the site of service for some elective 
procedures such as carpal tunnel release, cataract extraction, and 
laparoscopy has shifted from the inpatient to the outpatient setting, 
resulting in the CMS DRGs associated with these procedures having very 
low volume. These CMS DRGs were also consolidated into the most 
clinically similar proposed MS-DRG. In addition, there were some 
clinically related CMS DRGs that had significant Medicare patient 
volume but had no significant difference in resource use. For example, 
thyroid (CMS DRG 290) and parathyroid (CMS DRG 289) procedures were 
virtually identical in terms of hospital resource use and were, 
therefore, consolidated. In total, 34 of these CMS DRGs were 
consolidated. The DRG consolidations are summarized in Table E below.
    Four pairs of proposed MS-DRGs (223 and 224; 228 and 229; 323 and 
324; and 551 and 552) were defined based on the presence of a CC or 
some other condition. For example, proposed MS-DRG 323 is defined based 
on the presence of a CC or the performance of extracorporeal shock wave 
lithotripsy. For these proposed MS-DRGs, the CC condition was removed 
and the pair of DRGs remains separate but defined based only on the 
other condition (that is, proposed MS-DRG 323 became urinary stones 
with extracorporeal shock wave lithotripsy). As was done in the 1994 
severity DRG work, we did not consolidate any of the CMS DRGs for 
maternity or newborn cases.
    Before proceeding further, we made one additional change to a base 
DRG assignment after completing these consolidations. We assigned 
cranial-facial bone procedures to a proposed new base DRG (Cranial/
Facial Bone Procedures). These cases were previously assigned to DRGs 
52 and 55 through 63.
    Table E below shows how DRGs in the CMS DRGs (Version 24.0) were 
consolidated into proposed new base MS-DRGs. We refer readers to 
section II.D.2. of the preamble of this proposed rule for a detailed 
discussion of CCs and MCCs under the proposed MS-DRGs.

                                           Table E.--DRG Consolidation
----------------------------------------------------------------------------------------------------------------
                                                                         Proposed
         CMS-DRG Version 24.0                   DRG description          2008 MS-    Proposed new base MS-DRGs
                                                                           DRG              description
----------------------------------------------------------------------------------------------------------------
6.....................................  Carpal Tunnel Release.........         40  Peripheral & Cranial Nerve &
7,8...................................  Peripheral & Cranial Nerve &           41   Other Nervous System
                                         Other Nervous System                  42   Procedure with MCC, with CC,
                                         Procedure.                                 and without CC/MCC.
----------------------------------------------------------------------------------------------------------------
36....................................  Retinal Procedures............        116  Intraocular Procedures with
38....................................  Primary Iris Procedures.......        117   and without CC/MCC.
39....................................  Lens Procedures with or
42....................................   without Vitrectomy.
                                        Intraocular Procedures Except
                                         Retina, Iris & Lens.
----------------------------------------------------------------------------------------------------------------
43....................................  Hyphema.......................        124  Other Disorders of the Eye
46,47,48..............................  Other Disorders of the Eye....        125   with and without MCC.
----------------------------------------------------------------------------------------------------------------

[[Page 24701]]

 
50....................................  Sialoadenectomy...............        139  Salivary Gland Procedures.
51....................................  Salivary Gland Procedures
                                         Except Sialoadenectomy.
----------------------------------------------------------------------------------------------------------------
52....................................  Cleft Lip & Palate Repair.....        133  Other Ear, Nose, Mouth &
55....................................  Miscellaneous Ear, Nose, Mouth        134   Throat O.R. Procedures with
                                         & Throat Procedures.                       and without CC/MCC.
----------------------------------------------------------------------------------------------------------------
56....................................  Rhinoplasty...................        131  New DRG--Cranial/Facial Bone
57,58.................................  Tonsillectomy & Adenoidectomy         132   Procedures with and without
59,60.................................   Procedure, Except                          CC/MCC.
61,62.................................   Tonsillectomy &/or
63....................................   Adenoidectomy Only.
                                        Tonsillectomy &/or
                                         Adenoidectomy Only.
                                        Myringotomy with Tube
                                         Insertion.
                                        Other Ear, Nose, Mouth &
                                         Throat O.R. Procedures.
67....................................  Epiglottitis..................        152  Otitis Media & Upper
68,69,70..............................  Otitis Media & Upper                  153   Respiratory Infection with
71....................................   Respiratory Infection.                     and without MCC.
                                        Laryngotracheitis.............
----------------------------------------------------------------------------------------------------------------
72....................................  Nasal, Trauma & Deformity.....        154  Other Ear, Nose, Mouth &
73,74.................................  Other Ear, Nose, Mouth &              155   Throat Diagnoses with MCC,
                                         Throat Diagnoses.                    156   with CC, without CC/MCC.
----------------------------------------------------------------------------------------------------------------
185,186...............................  Dental & Oral Diseases Except         157  Dental & Oral Diseases with
187...................................   Extractions & Restorations.          158   MCC, with CC, without CC/
                                        Dental Extractions &                  159   MCC.
                                         Restorations.
----------------------------------------------------------------------------------------------------------------
199...................................  Hepatobiliary Diagnostic              420  Hepatobiliary Diagnostic
200...................................   Procedure for Malignancy.            421   Procedures with MCC, with
                                        Hepatobiliary Diagnostic              422   CC, without CC/MCC.
                                         Procedure for Non-Malignancy.
----------------------------------------------------------------------------------------------------------------
244,245...............................  Bone diseases & Specific              553  Bone Diseases & Arthropathies
246...................................   Arthropathies.                       554   with and without MCC.
                                        Non-Specific Arthropathies....
----------------------------------------------------------------------------------------------------------------
259,260...............................  Subtotal Mastectomy for               584  Breast Biopsy, Local Excision
261...................................   Malignancy *.                        585   & Other Breast Procedures
262...................................  Breast Procedures for Non-                  with and without CC/MCC.
                                         Malignancy Except Biopsy &
                                         Local Excision.
                                        Breast Biopsy & Local Excision
                                         for Non-Malignancy.
----------------------------------------------------------------------------------------------------------------
267...................................  Perianal & Pilonidal                  579  Other Skin, Subcutaneous
268...................................   Procedures.                          580   Tissue & Breast Procedures
269,270...............................  Skin, Subcutaneous Tissue &           581   with MCC, with CC, without
                                         Breast Plastic Procedures.                 CC/MCC.
                                        Other Skin, Subcutaneous
                                         Tissue & Breast Procedure.
----------------------------------------------------------------------------------------------------------------
289...................................  Parathyroid Procedures........        625  Thyroid, Parathyroid &
290...................................  Thyroid Procedures............        626   Thyroglossal Procedures with
291...................................  Thyroglossal Procedures.......        627   MCC, with CC, without CC/
                                                                                    MCC.
294...................................  Diabetes > 35.................        637  Diabetes with MCC, with CC,
295...................................  Diabetes < 35.................        638   without CC/MCC.
                                                                              639
----------------------------------------------------------------------------------------------------------------
338...................................  Testes Procedures for                 711  Testes Procedures with and
339,340...............................   Malignancy.                          712   without CC/MCC.
                                        Testes Procedures, Non-
                                         Malignancy.
----------------------------------------------------------------------------------------------------------------
342,343...............................  Circumcision..................  .........  Procedure 64.0 changed to non-
                                                                                    O.R. Cases with only this
                                                                                    procedure will go to medical
                                                                                    DRGs.
----------------------------------------------------------------------------------------------------------------
351...................................  Sterilization, Male...........        729  Other Male Reproductive
352...................................  Other Male Reproductive System        730   System Diagnoses with and
                                         Diagnoses.                                 without CC/MCC.
----------------------------------------------------------------------------------------------------------------
361...................................  Laparoscopy & Incisional Tubal        744  D&C, Conization, Laparascopy
362...................................   Interruption.                        745   & Tubal Interruption with
363...................................  Endoscopic Tubal Interruption.              and without CC/MCC.
364...................................  D&C, Conization & Radio-
                                         Implant, for Malignancy.
                                        D&C, Conization Except for
                                         Malignancy.
                                        History of Malignancy with
                                         Endoscopy.
----------------------------------------------------------------------------------------------------------------
411...................................  History of Malignancy without         843  Other Myeloproliferative
412...................................   Endoscopy.                           844   Disease or Poorly
413,414...............................  Other Myeloproliferative              845   Differentiated Neoplasm
                                         Disease or Poorly                          Diagnosis with MCC, with CC,
                                         Differentiated Neoplasm                    without CC/MCC.
                                         Diagnosis.
----------------------------------------------------------------------------------------------------------------

[[Page 24702]]

 
465...................................  Aftercare with History of             949  Aftercare with and without CC/
466...................................   Malignancy as Secondary              950   MCC.
                                         Diagnosis.
                                        Aftercare without History of
                                         Malignancy as Secondary
                                         Diagnosis.
----------------------------------------------------------------------------------------------------------------
*Codes 85.22 and 85.23 in CMS DRGs 259 and 260 were moved to proposed MS-DRG 582 and 583.

    As summarized in the Table F, the consolidation resulted in the 
formation of 335 proposed base MS-DRGs.

    Table F.--Consolidation of Current CMS DRGs Into Proposed MS-DRGs
------------------------------------------------------------------------
                                                                 Number
------------------------------------------------------------------------
Current CMS DRGs.............................................        538
Elimination of CC subgroups..................................       -114
Elimination of MCC subgroups.................................         -7
Elimination of CC complexity subgroups.......................         -5
Elimination of age 0-17 subgroups............................        -43
Consolidation due to volume or resource similarity...........        -34
New DRG......................................................         +1
Revised Base DRGs............................................        311
Newborn, maternity and error DRGs............................        +24
Base DRGs for severity subdivision...........................        335
------------------------------------------------------------------------

    The end result of the consolidation of the CMS DRGs in the proposed 
MS-DRGs was similar to the consolidation performed in the 1994 severity 
DRGs. The 1994 DRG consolidations resulted in 356 base DRGs plus 2 
error DRGs. The number of the 1994 base DRGs is different because new 
CMS DRGs have been added since 1994, the 43 age 0-17 pediatric CMS DRGs 
were not consolidated, and some of the volume shifts to outpatient care 
had not yet occurred in 1994. In the 1994 severity DRGs, 24 DRGs were 
consolidated due to volume or resource similarity. Sixteen of these 
1994 DRG consolidations are included in the 34 consolidations done in 
the 2007 consolidations. However, due to concerns expressed by our 
physician consultants, 8 of the DRG consolidations from 1994 were not 
done. For example, interstitial lung disease (DRGs 92 and 93) was not 
consolidated with simple pneumonia and pleurisy (DRGs 89, 90, 91) as 
was done in the 1994 consolidations.
(2) Categorization of Diagnoses
    We decided to establish three different levels of CC severity into 
which we would subdivide the diagnosis codes. The proposed three levels 
are MCC, CC, and non-CC. Diagnosis codes classified as MCCs reflect the 
highest level of severity. The next level of severity includes 
diagnosis codes classified as CCs. The lowest level is for non-CCs. 
Non-CCs are diagnosis codes that do not significantly affect severity 
of illness and resource use. Therefore, secondary diagnoses that are 
non-CCs do not affect the DRG assignment under either the current CMS 
DRGs or the proposed MS-DRGs.
    The categorization of diagnoses as an MCC, CC, or non-CC was 
accomplished using an iterative approach in which each diagnosis was 
evaluated to determine the extent to which its presence as a secondary 
diagnosis resulted in increased hospital resource use. In order to 
begin this iterative process, we started with an initial categorization 
of each diagnosis as an MCC, CC, or non-CC. As noted previously the 
1994 CC revision began by separating CCs into MCC and CC based on the 
AP-DRG major CCs. One way to begin this iterative process would have 
been to use the 1994 CC categorization. However, the 1994 CC 
categorization was based on FY 1992 data and ICD-9-CM diagnosis codes, 
which now are 15 years old. Since 1992, 1,897 new diagnoses codes have 
been added, and 346 diagnoses codes have been deleted. Because the 
revised CC list (explained in section II.C.2.a. of this preamble) was 
based on current ICD-9-CM codes and used recent data, we decided to 
utilize the revised CC list rather than the 1994 categorization as our 
starting point for determining whether each secondary diagnosis should 
be an MCC, a CC, or a non-CC.
    The revised CC list categorizes each diagnosis as a CC or a non-CC. 
We decided to use this list in combination with the categorization 
under the AP-DRGs and the APR DRGs. The AP-DRGs and the APR-DRGs are 
updated annually with current codes and provide a good comparison 
source to use with the revised CC list. We designated as an MCC any 
diagnosis that was a CC in the revised CC list and was an AP-DRG major 
CC and was an APR DRG default severity level 3 (major) or 4 
(extensive). We designated as a non-CC any diagnosis that was a non-CC 
in the revised CC list and was an AP-DRG non-CC and was an APR DRG 
default severity level of 1 (minor). Any diagnoses that did not meet 
either of the above two criteria was designated as a CC.
    The only exception to our approach was for diagnoses related to 
newborns, maternity, and congenital anomalies. These diagnoses are very 
low volume in the Medicare population and were not reviewed for 
purposes of creating the revised CC list. We used the APR DRGs to 
categorize these diagnoses. For newborn, obstetric, and congenital 
anomaly diagnoses, we designated the APR DRG default severity level 3 
(major) and 4 (extreme) diagnoses as an MCC, the APR-DRG default 
severity level 2 (moderate) diagnoses as a CC, and the APR DRG default 
severity 1 (minor) diagnoses as a non-CC. Table G summarizes the number 
of codes in each CC category.

              Table G.--Initial Categorization of CC Codes
------------------------------------------------------------------------
                                                               Number of
                                                                 codes
------------------------------------------------------------------------
MCC..........................................................      1,096
CC...........................................................      4,221
Non-CC.......................................................      8,232
                                                              ----------
    Total....................................................     13,549
------------------------------------------------------------------------

    This initial CC categorization of diagnosis codes was used to begin 
the iterative process of determining the proposed final CC 
categorization for each diagnosis code.
(3) Additional CC Exclusions
    For some CMS DRGs, the presence of specific secondary diagnoses 
affects the base DRG assignment. For example, in MDC 5 (Diseases and 
Disorders of the Circulatory System), the presence of an AMI code as 
the principal diagnosis or as a secondary diagnosis will cause the 
patient to be assigned to the AMI DRGs (CMS DRGs 121 through 123). 
Therefore, if the AMI code is present as

[[Page 24703]]

a secondary diagnosis, it should not be used to assign the CC category 
for a patient because it is redundant within the definition of the base 
DRG. Similarly, for MDC 24 (Multiple Significant Trauma), specific 
combinations of significant trauma as principal or secondary diagnosis 
cause the assignment to the multiple trauma DRGs (CMS DRGs 484 through 
487). Therefore, any secondary diagnosis of trauma is redundant with 
the definition of the multiple trauma DRGs and should not be used to 
determine the CC category for a patient. Any secondary diagnoses that 
are used to assign a specific proposed base MS-DRG were excluded from 
the determination of the CC category for patients assigned to that 
proposed base MS-DRG.
(4) Analysis of Secondary Diagnoses
    The 311 proposed base MS-DRGs (335 total base DRGs minus the MDC 
14, MDC 5, and error DRGs) were subdivided into three CC subgroups. 
Patients were assigned to the subgroup corresponding to the most 
extreme CC present). All but four of the proposed base MS-DRGs had 
strictly monotonically increasing average charges across the three CC 
subgroups (that is, average charges progressively increased from the 
non-CC to the CC to the MCC subgroups). The four proposed MS-DRGs that 
failed to have monotonically increasing charges all had at least one CC 
subgroup with very low volume. For example, the non-CC subgroup for the 
pancreas transplant DRG (CMS DRG 513) had only 2 cases. The overall 
statistics by CC subgroup for the 311 proposed base MS-DRG is contained 
in Table H. Patients in the MCC subgroup have average charges that are 
nearly double the average charge for patients in the CC subgroup. The 
CC subgroup with the largest number of patients is the non-CC subgroup 
with 41.1 percent of the patients.

               Table H.--Overall Statistics for Proposed MS-DRGs Excluding Those in MDCs 14 and 15
----------------------------------------------------------------------------------------------------------------
                                                                     Number of                        Average
                           CC subgroup                                 cases          Percent         charges
----------------------------------------------------------------------------------------------------------------
Major...........................................................       2,604,696            22.2         $44,246
CC..............................................................       4,293,744            36.6          24,131
Non-CC..........................................................       4,818,411            41.1          18,435
----------------------------------------------------------------------------------------------------------------

    In order to evaluate the initial assignment of secondary diagnoses 
to the three CC subclasses, we devised a system that determined the 
impact on resource use of each secondary diagnosis. For each secondary 
diagnosis, we measured the impact in resource use for the following 
three subsets of patients:
    (a) Patients with no other secondary diagnosis or with all other 
secondary diagnoses that are non-CCs.
    (b) Patients with at least one other secondary diagnosis that is a 
CC but none that is an MCC.
    (c) Patients with at least one other secondary diagnosis that is an 
MCC.
    Numerical resource impact values were assigned for each diagnosis 
as follows:

------------------------------------------------------------------------
             Value                               Meaning
------------------------------------------------------------------------
0.............................  Significantly below expected value for
                                 the non-CC subgroup.
1.............................  Approximately equal to expected value
                                 for the non-CC subgroup.
2.............................  Approximately equal to expected value
                                 for the CC subgroup.
3.............................  Approximately equal to expected value
                                 for the MCC subgroup.
4.............................  Significantly above the expected value
                                 for the MCC subgroup.
------------------------------------------------------------------------

    Each diagnosis for which Medicare data were available was evaluated 
to determine its impact on resource use and to determine the most 
appropriate CC subclass (non-CC, CC, or MCC) assignment. In order to 
make this determination, the average charge for each subset of cases 
was compared to the expected charge for cases in that subset. The 
following format was used to evaluate each diagnosis:

 
----------------------------------------------------------------------------------------------------------------
    Code           Diagnosis            Cnt1          C1          Cnt2          C2          Cnt3          C3
 
----------------------------------------------------------------------------------------------------------------

Count (Cnt) is the number of patients in each subset and C1, C2, and C3 
are a measure of the impact on resource use of patients in each of the 
subsets. The C1, C2, and C3 values are a measure of the ratio of 
average charges for patients with these conditions to the expected 
average charge across all cases. The C1 value reflects a patient with 
no other secondary diagnosis or with all other secondary diagnoses that 
are non-CCs. The C2 value reflects a patient with at least one other 
secondary diagnosis that is a CC but none that is a major CC. The C3 
value reflects a patient with at least one other secondary diagnosis 
that is a major CC. A value close to 1.0 in the C1 field would suggest 
that the code produces the same expected value as a non-CC diagnosis. 
That is, average charges for the case are similar to the expected 
average charges for that subset and the diagnosis is not expected to 
increase resource usage. A higher value in the C1 (or C2 and C3) field 
suggests more resource usage is associated with the diagnosis and an 
increased likelihood that it is more like a CC or major CC than a non-
CC. Thus, a value close to 2.0 suggests the condition is more like a CC 
than a non-CC but not as significant in resource usage as an MCC. A 
value close to 3.0 suggests the condition is expected to consume 
resources more similar to an MCC than a CC or non-CC. For example, a C1 
value of 1.8 for a secondary diagnosis means that for the subset of 
patients who have the secondary diagnosis and have either no other 
secondary diagnosis present, or all the other secondary diagnoses 
present are non-CCs, the impact on resource use of the secondary 
diagnoses is greater than the expected value for a non-CC by an amount 
equal to 80 percent of the difference between the expected value of a 
CC and a non-CC (that is, the impact on resource use of the secondary 
diagnosis is closer to a CC than a non-CC).

    Table I below shows examples of the results.

[[Page 24704]]



                       Table I.--Examples of Impact on Resource Use of Secondary Diagnoses
----------------------------------------------------------------------------------------------------------------
             Code                 Cnt1        C1       CntC2        C2        Cnt3        C3       CC subclass
----------------------------------------------------------------------------------------------------------------
401.1, Benign essential           12,308      0.955     40,113      1.715      5,297      2.384  Non-CC.
 hypertension.
530.81, Esophageal reflux....    294,673      0.986    917,058      1.639    122,076      2.302  Non-CC
560.1, Paralytic Ileus.......     10,651      1.466     87,788      2.320     51,303      3.226  CC
491.20, Obstructive chronic        7,003      1.416     32,276      2.193     13,355      3.035  CC
 bronchitis.
410.71, Subendocardial             1,657      2.245     30,226      2.778     42,862      3.232  MCC
 infarction initial episode.
518.81, Acute respiratory          5,332      2.096    118,937      2.936    223,054      3.337  MCC
 failure.
----------------------------------------------------------------------------------------------------------------

    The resource use impact reports were produced for all diagnoses 
except obstetric, newborn, and congenital anomalies (10,690 diagnoses). 
These mathematical constructs were used as guides in conjunction with 
the judgment of our clinical staff to classify each secondary diagnosis 
reviewed as an MCC, CC or non-CC. Our clinical panel reviewed the 
resource use impact reports and modified 14.9 percent of the initial CC 
subclass assignments as summarized in Table J below. The rows in the 
table are the initial CC subclass categories and the columns are the 
final CC subclass categories.

                                       Table J.--CC Subclass Modifications
----------------------------------------------------------------------------------------------------------------
                                               Final CC subclass
     Initial CC subclass      ---------------------------------------------------      Total          Percent
                                     MCC               CC             Non-CC
----------------------------------------------------------------------------------------------------------------
MCC..........................            847               62                0               909             8.5
CC...........................            542            2,579              737             3,858            36.1
Non-CC.......................              0              272            5,651             5,923            55.4
                              ----------------------------------------------------------------------------------
    Total....................          1,389            2,913            6,388            10,690  ..............
Percent......................             13.0             27.2             59.8  ..............  ..............
----------------------------------------------------------------------------------------------------------------

    Of the diagnoses initially designated as an MCC, 6.8 percent were 
made a CC (62/909), and of the diagnoses initially designated as non-
CC, 4.6 percent were made a CC (272/5,923). The major shift occurred in 
the diagnoses initially assigned to the CC subclass. Fourteen percent 
of the diagnoses initially designated as a CC were made an MCC (542/
3858), and 19.1 percent of the diagnoses initially designated a CC were 
made a non-CC (737/3,858). In determining the CC subclass assigned to a 
diagnosis, imprecise codes were, in general, not assigned to the MCC or 
CC subclass. For example, the congestive heart failure codes have the 
following CC subclass assignments:

------------------------------------------------------------------------
                   Code                        CC subclass assignment
------------------------------------------------------------------------
428.21, Acute systolic heart failure......  MCC
428.41, Acute systolic & diastolic heart    MCC
 failure.
428.43, Acute on chronic systolic heart     MCC
 failure.
428.31, Acute diastolic heart failure.....  MCC
428.33, Acute on chronic diastolic heart    MCC
 failure.
428.1, Left heart failure.................  CC
428.20, Systolic heart failure NOS........  CC
428.22, Chronic systolic heart failure....  CC
428.32, Chronic diastolic heart failure...  CC
428.40, Systolic & diastolic heart failure  CC
428.0, Congestive heart failure NOS.......  NonCC
428.9, Heart failure NOS..................  Non-CC
------------------------------------------------------------------------

    The acute heart failure codes are MCCs, and the chronic heart 
failure codes are CCs. However, Not Otherwise Specified (NOS) heart 
failure codes are non-CCs. Thus, the precise type of heart failure must 
be specified in order for an MCC or CC to be assigned.
    There are currently 13,549 ICD-9-CM diagnosis codes. The External 
Cause of Injury and Poisoning codes (E800--E999) and congenital codes 
were not included in our current CC review for the proposed MS-DRGs. We 
excluded the External Cause of Injury and Poisoning codes (E codes) 
from consideration as an MCC or a CC because they describe how an 
injury occurred, and not the exact nature of the injury. For instance, 
if a patient fell on the deck of a boat and fractured his or her skull, 
one would assign an E code to describe the fall on the boat. A separate 
diagnosis code would be assigned to describe the exact nature of any 
resulting injury such as a contusion, fractured bone, or skull fracture 
and concussion. A patient would be assigned to a severity level based 
on the exact nature of the injury and not the manner in which the 
injury occurred. Therefore, we decided not to classify any of the E 
codes as either an MCC or a CC. The congenital codes describe 
abnormalities when a baby is born. At times, a beneficiary may live 
with these congenital abnormalities for years without a problem. The 
congenital abnormalities may later lead to complications that require 
hospital admissions. Should these congenital abnormalities lead to 
medical problems that result in a hospital admission for a Medicare 
beneficiary, the exact nature of the condition being treated would also 
be assigned a code. This more precise code would be evaluated to 
determine whether or not it was an MCC or a CC. Therefore, we decided 
not to classify congenital abnormality codes as an MCC or a CC, but to 
instead use the other reported diagnosis codes that better describe the 
reason for the admission. Excluding the external cause of injury codes, 
we reviewed 10,690 diagnosis codes.
    As was done in our 1994 severity proposal, diagnoses that were 
closely associated with patient mortality were assigned different CC 
subclasses, depending on whether the patient lived or died. These 
diagnoses are:

 427.41, Ventricular fibrillation

[[Page 24705]]

 427.5, Cardiac arrest
 785.51, Cardiogenic shock
 785.59, Other shock without mention of trauma
 799.1, Respiratory arrest

    Resource use for patients with these diagnoses who were discharged 
alive was consistent with an MCC. Resource use for patients with these 
diagnoses who died was consistent with a non-CC. Further, most patients 
who died could legitimately have one of these diagnoses coded. As a 
result, these diagnoses are assigned an MCC subclass for patients who 
lived and a non-CC subclass for patients who died.
    For some secondary diagnoses assigned to the CC subclass, our 
medical consultants identified specific clinical situations in which 
the diagnosis should not be considered a CC. In such clinical 
situations, the CC exclusion list was used to exclude the secondary 
diagnosis from consideration in determining the CC subgroup essentially 
making the secondary diagnosis a non-CC. For example, primary 
cardiomyopathy (code 425.4) is designated as a CC. However, for 
patients admitted for congestive heart failure, our medical consultants 
believed that primary cardiomyopathy should be treated as a non-CC. In 
order to accomplish that, the congestive heart failure principal 
diagnoses were added to the CC exclusion list for primary 
cardiomyopathy as a secondary diagnosis.
    The list of diagnosis codes that we are proposing to classify as an 
MCC is included in Table 6J in the Addendum of this proposed rule. The 
diagnosis codes that we are proposing to classify as a CC are included 
in Table 6K in the Addendum of this proposed rule. The proposed E-
codes, which are diagnosis codes used to classify external causes of 
injury and poisoning, are not included in this list. All proposed E-
codes are designated as non-CCs under the current CMS DRG system and 
our evaluation supports this non-CC designation as appropriate.
3. Dividing Proposed MS-DRGs on the Basis of the CCs and MCCs
    In developing the proposed MS-DRGs, two of our major goals were to 
create DRGs that would more accurately reflect the severity of the 
cases assigned to them and to create groups that would have sufficient 
volume so that meaningful and stable payment weights could be 
developed. As noted above, we excluded the CMS DRGs in MDCs 14 and 15 
from consideration because these DRGs are low volume. As stated 
previously, we do not have the expertise or data to maintain the CMS 
DRGs for newborns, pediatric, and maternity patients. We continue to 
maintain MDCs 14 and 15 without modification in order to have MS-DRGs 
available for these patients in the rare instance where there is a 
Medicare beneficiary admitted for maternity or newborn care.
    In designating a proposed MS-DRG as one that will be subdivided 
into subgroups based on the presence of a CC or MCC, we developed a set 
of criteria to facilitate our decision-making process. In order to 
warrant creation of a CC or major CC subgroup within a base MS-DRG, the 
subgroup had to meet all of the following five criteria:
     A reduction in variance of charges of at least 3 percent.
     At least 5 percent of the patients in the MS-DRG fall 
within the CC or MCC subgroup.
     At least 500 cases are in the CC or MCC subgroup.
     There is at least a 20-percent difference in average 
charges between subgroups.
     There is a $4,000 difference in average charge between 
subgroups.
    Our objective in developing these criteria was to create 
homogeneous subgroups that are significantly different from one another 
in terms of resource use, that have enough volume to be meaningful, and 
that improve our ability to explain variance in resource use. These 
criteria are essentially the same criteria we used in our 1994 severity 
analysis.
    To begin our analysis, we subdivided each of the base MS-DRGs into 
three subgroups: non-CC, CC, and MCC. Each subgroup was then analyzed 
in relation to the other two subgroups using the volume, charge, and 
reduction in variance criteria. The criteria were applied in the 
following hierarchical manner:
     If a three-way subdivision met the criteria, we subdivided 
the base MS-DRG into three CC subgroups.
     If only one type of two-way subdivisions met the criteria, 
we subdivided the base MS-DRG into two CC subgroups based on the type 
of two-way subdivision that met the criteria.
     If both types of two-way subdivisions met the criteria, we 
subdivided the base MS-DRG into two CC subgroups based on the type of 
two-way subdivision with the highest R\2\ (most explanatory power to 
explain the difference in average charges).
     Otherwise, we did not subdivide the base MS-DRG into CC 
subgroups.
    For any given base MS-DRG, our evaluation in some cases showed that 
a subdivision between a non-CC and a combined CC/MCC subgroup was all 
that was warranted (that is, there was not a great enough difference 
between the CC and MCC subgroups to justify separate CC and MCC 
subgroups). Conversely, in some cases, even though an MCC subgroup was 
warranted, there was not a sufficient difference between the non-CC and 
CC subgroups to justify separate non-CC and CC subgroups.
    Based on this methodology, a base MS-DRG may be subdivided 
according to the following three alternatives, rather than the current 
``with CC'' and ``without CC'' division.
     DRGs with three subgroups (MCC, CC, and non-CC).
     DRGs with two subgroups consisting of an MCC subgroup but 
with the CC and non-CC subgroups combined. We refer to these groups as 
``with MCC'' and ``without MCC.''
     DRGs with two subgroups consisting of a non-CC subgroup 
but with the CC and MCC subgroups combined. We refer to these two 
groups as ``with CC/MCC'' and ``without CC/MCC.''
    As a result of the application of these criteria, 745 proposed MS-
DRGs were created as shown in the following table.

                    Table K.--Number of CC Subgroups
------------------------------------------------------------------------
                                             Number of       Number of
                Subgroups                  proposed base   proposed MS-
                                              MS-DRGs          DRGs
------------------------------------------------------------------------
No Subgroups............................              53              53
Three subgroups.........................             152             456
Two subgroups: major CC and CC; non-CC..              63             126
Two subgroups: non-CC and CC; major CC..              43              86
Subtotal................................             311             721
MDC 14..................................              22              22

[[Page 24706]]

 
Error DRGs..............................               2               2
                                         -------------------------------
    Total...............................             335             745
------------------------------------------------------------------------

    The 745 proposed MS-DRGs represent an increase over the 652 DRGs 
created in our 1994 CC revision analysis. The increase in the number of 
DRGs is primarily the result of an increase in the number of proposed 
base MS-DRGs that are subdivided into three CC subgroups. The 
distribution of patients across the different types of CC subdivisions 
is contained in Table L below. The table shows that 51.7 percent of the 
patients are assigned to base MS-DRGs with three CC subgroups, and only 
11.8 percent of the patients are assigned to base MS-DRGs with no CC 
subgroups.

      Table L.--Distribution of Patients by Type of CC Subdivision
------------------------------------------------------------------------
                CC subdivision                     Count       Percent
------------------------------------------------------------------------
None..........................................    1,382,810         11.8
(MCC and CC), Non-CC..........................      629,639          5.4
MCC, (CC and Non-CC)..........................    3,650,321         31.2
MCC, CC, and Non-CC...........................    6,054,081         51.7
------------------------------------------------------------------------

    Using Medicare charge data (without applying any criteria to remove 
statistical outlier cases), the reduction in variance (R\2\) was 
computed for current CMS DRGs, the MS-DRGs with all 311 base MS-DRGs 
subdivided into 3 CC subgroups, and the MS-DRGs collapsed into 745 
DRGs. Table L below shows that the R\2\ for the proposed MS-DRGs with 
all 311 base MS-DRGs subdivided into 3 CC subgroups (957 DRGs composed 
of 311 base MS-DRGs subdivided into 3 CC subgroups plus an additional 
22 MDC 14 and MDC 15 DRGs as well as 2 error DRGs) is 10.62 percent 
higher than the current CMS DRGs. Collapsing the 957 proposed MS-DRGs 
down to 745 proposed MS-DRGs lowers this increase in R\2\ slightly to 
9.41 percent. Although adopting a 3-way split for each base MS-DRG 
would produce a DRG system with higher explanatory power, the 957 MS-
DRGs would not meet the criteria we specified above for subdividing 
each base DRG. The criteria we specified above would create a monotonic 
DRG system. We believe that the value of having a monotonic DRG system 
outweighs the slight decrease in explanatory power. For this reason, we 
are proposing to adopt the 745 MS-DRGs.

         Table M.--Explanatory Power (R\2\) for Proposed MS-DRGs
------------------------------------------------------------------------
                                                                Percent
                                                       R\2\      change
------------------------------------------------------------------------
Current CMS DRG...................................      36.19  .........
2007 CMS Severity DRGs with 3 CC Subgroups........      40.03      10.62
2007 CMS Severity DRGs Collapsed to 714 DRGs......      39.59       9.41
------------------------------------------------------------------------

4. Conclusion
    We believe the proposed MS-DRGs represent a substantial improvement 
over the current CMS DRGs in their ability to differentiate cases based 
on severity of illness and resource consumption. As developed, the 
proposed MS-DRGs increase the number of DRGs by 207, while maintaining 
the reasonable patient volume in each DRG. The proposed MS-DRGs 
increase the explanation of variance in hospital resource use relative 
to the current CMS DRGs by 9.41 percent. Further, the data shown below 
in Table N and Table O illustrate how assignment of cases to different 
severity of illness subclasses improves in the proposed MS-DRGs 
relative to the CMS DRGs.

                Table N.--Overall Statistics for CMS DRGs
------------------------------------------------------------------------
                                                                Average
           CC subclass--Current CMS DRG              Percent    charges
------------------------------------------------------------------------
One or more CCs...................................      77.66    $24,538
Non-CC............................................      22.34     14,795
------------------------------------------------------------------------


            Table O.--Overall Statistics for Proposed MS-DRGs
------------------------------------------------------------------------
                                        Number of               Average
             CC subgroup                  cases      Percent    charges
------------------------------------------------------------------------
MCC..................................    2,607,351       22.2    $44,219
CC...................................    4,298,362       36.6     24,115
Non-CC...............................    4,826,980       41.1     18,416
------------------------------------------------------------------------

    Under the current CMS DRGs, 78 percent of cases are assigned to the 
highest severity levels (CC) and the remaining 22 percent are assigned 
to the lowest severity level (non-CC). Applying the three severity 
subclasses to FY 2006 data would result in approximately 22 percent of 
patients being assigned to the severity subgroup with the highest level 
of severity (MCC), 41 percent being assigned to the lowest severity 
subclass (non-CC), and the remaining 37 percent being assigned to the 
middle severity subclass (CC). Adding the new MCC subgroup greatly 
enhances our ability to identify and reimburse hospitals for treating 
patients with high levels of severity. As Table N above shows, the

[[Page 24707]]

new subgroups also have significantly different resource requirements. 
The MCC subgroup contains patients with average charges almost twice as 
large as for those in the CC group ($44,219 compared to $24,115).
    In addition to resulting in improvements in the DRG system's 
recognition of severity of illness, we believe the proposed MS-DRGs are 
responsive to the public comments that were made on last year's IPPS 
proposed rule with respect to how we should undertake further DRG 
reform. In the FY 2007 IPPS final rule, we identified three major 
concerns in the public comments about our proposed adoption of CS DRGs:
    We received comments after the FY 2007 IPPS final rule suggesting 
that further adjustments are needed to the proposed DRG system. The 
commenters believed that the CS DRGs did not incorporate many of the 
changes to the DRG assignments that have been made over the year to the 
CMS DRGs. There was significant interest in the public comments in 
either revising the CS DRGs to reflect these changes or using the CMS 
DRGs at the starting point to better recognize severity.
    We believe that the proposed MS-DRGs discussed in this proposed 
rule are responsive to these suggestions. The proposed MS-DRGs use the 
CMS DRGs as the starting point for revising the DRGs to better 
recognize resource complexity and severity of illness. We are generally 
retaining all of the refinements and improvements that have been made 
to the base DRGs over the years that recognize the significant 
advancements in medical technology and changes to medical practice. At 
the same time, the proposed MS-DRGs greatly improve our ability to 
identify groups of patients with varying levels of severity. They 
retain all of the improvements made to the DRGs over the years, while 
providing a more equitable basis for hospital payment.
    We received many comments about the potential use of a proprietary 
DRG system. The comments about the CS DRGs raised compelling issues 
about the potential government use of a proprietary system including 
concerns about the availability, price, and transparency of the source 
code, logic and documentation of the DRG system. The commenters noted 
that CMS makes available these resources in the public domain for 
purchase through the National Technical Information Service at nominal 
fees to cover costs. The commenters urged CMS not to adopt a 
proprietary DRG system that would not be available on the same terms as 
the current CMS DRGs.
    There are no proprietary issues associated with the proposed MS-
DRGs in this proposed rule. The proposed MS-DRGs would be available on 
the same terms as the current CMS DRGs through the National Technical 
Information Service.
    We also received other comments concerning the use of CS DRGs. The 
commenters stated that no alternatives to CS DRGs had been evaluated. 
The commenters suggested that alternative DRG systems can better 
recognize severity than the CS DRGs and should be evaluated before CMS 
decides which system to adopt.
    We currently have a contract with the RAND Corporation to evaluate 
several alternative DRG systems. We believe it is premature to propose 
adopting one of the systems as RAND has not yet completed its 
evaluation. However, we believe the proposed MS-DRGs should be part of 
this process and have asked RAND to evaluate the proposed MS-DRGs with 
other DRG products that have been submitted for review. Although we are 
proposing to adopt the MS-DRGs for FY 2008, this decision would not 
preclude us from adopting any of the systems being evaluated by RAND 
for FY 2009.
    As indicated above, we believe the proposed MS-DRGs offer 
significant improvements to the DRG system without many of the 
liabilities the public commenters identified with the CS DRGs. Thus, we 
believe the proposed MS-DRGs offer significant improvements in 
recognition of severity of illness and complexity of resources and are 
proposing to adopt them for FY 2008. However, we are continuing our 
evaluation of alternative DRG systems that can better recognize 
severity of illness and resource consumption and have submitted the 
proposed MS-DRGs to RAND for further evaluation.
5. Impact of the Proposed MS-DRGs
    Unlike the CS DRGs we proposed last year for FY 2008, the payment 
impacts from the MS-DRGs we are proposing to adopt this year would 
largely be redistributive within each base MS-DRG. Such a result occurs 
because we collapse the current CC/non-CC, age and other distinctions 
that exist in the CMS DRGs and redivide them based on MCCs, CCs, and 
non-CCs. Thus, within each proposed base MS-DRG, some cases will be 
paid more and some less, but the base MS-DRGs are retained so there is 
no redistribution between types of cases as would have occurred under 
the proposed CS DRGs. We encourage readers to review Table 5 in the 
Addendum to this proposed rule for a list of the proposed MS-DRGs and 
the proposed respective relative weight from the revisions we are 
proposing to better recognize severity of illness to better understand 
how payment for cases within each base MS-DRG will be affected.
    As indicated above, all of the severity DRG systems being evaluated 
by RAND can be expected to result in similar redistributions in case-
mix among hospitals. The payment models used by RAND and CMS (and RTI 
as well) all assume static utilization. That is, payment impact models 
simulate the effects of a change in policy, assuming no change to 
Medicare utilization. Any system adopted to better recognize severity 
of illness with a budget neutrality constraint will result in case-mix 
changes that can be expected to benefit urban hospitals at the expense 
of rural hospitals. This impact occurs because patients treated in 
urban hospitals are generally more severely ill than patients in rural 
hospitals and the CMS DRGs are not currently recognizing the full 
extent of these differences. Similarly, there will be differential 
impacts among other categories of hospitals (for example, teaching, 
disproportionate share, large urban, and other urban hospitals) 
depending on the mix of cases that each hospital treats. The impact of 
the proposed MS-DRGs can be expected to have similar effects on case-
mix as the DRG systems being analyzed by RAND. In addition, we believe 
that it is important to note that the MS-DRGs are proposed to be 
adopted for FY 2008 at the same time that we are phasing in cost 
weights. In the FY 2007 IPPS final rule, we adopted cost weights over a 
3-year transition period in \1/3\ increments. Thus, the full impact of 
adopting cost weights will not be incorporated into IPPS payments until 
FY 2009. Nevertheless, we believe it is important to consider together 
the effect on case-mix of the fully phased-in cost weights and proposed 
MS-DRGs to get a complete understanding of how IPPS payment reforms 
would affect case-mix for different categories of hospitals from FY 
2007 through FY 2009. For instance, using cost weights are estimated to 
increase payments to rural hospitals (see 71 FR 47917). In FY 2007, we 
are paying hospitals using a blend of \1/3\ cost and \2/3\ charge 
relative weights. In FY 2008, we will pay hospitals using a blend of 
\2/3\ cost and \1/3\ charge relative weights. In FY 2009, we will pay 
hospitals using 100 percent cost relative weights. Therefore, there 
will likely be some additional increases in payments to rural hospitals 
from the final year of the transition to fully implemented cost weights 
that are not

[[Page 24708]]

illustrated in the table in the impact section of this proposed rule.
6. Changes to Case-Mix Index (CMI) From the Proposed MS-DRGs
    After the 1983 implementation of the IPPS DRG classification 
system, CMS observed unanticipated growth in inpatient hospital case-
mix (the average relative weight of all inpatient hospital cases), 
which we use as a proxy measurement for severity of illness. We had 
projected the rate of growth in case-mix for the period 1981 to 1984 to 
be 3.4 percent. The realized rate of growth during this period, which 
included the introduction of the IPPS, was 8.4 percent, a variance in 
excess of 1.6 percent per year. The unexpected growth in payments was 
due to increases in the hospital case-mix index (CMI) beyond the 
previously projected trend. Hospitals' CMI values measure the expected 
treatment cost of the mix of patients treated by a particular hospital. 
There are three factors that determine changes in a hospital's CMI:
    (a) Admitting and treating a more resource intensive patient-mix 
(due, for example, to technical changes that allow treatment of 
previously untreatable conditions and/or an aging population);
    (b) Providing services (such as higher cost surgical treatments, 
medical devices, and imaging services) on an inpatient basis that 
previously were more commonly furnished in an outpatient setting; and
    (c) Changes in documentation (more complete medical records) and 
coding practice (more accurate and complete coding of the information 
contained in the medical record).
    We note that changes in patient-mix and medical practice signal 
real changes in underlying resource utilization and cost of treatment. 
While these changes may have occurred in response to incentives from 
IPPS policies, they represent real changes in resource needs. In 
contrast, changes in CMI as a result of improved documentation and 
coding do not represent real increases in underlying resource demands. 
For the implementation of the IPPS in 1983, improved documentation and 
coding were found to be the primary cause in the underprojection of CMI 
increases, accounting for as much as 2 percent in the annual rate of 
CMI growth observed post-PPS.\2\
---------------------------------------------------------------------------

    \2\ Carter, Grace M. and Ginsburg, Paul: The Medicare Case Mix 
Index Increase, Medical Practice Changes, Aging and DRG Creep, Rand, 
1985.
---------------------------------------------------------------------------

    The Medicare Trustees Technical Review Panel \3\ has previously 
determined the annual measured change in CMI for inpatient hospital 
services to oscillate around an underlying real trend of 1 percent 
annual growth. In 1991 the Medicare specific trend in real CMI growth 
was found in a then-HCFA funded study \4\ to be within a range of 1 to 
1.4 percent. In the annual study conducted by CMS, there has been no 
evidence to support a real case-mix increase in excess of the annually 
projected 1 percent upper bound in the period. MedPAC findings have 
echoed this with its recent study of real case-mix change finding 
growth rates for years 2002, 2003, and 2004 of 1 percent, 0.6 percent, 
and 0.4 percent, respectively.\5\
---------------------------------------------------------------------------

    \3\ Review of Assumptions and Methods of the Medicare Trustees' 
Financial Projections; Technical Review Panel on the Medicare 
Trustees Reports, December 2000.
    \4\ ``Has DRG Creep Crept Up? Decomposing the Case Mix Index 
Change Between 1987 and 1988''; Carter, Newhouse, Relles ; R-4098-
HCFA/ProPAC (1991).
    \5\ Medicare Payment Advisory Commission: Report to the 
Congress, March 2006 (p. 52).
---------------------------------------------------------------------------

    We believe that adoption of the MS-RGs proposed in this proposed 
rule would create a risk of increased aggregate levels of payment as a 
result of increased documentation and coding. MedPAC notes that 
``refinements in DRG definitions have sometimes led to substantial 
unwarranted increase in payments to hospitals, reflecting more complete 
reporting of patients' diagnoses and procedures.'' MedPAC further notes 
that ``refinements to the DRG definitions and weights would 
substantially strengthen providers' incentives to accurately report 
patients' comorbidities and complications.'' To address this issue, 
MedPAC recommended that the Secretary ``project the likely effect of 
reporting improvements on total payments and make an offsetting 
adjustment to the national average base payment amounts.'' \6\
---------------------------------------------------------------------------

    \6\ Medicare Payment Advisory Commission: Report to Congress on 
Physician-Owned Specialty Hospitals, March 2005, p. 42.
---------------------------------------------------------------------------

    The Secretary has broad discretion under section 1886(d)(3)(A)(vi) 
of the Act to adjust the standardized amount so as to eliminate the 
effect of changes in coding or classification of discharges that do not 
reflect real changes in case-mix. While we modeled the changes to the 
DRG system and relative weights to ensure budget neutrality, we are 
concerned that the large increase in the number of DRGs will provide 
opportunities for hospitals to do more accurate documentation and 
coding of information contained in the medical record. Coding that has 
no effect on payment under the current CMS DRGs may result in a case 
being assigned to a higher paid DRG under the proposed MS-DRGs. Thus, 
more accurate and complete documentation and coding may occur because 
it will result in higher payments under the proposed MS-DRGs. We 
believe the potential for more accuate and complete documentation and 
coding will apply equally under the acute IPPS as well as under the 
LTCH PPS because the same DRGs are used for both payment systems. Thus, 
the analysis below will apply to both the IPPS and the LTCH PPS.
    CMS in the past has adjusted standardized amounts under the IRF PPS 
to account for case-mix increases due to improvements in documentation 
and coding. In 2004, RAND \7\ published a technical report as part of 
the followup to the implementation of the IRF PPS. The initial weights 
used within the IRF PPS were based on a mix of CY 1999 and CY 1998 
data. The study reviewed the changes between this base data set and the 
IRF PPS implementation year of 2002. The report found that the weight 
per discharge for IRFs had grown by 3.4 percent between the CY 1999 
data set and the CY 2002 data set. In a detailed analysis of both 
statistical patterns in acute stay records and directly measured coding 
behaviors, RAND found that the level of case-mix increase associated 
with documentation and coding-induced changes in the transition year 
ranged between 1.9 and 5.8 percent, with the upper end of the estimate 
associated with real declines in resource use. (We note that RAND 
revised its report in late 2005 to reflect an upper bound of 5.9 
percent, instead of the 5.8 percent that we reported in the FY 2006 IRF 
PPS proposed and final rules.)
---------------------------------------------------------------------------

    \7\ Carter, Paddock: Preliminary Analyses of Changes in Coding 
and Case Mix Under the Inpatient Rehabilitation Facility Prospective 
Payment System, RAND, 2004.
---------------------------------------------------------------------------

    We used the results of this analysis to justify a 1.9 percent 
adjustment to payment rates for IRFs in FY 2006 (70 FR 47904) and a 2.6 
percent adjustment to payment rates for IRFs in FY 2007 (71 FR 48370), 
for a combined total adjustment of 4.5 percent. The implementation year 
was marked by the transitioning of hospitals to the IRF PPS payment 
based on cost reports beginning January 1, 2002, and staggered to 
October 1, 2002. A combination of increased familiarity with the system 
by providers and the staggered transition could mean that documentation 
and coding-induced case-mix change continued as hospitals experienced 
ongoing changes in the early years of the IRF PPS and as the

[[Page 24709]]

incentives within the system were more widely recognized. We also 
recognize that significant changes in IRF patient populations may be 
occurring as a result of recent regulatory changes, such as the phase-
in of the 75 percent rule compliance percentage. We intend to continue 
analyzing changes in coding and case-mix closely, using the most 
current available data, as part of our ongoing monitoring of the IRF 
PPS and, based on this analysis, we intend to propose additional 
payment refinements for IRFs in the future as the analysis indicates 
such adjustments are warranted.
    Furthermore, as part of our analysis of this issue, we considered 
the recent experience of the State of Maryland with adopting the APR 
DRG system. Maryland introduced APR DRGs for payment for three teaching 
hospitals in 2000. Between State fiscal years (SFYs) 2001 and 2005,\8\ 
the remaining hospitals continued to be paid using modified CMS DRGs. 
In June 2004, the remaining hospitals were notified that Maryland would 
expand the use of APR DRGs throughout its all payer charge-per-case 
system beginning in July 2005. Hospitals in Maryland improved coding 
and documentation in response to the adoption of APR DRGs. As a result 
of this improved documentation and coding, reported CMI increased at a 
greater rate than real CMI. Given the similarity between coding 
incentives using the APR DRGs in Maryland and the MS-DRGs that are 
being proposed for Medicare, we analyzed Maryland data to develop an 
adjustment for improved documentation and coding.
---------------------------------------------------------------------------

    \8\ Maryland uses a July 1 to June 30 State fiscal year. Prior 
to FY 2003, Maryland had a 6-month lag in the data used to calculate 
the hospital base case-mix index and case-mix change. Maryland used 
12 months data ending December even though the hospitals' rate year 
was July 1 to June 30. In FY 2003, Maryland moved to what it called 
``Real Time Case-Mix'' and started using 12 months data ending June 
30 to calculate case-mix index and case-mix change for a rate year 
beginning July 1.
---------------------------------------------------------------------------

    For the Maryland analysis, we assume that, in SFY 2005, those 
hospitals not already being paid under the APR DRG system began acting 
as if the transition to the new DRG logic had already taken place. This 
assumption is supported by the following facts: (a) Maryland hospitals 
were reporting to the Health Services and Cost Review Commission 
(HSCRC), Maryland's governing body of its all-payer ratesetting system) 
using the APR DRG GROUPER in 2005; (b) hospitals were provided training 
in coding under the APR DRG GROUPER; (c) hospitals had access to 
reports based on APR DRG logic; and (d) hospitals were given large 
amounts of feedback as to their performance under the GROUPER by the 
HSCRC relative to peer hospitals.
    The incentives for Maryland hospitals are to code as completely and 
accurately as possible because, beginning in July 2005, all Maryland 
hospitals were paid using APR DRGs. SFY 2005 was an important year in 
Maryland, as it marked the beginning of the 2-year period of transition 
after which a hospital's revenues were reduced if coding was not as 
complete as a peer hospital. Under the current CMS DRGs, each secondary 
diagnosis code is recognized as either a CC or non-CC. Hospitals in 
Maryland and nationally for Medicare only needed to code one secondary 
diagnosis as a CC when paid using CMS DRGs for the patient to be 
assigned to a higher weighted DRG split based on the presence or 
absence of a CC. Under the APR DRGs, each secondary diagnosis is 
designated as minor, moderate, major, or extreme. Under the proposed 
MS-DRGs, each secondary diagnosis is designated as a non-CC, CC, or 
MCC. Hospitals in Maryland have incentives under the APR DRGs to code 
until a case is assigned to the highest of the four severity levels 
within a base DRG. Under the proposed MS-DRGs, hospitals will have 
incentives to code until a case is assigned to one of up to three 
severity levels within a base DRG. Although the APR DRGs and the 
proposed MS-DRGs may be different, we believe that hospitals have the 
same incentive under both systems to code as completely as possible. 
For this reason, we believe that the Maryland experience is a 
reasonable basis for projecting behavioral changes in the wider 
national hospital population for the first 2 years of the MS-DRGs.
    We believe the analysis presented below provides a reasonable 
analysis of the potential growth in CMI due to improved documentation 
and coding. In addition to the similarity between coding incentives 
under the proposed MS-DRGs and the APR DRGs, we note that Maryland is 
an all-payer State; therefore, hospitals are paid by all third party 
payers--not just the State's Medicaid program--using the APR DRGs. 
Coding has been very important for each hospital's overall revenue for 
many years, and the incentives are uniform across all third party 
payers. The transition to APR DRGs was known well in advance of the 
actual date and, as stated above, hospitals were provided training in 
coding under the APR DRGs. It is reasonable to expect that hospitals' 
experience with improved documentation and coding will occur over a 
period of at least 2 years. Thus, the experience in Maryland may be 
similar to expectations for case-mix growth for the nation as a whole. 
Finally, in reviewing the results from Maryland, we note that three 
large teaching hospitals began using APR DRGs prior to SFY 2005. These 
facilities generally treat a wider variety of patients with higher 
acuity that gives them a greater potential for increasing coding under 
the APR DRG system than other hospitals throughout Maryland. Because 
these hospitals were paid using the APR DRGs earlier than other 
Maryland hospitals, we believe data for them need to be analyzed from 
an earlier time period. However, based on the consultations with the 
HSCRC, we believe there were special issues with one of these hospitals 
that may have made its case-mix growth during the early years of the 
transition to the APR DRGs atypical of the other teaching hospitals.\9\ 
Therefore, we did not separately analyze the data for this hospital 
from the earlier time period and, as stated below, included its data 
with the rest of Maryland hospitals.
---------------------------------------------------------------------------

    \9\ The HSCRC informed us that it began using APR DRGs for this 
hospital to calculate the CMI and case-mix change to set the 
hospital's charge per case target (CPC) that is used in Maryland's 
all-payer ratesetting system for payment. However the HSCRC also 
compared the reasonableness of hospital rates and costs for this 
hospital relative to peer institutions using modified CMS DRGs to 
calculate CMI and case-mix change. This use of dual systems to 
calculate CMI and case-mix change made it difficult for the hospital 
to code aggressively in the first few years of using APR DRGs.
---------------------------------------------------------------------------

    As part of its contract with CMS, 3M Health Information Systems 
reviewed the Maryland data in the context of our proposed changes to 
adopt MS-DRGs. 3M grouped Medicare cases in Maryland through both the 
CMS DRGs Version 24.0 and the MS-DRGs that we are proposing to adopt 
for FY 2008. At our request, 3M deleted two of the three early 
transition hospitals from the data. It compared the results of the 
observed growth in case-mix from these data to the same process applied 
to Medicare data, excluding Maryland hospitals.
    The MedPAR data file for Federal fiscal year (FFY) 2006 (October 
2005 through September 2006) was used to create relative weights for 
both CMS DRG Version 24.0 and the proposed MS-DRGs. The MedPAR data 
file contained 12,794,280 records. In constructing the weights, the 
following edits were used:
     Cases with zero covered charges or length of stay were 
excluded.
     Cases with length of stay greater than 2 years were 
excluded.
     Only hospitals contained in the impact file for the FY 
2007 IPPS final rule were included.

[[Page 24710]]

    The latter criterion excluded providers reimbursed outside of the 
IPPS, including Maryland hospitals, from the weight calculation. 3M 
employed standardized charge-based relative weights developed in 
accordance with the CMS methodology. Cost-based weights were not used 
and no adjustment to the charge weights was made for application of CMS 
transfer and postacute care transfer payment policy.
    3M further grouped 2 years of MedPAR data from FY 2004 and FY 2005, 
using CMS DRG Version 24.0 and the proposed MS-DRGs for hospitals 
nationally. Using 2 years of MedPAR data with one version of each DRG 
system further required 3M to make adjustments to the data to reflect 
revisions to ICD-9-CM codes that are made each year. MedPAR data for 
Maryland IPPS acute care providers within the IPPS data set were 
similarly assigned to the proposed MS-DRGs and CMS DRGs for FYs 2004 
through 2006.
    Each Maryland record, exclusive of the two early transition 
teaching hospitals for the 3 observed years (SFY 2004 to SFY 2006), was 
assigned to a proposed MS-DRG based on the ICD-9-CM codes the hospital 
submitted. The same results were obtained from data at the national 
level using the proposed MS-DRGs. Further, we obtained data from the 
HSCRC showing the weighted average increase in case-mix for calendar 
years 2001 to 2003 for the two large academic medical centers that 
began an early transition to the APR DRGs. In addition, we also 
obtained case-mix increases under the CMS DRGs for FYs 2004 through 
2006. The Medicare Actuary examined the data below:

    Table Q.--Maryland and National Data Used for Case-Mix Adjustment
                                Analysis
------------------------------------------------------------------------
                                     FY 2004 to  FY 2005 to   FY 2004 to
                                        2005        2006         2006
------------------------------------------------------------------------
Rest of Maryland MS-DRG CMI [Delta]       2.30%       2.57%        4.93%
                                     ..........  ..........   CY 2000 to
                                                               FY 2003
Early Transition Hospitals.........         4.4         6.7         11.4
National MS-DRG CMI [Delta]........        0.47        2.65         3.13
National CMS DRG CMI [Delta].......       -0.04        1.20         1.16
Blend of MS-DRG & CMS DRG [Delta]    ..........  ..........         1.68
 using 0.47 Percent for 2005 and
 1.2 Percent for 2006..............
Difference between Maryland Early    ..........  ..........         9.58
 Transition Hospitals and National
 Data..............................
Difference between Rest of Maryland  ..........  ..........         3.20
 and National Data.................
Medicare Actuary Estimate (75%/25%)  ..........  ..........          4.8
 between Early Transition and Rest
 of Maryland.......................
------------------------------------------------------------------------

    The data above show that case-mix for hospitals increased by 4.93 
percent from SFYs 2004 to 2006, during which Maryland adopted the APR 
DRGs for most hospitals. Case-mix for the two large teaching hospitals 
that were paid using the APR DRGs earlier than other hospitals in the 
State increased by 11.4 percent from SFYs 2001 to 2003. The weighted 
average increase in Maryland from these two categories of hospitals is 
5.58 percent. Case-mix using the proposed MS-DRGs would have increased 
0.47 percent in FY 2005 and 2.65 percent in FY 2006. Nationally, 
Medicare case-mix using the CMS DRGs decreased by 0.04 percent in FY 
2005 and increased by 1.2 percent in FY 2006. The Actuary calculated a 
Medicare case-mix increase nationally over 2 years using a blend of 
these data from proposed MS-DRGs for FY 2005 and national Medicare data 
for FY 2006 from the CMS DRGs. The Actuary did not use either the -0.04 
percent for the CMS DRGs or the 2.65 percent for the proposed MS-DRGs 
to create this blended case-mix because these figures appeared atypical 
to national trends. Therefore, the Actuary dropped one atypically high 
and low number from each of the 2 years of data and calculated an 
average increase of 1.68 percent from FY 2004 to FY 2006. These data 
demonstrate that the measure of average CMI for Medicare cases is 
growing more rapidly within Maryland than nationally. Case-mix for the 
Maryland teaching hospitals and the rest of Maryland increased 9.58 
percent and 3.20 percent more, respectively, than the national average 
over 2 years, suggesting that improved documentation and coding lead to 
perceived, but not real, changes in case-mix.
    The Actuary noted that the case-mix increase in Maryland for two 
large teaching hospitals over a 2-year period was much higher in the 
early years of the APR DRGs than other Maryland hospitals (11.4 percent 
compared to 4.93 percent for the rest of Maryland). Further, teaching 
hospitals generally treat cases with higher acuity than other hospitals 
and have more opportunity to improve coding and documentation to 
increase case-mix than other hospitals. Teaching hospitals also 
represent a higher proportion of national Medicare data than they do of 
the data in Maryland. The two early transition teaching hospitals in 
Maryland account for approximately 10 percent of the Medicare 
discharges in Maryland. Nationally, teaching hospitals account for 
approximately 50 percent of Medicare discharges. Therefore, the Actuary 
believes that the teaching hospitals should be given a higher weight in 
the national data than they represent in Maryland. However, like other 
hospitals, teaching hospitals vary in size and patient-mix and not all 
have the same opportunity to improve documentation and coding. 
Therefore, we believe the weight given to teaching hospitals should be 
higher than the 10 percent for the two early transition hospitals in 
Maryland but lower than the 50 percent of discharges that they account 
for in Maryland. The Actuary gave a weight of 25 percent for teaching 
hospitals and 75 percent for the rest of Maryland to the excess growth 
in case-mix over the national average and estimates that an adjustment 
of 4.8 percent will be necessary to maintain budget neutrality for the 
transition to the MS-DRGs. This analyis reflects our current estimate 
of the necessary adjustment needed to maintain budget neutrality for 
improvements in documentation and coding that lead to increases in 
case-mix. Consistent with the statute, we will compare the actual 
increase in case-mix due to documentation and coding to our projection 
once we have actual data to revise the Actuary's estimate and the 
adjustment we make to the standardized amounts.
    Based on the Actuary's analysis, using the Secretary's authority 
under section 1886(d)(3)(A)(vi) of the Act to adjust the standardized 
amount to eliminate the effect of changes in coding or classification 
of discharges that do not reflect real changes in case-mix, we are 
proposing to reduce the IPPS

[[Page 24711]]

standardized amounts by 2.4 percent each year for FY 2008 and FY 2009. 
We are considering proposing a 4.8 percent adjustment for FY 2008. 
However, we believe it would be appropriate to provide a transition 
because we would be making a significant adjustment to the standardized 
amounts. We are interested in public comments on whether we should 
apply the proposed adjustment in a single year, over 2 years, or in 
different increments than \1/2\ of the adjustment each year. Section 
1886(d)(3)(A)(vi) of the Act further gives the Secretary authority to 
revisit adjustments to the standardized amounts for changes in coding 
or classification of discharges that were based on estimates in a 
future year. Consistent with the statute, we will compare the actual 
increase in case-mix due to documentation and coding to our projection 
once we have actual data for FY 2008 and FY 2009 for the FY 2010 and FY 
2011 IPPS rules. At that time, if necessary, we may make a further 
adjustment to the standardized amounts to account for the difference 
between our projection and actual data.
    Under section 123(a)(1) of Pub. L. 105-33, as amended by section 
307(b) of Pub. L. 106-554, we are also proposing to adjust the DRG 
relative weights that are used for the LTCH PPS by -2.4 percent (0.976) 
in FYs 2008 and 2009 to account for the anticipated increase in case 
mix from improved documentation and coding. This proposed budget 
neutrality adjustment is necessary to ensure that estimated aggregate 
LTCH PPS payments would be neither greater than nor less than the 
estimated aggregate LTCH PPS payments that would have been made without 
the proposed LTC-DRG reclassification and update of the relative 
weights. As discussed earlier with regards to the IPPS, we have 
estimated that a 2.4 percent adjustment is needed to maintain budget 
neutrality. We believe an adjustment of at least 2.4 percent for both 
FYs 2008 and 2009 is appropriate under the LTCH PPS because LTCHs have 
an average inpatient length of stay greater than 25 days and due to the 
comorbidities of these patients, LTCHs will have a significantly 
increased opportunity to better code for these paitents under the 
proposed MS-LTC-DRG system. In the LTCH proposed rule (72 FR 4793) for 
rate year (RY) 2008, we proposed to update the LTCH standardized 
amounts by 0.71 percent. The proposed changes to the LTCH standardized 
amounts will be effective on July 1. However, the proposed changes to 
adopt MS-LTC-DRGs for LTCHs would not be effective until October 1 if 
finalized. Because changes to the LTCH standardized amounts for RY 2008 
are already being set through a separate rulemaking process and are 
effective on July 1 instead of October 1, we decided that the 
adjustment for increases in case mix due to improvements and 
documentation and coding should be applied to the LTCH relative weights 
rather than the standardized amounts.
7. Effect of the Proposed MS-DRGs on the Outlier Threshold
    To qualify for outlier payments, a case must have costs greater 
than Medicare's payment rate for the case plus a ``fixed loss'' or cost 
threshold. The statute requires that the Secretary set the cost 
threshold so that outlier payments for any year are projected to be not 
less than 5 percent or more than 6 percent of total operating DRG 
payments plus outlier payments. The Secretary is required by statute to 
reduce the average standardized amount by a factor to account for the 
estimated proportion of total DRG payments made to outlier cases. 
Historically, the Secretary has set the cost threshold so that 5.1 
percent of estimated IPPS payments are paid as outliers. The FY 2007 
cost outlier threshold is $24,485. Therefore, for any given case, a 
hospital's charge adjusted to cost by its hospital-specific CCR must 
exceed Medicare's DRG payment by $24,485 for the case to receive cost 
outlier payments.
    Adoption of the proposed MS-DRGs will have an effect on calculation 
of the outlier threshold. For this proposed rule, we analyzed how the 
outlier threshold would be affected by adopting the proposed MS-DRGs. 
Using FY 2005 MedPAR data, we have simulated the effect of the proposed 
MS-DRGs on the outlier threshold. By increasing the number of DRGs from 
538 to 745 to better recognize severity of illness, the proposed MS-
DRGs would be providing increased payment that better recognizes 
complexity and severity of illness for cases that are currently paid as 
outliers. That is, many cases that are high-cost outlier cases under 
the current CMS DRG system would be paid using an MCC DRG under the 
proposed MS-DRGs and could potentially be paid as nonoutlier cases. For 
this reason, we expected the proposed FY 2008 outlier threshold to 
decline from its FY 2007 level of $24,485. We are proposing an FY 2008 
outlier threshold of $23,015. In section II.A.4. of the Addendum to 
this proposed rule, we provide a more detailed explanation of how we 
determined the proposed FY 2008 cost outlier threshold.
8. Effect of the Proposed MS-DRGs on the Postacute Care Transfer Policy
    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. Section 412.4(c) 
establishes the conditions under which we consider a discharge to be a 
transfer for purposes of our postacute care transfer policy. In 
transfer situations, 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 postacute care 
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.
    Beginning with FY 2006 IPPS, the regulations at Sec.  412.4 
specified that, effective October 1, 2005, we make a DRG subject to the 
postacute care transfer policy if, based on Version 23.0 of the DRG 
Definitions Manual (FY 2006), using data from the March 2005 update of 
FY 2004 MedPAR file, the DRG meets the following criteria:
     The DRG had a geometric mean length of stay of at least 3 
days;
     The DRG had at least 2,050 postacute care transfer cases; 
and
     At least 5.5 percent of the cases in the DRG were 
discharged to postacute care prior to the geometric mean length of stay 
for the DRG.
    In addition, if the DRG was one of a paired set of DRGs based on 
the presence or absence of a CC or major cardiovascular condition 
(MCV), both paired DRGs would be included if either one met the three 
criteria above.

[[Page 24712]]

    If a DRG met the above criteria based on the Version 23.0 DRG 
Definitions Manual and FY 2004 MedPAR data, we made the DRG subject to 
the postacute care transfer policy. We noted in the FY 2006 final rule 
that we would not revise the list of DRGs subject to the postacute care 
transfer policy annually unless we make a change to a specific CMS DRG. 
We established this policy to promote certainty and stability in the 
postacute care transfer payment policy. Annual reviews of the list of 
CMS 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 reinstated the following 
year. However, we noted that, over time, as treatment practices change, 
it was possible that some CMS DRGs that qualified for the policy will 
no longer be discharged with great frequency to postacute care. 
Similarly, we explained that there may be other CMS DRGs that at that 
time had a low rate of discharges to postacute care, but which might 
have very high rates in the future.
    The regulations at Sec.  412.4 further specify that 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 became effective, using the most recent complete year 
of MedPAR data:
     The total number of discharges to postacute care in the 
DRG must equal or exceed the 55th percentile for all DRGs; and
     The proportion of short-stay discharges to postacute care 
to total discharges in the DRG exceeds the 55th percentile for all 
DRGs. A short-stay discharge is a discharge before the geometric mean 
length of stay for the DRG.
    A DRG also is a qualifying DRG if it is paired with another DRG 
based on the presence or absence of a CC or MCV that meets either of 
the above two criteria.
    The MS-DRGs that we are proposing to adopt for FY 2008 are a 
significant revision to the current CMS DRG system. Because the 
proposed new MS-DRGs are not reflected in Version 23.0 of the DRG 
Definitions Manual, consistent with Sec.  412.4, we will need to 
recalculate the 55th percentile thresholds in order to determine which 
proposed MS-DRGs, if adopted, would be subject to the postacute care 
transfer policy. Further, under the proposed MS-DRGs, the subdivisions 
within the base DRGs will be different than those under the current CMS 
DRGs. Unlike the current CMS DRGs, the proposed MS-DRGs are not divided 
based on the presence or absence of a CC or MCV. Rather, the proposed 
MS-DRGs have up to three subdivisions based on: (1) The presence of a 
MCC; (2) the presence a CC; or (3) the absence of either an MCC or CC. 
Consistent with our existing policy under which both DRGs in a CC/non-
CC pair are qualifying DRGs if one of the pair qualifies, we are 
proposing that each MS-DRG that shares a base MS-DRG would be a 
qualifying DRG if one of the MS-DRGs that shares the base DRG 
qualifies. We are proposing to revise Sec.  412.4(d)(3)(ii) to codify 
this proposed policy.
    Similarly, we believe that the proposed changes to adopt MS-DRGs 
also necessitate a revision to one of the criteria used in Sec.  
412.4(f)(5) of the regulations to determine whether a DRG meets the 
criteria for payment under the ``special payment methodology.'' Under 
the special payment methodology, a case subject to the special payment 
methodology that is transferred early to a postacute care setting will 
be paid 50 percent of the total IPPS payment plus the average per diem 
for the first day of the stay. Fifty percent of the per diem amount 
will be paid for each subsequent day of the stay, up to the full MS-DRG 
payment amount. A CMS DRG is currently subject to the special payment 
methodology if it meets the criteria of Sec.  412.4(f)(5). Section 
412.4(f)(5)(iv) specifies that if a DRG meets the criteria specified 
under Sec.  412.4(f)(5)(i) through (f)(5)(iii), any DRG that is paired 
with it based on the presence or absence of a CC or MCV is also subject 
to the special payment methodology. Given that this criterion would no 
longer be applicable under the proposed MS-DRGs, we are proposing to 
add a new Sec.  412.4(f)(6) that includes a DRG in the special payment 
methodology if it is part of a CC/non-CC MCV/non-MCV pair. We are 
proposing to update this criterion so that it conforms to the proposed 
changes to adopt MS-DRGs for FY 2008. The proposed revision would make 
an MS-DRG subject to the special payment methodology if it shares a 
base MS-DRG with an MS-DRG that meets the criteria for receiving the 
special payment methodology.
    Section 412.4(f)(3) states that the postacute care transfer policy 
does not apply to CMS DRG 385 for newborns who die or are transferred. 
We are proposing to make a conforming change to this paragraph to 
reflect that this CMS DRG would become MS-DRG 789 (Neonates, Died or 
Transferred to Another Acute Care Facility) under our proposed DRG 
changes for FY 2008.
    These revisions do not constitute a change to the application of 
the postacute care transfer policy. Therefore, any savings attributed 
to the postacute care transfer policy would be unchanged as a result of 
adopting the MS-DRGs. Consistent with section 1886(d)(4)(C)(iii) of the 
Act, aggregate payments from adoption of the proposed MS-DRGs cannot be 
greater or less than those that would have been made had we not 
proposed to make any DRG changes.
    We are also proposing technical changes to Sec. Sec.  
412.4(f)(5)(i) and (f)(5)(iv) to correct a cross-reference and a 
typographical error, respectively.

E. Refinement of the Relative Weight Calculation

    (If you choose to comment on issues in this section, please include 
the caption ``DRGs: Relative Weight Calculations'' at the beginning of 
your comment.)
    In the FY 2007 IPPS final rule (71 FR 47882), effective for FY 
2007, we began to implement significant revisions to Medicare's 
inpatient hospital rates by basing the relative weights on hospitals' 
estimated costs rather than on charges. This reform was one of several 
measured steps to improve the accuracy of Medicare's payment for 
inpatient stays that include using costs rather than charges to set the 
relative weights and making refinements to the current DRGs so they 
better account for the severity of the patient's condition. Prior to FY 
2007, we used hospital charges as a proxy for hospital resource use in 
setting the relative weights. Both MedPAC and CMS have found that the 
limitations of charges as a measure of resource use include the fact 
that hospitals cross-subsidize departmental services in many different 
ways that bear little relation to cost, frequently applying a lower 
charge markup to routine and special care services than to ancillary 
services. In MedPAC's 2005 Report to the Congress on Physician-Owned 
Specialty Hospitals, MedPAC found that hospitals charge much more than 
their costs for some types of services (such as operating room time, 
imaging services and supplies) than others (such as room and board and 
routine nursing care).\10\ Our analysis of the MedPAC report in the FY 
2007 IPPS proposed rule (71 FR 24006) produced consistent findings.
---------------------------------------------------------------------------

    \10\ Medicare Payment Advisory Commission: Report to the 
Congress: Physician-Owned Specialty Hospitals, March 2005, p. 26.
---------------------------------------------------------------------------

    In the FY 2007 IPPS proposed rule, we proposed to implement cost-
based weights incorporating aspects of a

[[Page 24713]]

methodology recommended by MedPAC, which we called the hospital-
specific relative value cost center (HSRVcc) methodology. MedPAC 
indicated that an HSRVcc methodology would reduce the effect of cost 
differences among hospitals that may be present in the national 
relative weights due to differences in case-mix adjusted costs. After 
studying Medicare cost report data, we proposed to establish 10 
national cost center categories from which to compute 10 national CCRs 
based upon broad hospital accounting definitions. We made several 
important changes to the HSRVcc methodology that MedPAC recommended 
using in its March 2005 Report to the Congress on Physician-Owned 
Specialty Hospitals. We refer readers to the FY 2007 IPPS proposed rule 
(71 FR 24007 through 24011) for an explanation and our reasons for the 
modification to MedPAC's methodology. In its public comments on the FY 
2007 IPPS proposed rule, MedPAC generally agreed with the adaptations 
we made to its methodology, with the exception of expanding the number 
of distinct hospital department CCRs being used from 10 to 13 and 
basing the CCRs on Medicare-specific costs and charges.\11\
---------------------------------------------------------------------------

    \11\ Hackbarth, Glenn: MedPAC Comments on the IPPS Rule, June 
12, 2006, page 2.
---------------------------------------------------------------------------

    We did not finalize the HSRVcc methodology for FY 2007 because of 
concerns raised in the public comments on the FY 2007 IPPS proposed 
rule (71 FR 47882 through 47898). Rather, we adopted a cost-weighting 
methodology without the hospital-specific relative weight feature. We 
also expanded the number of distinct hospital departments with CCRs 
from 10 to 13. We indicated our intent to study whether to adopt the 
HSRVcc methodology after we had the opportunity to further consider 
some of the issues raised in the public comments. In the interim, we 
adopted a cost-weighting methodology over a 3-year transition period, 
substantially mitigating the redistributive payment impacts illustrated 
in the proposed rule, while we engaged a contractor to assist us with 
evaluating the HSRVcc methodology.
    Some public commenters raised concerns about potential bias in cost 
weights due to ``charge compression,'' which is the practice of 
applying a lower percentage markup to higher cost services and a higher 
percentage markup to lower cost services. These commenters were 
concerned that our proposed weighting methodology may undervalue high 
cost items and overvalue low cost items if a single CCR is applied to 
items of widely varying costs in the same cost center. The commenters 
suggested that the HSRVcc methodology would exacerbate the effect of 
charge compression on the final relative weights. One of the commenters 
suggested an analytic technique of using regression analysis to 
identify adjustments that could be made to the CCRs to better account 
for charge compression. We indicated our interest in researching 
whether a rigorous model should allow an adjustment for charge 
compression to the extent that it exists. We engaged a contractor, RTI 
International (RTI), to study several issues with respect to the cost 
weights, including charge compression, and to review the statistical 
model provided to us by the commenter for adjusting the weights to 
account for it. We discuss RTI's findings in detail below.
    Commenters also suggested that the cost report data used in the 
cost methodology are outdated, not consistent across hospitals, and do 
not account for the costs of newer technologies such as medical 
devices. However, the relationship between costs and charges (not costs 
alone) is the important variable in setting the relative weights under 
this new system. Older cost reports also do not include the hospital's 
higher charges for these same medical devices. Therefore, it cannot be 
known whether the CCR for the more recent technologies will differ from 
those we are using to set the relative weights. The use of national 
average cost center CCRs rather than hospital-specific CCRs may 
mitigate potential inconsistencies in hospital cost reporting. 
Nevertheless, we agree that it is important to review how hospitals 
report costs and charges on the cost reports and on the Medicare claims 
and asked RTI to further study this issue as well.
    In summary, we proposed to adopt HSRVcc relative weights for FY 
2007 using national average CCRs for 10 hospital departments. Based on 
public comments concerned about charge compression and the accuracy of 
cost reporting, we decided not to finalize the HSRVcc methodology, but 
adopted costs weights without the hospital-specific feature. In 
response to comments from MedPAC, we expanded the number of hospital 
cost centers used in calculating the national CCRs from 10 to 13. 
Finally, we decided to implement the cost-based weighting methodology 
gradually, by blending the cost and charge weights over a 3-year 
transition period beginning with FY 2007, while we further studied many 
of the issues raised in the public comments. We refer readers to the FY 
2007 IPPS final rule (71 FR 47882) for more details on our final policy 
for calculating the cost-based DRG relative weights.
1. Summary of RTI's Report on Charge Compression
    In August 2006, we awarded a contract to RTI to study the effects 
of charge compression in calculating DRG relative weights. The purpose 
of the study was to develop more accurate estimates of the costs of 
Medicare inpatient hospital stays that can be used in calculating the 
relative weights per DRG. RTI was asked to assess the potential for 
bias in relative weights due to CCR differences within the 13 CCR 
groups used in calculating the cost-based DRG relative weights and to 
develop an analysis plan that explored alternative methods of 
estimating costs, with the objective of better aligning the charges and 
costs used in those calculations. RTI was asked to consider methods of 
reducing the variation in CCRs across services within cost centers by:
     Modifying existing cost centers and/or creating new costs 
centers.
     Using statistical methods, such as the regression 
adjustment for charge compression. Some commenters on the FY 2007 IPPS 
proposed rule suggested that we use a regression adjustment to account 
for charge compression.
    As part of its contract, RTI convened a Technical Expert Panel 
composed of individuals representing academic institutions, hospital 
associations, medical device manufacturers, and MedPAC. The members of 
the panel met on October 27, 2006, to evaluate RTI's analytic plan, to 
identify other areas that are likely to be affected by compression or 
aggregation problems, and to propose suggestions for adjustments for 
charge compression. We posted RTI's draft interim report on the CMS Web 
site in March 2007. For more information, interested individuals can 
view RTI's report at the following Web site: http://cms.hhs.gov/reports/downloads/Dalton.pdf.
    As the first step in its analysis, RTI compared the reported 
Medicare program charge amounts from the cost reports to the total 
Medicare charges summed across all claims filed by providers. Using 
cost and charge data from the most recent available Medicare cost 
reports and inpatient claims from IPPS hospitals, RTI was charged with 
performing an analysis to determine how well the MedPAR charges matched 
the cost report charges used to compute CCRs. The accuracy of the DRG 
cost estimates is directly affected by this match because MedPAR 
charges are multiplied by CCRs to estimate cost. RTI found consistent 
matching of charges

[[Page 24714]]

from the Medicare cost report to charges grouped in the MedPAR claims 
for some cost centers but there appeared to be problems with others. 
For example, RTI found that the data between the cost report and the 
claims matched well for total discharges, days, covered charges, 
nursing unit charges, pharmacy, and laboratory. However, there appeared 
to be inconsistent reporting between the cost reports and the claims 
data for charges in several ancillary departments (medical supplies, 
operating room, cardiology, and radiology). For example, the data 
suggested that hospitals often include costs and charges for devices 
and other medical supplies within the Medicare cost report cost centers 
for Operating Room, Radiology or Cardiology instead of the Medical 
Supplies cost center.
    RTI found that some charge mismatching results from the way in 
which charges are grouped in the MedPAR file. Examples include the 
intermediate care nursing charges being grouped with intensive care 
nursing charges, and electroencephalography (EEG) charges being grouped 
with laboratory charges. RTI suggested that reclassifying intermediate 
care charges from the intensive care unit to the routine cost center 
could address the former problem.
    As the second step in its analysis, RTI reviewed the existing cost 
centers that are combined into the 13 groups used in calculating the 
national average CCRs. RTI identified CCRs with potential aggregation 
problems and considered whether separating the charge groups could 
result in more accurate cost conversion at the DRG level. The analysis 
led RTI to calculate separate CCRs for Emergency Room and Blood and 
Blood Administration, both of which had been included in ``Other 
Services'' in FY 2007.
    During this second step, RTI noted that a variation of charge 
compression is also present in inpatient nursing services because most 
patients are charged a single type of accommodation rate per day that 
is linked to the type of nursing unit (routine, intermediate, or 
intensive), but not to the hours of nursing services given to 
individual patients. Unlike the situation with charge compression in 
ancillary service areas, there are virtually no detailed charge codes 
that can distinguish patient nursing care use. Therefore, any potential 
bias cannot be empirically evaluated or adjustments made without 
additional data.
    Next, RTI examined individual revenue codes within the cost centers 
and used regression analysis to determine whether certain revenue codes 
in the same cost center had significantly different markup rates. Those 
revenue codes include devices, prosthetics, implants within the Medical 
Supplies cost center, IV Solutions within the Drugs cost center, CT 
scanning and MRI within the Radiology cost center, Cardiac 
Catheterization within the Cardiology cost center, and Intermediate 
Care Units within the Routine Nursing Care cost center. Devices, 
prosthetics, and implants within the Medical Supplies cost center have 
a lower markup and, as a result, a higher CCR than the remainder of the 
medical supplies group according to RTI's analysis. Within the Drugs 
CCR, IV Solutions have a much higher markup and much lower CCR than the 
other drugs included in the category. Within the Radiology CCR, CT 
scanning and MRI have higher markups and lower CCRs than the remaining 
radiology services. RTI's results for Cardiac Catheterization and 
Intermediate Care Units were ambiguous due to data problems.
    RTI's analysis also determined the impact of the disaggregated CCRs 
on the relative weights. Differences in CCRs alone do not necessarily 
alter the DRG relative weights. The impact on the relative weights is 
the result of the interaction of CCR differences and DRG differences in 
the proportions of the services with different CCRs. In FY 2007, we 
calculated relative weights using CCRs for 13 hospital departments. The 
RTI analysis suggests expanding the number of distinct hospital 
department CCRs from 13 to 19. Of the additional six CCRs, two would 
result from separating the Emergency Department and Blood (Products and 
Administration) from the residual ``Other Services'' category. Four 
additional CCRs would result from applying a regression method similar 
to a method suggested in last year's public comments to three existing 
categories: supplies, radiology, and drugs. This method, as adapted by 
RTI, used detailed coding of charges to disaggregate hospital cost 
centers and derive separate, predicted alternative CCRs for the 
disaggregated services. RTI's analysis suggests splitting Medical 
Supplies into one CCR for devices, implants, and prosthetics and one 
CCR for Other Supplies; splitting Radiology into one CCR for MRIs, one 
CCR for CT scans, and one CCR for Other Radiology; and splitting Drugs 
into one CCR for IV Solutions and one CCR for Other Drugs.
    RTI's draft report provides the potential impacts of adopting these 
changes to the CCRs. We note that RTI's analysis was based on Version 
24.0 of the CMS DRGs. Because the proposed MS-DRGs were under 
development for the FY 2008 IPPS proposed rule, they were unavailable 
to RTI for their analysis. The results of RTI's analysis may be 
different if applied to the proposed MS-DRGs. However, it seems 
reasonable to believe that the impact of RTI's suggestions will be 
consistent using Version 24.0 of the CMS DRGs and the proposed MS-DRGs, 
as both systems generally use the same base DRGs while applying 
different subdivisions to recognize severity of illness. Of all the 
adjusted CCRs, the largest impact on weights came from accounting for 
charge compression in medical supplies for devices and implants. The 
impact on weights from accounting for CCR differences among drugs was 
modest. The impact of splitting MRI and CT scanning from the radiology 
CCR was greater than the impact of modifying the Drugs CCRs, but less 
than the impact of splitting the medical supplies group. Separating 
Emergency Department and Blood Products and Administration from the 
``Other Services'' category would raise the CCR for other services in 
the group.
    RTI found that disaggregating cost centers may have a mitigating 
effect on the impact of transitioning from charge-based weights to 
cost-based weights. That is, the changes being suggested by RTI will 
generally offset (fully or more than fully in some cases or in part in 
other cases) the impacts of fully implemented cost weights that we are 
adopting over the FY 2007-FY 2009 transition period. Thus, RTI's 
analysis suggests that expanding the number of distinct hospital 
department CCRs used to calculate cost weights from 13 to 19 will 
generally increase the relative weights for surgical DRGs and decrease 
them for the medical DRGs compared to the fully implemented cost-based 
weights to which we began transitioning in FY 2007.
2. RTI Recommendations
    In its report, RTI provides recommendations for the short term, 
medium term, and long term, to mitigate aggregation bias in the 
calculation of relative weights. We summarize RTI's recommendations 
below and respond to each of them.
a. Short-Term Recommendations
    Most of RTI's short-term recommendations have already been 
described above. The most immediate changes that RTI recommends 
implementing include expanding from 13 distinct hospital department 
CCRs to 19 by:

[[Page 24715]]

     Disaggregating ``Emergency Room'' and ``Blood and Blood 
Products'' from the ``Other Services'' cost center;
     Establishing regression-based estimates as a temporary or 
permanent method for disaggregating the Medical Supplies, Drugs, and 
Radiology cost centers; and
     Reclassifying intermediate care charges from the intensive 
care unit cost center to the routine cost center.
    We believe these recommendations have significant potential to 
address issues of charge compression and potential mismatches between 
how costs and charges are reported in the cost reports and on the 
Medicare claims.
    RTI's recommendations show significant promise in the short term 
for addressing issues raised in the public comments on the cost weights 
in the FY 2007 IPPS proposed rule. However, in the time available for 
the development of this proposed rule, we have been unable to 
investigate how RTI's recommended changes may interact with other 
potential changes to the DRGs and to the method of calculating the DRG 
relative weights. As we noted above, RTI's analysis was done on the 
Version 24.0 of the CMS DRGs and not the MS-DRGs we are proposing for 
FY 2008. For this proposed rule, we were not able to examine the 
combined impacts of the proposed MS-DRGs and RTI's recommendations. In 
addition, we believe it is also important to consider that, in the FY 
2007 IPPS final rule (71 FR 47897), we anticipated undertaking further 
analysis of the HSRVcc methodology over the next year in conjunction 
with the research we were to do on charge compression. Analysis of the 
HSRVcc methodology will be part of the second phase of the RAND study 
of alternative DRG systems to be completed by September 1, 2007, that 
has not been completed in time for this proposed rule. As a result, we 
have also been unable to consider the effects of the HSRVcc methodology 
together with the proposed MS-DRGs and RTI's recommendations. Finally, 
we note that in order to complete the analysis in time for this 
proposed rule, RTI's study used only inpatient hospital claims. 
However, hospital ancillary departments typically include both 
inpatient and outpatient services within the same department and only a 
single CCR covering both inpatient and outpatient services can be 
calculated from Medicare cost reports. Although we believe that 
applying the regression method used by RTI to only inpatient services 
is unlikely to have had much impact for the adjustments recommended by 
RTI, the preferred approach would be to apply the regression method to 
the combined inpatient and outpatient services. The latter approach 
would ensure that any potential CCR adjustments in the IPPS would be 
consistent with potential CCR adjustments in the OPPS. We hope to 
expand their analysis to incorporate outpatient services during the 
coming year. For all of these reasons, we are not proposing to adopt 
RTI's recommendations for FY 2008.
    Although we are not proposing to adopt RTI's recommendations for FY 
2008, we are interested in public comments on expanding from 13 CCRs to 
19 CCRs. Again, we note that RTI's analysis suggests significant 
improvements that could result in the cost weights from adopting its 
recommendations to adjust for charge compression. Therefore, we are 
also interested in public comments on whether we should proceed to 
adopt the RTI recommended changes for FY 2008 in the absence of a 
detailed analysis of how the relative weights would change if we were 
to address charge compression while simultaneously adopting an HSRVcc 
methodology together with the proposed MS-DRGs. Given the change in the 
impacts that were illustrated in last year's FY 2007 IPPS final rule 
(71 FR 47915-47916), going from a hospital-specific to a nonhospital-
specific cost-weighting methodology, we believe that sequentially 
adjusting for charge compression and later adopting an HSRVcc 
methodology could create the potential for instability in IPPS payments 
over the next 2 years (that is, payments for surgical DRGs would 
increase and payment for medical DRGs would decrease if we were adopt 
the RTI recommended changes for FY 2008, but could potentially reverse 
direction if we were to adopt an HSRVcc methodology for FY 2009). 
Again, we are interested in public comments on all of these issues 
before we make a final decision as to whether to proceed with the RTI's 
short-term recommendations in the final rule for FY 2008.
    Among its other short-term recommendations, RTI also suggested that 
we incorporate edits to reject or require more intensive review of cost 
reports from hospitals with extreme CCRs. This action would reduce the 
number of hospitals with excluded data in the national CCR 
computations, and would also improve the accuracy of all departmental 
CCRs within problem cost reports by forcing hospitals to review and 
correct the assignment of costs and charges before the cost report is 
filed. Although we do not have a substantive disagreement with the 
recommendation, we generally focus our audit resources on areas in 
which cost report information directly affects payments to individual 
providers.
    RTI further suggested revising cost report instructions to reduce 
cost and charge mismatching and program charge misalignment in its 
short-term recommendations. Although RTI suggests such an action could 
be immediately effective for correcting the reporting of costs and 
charges for medical supply items that are now distributed across 
multiple cost centers, we note that changes to improve cost reporting 
now will not become part of the relative weights for several years 
because of lags between the submission of hospital reports and our 
ability to use them in setting the relative weights. Currently, we 
expect there will continue to be a 3-year lag between a hospital's cost 
report fiscal year and the year it is used to set the relative weights. 
Thus, even if it were possible to issue instructions immediately 
beginning for FY 2008, revised reporting would not affect the relative 
weights until at least FY 2011. Nevertheless, we agree with this 
recommendation, and we welcome public input on potential changes to 
cost reporting instructions to improve consistency between how charges 
are reported on cost reports and in the Medicare claims. We will 
consider these changes to the cost reporting instructions as we 
consider further changes to the cost report described below.
b. Medium-Term Recommendations
    RTI recommended that we expand the MedPAR file to include separate 
fields that disaggregate several existing charge departments. For 
compatibility with prior years' data, the new fields should partition 
the existing ones rather than recombine charges. RTI recommended 
including additional fields in the MedPAR file for the hospital 
departments that it statistically disaggregated in its report, as well 
as intermediate care, observation beds, other special nursing codes, 
therapeutic radiation and EEG, and possibly others. As with some of 
RTI's earlier recommendations with respect to cost reports, we will 
examine this suggestion in conjunction with other competing priorities 
CMS has been given for our information systems. We have limited 
information systems resources, and we will need to consider whether the 
time constraints we have to develop the IPPS final rule, in conjunction 
with the inconvenience of using the SAF and accounting for charge 
compression through regression, will justify the infrastructure cost to 
our information

[[Page 24716]]

systems of incorporating these variables into the MedPAR.
    Finally, RTI's medium-term recommendations include encouraging 
providers to use existing standard cost centers, particularly those for 
Blood and Blood Administration and for Therapeutic Radiology, in the 
current Medicare cost report. We believe this recommendation is closely 
related to the one for improved cost reporting instructions. Therefore, 
we will consider this recommendation as part of any further effort we 
may undertake to revise cost reporting instructions or change the cost 
report.
c. Long-Term Recommendations
    RTI's long-term recommendations include adding new cost centers to 
the Medicare cost report and/or undertaking the following activities:
     Add ``Devices, Implants and Prosthetics'' under the line 
for ``Medical Supplies Charged to Patients.'' Consider also adding a 
similar line for IV Solutions as a subscripted line under the line for 
``Drugs Charged to Patients.''
     Add CT Scanning and MRI as subscripted lines under the 
line for ``Radiology-Diagnostic.'' About one-third of hospitals that 
offer CT Scanning and/or MRI services are already reporting these 
services on nonstandard line numbers. More consistent reporting for 
both cost centers would eliminate the need for statistical estimation 
on the radiology CCRs.
     In consultation with hospital industry representatives, 
determine the best way to separate cardiology cost centers and add a 
new standard cost center for cardiac catheterization and/or for all 
other cardiac diagnostic laboratory services. About 20 percent of 
hospitals already include a nonstandard line on their cost reports for 
catheterization. Creating a new standard cost center could improve 
consistency in reporting and substantially improve the program charge 
mismatching that now occurs.
     In consultation with hospital industry representatives, 
consider establishing a new cost center to capture intermediate care 
units as distinct from routine or intensive care.
     Establish expert study groups or other research vehicles 
to study options for improving patient-level charging within nursing 
units. Nursing accounts for one-fourth of IPPS charges and 41 percent 
of the computed costs from our claims analysis file. Historically, 
nursing charges and costs have been assigned to patients without 
relying on individual measures of service use. Consideration should be 
given to finding ways to improve precision in nursing cost-finding that 
will improve relative resource weights without adding substantial 
administrative costs to either the Medicare program or to hospitals.
    We agree with RTI that attention should be paid to these issues as 
we consider changes to the Medicare cost report. The cost report has 
not been revised in nearly 10 years. During this time, there have been 
significant changes to the Medicare statute and regulations that have 
affected the Medicare payment policies. Necessary incremental changes 
have been made to the Medicare cost report over the years to 
accommodate the Medicare wage index, disproportionate share payments, 
indirect and direct graduate medical education payments, reporting of 
uncompensated care costs, among others. The adoption of cost-based 
weights for the IPPS beginning in FY 2007 has brought further attention 
to the importance of the Medicare cost report and how hospitals report 
costs and charges. We recently began doing a comprehensive review of 
the Medicare cost report and plan to make updates that will consider 
its many uses. As we update the cost report, we will give strong 
consideration to RTI's recommendations and potential long-term 
improvements that could be made to the IPPS cost-based relative 
weighting methodology.

F. Hospital-Acquired Conditions, Including Infections

    (If you choose to comment on issues in this section, please include 
the caption ``DRGs: Hospital-Acquired Conditions'' at the beginning of 
your comment.)
1. General
    Medicare's IPPS encourages hospitals to treat patients efficiently. 
Hospitals receive the same DRG payment for stays that vary in length. 
In many cases, complications acquired in the hospital do not generate 
higher payments than the hospital would otherwise receive for other 
cases in the same DRG. To this extent, the IPPS does encourage 
hospitals to manage their patients well and to avoid complications, 
when possible. However, complications, such as infections, acquired in 
the hospital can trigger higher payments in two ways. First, the 
treatment of complications can increase the cost of hospital stays 
enough to generate outlier payments. However, the outlier payment 
methodology requires that hospitals experience large losses on outlier 
cases (for example, in FY 2007, the fixed-loss amount was $24,485 
before a case qualified for outlier payments, and the hospital then 
only received 80 percent of its costs above the fixed-loss cost 
threshold). Second, there are about 121 sets of DRGs that split based 
on the presence or absence of a complication or comorbidity (CC). The 
CC DRG in each pair would generate a higher Medicare payment. If a 
condition acquired during the beneficiary's hospital stay is one of the 
conditions on the CC list, the result may be a higher payment to the 
hospital under a CC DRG. Under the proposed MS-DRGs, there will be 258 
sets of DRGs that are split into 2 or 3 subgroups based on the presence 
or absence of a major CC (MCC) or CC. If a condition acquired during 
the beneficiary's hospital stay is one of the conditions on the MCC or 
CC list, the result may be a higher payment to the hospital under the 
MS-DRGs. (See section II.C. of the FY 2007 IPPS final rule (71 FR 
47881) for a detailed discussion of proposed DRG reforms.)
2. Legislative Requirement
    Section 5001(c) of Pub. L. 109-171 requires the Secretary to 
select, by October 1, 2007, at least two conditions that are (a) high 
cost or high volume or both, (b) result in the assignment of a case to 
a DRG that has a higher payment when present as a secondary diagnosis, 
and (c) could reasonably have been prevented through the application of 
evidence-based guidelines. For discharges occurring on or after October 
1, 2008, hospitals will not receive additional payment for cases in 
which one of the selected conditions was not present on admission. That 
is, the case will be paid as though the secondary diagnosis was not 
present. Section 5001(c) provides that we can revise the list of 
conditions from time to time, as long as the list contains at least two 
conditions. Section 5001(c) also requires hospitals to submit the 
secondary diagnoses that are present at admission when reporting 
payment information for discharges on or after October 1, 2007.
3. Public Input
    In the FY 2007 IPPS proposed rule (71 FR 24100), we sought input 
from the public about which conditions and which evidence-based 
guidelines should be selected in order to implement section 5001(c) of 
Public Law 109-171. The comments that we received were summarized in 
the FY 2007 IPPS final rule (71 FR 48051 through 48053). In that final 
rule, we indicated that the next opportunity for formal public comment 
would be this FY 2008 proposed rule and encouraged the public to 
comment on our proposal at that time.

[[Page 24717]]

    In summary, the majority of the comments that we received in 
response to the FY 2007 IPPS proposed rule addressed conceptual issues 
concerning the selection, measurement, and prevention of hospital-
acquired infections. Many commenters encouraged CMS to engage in a 
collaborative discussion with relevant experts in designing, 
evaluating, and implementing this section. The commenters urged CMS to 
include individuals with expertise in infection control and prevention, 
as well as representatives from the provider community, in the 
discussions.
    Many commenters supported the statutory requirement for hospitals 
to submit information regarding secondary diagnoses present on 
admission beginning in FY 2008, and suggested that it would better 
enable CMS and health care providers to more accurately differentiate 
between comorbidities and hospital-acquired complications. MedPAC, in 
particular, noted that this requirement was recommended in its March 
2005 Report to Congress and indicated that this information is 
important to Medicare's value-based purchasing efforts. Other 
commenters cautioned us about potential problems with relying on 
secondary diagnosis codes to identify hospital-acquired complications, 
and indicated that secondary diagnosis codes may be an inaccurate 
method for identifying true hospital-acquired complications.
    A number of commenters expressed concerns about the data coding 
requirement for this payment change and asked for detailed guidance 
from CMS to help them identify and document hospital-acquired 
complications. Other commenters expressed concern that not all 
hospital-acquired infections are preventable and noted that sicker and 
more complex patients are at greater risk for hospital-acquired 
infections and complications. Commenters suggested that CMS include 
standardized infection-prevention process measures, in addition to 
outcome measures of hospital-acquired infections.
    Some commenters proposed that CMS expand the scope of the payment 
changes beyond the statutory minimum of two conditions. They noted that 
the death, injury, and cost of hospital-acquired infections are too 
high to limit this provision to only two conditions. Commenters also 
recommended that CMS annually select additional hospital-acquired 
complications for the payment change. Conversely, a number of 
commenters proposed that CMS initially begin with limited 
demonstrations to test CMS' methodology before nationwide 
implementation. One commenter recommended that CMS include appropriate 
consumer protections to prevent providers from billing patients for the 
nonreimbursed costs of the hospital-acquired complications and to 
prevent hospitals from selectively avoiding patients perceived at risk 
of complications.
    In addition to the broad conceptual suggestions, some commenters 
recommended specific conditions for possible inclusion in the payment 
changes, which we discuss in detail in section II.D.4. of this 
preamble. We also discuss throughout section II.D. of this preamble 
other comments that we have considered in developing hospital-acquired 
conditions that would be subject to reporting.
4. Collaborative Effort
    CMS worked with public health and infectious disease experts from 
the Centers for Disease Control and Prevention (CDC) to identify a list 
of hospital-acquired conditions, including infections, as required by 
section 5001(c) of Public Law 109-171. As previously stated, the 
selected conditions must meet the following three criteria: (a) High 
cost or high volume or both; (b) result in the assignment of the case 
to a DRG that has a higher payment when present as a secondary 
diagnosis; and (c) could reasonably have been prevented through the 
application of evidence-based guidelines. CMS and CDC staff also 
collaborated on developing a process for hospitals to submit a Present 
on Admission (POA) indicator with each secondary condition. The statute 
requires the Secretary to begin collecting this information as of 
October 1, 2007. The POA indicator is required in order for us to 
determine which of the selected conditions developed during a hospital 
stay. The current electronic format used by hospitals to obtain this 
information (ASC X12N 837, Version 4010) does not provide a field to 
obtain the POA information. We are in the process of issuing 
instructions to require acute care IPPS hospitals to submit the POA 
indicator for all diagnosis codes effective October 1, 2007. The 
instructions will specify how hospitals under the IPPS will submit this 
information in segment K3 in the 2300 loop, data element K301 on the 
ASC X12N 837, Version 4010 claim. Specific instructions on how to 
select the correct POA indicator for a diagnosis code are included in 
the ICD-9-CM Official Guidelines for Coding and Reporting. These 
guidelines can be found at the following Web site: http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/ftpicd9.htm
    CMS and CDC staff also received input from a number of groups and 
organizations on hospital-acquired conditions, including infections. 
Many of these groups and organizations recommended the selection of 
conditions mentioned in the FY 2007 IPPS final rule, including the 
following because of the high cost or high volume (frequency) of the 
condition, or both, and because in some cases preventable guidelines 
already exist:
     Surgical site infections. The groups and organizations 
stated that there were evidence-based measures to prevent the 
occurrence of these infections which are currently measured and 
reported as part of the Surgical Care Improvement Program (SCIP).
     Ventilator-associated pneumonias. The groups and 
organizations pointed out that these conditions are currently measured 
and reported through SCIP. However, other organizations counseled 
against selecting these conditions because they believed it was 
difficult to obtain good definitions and that it was not always clear 
which ones are hospital-acquired.
     Catheter associated bloodstream infections.
     Pressure ulcers, as an alternative to hospital-acquired 
infections. The groups and organizations pointed out that the specific 
language in section 5001(c) of Public Law 109-171 mentions hospital-
acquired conditions; therefore, the language does not restrict the 
Secretary to the selection of infections.
     Hospital falls, as an alternative to hospital-acquired 
infections. The injury prevention groups included this condition among 
a group referred to as ``serious preventable events,'' also commonly 
referred to as ``never events'' or ``serious reportable events.'' A 
serious preventable event is defined as a condition which should not 
occur during an inpatient stay.
    In addition to the aforementioned conditions, we received other 
recommendations for the selection of hospital-acquired conditions. 
These recommendations were also based on the high cost and the high 
volume of the condition, or both, or the fact that preventable 
guidelines exist. The recommendations include--
     Bloodstream infections/septicemia. Some commenters 
suggested that we focus on one specific organism, such as staph aureus 
septicemia.
     Pneumonia. Some commenters recommended the inclusion of a 
broader group of pneumonia patients, instead of restricting cases to 
ventilator-associated pneumonias. Some commenters

[[Page 24718]]

mentioned that while prevention guidelines exist for pneumonia, it is 
not clear how effective these guidelines may be in preventing 
pneumonia.
     Vascular catheter associated infections. Commenters 
pointed out that there are CDC guidelines for these infections. Other 
commenters pointed out that while this condition certainly deserves 
focused attention by health care providers, there is not a clear one 
unique ICD-9-CM code that identifies vascular catheter-associated 
infections. Therefore, these commenters suggested that there would be 
difficulty separately identifying these conditions.
     Clostridium difficile-associated disease (CDAD). Several 
commenters identified this condition as a significant public health 
issue. Other commenters pointed out that while prevalence of this 
condition is emerging as a public health problem, there is not 
currently a strategy for reasonably preventing these infections.
     Methicillin-resistant staphylococcus aureus (MRSA). 
Several commenters pointed out that MRSA has become a very common 
bacteria occurring both in and outside the hospital environment. 
However, other organizations pointed out that the code for MRSA (V09.0, 
Infection with microorganism resistant to penicillins Methicillin-
resistant staphylococcus aureus) is not currently classified as a CC. 
Therefore, the commenters stated that MRSA does not lead to a higher 
reimbursement when the code is reported.
     Serious preventable events. As stated earlier, some 
commenters representing injury prevention groups suggested including a 
broader group of conditions than hospital falls which should not be 
expected to occur during a hospital admission. Hey notes that these 
conditions are referred to as ``serious preventable events,'' and 
include events such as the following: (a) Leaving an object in during 
surgery; (b) operating on the wrong body part or patient, or performing 
the wrong surgery; (c) air embolism as a result of surgery; and (d) 
providing incompatible blood or blood products. Other commenters 
indicated that serious preventable events are so rare that they should 
not be selected as a hospital condition that cannot result in a case 
being assigned to a higher paying DRG.
5. Criteria for Selection of the Hospital-Acquired Conditions
    CMS and CDC staff greatly appreciate the many comments and 
suggestions offered by organizations and groups that were interested in 
providing input into the selection of the initial hospital-acquired 
conditions.
    CMS and CDC staff evaluated each recommended condition under the 
three criteria established by section 1886(d)(4)(D)(iv) of the Act. In 
order to meet the higher payment criterion, the condition selected must 
have an ICD-9-CM diagnosis code that clearly identifies the condition 
and is classified as a CC, or as an MCC as proposed for the MS-DRGs in 
this proposed rule. Some conditions recommended for inclusion among the 
initial hospital-acquired conditions did not have codes that clearly 
identified the conditions. Because there has not been national 
reporting of a POA indicator for each diagnosis, there is no Medicare 
data to determine the incidence of the reported secondary diagnoses 
occurring after admission. To the extent possible, we used information 
from the CDC on the incidence of these conditions. CDC's data reflect 
the incidence of hospital-acquired conditions in 2002. We also examined 
FY 2006 Medicare data on the frequency that these conditions were 
reported as secondary diagnoses. We developed the following criteria to 
assist in our analysis of the conditions. The conditions described were 
those recommended for inclusion in the initial hospital-acquired 
infection provision.
     Coding--Under section 1886(d)(4)(D)(ii)(I) of the Act, a 
discharge is subject to the payment adjustment if ``the discharge 
includes a condition identified by a diagnosis code'' selected by the 
Secretary under section 1886(d)(4)(D)(iv) of the Act. We only selected 
conditions that have (or could have) a unique ICD-9-CM code that 
clearly describes the condition. Some conditions recommended by the 
commenters would require the use of two or more ICD-9-CM codes to 
clearly identify the conditions. Although we did not exclude these 
conditions from further consideration, the need to utilize multiple 
ICD-9-CM codes to identify them may present operational issues. For 
instance, below we describe in detail the complexities associated with 
selecting septicemia as a hospital-acquired condition that would be 
subject to section 5001(c) of the DRA. In some cases, septicemia may be 
a reasonably preventable condition with proper hospital care. However, 
in other cases, clinicians may argue that the condition arose from 
further development of another infection the patient did have upon 
admission and the septicemia was not preventable. As we indicate in 
detail below, there could be a significant variety of clinical 
scenarios and potential coding vignettes to describe situations where 
septicemia occurs. Although we could select septicemia, we would also 
have to identify many exclusions for situations where the septicemia is 
not preventable. The vast number of clinical scenarios that we would 
have to account for could complicate implementation of the provision.
     Burden (High Cost/High Volume)--Under section 
1886(d)(4)(D)(iv)(I) of the act, we must select cases that have 
conditions that are high cost or high volume, or both.
     Prevention guidelines--Under section 1886(d)(4)(D)(iv)(II) 
of the Act, we must select codes that describe conditions that could 
reasonably have been prevented through application of evidence-based 
guidelines. We evaluated whether there is information available for 
hospitals to follow to prevent the condition from occurring.
     CC--Under section 1886(d)(4)(D)(iv)(III) of the Act, we 
must select codes that result in assignment of the case to a DRG that 
has a higher payment when the code it present as a secondary diagnosis. 
The condition must be an MCC or a CC that would, in the absence of this 
provision, result in assignment to a higher paying DRG.
     Considerations--We evaluate each condition above according 
to how it meets the statutory criteria in light of the potential 
difficulties that we would face if the condition were selected.
6. Proposed Selection of Hospital-Acquired Conditions
    We discuss below our analysis of each of the conditions that were 
raised as possible candidates for selection under section 5001(c) of 
Pub. L. 109-171 according to the criteria described above in section 
II.D.5. of this preamble. We also discuss any considerations, which 
would include any administrative issues surrounding the selection of a 
proposed condition. For example, the condition may only be able to be 
identified by multiple codes, thereby requiring the development of 
special GROUPER logic to also exclude similar or related ICD-9-CM codes 
from being classified as a CC. Similarly, a condition acquired during a 
hospital stay may arise from another condition that the patient had 
prior to admission, making it difficult to determine whether the 
condition was reasonably preventable. Following a discussion of each 
condition, we provide a summary table that describes the extent to 
which each condition meets each of the above criteria. We present 13 
conditions in rank order. In our view, the conditions listed at the top 
of the table best meet the statutory selection criteria, while the 
conditions

[[Page 24719]]

listed lower may meet the selection criteria but could present a 
particular challenge (that is, they may be preventable only in some 
circumstances but not in others). Therefore, we would submit that the 
first conditions listed should receive the highest consideration of 
selection among our initial group of hospital-acquired conditions. We 
encourage comments on whether or not we have ranked these conditions 
appropriately. We also encourage additional comments on clinical, 
coding, and prevention issues that may affect the conditions selected. 
While we have ranked these conditions, there may be compelling public 
health reasons for including conditions that are not at the top of our 
list. We ask commenters to recommend how many and which conditions 
should be selected for implementation on October 1, 2008, along with 
justifications for these selections.
(a) Catheter-Associated Urinary Tract Infections
     Coding--ICD-9-CM code 996.64 (Infection and inflammatory 
reaction due to indwelling urinary catheter) clearly identifies this 
condition. The hospital would also report the code for the specific 
type of urinary infection. For instance, when a patient develops a 
catheter associated urinary tract infection during the inpatient stay, 
the hospital would report code 996.64 and 599.0 (Urinary tract 
infection, site not specified) to clearly identify the condition. There 
are also a number of other more specific urinary tract infection codes 
that could also be coded with code 996.64. These codes are classified 
as CCs. If we were to select catheter-associated urinary tract 
infections, we would implement the decision by not counting code 996.64 
and any of the urinary tract infection codes listed below when both 
codes are present and the condition was acquired after admission. If 
only code 996.64 were coded on the claim as a secondary diagnosis, we 
would not count it as a CC.
    Burden (High Cost/High Volume)--CDC reports that there are 561,667 
catheter-associated urinary tract infections per year. For FY 2006, 
there were 11,780 reported cases of Medicare patients who had a 
catheter associated urinary tract infection as a secondary diagnosis. 
The cases had average charges of $40,347 for the entire hospital stay. 
According to a study in the American Journal of Medicine, catheter-
associated urinary tract infection is the most common nosocomial 
infection, accounting for more than 1 million cases in hospitals and 
nursing homes nationwide.\12\ Approximately 11.3 million women in the 
United States had at least one presumed acute community-acquired 
urinary tract infection resulting in antimicrobial therapy in 1995, 
with direct costs estimated at $659 million and indirect costs totaling 
$936 million. Nosocomial urinary tract infection necessitates one extra 
hospital day per patient, or nearly 1 million extra hospital days per 
year. It is estimated that each episode of symptomatic urinary tract 
infection adds $676 to a hospital bill. In total, according to the 
study, the estimated annual cost of nosocomial urinary tract infection 
in the United States ranges between $424 and $451 million.
---------------------------------------------------------------------------

    \12\ Foxman, B.: ``Epidemiology of urinary tract infections: 
incidence, morbidity, and economic costs,'' The American Journal of 
Medicine, 113 Suppl. 1A, pp. 5s-13s, 2002.
---------------------------------------------------------------------------

    Prevention guidelines--There are widely recognized guidelines for 
the prevention of catheter-associated urinary tract infections. 
Guidelines can be found at the following Web site: http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html.
    CC--Codes 996.64 and 599.0 are classified as CCs in the current CMS 
DRGs as well as in the proposed MS-DRGs.
    Considerations--The primary prevention intervention would be not 
using catheters or removing catheters as soon as possible, both of 
which are worthy goals because once catheters are in place for 3 to 4 
days, most clinicians and infectious disease/infection control experts 
do not believe urinary tract infections are preventable. While there 
may be some concern about the selection of catheter associated urinary 
tract infections, it is an important public health goal to encourage 
practices that will reduce urinary tract infections. Approximately 40 
percent of Medicare beneficiaries have a urinary catheter during 
hospitalization based on Medicare Patient Safety Monitoring System 
(MPSMS) data.
    As stated above in the Coding section, this condition is clearly 
identified through ICD-9-CM code 996.64. Code 996.64 is classified as a 
CC. The hospital would also report the code for the specific type of 
urinary infection. For instance, when a patient develops a catheter 
associated urinary tract infection during the inpatient stay, the 
hospital would report codes 996.64 and 599.0 or another more specific 
code that clearly identifies the condition. These codes are classified 
as CCs under the current CMS DRGs as well as the proposed MS-DRGs. To 
select catheter-associated urinary tract infections as one of the 
hospital-acquired conditions that would not be counted as a CC, we 
would not classify code 996.64 as a CC if the condition occurred after 
admission. Furthermore, we would also not classify any of the codes 
listed below as CCs if present on the claim with code 996.64 because 
these additional codes identify the same condition. The following codes 
represent specific types of urinary infections. We did not include 
codes for conditions that could be considered chronic urinary 
infections, such as code 590.00 (Chronic pyelonephritis, without lesion 
or renal medullary necrosis). Chronic conditions may indicate that the 
condition was not acquired during the current stay. We would not count 
code 996.64 or any of the following codes representing acute urinary 
infections if they developed after admission and were coded together on 
the same claim.
     112.2 (Candidiasis of other urogenital sites)
     590.10 (Acute pyelonephritis, without lesion of renal 
medullary necrosis)
     590.11 (Acute pyelonephritis, with lesion of renal 
medullary necrosis)
     590.2 (Renal and perinephric abscess)
     590.3 (Pyeloureteritis cystica)
     590.80 (Pyelonephritis, unspecified)
     590.81 (Pyelitis or pyelonephritis in diseases classified 
elsewhere)
     590.9 (Infection of kidney, unspecified)
     595.0 (Acute cystitis)
     595.3 (Trigonitis)
     595.4 (Cystitis in diseases classified elsewhere)
     595.81 (Cystitis cystica)
     595.89 (Other specified type of cystitis, other)
     595.9 (Cystitis, unspecified)
     597.0 (Urethral abscess)
     597.80 (Urethritis, unspecified)
     599.0 (Urinary tract infection, site not specified)
    We believe the condition of catheter-associated urinary tract 
infection meets all of our criteria for selection as one of the initial 
hospital-acquired conditions. We can easily identify the cases with 
ICD-9-CM codes. The condition is a CC under both the current CMS DRGs 
and the proposed MS-DRGs that are discussed earlier in this proposed 
rule. The condition meets our burden criterion with its high cost and 
high frequency. There are prevention guidelines on which the medical 
community agrees. Of all 13 conditions discussed in this proposed rule, 
we believe this condition best meets the

[[Page 24720]]

criteria discussed. Therefore, we are proposing the selection of 
catheter-associated urinary tract infections as one of the initial 
hospital-acquired conditions.
    We encourage comments on both the selection of this condition and 
the related conditions that we are proposing to exclude from being 
counted as CCs.
(b) Pressure Ulcers
    Coding--Pressure ulcers are also referred to as decubitus ulcers. 
The following codes clearly identify pressure ulcers.
     707.00 (Decubitus ulcer, unspecified site)
     707.01 (Decubitus ulcer, elbow)
     707.02 (Decubitus ulcer, upper back)
     707.03 (Decubitus ulcer, lower back)
     707.04 (Decubitus ulcer, hip)
     707.05 (Decubitus ulcer, buttock)
     707.06 (Decubitus ulcer, ankle)
     707.07 (Decubitus ulcer, heel)
     707.09 (Decubitus ulcer, other site)
    Burden (High Cost/High Volume)--This is both a high-cost and high-
volume condition. For FY 2006, there were 322,946 reported cases of 
Medicare patients who had a pressure ulcer as a secondary diagnosis. 
These cases had average charges for the hospital stay of $40,381.
    Prevention guidelines--Prevention guidelines can be found at the 
following Web sites: http://www.npuap.org/positn1.html. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.4409
    CC--Decubitus ulcer codes are classified as CCs under the current 
CMS DRGs. Codes 707.00, 707.01, and 707.09 are CCs under the proposed 
MS-DRGs. Codes 707.02 through 707.07 are considered MCCs under the 
proposed MS-DRGs. As discussed earlier, MCCs result in even larger 
payments than CCs.
    Considerations--Pressure ulcers are an important hospital-acquired 
complication. Prevention guidelines exist (non-CDC) and can be 
implemented by hospitals. Clinicians may state that some pressure 
ulcers present on admission cannot be identified (skin is not yet 
broken (Stage I) but damage to tissue is already done and skin will 
eventually break down. However, by selecting this condition, we would 
provide hospitals the incentive to perform careful examination of the 
skin of patients on admission to identify decubitus ulcers. If the 
condition is present on admission, the provision will not apply. We are 
proposing to include pressure ulcers as one of our initial hospital-
acquired conditions. This condition can be clearly identified through 
ICD-9-CM codes. These codes are classified as a CC under the current 
CMS DRGs and as a CC or MCC under the proposed MS-DRGs. Pressure ulcers 
meet the burden criteria because they are both high cost and high 
frequency cases. There are clear prevention guidelines. While there is 
some question as to whether all cases with developing pressure ulcers 
can be identified on admission, we believe the selection of this 
condition will result in a closer examination of the patient's skin on 
admission. This will result in better quality of care. We welcome 
comments on the proposed inclusion of this condition.
Serious Preventable Events
    Serious preventable events are events that should not occur in 
health care. The injury prevention community has developed information 
on serious preventable events. CMS reviewed the list of serious 
preventable events and identified those events for which there was an 
ICD-9-CM code that would assist in identifying them. We identified four 
types of serious preventable events to include in our evaluation. These 
include leaving an object in a patient; performing the wrong surgery 
(surgery on the wrong body part, wrong patient, or the wrong surgery); 
air embolism following surgery; and providing incompatible blood or 
blood products. Three of these serious preventable events have unique 
ICD-9-CM codes to identify them. There is not a clear and unique code 
for surgery performed on the wrong body part, wrong patient, or the 
wrong surgery. Each of these events is discussed separately.
(c) Serious Preventable Event--Object Left in During Surgery
    Coding--Retention of a foreign object in a patient after surgery is 
identified through ICD-9-CM code 998.4 (Foreign body accidentally left 
during a procedure).
    Burden (High Cost/High Volume)--For FY 2006, there were 764 cases 
reported of Medicare patients who had an object left in during surgery 
reported as a secondary diagnosis. The average charges for the hospital 
stay were $61,962. This is a rare event. Therefore, it is not high 
volume. However, an individual case will likely have high costs, given 
that the patient will need additional surgery to remove the foreign 
body. Potential adverse events stemming from foreign body could further 
raise costs for an individual case.
    Prevention guidelines--There are widely accepted and clear 
guidelines for the prevention of this event. Prevention guidelines for 
avoiding leaving objects in during surgery are located at the following 
Web site: http://www.qualityindicators.ahrq.gov/psi_download.htm. This 
event should not occur.
    CC--This code is a CC under the current CMS DRGs as well as under 
the proposed MS-DRGs.
    Considerations--There are no significant considerations for this 
condition. There is a unique ICD-9-CM code and wide agreement on the 
prevention guidelines. We are proposing to include this condition as 
one of our initial hospital-acquired conditions. The cases can be 
clearly identified through an ICD-9-CM. This code is a CC under both 
the current CMS DRGs and the proposed MS-DRGs. There are clear 
prevention guidelines. While the cases may not meet the high frequency 
criterion, they do meet the high-cost criterion. Individual cases can 
be high cost. We welcome comments on including this condition as one of 
our initial hospital-acquired conditions.
(d) Serious Preventable Event--Air Embolism
    Coding--An air embolism is identified through ICD-9-CM code 999.1 
(Complications of medical care, NOS, air embolism).
    Burden (High Cost/High Volume)--This event is rare. For FY 2006, 
there were 45 reported cases of air embolism for Medicare patients. The 
average charges for the hospital stay were $66,007.
    Prevention guidelines--There are clear prevention guidelines for 
air embolisms. This event should not occur. Serious preventable event 
guidelines can be found at the following Web site: http://www.qualityindicators.ahrq.gov/psi_download.htm.
    CC--This code is a CC under the current CMS DRGs and is an MCC 
under the proposed MS-DRGs.
    Considerations--There are no significant considerations for this 
condition. There is a unique ICD-9-CM code and wide agreement on the 
prevention guidelines. In addition, as stated earlier, the condition is 
a CC under the current CMS DRGs and an MCC under the proposed MS-DRGs. 
While the condition is rare, it does meet the cost burden criterion 
because individual cases can be expensive. Therefore, air embolism is a 
high-cost condition because average charges per case are high. We 
welcome comments on the proposal to include this condition.

[[Page 24721]]

(e) Serious Preventable Event--Blood Incompatibility
Coding--Delivering ABO-incompatible blood or blood products is 
identified by ICM-9-CM code 999.6 (Complications of medical care, NOS, 
ABO incompatibility reaction).
    Burden (High Cost/High Volume)--This event is rare. Therefore, it 
is not high volume. For FY 2006, there were 33 reported cases of blood 
incompatibility among Medicare patients, with average charges of 
$46,492 for the hospital stay. Therefore, individual cases have high 
costs.
    Prevention guidelines--There are prevention guidelines for avoiding 
the delivery of incompatible blood or blood products. The event should 
not occur. Serious preventable event guidelines can be found at the 
following Web site: http://www.qualityindicators.ahrq.gov/psi_download.htm
    CC--This code is a CC under the current CMS DRGs as well as the 
proposed MS-DRGs.
    Considerations--There are no significant considerations for this 
condition. There is a unique ICD-9-CM code which is classified as a CC 
under the CMS DRGs as well as the proposed MS-DRGs. There is wide 
agreement on the prevention guidelines. While this may not be a high-
volume condition, average charges per case are high. Therefore, we 
believe this condition is a high-cost condition and, therefore, meets 
our burden criterion. We are proposing to include this condition as one 
of our initial hospital-acquired conditions.
(f) Staphylococcus Aureus Bloodstream Infection/Septicemia
    Coding--ICD-9-CM Code 038.11 (Staphylococcus aureus septicemia) 
identifies this condition. However, the codes selected to identify 
septicemia are somewhat complex. The following ICD-9-CM codes may also 
be reported to identify septicemia:
     995.91 (Sepsis) and 995.92 ( Severe sepsis). These codes 
are reported as secondary codes and further define cases with 
septicemia.
     998.59 (Other postoperative infections). This code 
includes septicemia that develops postoperatively.
     999.3 (Other infection). This code includes but is not 
limited to sepsis/septicemia resulting from infusion, injection, 
transfusion, vaccination (ventilator-associated pneumonia also included 
here).
    Burden (High Cost/High Volume)--CDC reports that there are 290,000 
cases of staphylococcus aureus infection annually in hospitalized 
patients of which approximately 25 percent are bloodstream infections 
or sepsis. For FY 2006, there were 29,500 cases of Medicare patients 
who had staphylococcus aureus infection reported as a secondary 
diagnosis. The average charges for the hospital stay were $82,678. 
Inpatient staphylococcus aureus result in an estimated 2.7 million days 
in excess length of stay, $9.5 billion in excess charges, and 
approximately 12,000 inpatient deaths per year.
    Prevention guidelines--CDC guidelines are located at the following 
Web site: http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html.
    CC--Codes 038.11, 995.91, 998.59, and 999.3 are classified as CCs 
under the current CMS DRGs and as MCCs under the proposed MS-DRGs.
    Considerations--Preventive health care associated bloodstream 
infections/septicemia that are preventable are primarily those that are 
related to a central venous/vascular catheter, a surgical procedure 
(postoperative sepsis) or those that are secondary to another 
preventable infection (for example, sepsis due to catheter-associated 
urinary tract infection). Otherwise, physicians and other public health 
experts may argue whether septicemia is reasonably preventable. The 
septicemia may not be simply a hospital-acquired infection. It may 
simply be a progression of an infection that occurred prior to 
admission. Furthermore, physicians cannot always tell whether the 
condition was hospital-acquired. We examined whether it might be better 
to limit the septicemia cases to a specific organism (for example, code 
038.11 (Staphylococcus aureus septicemia)). CDC staff recommended that 
we focus on staphylococcus aureus septicemia because this condition is 
a significant public health issue. As stated earlier, there is a 
specific code for staphylococcus aureus septicemia, code 038.11. 
Therefore, the cases would be easy to identify. However, as stated 
earlier, while this type of septicemia is identified through code 
038.11, coders may also provide sepsis code 995.91 or 995.92 to more 
fully describe the staphylococcus aureus septicemia. Codes 995.91 and 
995.92 are reported as secondary codes and further define cases with 
septicemia. Codes 995.91 and 995.92 are CCs under the current CMS DRGs 
and MCCs under the proposed MS-DRGs.
     998.59 (Other postoperative infections). This code 
includes septicemia that develops postoperatively.
     999.3 (Other infection). This code includes but is not 
limited to sepsis/septicemia resulting from infusion, injection, 
transfusion, vaccination (ventilator-associated pneumonia also indexed 
here).
    To implement this condition as one of our initial ones, we would 
have to exclude the specific code for staphylococcus aureus septicemia, 
038.11, and the additional septicemia codes, 995.91, 995.92, 998.59, 
and 999.3.
    We acknowledge that there are additional issues involved with the 
selection of this condition that may involve developing an exclusion 
list of conditions present on admission for which we would not apply a 
CC exclusion to staphylococcus aureus septicemia. For example, a 
patient may come into the hospital with a staphylococcus aureus 
infection such as pneumonia. The pneumonia might develop into 
staphylococcus aureus septicemia during the admission. It may be 
appropriate to consider excluding cases such as those of patients 
admitted with staphylococcus aureus pneumonia that subsequently develop 
staphylococcus aureus septicemia from the provision. In order to 
exclude cases that did not have a staphylococcus aureus infection prior 
to admission, we would have to develop a list of specific codes that 
identified all types of staphylococcus aureus infections such as code 
482.41 (Pneumonia due to staphylococcus aureus). We likely would not 
apply the new provision to cases of staphylococcus aureus septicemia if 
a patient were admitted with staphylococcus aureus pneumonia. However, 
if the patient had other types of infections, not classified as being 
staphylococcus aureus, and then developed staphylococcus aureus 
septicemia during the admission, we would apply the provision and 
exclude the staphylococcus aureus septicemia as a CC. We were not able 
to identify any other specific ICD-9-CM codes that identify specific 
infections as being due to staphylococcus aureus.
    Other types of infections, such as urinary tract infections, would 
require the reporting of an additional code, 041.11 (Staphylococcus 
aureus), to identify the staphylococcus aureus infection. This 
additional coding presents administrative issues, because it will not 
always be clear which condition code 041.11 (Staphylococcus aureus) is 
describing. We do not believe it would be appropriate to make code 
041.11, in combination with other codes, subject to the hospital-
acquired conditions provision until we better understand how to address 
the

[[Page 24722]]

administrative issues that would be associated with their selection. 
Therefore, we would exclude staphylococcus aureus septicemia cases with 
code 482.41 reported as being subject to the hospital-acquired 
conditions provision. Stated conversely, we would allow staphylococcus 
aureus septicemia to count as a CC if the patient was admitted with 
staphylococcus aureus pneumonia.
    We recognize that there may be other conditions which we should 
consider for this type of exclusion. We are proposing to include 
staphylococcus aureus bloodstream infection/septicemia (code 038.11) as 
one of our initial hospital-acquired conditions. We would also exclude 
codes 995.91, 998.59, and 999.3 from counting as an MCC/CC when they 
are reported with code 038.11. The condition can be clearly identified 
through ICD-9-CM codes that are classified as CC under the current CMS 
DRGs and MCCs under the proposed MS-DRGs. The condition meets our 
burden criterion by being both high cost and high volume. There are 
prevention guidelines which we acknowledge are subject to some debate 
among the medical community. We also acknowledge that we would have to 
exclude this condition if a patient were admitted with a staphylococcus 
aureus infection of a more limited location, such as pneumonia. We 
encourage commenters to make suggestions on this issue and to recommend 
any other appropriate exclusion for staphylococcus aureus septicemia. 
We encourage comments on the appropriateness of selecting 
staphylococcus aureus septicemia as one of our proposed initial 
hospital-acquired conditions.
(g) Ventilator Associated Pneumonia (VAP) and Other Types of Pneumonia 
Coding `` Pneumonia is identified through the following codes:
     073.0 (Ornithosis with pneumonia)
     112.4 (Candidiasis of lung)
     136.3 (Pneumocystosis)
     480.0 (Pneumonia due to adenovirus)
     480.1 (Pneumonia due to respiratory syncytial virus)
     480.2 (Pneumonia due to parainfluenza virus)
     480.3 (Pneumonia due to SARS-associated coronavirus)
     480.8 (Pneumonia due to other virus not elsewhere 
classified)
     480.9 (Viral pneumonia, unspecified)
     481 (Pneumococcal pneumonia [Streptococcus pneumoniae 
pneumonia])
     482.0 (Pneumonia due to Klebsiella pneumoniae)
     482.1 (Pneumonia due to Pseudomonas)
     482.2 (Pneumonia due to Hemophilus influenzae [H. 
influenzae])
     482.30 (Pneumonia due to Streptococcus, unspecified)
     482.31 (Pneumonia due to Streptococcus, Group A)
     482.32 (Pneumonia due to Streptococcus, Group B)
     482.39 (Pneumonia due to other Streptococcus)
     482.40 (Pneumonia due to Staphylococcus, unspecified)
     482.41 (Pneumonia due to Staphylococcus aureus)
     482.49 (Other Staphylococcus pneumonia)
     482.81 (Pneumonia due to Anaerobes)
     482.82 (Pneumonia due to Escherichia coli [E. coli])
     482.83 (Pneumonia due to other gram-negative bacteria)
     482.84 (Pneumonia due to Legionnaires' disease)
     482.89 (Pneumonia due to other specified bacteria)
     482.9 (Bacterial pneumonia unspecified)
     483.0 (Pneumonia due to Mycoplasma pneumoniae)
    There is not a unique code that identifies ventilator associated 
pneumonia. The creation of a code for ventilator associated pneumonia 
was discussed at the September 29, 2006 meeting of the ICD-9-CM 
Coordination and Maintenance Committee meeting. Many issues and 
concerns were raised at the meeting concerning the creation of this 
proposed new code. It has been difficult to define ventilator-
associated pneumonia. We plan to continue working closely with the CDC 
to develop a code that can accurately describe this condition for 
implementation in FY 2009. CDC will address the creation of a unique 
code for this condition at the September 28-29, 2007 ICD-9-CM 
Coordination and Maintenance Committee meeting.
    While we list 27 pneumonia codes above, our clinical advisors do 
not believe that all of the codes mentioned could possibly be 
associated with ventilator-associated pneumonia. Our clinical advisors 
specifically question whether the following codes would ever represent 
cases of ventilator-associated pneumonia: 073.0, 480.0, 480.1, 480.2, 
480.3, 480.8, 480.9, and 483.0. Therefore, we have a range of pneumonia 
codes, all of which may not represent cases that could involve 
ventilator-associated pneumonia. In addition, we do not have a specific 
code that uniquely identifies cases of ventilator-associated pneumonia.
    Burden (High Cost/High Volume)--CDC reports that there are 250,205 
ventilator-associated pneumonias per year. Because there is not a 
unique ICD-9-CM code for ventilator-associated pneumonia, there is not 
accurate data for FY 2006 on the number of Medicare patients who had 
this condition as a secondary diagnosis. However, we did examine data 
for FY 2006 on the number of Medicare patients who listed pneumonia as 
a secondary diagnosis. There were 92,586 cases with a secondary 
diagnosis of pneumonia, with average charges of $88,781. According to 
the journal Critical Care Medicine, patients with ventilator-associated 
pneumonia have statistically significantly longer intensive care 
lengths of stay (mean = 6.10 days) than those who do not (mean = 5.32-
6.87 days). In addition, patients who develop ventilator-associated 
pneumonia incur, on average, greater than or equal to $10,019 in 
additional hospital costs compared to those who do not.\13\ Therefore, 
we believe that this is a high-volume condition.
---------------------------------------------------------------------------

    \13\ Safdar N.: Clinical and Economic Consequences of 
Ventilator-Associated Pneumonia: A Systematic Review, Critical Care 
Medicine, 2005, 33(10), pp. 2184-2193.
---------------------------------------------------------------------------

    Prevention guidelines--Prevention guidelines are located at the 
following Web site: http://www.cdc.gov/ncidod/dhqp/ gl--
hcpneumonia.html. However, it is not clear how effective these 
guidelines are in preventing pneumonia. Ventilator-associated pneumonia 
may be particularly difficult to prevent.
    CC--All of the pneumonia codes listed above are CCs under the 
current CMS DRGs and under the proposed MS-DRGs, except for the 
following pneumonia codes which are non-CCs: 073.0, 480.0, 480.1, 
480.2, 480.3, 480.8, 480.9, 483.0. However, as mentioned earlier, there 
is not a unique ICD-9-CM code for ventilator-associated pneumonia. 
Therefore, this condition does not currently meet the statutory 
criteria for being selected.
    Considerations--Hospital-acquired pneumonias, and specifically 
ventilator associated pneumonias, are an important problem. However, 
based on our work with the medical community to develop specific codes 
for this condition, we have learned that it is difficult to define what 
constitutes ventilator associated pneumonia. Although prevention 
guidelines exist, it is not clear how effective these are in preventing 
pneumonia. Clinicians cannot always tell which pneumonias are acquired 
in a hospital. In addition,

[[Page 24723]]

as mentioned above, there is not a unique code that identifies 
ventilator-associated pneumonia. There are a number of codes that 
capture a range of pneumonia cases. It is not possible to specifically 
identify if these pneumonia cases are ventilator-associated or arose 
from other sources. Because we cannot identify cases with ventilator-
associated pneumonia and there are questions about its preventability, 
we are not proposing to select this condition as one of our initial 
hospital-acquired conditions. However, we welcome public comments on 
how to create an ICD-9-CM code that identifies ventilator-associated 
pneumonia, and we encourage participation in our September 28-29, 2007 
ICD-9-CM Coordination and Maintenance Committee meeting where this 
issue will be discussed. We will reevaluate the selection of this 
condition in FY 2009.
(h) Vascular Catheter-Associated Infections
    Coding--The code used to identify vascular catheter associated 
infections is ICD-9-CM code 996.62 (Infection due to other vascular 
device, implant, and graft). This code includes infections associated 
with all vascular devices, implants, and grafts. It does not uniquely 
identify a vascular catheter associated infections. Therefore, there is 
not a unique ICD-9-CM code for this infection. CDC and CMS staff 
requested that the ICD-9-CM Coordination and Maintenance Committee 
discuss the creation of a unique ICD-9-CM code for vascular catheter 
associated infections because the issue is important for public health. 
The proposal to create a new ICD-9-CM was discussed at the March 22-23, 
2007 meeting of the ICD-9-CM Coordination and Maintenance Committee. A 
summary of this meeting can be found at: http://www.cdc.gov/nchs/icd9.htm. Coders would also assign an additional code for the infection 
such as septicemia. Therefore, a list of specific infection codes would 
have to be developed to go along with code 996.62. If the vascular 
catheter associated infection was hospital-acquired, the DRG logic 
would have to be modified so that neither the code for the vascular 
catheter associated infection along with the specific infection code 
would count as a CC.
    Burden (High Cost/High Volume)--CDC reports that there are 248,678 
central line associated bloodstream infections per year. It appears to 
be both high cost and high volume. However, we were not able to 
identify Medicare data on these cases because there is no existing 
unique ICD-9-CM code.
    Prevention guidelines--CDC guidelines are located at the following 
Web site: http://www.cdc.gov/ncidod/dhqp/gl_intravascular.html.
    CC--Code 996.62 is a CC under the current CMS DRGs and the proposed 
MS-DRGs. However, as stated earlier, this code is broader than vascular 
catheter-associated infections. Therefore, there is not a unique ICD-9-
CM code to identify the condition at this time, and it does not 
currently meet the statutory criteria to be selected. However, as 
indicated above, we will be creating a code(s) to identify this 
condition and may select it as a condition under the provision 
beginning in FY 2009.
    Considerations--There is not yet a unique ICD-9-CM code to capture 
this condition. If one is implemented on October 1, 2007, we would be 
able to specifically identify these cases. Some patients require long-
term indwelling catheters, which are more prone to infections. Ideally 
catheters should be changed at certain time intervals. However, 
circumstances might prevent such practice (for example, the patient has 
a bleeding diathesis). In addition, a patient may acquire an infection 
from another source which can colonize the catheter. As mentioned 
earlier, coders would also assign an additional code for the infection, 
such as septicemia. Therefore, a list of specific infection codes would 
have to be developed to go along with code 996.62. If the vascular 
catheter-associated infection was hospital-acquired, the DRG logic 
would have to be modified so that neither the code for the vascular 
catheter-associated infection along with the specific infection code 
would count as a CC. Without a specific code for infections due to a 
catheter, it would be difficult to identify these patients. Given the 
current lack of an ICD-9-CM code for this condition, we are not 
proposing to include it as one of our initial hospital-acquired 
conditions at this time. However, we believe it shows merit for 
inclusion in future lists of hospital-acquired conditions once we have 
resolved the coding issues and are able to better identify the 
condition in the Medicare data. We will reevaluate the selection of 
this condition in FY 2009.
    We encourage comments on this condition which was identified as an 
important public health issue by several organizations that provided 
recommendations on hospital-acquired conditions. We are particularly 
interested in receiving comments on how we should handle additional 
associated infections that might develop along with the vascular 
catheter-associated infection.
(i) Clostridium Difficile-Associated Disease (CDAD)
    Coding--This condition is identified by ICD-9-CM code 008.45 
(Clostridium difficile).
    Burden (High Cost/High Volume)--CDC reports that there are 178,000 
cases per year in U.S. hospitals. For FY 2006, there were 110,761 
reported cases of Medicare patients with CDAD as a secondary diagnosis, 
with average charges for the hospital stay of $52,464. Therefore, this 
is a high-volume condition.
    Prevention guidelines--Prevention guidelines are not available. 
Therefore, we do not believe this condition can reasonably be prevented 
through the application of evidence-based guidelines.
    CC--Code 008.45 is a CC under the current CMS DRGs and the proposed 
MS-DRGs.
    Considerations--CDAD is an emerging problem with significant public 
health importance. If found early CDAD cases can easily be treated. 
However, cases not diagnosed early can be expensive and difficult to 
treat. CDAD occurs in patients on a variety of antibiotic regiments, 
many of which are unavoidable, and therefore preventability is an 
issue. We are not proposing to include CDAD as one of our initial 
hospital-acquired conditions at this time, given the lack of prevention 
guidelines. We welcome public comments on CDAD, specifically on its 
preventability and whether there is potential to develop guidelines to 
identify it early in the disease process and/or diminish its incidence. 
We will reevaluate the selection of this condition in FY 2009.
(j) Methicillin-Resistant Staphylococcus Aureus (MRSA)
    Coding--MRSA is identified by ICD-9-CM code V09.0 (Infection with 
microorganisms resistant to penicillins). One would also assign a 
code(s) to describe the exact nature of the infection.
    Burden (High Cost/High Volume)--For FY 2006, there were 95,103 
reported cases of Medicare patients who had MRSA as a secondary 
diagnosis. The average charges for these cases were $31,088. This 
condition is a high-cost and high-volume infection. MRSA has become a 
very common bacteria occurring both in and outside of the hospital 
environment.
    Prevention guidelines--CDC guidelines are located at the following 
Web site: http://www.cdc.gov/ncidod/dhqp/pdf/ar/mdroGuideline2006.pdf.
    CC--Code V09.0 is not a CC under the current CMS DRGs and the 
proposed

[[Page 24724]]

MS-DRGs. The specific infection would be identified in a code 
describing the exact nature of the infection, which may be a CC.
    Considerations--As stated earlier, preventability may be hard to 
ascertain since the bacteria has become so common both inside and 
outside the hospital. There are also considerations in identifying MRSA 
infections because hospitals would report the code for MRSA along with 
additional codes that would describe the exact nature of the infection. 
We would have to develop a list of specific infections that could be 
the result of MRSA. We are not proposing to include MRSA as one of our 
initial hospital-acquired conditions because the condition is not a CC. 
We recognize that associated conditions may be a CC. We welcome 
comments on the proposal not to include this condition. Should there be 
support for including this condition, we request recommendations on 
what codes might be selected to identify the specific types of 
infections associated with MRSA.
(k) Surgical Site Infections
    Coding--Surgical site infections are identified by ICD-9-CM code 
998.59 (Other postoperative infection). The code does not tell the 
exact location or nature of the postoperative wound infection. The code 
includes wound infections and additional types of postoperative 
infections such as septicemia. The coding guidelines instruct the coder 
to add an additional code to identify the type of infection. To 
implement this condition we would have to remove both code 998.59 and 
the specific infection from counting as a CC if they occurred after the 
admission. We would have to develop an extensive list of possible 
infections that would be subject to the provision. We may also need to 
recommend the creation of a series of new ICD-9-CM codes to identify 
various types of surgical site infections, should this condition merit 
inclusion among those that are subject to the proposed hospital-
acquired conditions provision.
    Burden (High Cost/High Volume)--CDC reports that there are 290,485 
surgical sites infections each year. As stated earlier, there is not a 
unique code for surgical site infection. Therefore, we examined 
Medicare data on patients with any type of postoperative infection. For 
FY 2006, there were 38,763 reported cases of Medicare patients who had 
a postoperative infection. These patients had average charges for the 
hospital stay of $79,504. We are unable to determine how many of these 
patients had surgical site infections.
    Prevention guidelines--CDC guidelines are available at the 
following Web site: http://www.cdc.gov/ncidod/dhqp/gl_surgicalsite.html
    CC--Code 998.59 is a CC under the current CMS DRGs and the proposed 
MS-DRGs.
    Considerations--As mentioned earlier, code 998.59 is not exclusive 
to surgical site infections. It includes other types of postoperative 
infections. Therefore, code 998.59 does not currently meet the 
statutory criteria for being subject to the provision because it does 
not uniquely identify surgical site infections. To identify surgical 
site infections, we would need new codes that provide more detail about 
the type of postoperative infection as well as the site of the 
infection. In addition, one would report both code 998.59 as well a 
more specific code for the specific type of infection, making 
implementation difficult. While there are prevention guidelines, it is 
not always possible to identify the specific types of surgical 
infections that are preventable. Therefore, we are not proposing to 
select surgical site infections as one of our proposed hospital-
acquired conditions at this time. However, we welcome public comments 
on whether we can develop criteria and codes to identify preventable 
surgical site infections that would assist us in reducing their 
incidence. We are exploring ways to identify surgical site infections 
and will reevaluate this condition in FY 2009.
(l) Serious Preventable Event--Surgery on Wrong Body Part, Patient, or 
Wrong Surgery
    Coding--Surgery performed on the wrong body part, wrong patient, or 
the wrong surgery would be identified by ICD-9-CM code E876.5 
(Performance of inappropriate operation). This diagnosis code does not 
specifically identify which of these events has occurred.
    Burden (High Cost/High Volume)--As stated earlier, there are not 
unique ICD-9-CM codes which capture surgery performed on the wrong body 
part or the wrong patient, or the wrong surgery. Therefore, we examined 
Medicare data on the code for performance of an inappropriate 
operation. For FY 2006, there was one Medicare case reported with this 
code, and the patient had average charges for the hospital stay of 
$24,962. This event is rare. Therefore, it is not high volume. 
Individual cases could have high costs. However, we were unable to 
determine the impact with our limited data.
    Prevention guidelines--There are prevention guidelines for 
performing the correct surgery on the correct patient or correct 
patient's body part. This event should not occur.
    CC--This code is not a CC under the current CMS DRGs and the 
proposed MS-DRGs. Therefore, it does not meet the criteria for 
selection under section 1886(d)(4)(D)(iv) of the Act. However, Medicare 
does not pay for performing surgery on the wrong body part or patient, 
or performing the wrong surgery. These services are not considered to 
be reasonable and necessary and are excluded from Medicare coverage.
    Considerations--There are significant considerations for the 
selection of this condition. There is not a unique ICD-9-CM code that 
would describe the nature of the inappropriate operation. All types of 
inappropriate operations are included in code E876.5. Unlike other 
conditions, performance of an inappropriate operation is not a 
complication of a prior medical event that was medically necessary. 
Rather, in this case, there was a needed intervention but it was done 
to either the wrong body part or the wrong patient, or was not the 
correct operation. Thus, a service was completed that was not 
reasonable and necessary and Medicare does not pay for any inpatient 
service associated with the wrong surgery. It is not necessary for us 
to select this condition because Medicare does not pay for it under any 
circumstances.
(m) Falls
    Coding--There is no single code that shows that a patient has 
suffered a fall in the hospital. Codes would be assigned to identify 
the nature of any resulting injury from the fall such as a fracture, 
contusion, concussion, etc. There is a code to indicate that a patient 
fell from bed, code E884.4 (Fall from bed). One would then assign a 
code that identifies the external cause of the injury (the fall from 
the bed) and an additional code(s) for any resulting injury (a 
fractured bone).
    Burden (High Cost/High Volume)--As stated earlier, there is not a 
code to capture all types of falls. Therefore, we examined Medicare 
data on the number of Medicare beneficiaries who fell out of bed. For 
FY 2006, there were 2,591 cases reported of Medicare patients who fell 
out of bed. These patients had average charges of the hospital stay of 
$24,962. However, depending on the nature of the injury, costs may vary 
in specific cases.
    Prevention guidelines--Falls may or may not be preventable. Serious 
preventable event guidelines can be found at the following Web site: 
http://www.qualityindicators.ahrq.gov/psi_download.htm

[[Page 24725]]

    CC--Code E884.4 is not a CC under the current CMS DRGs or the 
proposed MS-DRGs.
    Considerations--There are not clear codes that identify all types 
of falls. Hospitals would also have to use additional codes for 
fractures and other injuries that result from the fall. In addition, 
depending on the circumstances, the falls may or may not be 
preventable. We are not proposing the inclusion of falls as one of our 
initial hospital-acquired conditions at this time because we can only 
identify a limited number of these cases, and they are not classified 
as a CC. However, we welcome public comments on how to develop codes or 
coding logic that would allow us to identify injuries that result from 
falls in the hospital so that Medicare would not recognize the higher 
costs associated with treating patients who acquire these conditions in 
the hospital. We will reevaluate this condition in FY 2009.
    The following table summarizes whether or not the potential 
conditions meet our criteria and if there are significant 
considerations with selecting the particular condition. As mentioned 
earlier, we have listed these conditions in the priority order 
according to how well they meet the statutory criteria. As discussed 
earlier, we are proposing to select the first six conditions (catheter 
associated urinary tract infections through Staphylococcus aureus 
septicemia) as our initial hospital-acquired conditions. We would not 
include the last seven conditions (ventilator-associated pneumonia 
through falls) as initial hospital-acquired conditions. We welcome 
comments on how appropriately we have evaluated and proposed the 
selection of the first six conditions. We also encourage specific 
comments on any additional conditions we should select for October 1, 
2008 implementation. We request commenters to include a rationale for 
selecting any suggested additional conditions, as well as an analysis 
of why each suggested additional condition meets the criteria under 
section 1886(d)(4)(D)(iv) of the Act and whether there would be coding 
issues or other considerations associated with selecting each 
condition.

                                                   Proposed Hospital-Acquired Conditions and Criteria
--------------------------------------------------------------------------------------------------------------------------------------------------------
    Proposed hospital-acquired                             Burden--high cost        Prevention
            condition              Coding--unique code?   and/or high volume?       guidelines?               CC?                 Considerations?
--------------------------------------------------------------------------------------------------------------------------------------------------------
1. Catheter associated urinary     Yes.................  Yes.................  Yes.................  Yes.................  Minimal--additional infection
 tract infections.                                                                                                          codes.
2. Pressure ulcers (Decubitus      Yes.................  Yes.................  Yes.................  Yes.................  No.
 ulcers).
3. Serious preventable event--     Yes.................  Yes--high cost in     Yes.................  Yes.................  No.
 Object left in surgery.                                  specific
                                                          circumstances.
4. Serious preventable event--air  Yes.................  Yes--high cost in     Yes.................  Yes.................  No .
 embolism.                                                specific
                                                          circumstances.
5. Serious preventable event--     Yes.................  Yes--high cost in     Yes.................  Yes.................  No.
 Blood incompatibility.                                   specific
                                                          circumstances.
6. Staphylococcus aureus           Yes--multiple codes   Yes.................  Yes.................  Yes.................  Multiple codes.
 septicemia.                        reported.
7. Ventilator associated           No VAP code,          Yes.................  Yes.................  No--no unique codes.  Preventability issues. VAPs--
 pneumonia (VAP)/Pneumonia/.        multiple pneumonia                                                                      identification issues.
                                    codes.
8. Vascular catheter associated    No..................  Yes.................  Yes.................  Yes--but code is too  Preventability issues.
 infections.                                                                                          broad.
9. Clostridium difficile-          Yes.................  Yes.................  No..................  Yes.................  Preventability issues.
 associated disease (CDAD).
10. Methicillin-resistant          Yes.................  Yes.................  Yes.................  No..................  Preventability issues.
 staphylococcus aureus (MRSA).
11. Surgical site infections.....  No..................  Yes.................  Yes.................  Yes--but code is too  Cannot identify.
                                                                                                      broad.
12. Serious preventable event--    Yes.................  Yes--high cost in     Yes.................  No..................  Not a CC.
 Wrong surgery.                                           specific
                                                          circumstances.
13. Falls........................  No--not for all       Yes--high cost in     No--for all types of  No..................  Cannot identify.
                                    types of falls.       specific              falls.
                                                          circumstances.
--------------------------------------------------------------------------------------------------------------------------------------------------------

    As stated earlier, we are soliciting comments on the six conditions 
we proposed to include among the initial hospital-acquired conditions. 
We welcome any comments on the clinical aspects of the conditions and 
on which conditions should be selected for implementation on October 1, 
2008. We also solicit comments on any problematic issues for specific 
conditions that may support not selecting them as one of the initial 
conditions. We encourage comments on how some of the administrative 
problems can be overcome if there is support for a particular 
condition.
7. Other Issues
    Under section 1886(d)(4)(D)(vi) of the Act, ``[a]ny change 
resulting from the application of this subparagraph shall not be taken 
into account in adjusting the weighting factors under subparagraph 
(C)(i) or in applying budget neutrality under subparagraph (C)(iii).'' 
Subparagraph (C)(i) refers to DRG classifications and relative weights. 
Therefore, the statute requires the Secretary to continue counting the 
conditions selected under section 5001(c) of the DRA as MCCs or CCs 
when updating the relative weights annually. Thus, the higher costs

[[Page 24726]]

associated with a case with a hospital-acquired MCC or CC will continue 
to be assigned to the MCC or CC DRG when calculating the relative 
weight but payment will not be made to the hospital at one of these 
higher-paying DRGs. Further, subparagraph (C)(iii) refers to the budget 
neutrality calculations that are done so aggregate payments do not 
increase as a result of changes to DRG classifications and relative 
weights. Again, the higher costs associated with the cases that have a 
hospital-acquired MCC or CC will be included in the budget neutrality 
calculation but Medicare will make a lower payment to the hospital for 
the specific case that include an MCC or CC. Thus, to the extent that 
the provision applies and cases with an MCC or CC are assigned to a 
lower-paying DRG, section 5001(c) of the DRA will result in cost 
savings to the Medicare program. We note that the provision will only 
apply when the selected conditions are the only MCCs and CCs present on 
the claim. Therefore, if a nonselected MCC or CC is on the claim, the 
case will continue to be assigned to the higher paying MCC or CC DRG, 
and there will be no savings to Medicare from the case. We believe the 
provision will apply in a small minority of cases because it is rare 
that one of the selected conditions will be the only MCC or CC present 
on the claim. We provide our estimate of the savings associated with 
this provision in the impact section of this proposed rule.

G. Proposed Changes to Specific DRG Classifications

1. Pre-MDC: Intestinal Transplantation
    (If you choose to comment on issues in this section, please include 
the caption ``DRGs: Intestinal Transplantation'' at the beginning of 
your comment.)
    In the FY 2005 IPPS final rule (69 FR 48976), we reassigned 
intestinal transplant cases from CMS DRG 148 (Major Small and Large 
Bowel Procedures with CC) and CMS DRG 149 (Major Small and Large Bowel 
Procedures without CC) to CMS DRG 480 (Liver Transplant and/or 
Intestinal Transplantation). In the FY 2006 IPPS final rule (70 FR 
47286), we continued to evaluate these cases to see if a further DRG 
change was warranted. While we found that intestinal only transplants 
and combination liver-intestine transplants have higher average charges 
than other cases in CMS DRG 480, these cases are extremely rare (there 
were only 4 cases in FY 2004) and the insufficient number of cases does 
not warrant creating a separate DRG.
    For FY 2008, we examined the September 2006 update of the FY 2006 
MedPAR file and found 1,208 cases assigned to CMS DRG 480. In the 
proposed MS-DRGs described in section II.C. of the preamble of this 
proposed rule, we are proposing to split CMS DRG 480 into two severity 
levels: proposed MS-DRG 005 (Liver Transplant and/or Intestinal 
Transplant with MCC) and proposed MS-DRG 006 (Liver Transplant and/or 
Intestinal Transplant without MCC). The following table displays our 
results:

 
------------------------------------------------------------------------
                                                    Average
           Proposed MS-DRG             Number of   length of    Average
                                         cases       stay       charges
------------------------------------------------------------------------
MS-DRG 006--All cases...............         446       10.05    $129,519
MS-DRG 006--Intestinal transplant              3          34     354,793
 cases only.........................
MS-DRG 005--All cases...............         762       22.25     243,271
MS-DRG 005--Intestinal transplant              9       40.22     460,089
 cases only.........................
MS-DRG 005--Intestinal and liver               1          56   1,179,425
 transplant.........................
------------------------------------------------------------------------

    Under the proposed MS-DRGs, 10 of 13 intestinal transplant cases 
are assigned to proposed MS-DRG 005 based on the secondary diagnosis of 
the patient. The three remaining intestinal transplant cases do not 
have an MCC and would have been assigned to proposed MS-DRG 006, absent 
further changes to the DRG logic. These three intestinal transplants 
have average charges of approximately $354,793 and an average length of 
stay of 34 days. Average charges and length of stay for these three 
cases are more comparable to the average charges of approximately 
$243,271 and average length of stay of 40.22 days for all cases 
assigned to proposed MS-DRG 005. For this reason, we are proposing to 
move all intestinal transplant cases to proposed MS-DRG 005. As part of 
this proposal, we would redefine proposed MS-DRG 005 as ``Liver 
Transplant with MCC or Intestinal Transplant.'' The presence of a liver 
transplant with MCC or an intestinal transplant would assign a case to 
the higher severity level. Proposed MS-DRG would also be redefined as 
``Liver Transplant without MCC.''
2. MDC 1 (Diseases and Disorders of the Nervous System)
a. Implantable Neurostimulators
    (If you choose to comment on issues in this section, please include 
the caption ``DRGs: Neurostimulators'' at the beginning of your 
comment.)
    We received a joint request from three manufacturers to review the 
DRG assignment for cases involving neurostimulators. The commenters are 
concerned that:
     Neurostimulator cases may be assigned to 30 different DRGs 
in 12 different MDCs depending upon the patient's principal diagnosis.
     Neurostimulator cases represent a small proportion of the 
total cases in their assigned DRG and have higher costs.
     The 11 new ICD-9-CM codes created beginning in FY 2007 
that identify pain are assigned to MDC 23 (Factors Influencing Health 
Status and Other Contacts With Health Services) rather than MDC 1 
(Diseases and Disorders of the Nervous System). The commenters are 
concerned that these pain codes will be a common principal diagnosis 
for patients who receive a neurostimulator and will be assigned to MDC 
23, which contains a wide variety of dissimilar diagnoses. The new ICD-
9-CM codes are: 338.0 (Central pain syndrome), 338.11 (Acute pain due 
to trauma), 338.12 (Acute post-thoracotomy pain), 338.18 (Other acute 
postoperative pain), 338.19 (Other acute pain), 338.21 (Chronic pain 
due to trauma), 338.22 (Chronic post-thoracotomy pain), 338.28 (Other 
chronic postoperative pain), 338.29 (Other chronic pain), 338.3 
(Neoplasm related pain (acute)(chronic)), and 338.4 (Chronic pain 
syndrome)
    The commenters recommended that we:
     Reroute all spinal and peripheral neurostimulator cases 
into a common set of base DRGs.

[[Page 24727]]

     Reclassify ICD-9-CM pain codes 338.0 through 338.4 
currently assigned to MDC 23 into MDC 1 when reported as principal 
diagnosis.
     Revise surgical CMS DRGs in MDC 1 based on whether the 
patient received a major device.
     Split the single surgical CMS DRG in MDC 19 (Mental 
Diseases and Disorders) and MDC 23 into two CMS DRGs: one CMS DRG for 
minor procedures as defined by CMS DRGs 477 (Non-Extensive O.R. 
Procedure Unrelated to Principal Diagnosis) and CMS DRG 468 (Extensive 
O.R. Procedure Unrelated to Principal Diagnosis) and one CMS DRG for 
major procedures.
     Create a new CMS DRG in MDC 1 for major devices.
    The commenters recognize that implementing a re-routing feature in 
the CMS DRG system would be a major undertaking and, alternatively, 
suggested reassigning the pain codes to MDC 1 as an interim step. We 
agree with this suggestion as described further below. With respect to 
the suggestion to split the single surgical CMS DRG in MDCs 19 and 23 
into two CMS DRGs and create a major device CMS DRG within MDC 1, we 
encourage the commenters to examine the assignment of neurostimulator 
cases under the MS-DRGs to determine whether the changes we are 
proposing to adopt to better recognize severity in the CMS DRG system 
would address these concerns.
    The implantation of a neurostimulator requires two types of 
procedures. First, the surgeons implant leads containing electrodes 
into the targeted section of the brain, spine, or peripheral nervous 
system. Second, a neurostimulator pulse generator is implanted into the 
pectoral region and extensions from the neurostimulator pulse generator 
are tunneled under the skin and connected with the proximal ends of the 
leads. Hospitals stage the two procedures required for a full system 
neurostimulator implant.
    There are separate ICD-9-CM procedure codes that identify the 
implant of the leads and the insertion of the pulse generator. The 
three codes for the leads insertion are: 02.93 (Implantation or 
replacement of intracranial neurostimulator lead(s)); 03.93 
(Implantation or replacement of spinal neurostimulator lead(s)); and 
code 04.92 (Implantation or replacement of peripheral neurostimulator 
lead(s). The five codes for the insertion of the pulse generator are: 
86.94 (Insertion or replacement of single array neurostimulator pulse 
generator, not specified as rechargeable); 86.95 (Insertion or 
replacement of dual array neurostimulator pulse generator, not 
specified as rechargeable); 86.96 (Insertion or replacement of other 
neurostimulator pulse generator); 86.97 (Insertion or replacement of 
single array rechargeable neurostimulator pulse generator); and 86.98 
(Insertion or replacement of dual array rechargeable neurostimulator 
pulse generator).
    The patient's principal diagnosis determines the MDC assignment. 
Implant of a cranial, spinal or peripheral neurostimulator will result 
in assignment of the case to a surgical DRG within that MDC. Although 
the commenters are correct that neurostimulator cases can potentially 
be assigned to many different CMS DRGs based on the patient's principal 
diagnosis, they also provided data that showed that nearly 90 percent 
are assigned to 6 different CMS DRGs that cross two MDCs. In MDC 1, 
neurostimulator cases are assigned to four CMS DRGs: CMS DRG 7 
(Peripheral and Cranial Nerve and Other Nervous System Procedures With 
CC); CMS DRG 8 (Peripheral and Cranial Nerve and Other Nervous System 
Procedures Without CC); CMS DRG 531 (Spinal Procedures With CC); and 
CMS DRG 532 (Spinal Procedures Without CC). In MDC 8 (Disease and 
Disorders of the Musculoskeletal System and Connective Tissue), 
neurostimulator cases are assigned to two CMS DRGs: CMS DRG 499 (Back 
and Neck Procedures Except Spinal Fusion With CC); and CMS DRG 500 
(Back and Neck Procedures Except Spinal Fusion Without CC).
    With very limited exceptions, such as tracheostomies and certain 
types of transplants, the principal diagnosis is fundamental to the 
assignment of a case to an MDC within the DRG system. By relying on the 
patient's principal diagnosis, the DRG system will group together 
patients who are clinically similar. For this reason, we are concerned 
about adopting the suggestion that all neurostimulator cases be 
rerouted to a common DRG irrespective of the patient's principal 
diagnosis. We believe such a step would be fundamentally inconsistent 
with the idea of creating common groups of patients who are clinically 
similar based on diagnosis and procedures. For this reason, we do not 
believe that a rerouting step should be adopted that would group 
together all neurostimulator cases.
    However, we do agree with the commenters' suggestion that the new 
ICD-9-CM codes created in FY 2007 for central and chronic pain syndrome 
and chronic pain (codes 338.0, 338.21 through 338.29, and 338.4) should 
be assigned to MDC 1 when present as the principal diagnosis. The 
commenters requested that we reclassify the pain codes (338.0 through 
338.4) from MDC 23 to MDC 1. Our medical consultants advised that the 
acute pain codes (codes 338.11 through 338.19) should remain in MDC 23 
because the acute pain is not a neurological condition. According to 
the commenters, the National Center for Health Statistics' (NCHS) 
choice in locating the pain codes within ICD-9-CM's Nervous System 
chapter has much clinical validity, particularly for chronic pain. The 
commenters further noted that acute pain is typically self-limited, a 
symptomatic response to an immediate insult that serves the body as a 
warning sign. However, chronic pain is unrelenting and serves no 
warning or protective function. It is a disease process of its own 
accord, according to the commenters.
    The commenters described pain as follows. Broadly, there are two 
main categories of pain: nociceptive and neuropathic. Nociceptive pain 
is caused by sensory neurons, called nociceptors, responding to tissue 
damage. This type of pain is the body's normal response to injury. The 
pain is usually localized and time-limited. That is, when the tissue 
damage heals, the pain typically resolves. Acute pain is typically 
nociceptive. In general, nociceptive pain is typically treated with 
anti-inflammatories and, in more severe cases, with opioids via a 
morphine pump for example.
    In contrast, neuropathic pain is caused by malfunctioning or 
pathologically altered nervous pathways stemming from injury to the 
nervous system, either as a direct result of trauma to a nerve (phantom 
limb syndrome, reflex sympathetic dystrophy/complex regional pain 
syndrome after injury) or due to other medical conditions that cause 
damage to the nerve such as herpes (postherpetic neuralgia), diabetes 
(diabetic neuropathy), and peripheral vascular disease (critical limb 
ischemia). Failed back surgery syndrome (FBSS) is another common source 
of neuropathic pain. Typically, neuropathic pain is chronic and may 
persist for months or years beyond the healing of damaged tissue. 
Because the nerves themselves have been damaged, neuropathic pain can 
be considered its own disease process. Neuropathic pain may be more 
difficult to treat than nociceptive pain and has been shown to be more 
responsive to neurostimulation.
    The pain codes, created effective October 1, 2006, are currently 
assigned to MDC 23. The neurostimulator cases with a principal 
diagnosis using the pain codes were assigned to CMS DRG

[[Page 24728]]

461 (O.R. Procedure With Diagnoses of Other Contact With Health 
Services) for the first time in FY 2007. As explained above, prior to 
our adoption of the new pain codes in FY 2007, these cases had 
historically been assigned to CMS DRGs 7 and 8 (Peripheral and Cranial 
Nerve and Other Nervous System Procedure With and Without CC, 
respectively) tin MDC 1. Adopting the commenters' recommendation would 
result in the neurostimulator cases being assigned to their historic 
CMS DRGs.
    Our medical officers agree that cases that use the new pain 
diagnosis codes for central and chronic pain syndrome and chronic pain 
(codes 338.0, 338.21 through 338.29, and 338.4) as a principal 
diagnosis should be assigned to MDC 1. For this reason, we are 
proposing to assign cases with a principal diagnosis of central pain 
syndrome (code 338.0), chronic pain due to trauma (code 338.21), 
chronic post-thoracotomy pain (code 338.22), other chronic 
postoperative pain (code 338.28), other chronic pain (code 338.29), or 
chronic pain syndrome (code 338.4) to MDC 1, although we plan to 
monitor their use and may reassign them if needed.
b. Intracranial Stents
    (If you choose to comment on issues in this section, please include 
the caption ``DRGs: Intracranial Stents'' at the beginning of your 
comment.)
    Effective October 1, 2004, the ICD-9-CM Coordination and 
Maintenance Committee created procedure code 00.62 (Percutaneous 
angioplasty or atherectomy of intracranial vessel(s)). At the same 
time, we created code 00.65 (Percutaneous insertion of intracranial 
vascular stent(s)). It is our customary practice to assign new codes to 
the same DRG as their predecessor codes. Code 00.62 was removed from 
code 39.50 (Angioplasty or atherectomy of other noncoronary vessel(s)), 
which is assigned to CMS DRG 533 (Extracranial Procedures with CC) and 
CMS DRG 534 (Extracranial Procedures Without CC) (proposed MS-DRGs 37, 
38, and 39 (Extracranial Procedures With MCC, With CC, and Without CC/
MCC, respectively)) when the patient has principal diagnosis in MDC 1. 
Therefore, we assigned code 00.62 to CMS DRGs 533 and 534 in MDC 1 
beginning in FY 2005. In addition, we made code 00.65 a non-O.R. 
procedure for DRG assignment. We also assigned code 00.62 to the Non-
Covered Procedure edit of the MCE, as Medicare had a national 
noncoverage determination for intracranial angioplasty and atherectomy 
with stenting.
    Effective November 7, 2006, Medicare covers percutaneous 
transluminal angioplasty (PTA) and stenting of intracranial arteries 
for the treatment of cerebral artery stenosis in cases in which 
stenosis is 50 percent or greater in patients with intracranial 
atherosclerotic disease when furnished in accordance with FDA-approved 
protocols governing Category B Investigational Device Exemption (IDE) 
clinical trials. CMS determined that coverage of intracranial PTA and 
stenting is reasonable and necessary under these circumstances. All 
other indications for PTA without stenting to treat obstructive lesions 
of the vertebral and cerebral arteries remain noncovered. This decision 
can be found online in the CMS Coverage Manual: http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp at section 20.7.B.5.
    A manufacturer recently met with CMS to request that code 00.62 be 
reassigned to CMS DRGs 1 and 2 (Craniotomy Age > 17 With and Without 
CC, respectively) (proposed MS-DRGs 37 (Extracranial Procedures With 
MCC), 38 (Extracranial Procedures With CC), and 39 (Extracranial 
Procedures Without CC/MCC)) and CMS DRG 543 (Craniotomy with Major 
Device Implant or Acute Complex Central Nervous System Principal 
Diagnosis) (proposed MS-DRGs 23 and 24 (Craniotomy With Major Device 
Implant or Acute Complex Central Nervous System Principal Diagnosis 
With MCC and Without MCC, respectively). The manufacturer noted that 
other similar endovascular intracranial procedures that treat a 
cerebrovascular blockage are currently assigned to the craniotomy CMS 
DRGs. These endovascular-approach cases already assigned to the 
craniotomy CMS DRGs are identified by procedure codes 39.72 
(Endovascular repair or occlusion of head and neck vessels), 39.74 
(Endovascular removal of obstruction from head and neck vessel(s)), and 
39.79 (Other endovascular repair (of aneurysm) of other vessels). Under 
the proposed MS-DRGs, we are proposing to assign procedure codes 39.72, 
39.74, and 39.79 to MS-DRGs 011 through 013 and MS-DRG 543. Although we 
are concerned about the assignment of additional endovascular 
procedures to an open surgical DRG, we agree that there is clinical 
consistency between procedure codes 39.72, 39.74, and 39.79 and 
procedure code 00.62. For this reason, we agree that procedure code 
00.62 should be assigned to CMS DRGs 1, 2, and 543 (proposed MS-DRGs 
37, 38, and 39 and 243 and 24, respectively, that are divided by the 
presence or absence of specific CCs).
    For FY 2008, we are proposing to remove code 00.62 from CMS DRGs 
533 and 534 and assign them to proposed MS-DRGs 37, 38, and 39, as well 
as to proposed MS-DRGs 23 and 24.
    In order to assure appropriate DRG assignment as described above, 
we are proposing to make conforming changes to the MCE by removing code 
00.62 from the Non-Covered Procedure edit. However, as intracranial PTA 
is only covered when performed in conjunction with insertion of a 
stent, we are proposing to redefine the edit by specifying that code 
00.62 must be accompanied by code 00.65 (Percutaneous insertion of 
intracranial vascular stent(s)). Should code 00.65 not be reported on 
the claim, the case would fail the MCE edit. For a full discussion of 
this proposed change, we refer readers to the MCE discussion in section 
II.F.6. of the preamble of this proposed rule.
    Although we are proposing to assign endovascular intracranial 
procedures to the same DRG as craniotomy, we remain concerned that 
endovascular intracranial procedures are clinically different than open 
craniotomy surgical procedures and may have very different resource 
requirements. At the current time, there are an insufficient number of 
cases to warrant creation of a separate base DRG for endovascular 
intracranial procedures. However, we intend to revisit the assignment 
of intracranial endovascular procedures at a later date when more data 
are available to analyze these cases.
3. MDC 3 (Diseases and Disorders of the Ear, Nose, Mouth, and Throat)--
Cochlear Implants
    (If you choose to comment on issues in this section, please include 
the caption ``DRGs: Cochlear Implants'' at the beginning of your 
comment.)
    Cochlear implants were first covered by Medicare in 1986 and were 
assigned to CMS DRG 49 (Major Head and Neck Procedures) in MDC 3 
(Diseases and Disorders of the Ear, Nose, Mouth, and Throat). CMS DRG 
49 is the highest weighted DRG in that MDC. However, two manufacturers 
of cochlear implants contend that this DRG assignment is clinically and 
economically inappropriate and have requested that cochlear implant 
cases be reassigned from CMS DRG 49 to CMS DRG 543 (Craniotomy With 
Major Device Implant or Acute Complex Central Nervous System Principal 
Diagnosis).
    The manufacturers stated that procedures assigned to CMS DRG 49 are 
performed mostly for diseases such as head and neck cancers, while 
procedures in CMS DRG 543 include

[[Page 24729]]

operations on and inside the skull and implantation of complex devices, 
including intracranial neurostimulators. The manufacturers described 
the cochlear implant procedure as requiring incisions behind the ear to 
remove a section of the temporal bone, followed by microscopic 
neurotologic surgery under general anesthesia, and is typically 
completed in 2 to 4 hours to restore hearing to the profoundly deaf. 
For these reasons, these manufacturers believe cochlear implant 
procedures are similar to open craniotomies.
    Based on their analysis of the FY 2005 MedPAR data, the 
manufacturers identified a total of 139 cochlear implant cases using 
ICD-9-CM procedure codes 20.96 (Implantation or replacement of cochlear 
prosthetic device NOS), 20.97 (Implantation or replacement of cochlear 
prosthetic device, single channel), and 20.98 (Implantation or 
replacement of cochlear prosthetic device, multiple channel). The 
manufacturers reported 121 out of 139 cochlear implant cases were 
assigned to CMS DRG 49 with average standardized charges of 
approximately $58,078.
    When we reviewed the FY 2006 MedPAR data, we identified 104 
cochlear implant cases assigned to CMS DRG 49. In the proposed MS-DRGs, 
CMS DRG 49 is subdivided into two severity levels: Proposed MS-DRG 129 
(Major Head and Neck Procedures With CC or MCC) and proposed MS-DRG 130 
(Major Head and Neck Procedures Without CC). The following table 
displays our results:

------------------------------------------------------------------------
                                                  Average
         Proposed MS-DRG            Number of    length of     Average
                                      cases         stay       charges
------------------------------------------------------------------------
MS-DRG 130--All cases............        1,095         3.04      $23,928
MS-DRG 130--Code 20.96 cases only           38         1.63       51,740
MS-DRG 130--Code 20.97 only......            2         1.50       38,855
MS-DRG 130--Code 20.98 only......           45         1.24       50,219
MS-DRG 129--All cases............        1,244         5.35       34,169
MS-DRG 129--Code 20.96 only......           10         2.70       81,351
MS-DRG 129--Code 20.97 only......            1         5.00       95,441
MS-DRG 129--Code 20.98 only......            8         3.13       53.510
------------------------------------------------------------------------

    Under the proposed MS-DRGs, 19 out of 104 cochlear implant cases 
are assigned to proposed MS-DRG 129 based on the secondary diagnosis of 
the patient. The 85 remaining cochlear implant cases do not have a CC 
or MCC and would be assigned to proposed MS-DRG 130, absent further 
changes to the DRG logic.
    The average charges of approximately $54,238 for cochlear implant 
cases are higher than the average charges of approximately $29,375 for 
the other cases in CMS DRG 49. However, the average charges are not as 
high as the average charges of approximately $78,118 for cases assigned 
to CMS DRG 543. Further, our medical advisors do not believe that 
surgery to implant a cochlear implant is clinically similar to an open 
craniotomy in MDC 1 because typically a craniotomy involves removing 
and then replacing a section of the skull in order to perform a 
procedure on or within the brain, whereas a cochlear implant involves 
drilling a hole in the mastoid bone in order to insert the implant into 
the inner ear.
    We have been unable to address this issue under the current DRGs 
because there are not enough inpatient cochlear implant cases to 
warrant creation of a separate DRG. Although these cases will continue 
to have higher charges than other cases in their assigned DRG, we are 
proposing to move the cochlear implant cases to the higher DRG severity 
level within CMS DRG 49. As part of this proposal, we would redefine 
proposed MS-DRG 129 as ``Major Head and Neck Procedures With CC or MCC 
or Major Device''. The presence of a major head and neck procedure with 
a CC or MCC or major device would assign the case to the higher 
severity level within CMS DRG 49.
4. MDC 8 (Diseases and Disorders of the Musculoskeletal System and 
Connective Tissue)
a. Hip and Knee Replacements
    (If you choose to comment on issues in this section, please include 
the caption ``DRGs: Hip and Knee Replacements'' at the beginning of 
your comment.)
    In the FY 2006 IPPS final rule (70 FR 47303), we deleted DRG 209 
(Major Joint and Limb Reattachment Procedures of Lower Extremity) and 
created two new DRGs: 544 (Major Joint Replacement or Reattachment of 
Lower Extremity) and 545 (Revision of Hip or Knee Replacement). The two 
new DRGs were created to identify that revisions of joint replacement 
procedures are significantly more resource intensive than original hip 
and knee replacements procedures. DRG 544 includes the following 
procedure 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 or ankle reattachment
     84.28, Thigh reattachment
    DRG 545 includes the following procedure 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
    Further, we created a number of new ICD-9-CM procedure codes 
effective October 1, 2005, that better distinguish the many different 
types of joint replacement procedures that are currently being 
performed. In the FY 2006 IPPS final rule (70 FR 47305), we indicated 
that a commenter had requested that, once we receive claims data using 
the new procedure codes, we closely examine data from the use of the 
codes under the two new DRGs to determine if future additional DRG 
modifications are needed.
    Further, the American Association of Hip & Knee Surgeons (AAHKS) 
recommended that we make further

[[Page 24730]]

refinements to the DRGs for knee and hip arthroplasty procedures. AAHKS 
previously presented data to CMS on the important differences in 
clinical characteristics and resource utilization between primary and 
revision total joint arthroplasty procedures. AAHKS stated that CMS' 
decision to create a separate DRG for revision of total joint 
arthroplasty (TJA) in October 2005 resulted in more equitable 
reimbursement for hospitals that perform a disproportionate share of 
complex revision of TJA procedures, recognizing the higher resource 
utilization associated with these cases. AAHKS stated that this 
important payment policy change led to increased access to care for 
patients with failed total joint arthroplasties, and ensured that high 
volume TJA centers could continue to provide a high standard of care 
for these challenging patients.
    AAHKS further stated that the addition of new, more descriptive 
ICD-9-CM diagnosis and procedure codes for TJA in October 2005 gave it 
the opportunity to further analyze differences in clinical 
characteristics and resource intensity among TJA patients and 
procedures. Inclusive of the preparatory work to submit its 
recommendations, the AAHKS compiled, analyzed, and reviewed detailed 
clinical and resource utilization data from over 6,000 primary and 
revision TJA procedure codes from 4 high volume joint arthroplasty 
centers located within different geographic regions of the United 
States: University of California, San Francisco, CA; Mayo Clinic, 
Rochester, MN; Massachusetts General Hospital, Boston, MA; and the 
Hospital for Special Surgery, New York, NY. Based on its analysis, 
AAHKS recommended that CMS examine Medicare claims data and consider 
the creation of separate DRGs for total hip and total knee arthroplasty 
procedures. DRG 545 currently contains revisions of both hip and knee 
replacement procedures. AAHKS stated that based on the differences 
between patient characteristics, procedure characteristics, resource 
utilization, and procedure code payment rates between total hip and 
total knee replacements, separate DRGs were warranted. Furthermore, 
AAHKS recommended that CMS create separate base DRGs for routine versus 
complex joint revision or replacement procedures as shown below.

Routine Hip Replacements

     00.73, Revision of hip replacement, acetabular liner and/
or femoral heal only
     00.85, Resurfacing hip, total, acetabulum and femoral head
     00.86, Resurfacing hip, partial, femoral head
     00.87, Resurfacing hip, partial, acetabulum
     81.51, Total hip replacement
     81.52, Partial hip replacement
     81.53, Revision of hip replacement, not otherwise 
specified

Complex Hip Replacements

     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

Routine Knee Replacements and Ankle Procedures

     00.83, Revision of knee replacement, patellar component
     00.84, Revision of knee replacement, tibial insert (liner)
     81.54, Revision of knee replacement, not otherwise 
specified
     81.55, Revision of knee replacement, not otherwise 
specified
     81.56, Total ankle replacement

Complex Knee Replacements and other reattachments

     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
     84.26, Foot reattachment
     84.27, Lower leg or ankle reattachment
     84.28, Thigh reattachment
    AAHKS also recommended the continuation of DRG 471 (Bilateral or 
Multiple Major Joint Procedures of Lower Extremity) without 
modifications. DRG 471 includes any combination of two or more of the 
following procedure codes:
     00.70, Revision of hip replacement, both acetabular and 
femoral components
     00.80, Revision of knee replacement, total (all 
components)
     00.85, Resurfacing hip, total, acetabulum and femoral head
     00.86, Resurfacing hip, partial, femoral head
     00.87, Resurfacing hip, partial, acetabulum
     81.51, Total hip replacement
     81.52, Partial hip replacement
     81.54, Total knee replacement
     81.56, Total ankle replacement
    As discussed in section II.C. of the preamble of this proposed 
rule, we are proposing to adopt MS-DRGs to better recognize severity of 
illness for FY 2008. The proposed MS-DRGs include two new severity of 
illness levels under the current base DRG 544. We are also proposing to 
add three new severity of illness levels to the base DRG for Revision 
of Hip or Knee Replacement (currently DRG 545). The new MS-DRGs are as 
follows:
     Proposed MS-DRG 466 (Revision of Hip or Knee Replacement 
with MCC)
     Proposed MS-DRG 467 (Revision of Hip or Knee Replacement 
with CC)
     Proposed MS-DRG 468 (Revision of Hip or Knee Replacement 
without CC)
     Proposed MS-DRG 483 (Major Joint Replacement or 
Reattachment of Lower Extremity with CC/MCC)
     Proposed MS-DRG 484 (Major Joint Replacement or 
Reattachment of Lower Extremity without CC/MCC)
    We found that the proposed MS-DRGs greatly improved our ability to 
identify joint procedures with higher resource costs. The following 
table indicates the average charges for each new proposed MS-DRG for 
the joint procedures.

                     Proposed MS-DRGs That Replace DRGs 544 and 535 With New Severity Levels
----------------------------------------------------------------------------------------------------------------
                                                                     Number of    Average length      Average
                         Proposed MS-DRG                               cases          of stay         charges
----------------------------------------------------------------------------------------------------------------
MS-DRG 466......................................................         390,344            4.03      $33,465.85
MS-DRG 467......................................................          28,211            8.46       53,676.09
MS-DRG 468......................................................          26,718            4.06       38,720.28
MS-DRG 483......................................................          10,078            6.06       48,575.01
MS-DRG 484......................................................           3,886            9.55       69,649.08
----------------------------------------------------------------------------------------------------------------


[[Page 24731]]

    AAHKS analyzed Medicare data under the current DRG system and was 
unaware of how its analysis would change under the proposed MS-DRGs. 
Under the current DRGs, the AAHKS recommendation would replace 2 DRGs 
with 4 new ones. However, under the proposed MS-DRGs, the AAHKS 
recommendation would result in 5 DRGs becoming 12. Because AAHKS is 
recommending four new joint replacement DRGs (two for knees and two for 
hips), each would need to be subdivided into severity levels under our 
proposed MS-DRG system. Therefore, the four new joint DRGs could be 
subdivided into three levels each, leading to 12 new DRGs. At this 
time, we believe that the changes we are proposing to make to adopt the 
proposed MS-DRGs are sufficiently better for recognizing severity of 
illness among the hip and knee replacement cases. We do not believe 
that there would be significant improvements in the proposed MS-DRGs 
recognition of severity of illness from creating an additional 7 DRGs. 
However, we acknowledge the valuable assistance the AAHKS has provided 
to CMS in creating the new joint replacement procedure codes and 
modifying the joint replacement DRGs beginning in FY 2006. These 
efforts greatly improved our ability to categorize significantly 
different groups of patients according to severity of illness. We 
welcome comments from AAHKS on whether the proposed MS-DRGs recognize 
patient complexity and severity of illness in the hip and knee 
replacement DRGs consistent with the concerns it expressed to us in 
previous comments. We also welcome public comments from others as well 
on whether the proposed changes to the hip and knee replacement DRGs 
better recognize severity of illness and complexity of these operations 
in the Medicare patient population.
b. Spinal Fusions
    (If you choose to comment on issues in this section, please include 
the caption ``DRGs: Spinal Procedures'' at the beginning of your 
comment.)
    In the FY 2007 final rule (71 FR 47947), we discussed a request 
that urged CMS to consider applying a severity concept to all of the 
back and spine surgical cases, similar to the approach that was used in 
the FY 2006 final rule in refining the cardiac DRGs with an MCV. 
Specifically, the commenter recommended that the use of spinal devices 
be uniquely identified within the spine DRGs. The commenter's 
suggestion involved the development of 10 new spine DRGs as well as 
additional modifications. One of these modifications included revising 
DRG 546 (Spinal Fusions Except Cervical with Curvature of the Spine or 
Malignancy). The commenter stated DRG 546 did not adequately recognize 
clinical severity or the resource differences among spinal fusion 
patients whose surgeries include fusing multiple levels of their spinal 
vertebrae.
    We agreed with the commenter that it was important to recognize 
severity when classifying groups of patients into specific DRGs. In 
addition, in response to recommendations from MedPAC's March 2005 
Report to Congress, we stated that we were conducting a comprehensive 
analysis of the entire DRG system to determine if we could better 
identify severity of illness. We further stated that until results from 
our analysis were available, it would be premature to implement a 
severity concept for the spine DRGs. Therefore, we did not make any 
adjustments to those DRGs at that time.
    Under the proposed MS-DRGs described in section II.D. of the 
preamble of this proposed rule, we are proposing a number of 
refinements that would better recognize severity for FY 2008. The 
proposed MS-DRGs include several refinements to the spine DRGs. These 
refinements are described in detail below.
    In the FY 2006 IPPS final rule, we noted that there are numerous 
innovations occurring in spinal surgery such as artificial spinal disc 
prostheses, kyphoplasty, vertebroplasty and the use of spine 
decompression devices. As part of our analysis of the DRG system for 
this proposed rule, we did a comprehensive review of the DRGs for 
spinal fusion and other back and neck procedures to determine whether 
additional refinements beyond the proposed MS-DRGs were necessary. We 
studied data from the FY 2006 MedPAR file for the entire group of spine 
DRGs. This group included DRG 496 (Combined Anterior/Posterior Spinal 
Fusion), DRGs 497 and 498 (Spinal Fusion Except Cervical With and 
Without CC, respectively), DRGs 499 and 500 (Back and Neck Procedures 
Except Spinal Fusion With and Without CC, respectively), DRGs 519 and 
520 (Cervical Spinal Fusion With and Without CC, respectively), and DRG 
546 (Spinal Fusion Except Cervical with Curvature of the Spine or 
Malignancy).
    As indicated earlier, we are proposing a two or three-way split for 
each of these spine DRGs to better recognize severity of illness, 
complexity of service, and resource utilization. In addition, we 
examined the procedure codes that identify multiple fusion or refusion 
of the vertebrae (codes 81.62 through 81.64) to determine if the data 
supported further refinement when a greater number of vertebrae are 
fused.
    In applying the proposed MS-DRG logic, CMS DRG 497 and 498 were 
collapsed and the result is a split with two severity levels: proposed 
MS-DRG 459 (Spinal Fusion Except Cervical With MCC) and proposed MS-DRG 
460 (Spinal Fusion Except Cervical Without MCC). There were a total of 
51,667 cases in proposed MS-DRGs 459 and 460. We identified 288 cases 
where nine or more noncervical vertebrae were fused (code 81.64) that 
currently are assigned to proposed MS-DRGs 459 and 460. The average 
charges and length of stay for cases in these MS-DRGs are closer to the 
average charges and length of stay for cases in proposed MS-DRGs 456 
through 458 (Spinal Fusion Except Cervical With Curvature of the Spine 
or Malignancy With MCC, With CC, and Without CC, respectively). For 
example, in proposed MS-DRG 460, there were 238 cases with an average 
length of stay of 6.20 days and average charges of $110,908 when nine 
or more noncervical vertebrae are fused. There are an additional 50 
cases where nine or more vertebrae were fused in proposed MS-DRG 459 
with average charges of $171,839. Without any further modification to 
the proposed MS-DRGs, these cases would be assigned to proposed MS-DRGs 
459 and 460 that have average charges of $59,698, and $99,298, 
respectively. The average charges for these cases are more comparable 
to $142,871, $95,489, and $77,528, respectively, for proposed MS-DRGs 
456 through 458. We believe these data support assigning cases where 
nine or more noncervical vertebrae are fused from proposed MS-DRG 459 
and 460 into proposed MS-DRG 456 through 458. The table below 
represents our findings.

------------------------------------------------------------------------
                                                  Average
         Proposed MS-DRG            Number of    length of     Average
                                      cases         stay       charges
------------------------------------------------------------------------
MS-DRG 459 (Spinal Fusion Except         3,186        10.10      $99,298
 Cervical With MCC)--All Cases...

[[Page 24732]]

 
MS-DRG 459 (Spinal Fusion Except            50        13.00      171.839
 Cervical With MCC)--Cases with
 Procedure Code 81.64 (Fusion or
 refusion of 9 or more vertebrae)
MS-DRG 460 (Spinal Fusion Except        48,481         4.36       59,698
 Cervical Without MCC)--All Cases
MS-DRG 460 (Spinal Fusion Except           238         6.20      110,908
 Cervical Without MCC)--Cases
 with Procedure Code 81.64
 (Fusion or refusion of 9 or more
 vertebrae)......................
MS-DRG 456 (Spinal Fusion Except           548        14.79      142,871
 Cervical With Curvature of the
 Spine or Malignancy With MCC)--
 All Cases.......................
MS-DRG 456 (Spinal Fusion Except            61        13.34      170,655
 Cervical With Curvature of the
 Spine or Malignancy With MCC)--
 Cases With Procedure Code 81.64
 (Fusion or refusion of 9 or more
 vertebrae)......................
MS-DRG 457 (Spinal Fusion Except         1,500         8.14       95,489
 Cervical With Curvature of the
 Spine or Malignancy With CC)--
 All Cases.......................
MS-DRG 457 (Spinal Fusion Except           146         8.88      125,722
 Cervical With Curvature of the
 Spine or Malignancy With CC)--
 Cases With Procedure Code 81.64
 (Fusion or refusion of 9 or more
 vertebrae)......................
MS-DRG 458 (Spinal Fusion Except         1,340         4.58       77,528
 Cervical With Curvature of the
 Spine or Malignancy Without CC--
 All Cases.......................
MS-DRG 458 (Spinal Fusion Except            81         6.21      123,823
 Cervical With Curvature of the
 Spine or Malignancy Without CC)--
 Cases With Procedure Code 81.64
 (Fusion or refusion of 9 or more
 vertebrae)......................
------------------------------------------------------------------------

    Therefore, we are proposing to move those cases that include fusing 
or refusing nine or more vertebrae from proposed MS-DRGs 459 and 460 
into proposed MS-DRGs 456 through 458. This proposed modification would 
include revising the MS-DRG title to reflect the fusion of nine or more 
vertebrae. The revised titles for proposed MS-DRGs 456 through 458 
would be as follows:
     Proposed MS-DRG 456 (Spinal Fusion Except Cervical with 
Spinal Curvature or Malignancy or 9+ Fusions With MCC)
     Proposed MS-DRG 457 (Spinal Fusion Except Cervical with 
Spinal Curvature or Malignancy or 9+ Fusions With CC)
     Proposed MS-DRG 458 (Spinal Fusion Except Cervical with 
Spinal Curvature or Malignancy or 9+ Fusions Without CC/MCC)
    We invite public comment on this topic as well as on the additional 
changes we are proposing to the spine MS-DRGs discussed below.
    Further analysis demonstrates that spinal fusion cases with a 
principal diagnosis of tuberculosis or osteomyelitis also have higher 
average charges than other cases in CMS DRG 497 (proposed MS-DRGs 459 
and 460) that are more similar to the cases assigned to CMS DRG 546 
(proposed MS-DRGs 456 through 458). Although the volume of cases is 
relatively low, the data show very high average charges for these 
patients. The following tables display our results:

------------------------------------------------------------------------
                                                   Average
         Proposed MS-DRG            Number of    length of     Average
                                      cases         stay       charges
------------------------------------------------------------------------
MS-DRG 459 (Spinal Fusion Except         3,186        10.10      $99,298
 Cervical With MCC)..............
MS-DRG 460 (Spinal Fusion Except        48,481         4.36       59,698
 Cervical Without MCC)...........
------------------------------------------------------------------------


------------------------------------------------------------------------
                                                  Average
         Proposed MS-DRG            Number of    length of     Average
                                      cases         stay       charges
------------------------------------------------------------------------
MS-DRG 456 (Spinal Fusion Except           548        14.79     $142,870
 Cervical with Spinal Curvature
 or Malignancy or 9+ Fusions With
 MCC)............................
MS-DRG 457 (Spinal Fusion Except         1,500         8.14       95,489
 Cervical with Spinal Curvature
 or Malignancy or 9+ Fusions With
 CC).............................
MS-DRG 458 (Spinal Fusion Except         1,340         4.58       77,528
 Cervical With Spinal Curvature
 or Malignancy or 9+ Fusions
 Without CC/MCC).................
------------------------------------------------------------------------


------------------------------------------------------------------------
                     Tuberculosis and Osteomyelitis
-------------------------------------------------------------------------
                                                   Average
       Principal diagnosis          Number of    length of     Average
                                      cases         stay       charges
------------------------------------------------------------------------
Codes 015.02, 015.04, 015.05,              194         24.8     $128,073
 730.08, 730.18 and 730.28.......
------------------------------------------------------------------------

    For this reason, we are proposing to add the following diagnoses to 
the principal diagnosis list for proposed MS-DRGs 456 through 458:
     015.02, Tuberculosis of bones and joints, vertebral 
column, bacteriological or histological examination unknown (at 
present)
     015.04, Tuberculosis of bones and joints, vertebral 
column, tubercle bacilli not found (in sputum) by microscopy, but found 
by bacterial culture
     015.05, Tuberculosis of bones and joints, vertebral 
column, tubercle bacilli not found by bacteriological examination, but 
tuberculosis confirmed histologically
     730.08, Acute osteomyelitis of other specified sites

[[Page 24733]]

     730.18, Chronic osteomyelitis of other specified sites
     730.28, Unspecified osteomyelitis of other specified sites
    For the complete list of principal diagnosis codes that lead to 
assignment of CMS DRG 546 (proposed MS-DRGs 496 through 498), we refer 
readers to section II.D.4.b. of the preamble of the FY 2007 IPPS final 
rule (71 FR 47947).
c. Spinal Disc Devices
    Over the past several years, manufacturers of spinal disc devices 
have requested reassignment of DRGs for their products and applied for 
new technology add-on payments. CHARITETM is one of these 
devices. CHARITETM is a prosthetic intervertebral disc. On 
October 26, 2004, the FDA approved the CHARITETM Artificial 
Disc for single level spinal arthroplasty in skeletally mature patients 
with degenerative disc disease between L4 and S1. On October 1, 2004, 
we created new procedure codes for the insertion of spinal disc 
prostheses (codes 84.60 through 84.69). We provided the CMS DRG 
assignments for these new codes in Table 6B of the FY 2005 IPPS 
proposed rule (69 FR 28673). We received comments on the FY 2005 
proposed rule recommending that we change the assignments for these 
codes from CMS DRG 499 (Back and Neck Procedures Except Spinal Fusion 
With CC) and CMS DRG 500 (Back and Neck Procedures Except Spinal Fusion 
Without CC) to the CMS DRGs for spinal fusion, CMS DRG 497 (Spinal 
Fusion Except Cervical With CC) and CMS DRG 498 (Spinal Fusion Except 
Cervical Without CC) for procedures on the lumbar spine and to CMS DRGs 
519 and 520 for procedures on the cervical spine. In the FY 2005 IPPS 
final rule (69 FR 48938), we indicated that CMS DRGs 497 and 498 are 
limited to spinal fusion procedures. Because the surgery involving the 
CHARITETM Artificial Disc is not a spinal fusion, we decided 
not to include this procedure in these CMS 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.
    In the FY 2006 final rule (70 FR 47353), we noted that, if a 
product meets all of the criteria for Medicare to pay for the product 
as a new technology under section 1886(d)(5)(K) of the Act, 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 or costs. However, for FY 2006, we did not find that 
the CHARITETM Artificial Disc met the substantial clinical 
improvement criterion and, thus, did not qualify as a new technology. 
Consequently, we did not address the DRG classification request made 
under the authority of this provision of the Act.
    We did evaluate whether to reassign the CHARITETM 
Artificial Disc to different CMS DRGs using the Secretary's authority 
under section 1886(d)(4) of the Act (70 FR 47308). We indicated that we 
did not have Medicare charge information to evaluate CMS DRG changes 
for cases involving an implant of a prosthetic intervertebral disc like 
the CHARITETM and did not make a change in its CMS DRG 
assignments. We stated that we would consider whether changes to the 
CMS DRG assignments for the CHARITETM Artificial Disc were 
warranted for FY 2007, once we had information from Medicare's data 
system that would assist us in evaluating the costs of these patients.
    As we discussed in the FY 2007 IPPS proposed rule (71 FR 24036), we 
received correspondence regarding the CMS DRG assignments for the 
CHARITETM Artificial Disc, code 84.65 (Insertion of total 
spinal disc prosthesis, lumbosacral). The commenter had previously 
submitted an application for the CHARITETM Artificial Disc 
for new technology add-on payments for FY 2006 and had requested a 
reassignment of cases involving CHARITETM implantation to 
CMS DRGs 497 and 498. The commenter asked that we examine claims data 
for FY 2005 and reassign procedure code 84.65 from CMS DRGs 499 and 500 
into CMS DRGs 497 and 498. The commenter again stated the view that 
cases with the CHARITETM Artificial Disc reflect comparable 
resource use and similar clinical indications as do those in CMS DRGs 
497 and 498. If CMS were to reject reassignment of the 
CHARITETM Artificial Disc to CMS DRGs 497 and 498, the 
commenter suggested creating two separate DRGs for lumbar disc 
replacements.
    On February 15, 2006, we posted a proposed national coverage 
determination (NCD) on the CMS Web site seeking public comment on our 
proposed finding that the evidence is not adequate to conclude that 
lumbar artificial disc replacement with the CHARITETM 
Artificial Disc is reasonable and necessary. The proposed NCD stated 
that lumbar artificial disc replacement with the CHARITETM 
Artificial Disc is generally not indicated in patients over 60 years 
old. Further, it stated that there is insufficient evidence among 
either the aged or disabled Medicare population to make a reasonable 
and necessary determination for coverage. With an NCD pending to make 
spinal arthroplasty with the CHARITETM Artificial Disc 
noncovered, we indicated in the FY 2007 IPPS proposed rule that we did 
not believe it was appropriate at that time to reassign procedure code 
84.65 from CMS DRGs 499 and 500 to CMS DRGs 497 and 498.
    After considering the public comments and additional evidence 
received, we made a final NCD on May 16, 2006, that Medicare would not 
cover the CHARITETM Artificial Disc for the Medicare 
population over 60 years of age. For Medicare beneficiaries 60 years of 
age and under, local Medicare contractors have the discretion to 
determine coverage for lumbar artificial disc replacement procedures 
involving the CHARITETM Artificial Disc. The final NCD can 
be found on the CMS Web site at: http://www.cms.hhs.gov/mcd/viewncd.asp:ncd-id 150.10&ncd--
version1&basket=ncd%3A150%2E10%3A1%3ALumbar+Artificial+Disc+Replacement%
280ADR%29.
    We agreed with a commenter on the FY 2007 IPPS proposed rule that 
it was not appropriate to consider a DRG revision at that time for the 
CHARITETM Artificial Disc, given the recent decision to 
limit coverage for surgical procedures involving this device. Although 
we had reviewed the Medicare charge data, we were concerned that there 
were a very small number of cases for patients under 60 years of age 
who had received the CHARITETM Artificial Disc. We believed 
it appropriate to base the decision of a DRG change on charge data only 
on the population for which the procedure is covered. We had an 
extremely small number of cases for Medicare beneficiaries under 60 on 
which to base such a decision. For this reason, we did not believe it 
was appropriate to modify the CMS DRGs in FY 2007 for 
CHARITETM cases.
    For FY 2008, we collapsed CMS DRGs 499 and 500 (Back and Neck 
Procedures Except Spinal Fusion With and Without CC, respectively) and 
identified a total of 74,989 cases. Under the proposed MS-DRGs, the 
result of the analysis of the data supports that these CMS DRGs split 
into two severity levels: proposed MS-DRG 490 (Back and Neck Procedures 
Except Spinal Fusion with CC or MCC) and proposed MS-DRG 491 (Back and 
Neck Procedures Except Spinal Fusion Without CC or MCC). We found a 
total of 53 cases that used the CHARITETM Artificial Disc. 
Without any further modification to the proposed MS-DRGs, average 
charges are $26,481 for 6 cases with a CC or MCC and $37,324 for 47 
CHARITETM cases

[[Page 24734]]

without a CC or MCC. (We find it counterintuitive that average charges 
for cases in the higher severity level are lower but checked our data 
and found it to be correct).
    We also analyzed data for other spinal disc devices. Average 
charges for the X Stop Interspinous Process Decompression Device (code 
84.58) are $31,400 for cases with a CC or MCC and $28,821 for cases 
without a CC or MCC. Average charges for other specified spinal devices 
described by code 84.59 (Coflex, Dynesys, M-Brace) are $34,002 for 18 
cases with a CC or MCC and $33,873 for 65 cases without a CC or MCC. We 
compared these average charges to data in the proposed spinal fusion 
MS-DRGs 453 (Combined Anterior/Posterior Spinal Fusion With MCC), 454 
(Combined Anterior/Posterior Spinal Fusion With CC), 455 (Combined 
Anterior/Posterior Spinal Fusion Without CC/MCC), 459 (Spinal Fusion 
Except Cervical With MCC), and 460 (Spinal Fusion Except Cervical 
Without MCC). These cases have lower average charges than the spinal 
fusion MS-DRGs. The following tables display the results:

------------------------------------------------------------------------
                                                  Average
   Proposed MS-DRGs 490 and 491     Number of    length of     Average
                                      cases         stay       charges
------------------------------------------------------------------------
MS-DRG 490--All Cases............       17,493         5.13      $29,656
MS-DRG 490--Cases with Procedure             6         3.33       26,481
 Code 84.65 (CHARITETM)..........
MS-DRG 491--All Cases............       57,496         2.27       17,789
MS-DRG 491--Cases with Procedure            47         2.43       37,324
 Code 84.65 (CHARITETM)..........
MS-DRG 491--Cases without               57,449         2.27       17,773
 Procedure Code 84.65 (CHARITETM)
------------------------------------------------------------------------


------------------------------------------------------------------------
                                                  Average
   Proposed MS-DRGs 490 and 491     Number of    length of     Average
                                      cases         stay       charges
------------------------------------------------------------------------
MS-DRG 490--All Cases............       17,493         5.13      $29,656
MS-DRG 490--Cases with Procedure           179         2.65       31,400
 Code 84.58 (X Stop).............
MS-DRG 490--Cases without               17,314         5.15       29,638
 Procedure Code 84.58 (X Stop)...
MS-DRG 491--All Cases............       57,496         2.27       17,789
MS-DRG 491--Cases with Procedure         1,174         1.34       28,821
 Code 84.58 (X Stop).............
MS-DRG 491--Cases without               56,322         2.29       17,559
 Procedure Code 84.58 (X-Stop)...
------------------------------------------------------------------------


------------------------------------------------------------------------
                                                  Average
   Proposed MS-DRGs 490 and 491     Number of    length of     Average
                                      cases         stay       charges
------------------------------------------------------------------------
MS-DRG 490--All Cases............       17,493         5.13      $29,656
MS-DRG 490--Cases with Procedure            18         5.56       34,002
 Code 84.59 (Coflex/Dynesys/M-
 Brace)..........................
MS-DRG 490--Cases without               17,475         5.13       29,651
 Procedure Code 84.59 (Coflex/
 Dynesys/M-Brace)................
MS-DRG 491--All Cases............       57,496         2.27       17,789
MS-DRG 491--Cases with Procedure            65         2.35       33,873
 Code 84.59 (Coflex/Dynesys/M-
 Brace)..........................
MS-DRG 491--Cases without               57,431         2.27       17,770
 Procedure Code 84.59 (Coflex/
 Dynesys/M-Brace)................
------------------------------------------------------------------------


------------------------------------------------------------------------
                                                  Average
 Proposed MS-DRGs 453, 454, 455,    Number of    length of      Average
           459 and 460                cases         stay       charges
------------------------------------------------------------------------
MS-DRG 453--Combined Anterior/             792        15.84     $180,658
 Posterior Spinal Fusion With MCC
MS-DRG 454--Combined Anterior/           1,411         8.69      116,402
 Posterior Spinal Fusion With CC.
MS-DRG 455--Combined Anterior/           1,794         4.84       85,927
 Posterior Spinal Fusion Without
 CC/MCC..........................
MS-DRG 459--Spinal Fusion Except         3,186        10.10       99,298
 Cervical with MCC...............
MS-DRG 460--Spinal Fusion Except        48,481         4.36       59,698
 Cervical Without MCC............
------------------------------------------------------------------------

    The data demonstrate that the average charges for 
CHARITETM and the other devices are higher than other cases 
in proposed MS-DRGs 490 and 491 but lower than proposed MS-DRGs 453 
through 55 and 459 and 460. For this reason, we do not believe that any 
of the cases that use these spine devices should be assigned to the 
spinal fusion MS-DRGs. However, we do believe that the average charges 
for cases using these spine devices are more similar to the higher 
severity level in MS-DRG 490.
    As such, we are proposing to move cases with procedure codes 84.58, 
84.59, and 84.65 into proposed MS-DRG 490 and revise the title to 
reflect disc devices. The proposed modified MS-DRG title would be: MS-
DRG 490 (Back and Neck Procedures Except Spinal Fusion with CC or MCC 
or Disc Devices).
    We believe these proposed changes to the spine DRGs are appropriate 
to recognize the similar utilization of resources, differences in 
levels of severity, and complexity of the services performed for 
various types of spinal procedures described above. We encourage 
commenters to provide input on this approach to better recognize the 
types of patients these procedures are being performed upon and their 
outcomes.
d. Other Spinal DRGs
    We did not identify any data to support moving cases in or out of 
CMS DRGs 496 (Combined Anterior/Posterior Spinal Fusion), 519 (Cervical 
Spinal Fusion With CC), or 520 (Cervical Spinal Fusion Without CC)). 
Under the proposed MS-DRG system, CMS DRG 496 would be split into three 
severity levels: proposed MS-DRG 453 (Combined Anterior/Posterior 
Spinal Fusion With MCC), proposed MS-DRG 454 (Combined Anterior/
Posterior Spinal Fusion With CC), and proposed MS-DRG 455 (Combined 
Anterior/Posterior Spinal Fusion Without CC).

[[Page 24735]]

CMS DRG 519 would also be split into three severity levels: proposed 
MS-DRG 471 (Cervical Fusion With MCC), proposed MS-DRG 472 (Cervical 
Fusion With CC), and proposed MS-DRG 473 (Cervical Fusion Without CC). 
We are not proposing changes to these DRGs at this time.
5. MDC 17 (Myeloproliferative Diseases and Disorders, Poorly 
Differentiated Neoplasm): Endoscopic Procedures
    (If you choose to comment on issues in this section, please include 
the caption ``DRGs: Endoscopy'' at the beginning of your comment.)
    We received a request from a manufacturer to review the DRG 
assignment of codes 33.71 (Endoscopic insertion or replacement of 
bronchial valve(s)), 33.78 (Endoscopic removal of bronchial device(s) 
or substances), and 33.79 (Endoscopic insertion of other bronchial 
device or substances) with the intent of moving these three codes out 
of CMS DRG 412 (History of Malignancy With Endoscopy) (proposed MS-DRGs 
843, 844, and 845). The requestor has noted that CMS DRG 412 is titled 
to be a DRG for cases with a history of malignancy, and none of the 
three codes (33.71, 33.78, or 33.79) necessarily involve treatment for 
malignancies. In addition, the requestor believed the integrity of the 
DRG is compromised because the other endoscopy codes assigned to CMS 
DRG 412 are all diagnostic in nature, while codes 33.71, 33.78, and 
33.79 represent therapeutic procedures.
    The requestor also stated that while the diagnostic endoscopies in 
CMS DRG 412 do not have significant costs for equipment or 
pharmaceutical agents beyond the basic endoscopy, the therapeutic 
procedures described by codes 33.71, 33.78, and 33.79 involve 
substantial costs for devices or substances in relation to the cost of 
the endoscopic procedure itself. The requestor was concerned that, if 
these three codes continue to be assigned to CMS DRG 412, payment will 
be so inadequate as to constitute a substantial barrier to Medicare 
beneficiaries for these treatments.
    ICD-9-CM procedure codes 33.71, 33.78, and 33.79 were all created 
for use beginning October 1, 2006. As these codes have been in use only 
for a few months, we have no data to make a different DRG assignment. 
We assigned these codes based on the advice of our medical officers to 
a DRG that includes similar clinical procedures.
    On the matter of codes 33.71, 33.78, and 33.79 being therapeutic in 
nature while all other endoscopies assigned to CMS DRG 412 are 
diagnostic, we disagree with the commenter. CMS DRG 412 includes 
procedure codes for therapeutic endoscopic destruction of lesions of 
the bronchus, lung, stomach, anus, and duodenum, as well as codes for 
polypectomy of the intestine and rectum. In addition, we note that 
there are codes for insertion of therapeutic devices currently located 
in this DRG.
    We believe it would be premature to assign these codes to another 
DRG without any supporting data. We will reconsider our decision for 
these codes if we have data suggesting that a DRG reassignment is 
warranted. Therefore, aside from the proposed changes to the MS-DRGs, 
we are not proposing to change the current DRG assignment for codes 
33.71, 33.78, and 33.79 at this time.
6. Medicare Code Editor (MCE) Changes
    (If you choose to comment on issues in this section, please include 
the caption ``Medicare Code Editor'' at the beginning of your comment.)
    As explained under section II.B.1. of this preamble, the Medicare 
Code Editor (MCE) is a software program that detects and reports errors 
in the coding of Medicare claims data. Patient diagnoses, procedure(s), 
discharge status, and demographic information go into the Medicare 
claims processing systems and are subjected to a series of automated 
screens. The MCE screens are designed to identify cases that require 
further review before classification into a DRG.
    For FY 2008, we are proposing to make the following changes to the 
MCE edits.
a. Non-Covered Procedure Edit: Code 00.62 (Percutaneous angioplasty or 
atherectomy of intracranial vessel(s))
    As discussed in II.G.2. of the preamble of this proposed rule, 
under MDC 1, code 00.62 is a covered service when performed in 
conjunction with code 00.65 (Percutaneous insertion of intracranial 
vascular stent(s)). Effective November 6, 2006, Medicare covers PTA and 
stenting of intracranial arteries for the treatment of cerebral artery 
stenosis in cases in which stenosis is 50 percent or greater in 
patients with intracranial atherosclerotic disease when furnished in 
accordance with the FDA-approved protocols governing Category B 
Investigational Device Exemption (IDE) clinical trials. CMS determines 
that coverage of intracranial PTA and stenting is reasonable and 
necessary under these circumstances. Therefore, we are proposing to 
make a conforming change and to add the following language to this 
edit: Procedure code 00.62 (PTA of intracranial vessel(s)) is 
identified as a noncovered procedure except when it is accompanied by 
procedure code 00.65 (Intracranial stent).
b. Non-Specific Principal Diagnosis Edit 7 and Non-Specific O.R. 
Procedures Edit 10
    When MCE Non-Specific Principal Diagnosis Edit 7 and Non-Specific 
O.R. Procedures Edit 10 were created at the beginning of the IPPS, it 
was with the intent that they were to encourage hospitals to code as 
specifically as possible. While the codes on both edits are valid 
according to the ICD-9-CM coding scheme, more precise codes are 
preferable to give a more complete understanding of the services 
provided on the Medicare claims. When the MCE was created, we had 
intended that these specific edits would allow educational contact 
between the provider and the contractor. It was never the intention 
that these edits would be used to deny/reject or return-to-provider 
claims submitted with non-specific codes. However, we found these two 
edits to be misunderstood, and found that claims were erroneously being 
denied, rejected, or returned. On November 11, 2006, CMS issued a Joint 
Signature Memorandum which instructed all fiscal intermediaries and all 
Part A and Part B Medicare Administrative Contractors (A/B MACs) to 
deactivate the Fiscal Intermediary Shared System Edits W1436 through 
W1439 and W1489 through W1491 which edited for Non-Specific Diagnoses 
and the Non-Specific Procedures.
    Therefore, we are proposing to make a conforming change to the MCE 
by removing the following codes from Edit 7:

            00320                     1109                    1543
            01590                     1129                    1579
            01591                     1149                    1589
            01592                     1279                    1590
            01593                      129                    1609
            01594                     1309                    1619
            01596                    13100                    1629
             0369                     1319                    1639
             0399                     1329                    1649
             0528                     1369                    1709
            05310                     1370                    1719
             0538                     1371                    1729
            05440                     1372                    1739
             0548                     1373                    1749
             0558                     1374                    1769
            05600                      138                     179
             0568                     1390                    1809
            06640                     1391                    1839
            07070                     1398                    1874
            07071                     1409                    1879
             0728                     1419                    1889
             0738                     1429                    1899
            07420                     1439                    1909
            08240                     1449                    1929
             0979                     1469                    1949
            09810                     1479                    1969
            09830                     1509                    1991

[[Page 24736]]

 
            09950                     1519                   20490
             0999                     1529                   20491
             1009                     1539                   20590
            20591                     2779                   36910
            20690                     2793                   36911
            20691                     2799
            20890                    28730                   36912
            20891                    28800                   36913
             2129                    28850                   36914
             2139                    28860                   36915
             2149                    28950                   36916
             2159                     3239                   36917
             2169                     3249                   36918
             2189                      326                   36920
             2199                    32700                   36921
             2229                    32710                   36922
             2239                    32720                   36923
             2249                    32730                   36924
             2259                    32740                   36925
             2279                     3309                    3693
            22800                     3319                    3694
             2299                     3349                   36960
             2306                     3359                   36961
             2319                    34120                   36962
             2329                     3419                   36963
             2349                     3439                   36964
            23690                     3449                   36965
            23770                    34690                   36966
            23875                    34691                   36967
             2390                     3489                   36968
             2391                     3499                   36969
             2392                     3509                   36970
             2393                     3519                   36971
             2394                     3529                   36972
             2396                     3539                   36973
             2397                     3569                   36974
             2398                     3579                   36975
             2399                     3589                   36976
             2469                     3599                    3698
             2519                     3609                    3699
            25200                     3619                    3709
             2529                     3629                    3719
             2539                     3639                    3729
             2549                     3649                    3739
            25510                     3659                    3749
             2569                     3669                    3759
             2579                     3679                    3769
             2589                     3689                    3779
             2681                    36900                    3789
             2709                    36901                   37960
             2719                    36902                    3809
             2729                    36903                    3819
             2739                    36904                    3829
            27540                    36905                    3839
             2759                    36906                    3849
            27650                    36907                    3859
            27730                    36908                    3879
            38800                    52140                    6089
            38810                     5219                    6109
            38830                    52320                    6169
            38840                    52330                    6170
            38860                    52340                   61800
            38870                     5239                    6184
             3889                    52400                    6189
            38900                    52420                    6199
            38910                    52430                    6209
             3897                    52450                   62130
             3899                    52460                    6219
            41090                    52470                   62210
            41091                     5249                    6229
            41092                    52520                    6239
              412                    52540                    6249
             4149                    52550                    6269
             4179                    52560                    6279
            42650                     5259                   62920
             4275                     5269                   63390
             4279                     5279                   63391
            42820                    52800                   64090
            42830                     5299                   64091
            42840                     5309                   64093
             4289                    53640                   64100
             4299                     5379                   64110
             4329                     5539                   64120
            43390                    56400                   64130
            43490                     5649                   64180
             4379                     5679                   64190
             4389                     5689                   64191
             4419                    56960                   64193
             4429                     5699                   64200
             4449                     5739                   64210
            44620                    57510                   64220
             4479                     5759                   64230
             4519                     5769                   64240
            45340                     5779                   64250
             4539                     5799                   64260
             4579                     5859                   64270
             4599                     5889                   64290
             4619                     5890                   64300
            46450                     5891                   64310
            46451                     5899                   64320
             4749                     5909                   64380
             4919                     5959                   64390
             5169                     5969                   64400
            51900                     5989                   64410
             5199                    59960                   64420
             5209                     5999                   64600
            52100                    60090                   64610
                                     60091                   64620
            52110                     6019                   64630
            52120                     6029                   64640
            52130                    60820                   64650
            64660                    65290                   65820
            64670                    65291                   65830
            64680                    65293                   65840
            64690                    65300                   65880
            64700                    65310                   65890
            64710                    65320                   65891
            64720                    65330                   65893
            64730                    65340                   65900
            64740                    65350                   65910
            64750                    65360                   65920
            64760                    65370                   65930
            64780                    65380                   65940
            64790                    65390                   65950
            64791                    65391                   65960
            64792                    65393                   65980
            64793                    65400                   65990
            64794                    65410                   65991
            64800                    65420                   65993
            64810                    65430                   66000
            64820                    65440                   66010
            64830                    65450                   66020
            64840                    65460                   66030
            64850                    65470                   66040
            64860                    65480                   66050
            64870                    65490                   66060
            64880                    65491                   66070
            64890                    65492                   66080
            64900                    65493                   66090
            64910                    65494                   66100
            64920                    65500                   66110
            64930                    65510                   66120
            64940                    65520                   66130
            64950                    65530                   66140
            64960                    65540                   66190
            65100                    65550                   66191
            65110                    65560                   66193
            65120                    65570                   66200
            65130                    65580                   66210
            65140                    65590                   66220
            65150                    65591                   66230
            65160                    65593                   66300
            65180                    65600                   66310
            65190                    65610                   66320
            65191                    65620                   66330
            65193                    65630                   66340
            65200                    65640                   66350
            65210                    65650                   66360
            65220                    65660                   66380
            65230                    65670                   66390
            65240                    65680                   66391
            65250                    65690                   66393
            65260                    65700                   66400
            65270                    65800                   66410
            65280                    65810                   66420
            66430                    67110                    7059
            66440                    67120                    7069
            66441                    67130                   70700
            66444                    67140                   70710
            66450                    67150                    7079
            66480                    67180                    7149
            66490                    67190                   71590
            66491                    67191                    7179
            66494                    67192                   71849
            66500                    67193                   71850
            66510                    67194                   71870
            66520                    67200                   72230
            66530                    67300                   72270
            66540                    67310                   72280
            66550                    67320                   72290
            66560                    67330                    7239
            66570                    67380                    7244
            66580                    67400                    7289
            66590                    67410                   73000
            66591                    67420                   73010
            66592                    67430                   73020
            66593                    67440                   73030
            66594                    67450                   73090
            66600                    67480                   73091
            66610                    67490                   73092
            66620                    67492                   73093
            66630                    67494                   73094
            66700                    67500                   73095
            66710                    67510                   73096
            66800                    67520                   73097
            66810                    67580                   73098
            66820                    67590                   73099
            66880                    67600                   73310
            66890                    67610                   73340
            66891                    67620                   73390
            66892                    67630                    7359
            66893                    67640                   73600
            66894                    67650                   73620
            66900                    67660                   73630
            66910                    67680                   73670
            66920                    67690                    7369
            66930                    67691                   73810
            66940                    67692                    7389
            66950                    67693                   74100
            66960                    67694                   74190
            66970                      677                    7429
            66980                     6809                    7439
            66990                     6819                    7449
            66991                     6829                    7459
            66992                    68600                    7469
            66993                     6869                   74760
            66994                     6949                    7489
            67000                     7019                   74900
            67100                     7049                   74910
             7509                     7769                    9009
             7529                     7789                    9029
            75310                     7799                    9039
            75312                    78031                    9048
            75320                    78051                    9049
             7539                    78052                    9050
             7559                    78053                    9051
            75670                    78054                    9052
             7579                    78055                    9053

[[Page 24737]]

 
             7599                    78057                    9054
             7600                    78058                    9055
             7601                    78079                    9056
             7602                     7825                    9057
             7603                    78261                    9058
             7604                    78262                    9059
             7605                    78340                    9060
             7606                    78830                    9061
            76070                    78900                    9062
            76072                    78930                    9063
            76073                    78940                    9064
            76074                    78960                    9065
            76079                    79009                    9066
             7608                     7901                    9067
             7609                     7904                    9068
             7610                     7905                    9069
             7611                     7906                    9070
             7612                    79091                    9071
             7613                    79092                    9072
             7614                    79099                    9073
             7615                     7929                    9074
             7616                    79380                    9075
             7617                    79500                    9079
             7618                     7954                    9080
             7619                     7964                    9081
             7629                     7969                    9082
             7630                     7993                    9083
             7631                    79989                    9084
             7632                     7999                    9085
             7633                     8290                    9086
             7634        .......................              9089
             7635                     8291                    9090
             7636                     8398                    9091
             7637                     8399                    9092
            76383                     8409                    9093
             7639                     8419                    9094
            76520                     8439                    9095
             7679                     8469                    9099
             7689                     8479                    9219
            77010                     8489                    9229
             7709                     8678                    9239
            77210                     8679                    9249
             7729                    86800                    9269
             7759                    86810                    9279
             9289                    94404                    9659
             9299                    94405                    9679
             9349                    94406                    9699
             9399                    94407                    9709
            94100                    94408                    9739
            94101                    94500                    9769
            94102                    94501                    9779
            94103                    94502                    9809
            94104                    94503                    9849
            94105                    94504                    9859
            94106                    94505                    9889
            94107                    94506                    9899
            94108                    94509                    9929
            94109                     9460                    9939
            94200                     9479                   99520
            94201                     9490                   99522
            94202                     9491                   99523
            94203                     9492                   99529
            94204                     9493                   99550
            94205                     9494                   99580
            94209                     9495                   99590
            94300                     9519                   99600
            94301                     9529                   99630
            94302                     9539                   99640
            94303                     9549                   99660
            94304                     9559                   99670
            94305                     9569                   99680
            94306                     9579                   99690
            94309                    95890                   99700
            94400                     9599                   99760
            94401                     9609                    9989
            94402                     9639        ......................
            94403                     9649        ......................
 

    In addition, we are proposing to make a conforming change to the 
MCE by removing the following codes from Edit 10:

             0650                     3770                    4400
             0700                     3800                    4440
             0763                     3810                    4500
             0769                     3830                    4590
             0780                     3840                    4610
             2630                     3850                    4620
             3500                     3860                    4640
             3510                     3880                    4650
             3520                     4040                    4660
             3550                     4050                    4680
             3560                     4100                    5300
             3570                     4210                    5310
             3610                     4240                    5640
             3710        .......................              7550
             7670                     7880                    8070
             7700                     7890                    8080
             7720                     7910                    8090
             7760                     7920                    8100
             7770                     7930                    8120
             7780                     7940                    8130
             7790                     7950                    8153
             7800                     7960                    8155
             7810                     7980                    8400
             7820                     7990                    8440
             7830                     8000                    8460
             7840                     8010                    8469
             7850                     8020                    8660
             7870                     8040                    8670
 

c. Limited Coverage Edit 17
    Edit 17 in the MCE contains ICD-9-CM procedure codes describing 
medically complex procedures, including lung volume reduction surgery, 
organ transplants, and implantable heart assist devices which are to be 
performed only in certain preapproved medical centers. CMS has 
established, through a regulation (CMS-3835-F: Medicare Conditions of 
Participation: Requirements for Approval and Reapproval of Transplant 
Centers to Perform Organ Transplants, published in the Federal Register 
on March 30, 2007 (72 FR 15198)), a survey and certification process 
for organ transplant programs. The organs covered in this regulation 
are heart, heart and lung combined, intestine, kidney, liver, lung, 
pancreas, and multivisceral. Historically, kidney transplants have been 
regulated under the End-Stage Renal Disease (ESRD) conditions for 
coverage. Other types of organ transplant facilities have been 
regulated under various NCDs.
    The regulation becomes effective on June 28, 2007. Organ transplant 
programs will have 180 days from the June 28, 2007 effective date of 
the regulation to apply for participation in the Medicare program under 
the new survey and certification process. After these programs apply, 
we will survey and approve programs that meet the new Medicare 
conditions of participation. Until transplant facilities are surveyed 
and approved, kidney transplant facilities will continue to be 
regulated under the ESRD conditions for coverage, and other types of 
organ transplant facilities will continue to be regulated under the 
NCDs.
    In this proposed rule, we are proposing to add conforming Medicare 
Part A payment edits to the MCE, consistent with the requirements of 
the organ transplant regulation (CMS-3835-F), to ensure that Medicare 
covers only those organ transplants performed in Medicare-approved 
facilities. We are proposing to add the following procedure codes to 
the existing list of limited coverage procedures under Edit 17:
     55.69, Other kidney transplantation
     52.80, Pancreatic transplant, not otherwise specified
     52.82, Homotransplant of pancreas
7. Surgical Hierarchies
    (If you choose to comment on issues in this section, please include 
the caption ``Surgical Hierarchies'' at the beginning of your comment.)
    Some inpatient stays entail multiple surgical procedures, each one 
of which, occurring by itself, could result in assignment of the case 
to a different DRG within the MDC to which the principal diagnosis is 
assigned. Therefore, it is necessary to have a decision rule within the 
GROUPER by which these cases are assigned to a single DRG. The surgical 
hierarchy, an ordering of surgical classes from most resource-intensive 
to least resource-intensive, performs that function. Application of 
this hierarchy ensures that cases involving multiple surgical 
procedures are assigned to the DRG associated with the most resource-
intensive surgical class.
    Because the relative resource intensity of surgical classes can 
shift as a function of DRG reclassification and recalibrations, we 
reviewed the surgical hierarchy of each MDC, as we have for previous 
reclassifications and recalibrations, to determine if the ordering of 
classes coincides with the intensity of resource utilization.
    A surgical class can be composed of one or more DRGs. For example, 
in MDC 11, the surgical class ``kidney transplant'' consists of a 
single DRG (DRG 302) and the class ``kidney, ureter and major bladder 
procedures'' consists of three DRGs (DRGs 303, 304, and 305). 
Consequently, in many cases, the surgical hierarchy has an impact on 
more than one DRG. The methodology for determining the most resource-
intensive surgical class involves weighting the average resources for 
each

[[Page 24738]]

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.
    For FY 2008, we are not proposing any revisions of the surgical 
hierarchy for any MDC. In general, the MS-DRGs that are being proposed 
for use in FY 2008 and discussed in section II.D. of the preamble of 
this proposed rule follow the same hierarchical order as the CMS DRGs 
they are to replace, except for DRGs that were deleted and 
consolidated.
8. CC Exclusion List Proposed for FY 2008
    (If you choose to comment on issues in this section, please include 
the caption ``CC Exclusion List'' at the beginning of your comment.)
a. Background
    As indicated earlier in this preamble, under the IPPS DRG 
classification system, we have developed a standard list of diagnoses 
that are considered complications or comorbidities (CCs). Historically, 
we developed this list using physician panels that classified each 
diagnosis code based on whether the diagnosis, when present as a 
secondary condition, would be considered a substantial complication or 
comorbidity. A substantial complication or comorbidity was defined as a 
condition that, because of its presence with a specific principal 
diagnosis, would cause an increase in the length of stay by at least 1 
day in at least 75 percent of the patients. We refer readers to section 
II.D.2. and 3. of the preamble of this proposed rule for a discussion 
of the refinement of CCs in relation to the MS-DRGs we are proposing to 
adopt for FY 2008.
b. Proposed CC Exclusions List for FY 2008
    In the September 1, 1987 final notice (52 FR 33143) concerning 
changes to the DRG classification system, we modified the GROUPER logic 
so that certain diagnoses included on the standard list of CCs would 
not be considered valid CCs in combination with a particular principal 
diagnosis. We created the CC Exclusions List for the following reasons: 
(1) To preclude coding of CCs for closely related conditions; (2) to 
preclude duplicative or inconsistent coding from being treated as CCs; 
and (3) to ensure that cases are appropriately classified between the 
complicated and uncomplicated DRGs in a pair. As we indicated above, we 
developed 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.
    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.\14\
---------------------------------------------------------------------------

    \14\ 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; the FY 2005 final rule (69 FR 49848, August 
11, 2004), for the FY 2005 revisions; the FY 2006 final rule (70 FR 
47640, August 12, 2005), for the FY 2006 revisions; and the FY 2007 
final rule (71 FR 47870) for the FY 2007 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.
---------------------------------------------------------------------------

    For FY 2008, we are proposing to make limited revisions to the CC 
Exclusions List to take into account the changes that will be made in 
the ICD-

[[Page 24739]]

9-CM diagnosis coding system effective October 1, 2007. (See section 
II.G.10. of this preamble for a discussion of ICD-9-CM changes.) We are 
proposing to make these changes in accordance with the principles 
established when we created the CC Exclusions List in 1987. In 
addition, as discussed in section II.D.3. of the preamble of this 
proposed rule, we are proposing to indicate on the CC Exclusion List 
some updates to reflect the proposed exclusion of a few codes from 
being an MCC under the MS-DRG system that we are proposing to adopt for 
FY 2008.
    Table 6I (which is available through the Internet on the CMS Web 
site at: http://www.cms.hhs.gov/AcuteInpatientPPS) contains the 
complete CC Exclusions List that will be effective for discharges 
occurring on or after October 1, 2007. Table 6I shows the principal 
diagnoses for which there is a CC exclusion. Each of these principal 
diagnoses is shown with an asterisk, and the conditions that will not 
count as a CC, are provided in an indented column immediately following 
the affected principal diagnosis. Tables 6G and 6H, Additions to and 
Deletions from the CC Exclusion List, respectively, are also available 
through the Internet on the CMS Web site at: http://www.cms.hhs.gov/AcuteInpatientPPS.)
    Beginning with discharges on or after October 1, 2007, the indented 
diagnoses will not be recognized by the GROUPER as valid CCs for the 
asterisked principal diagnosis.
    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 24.0, is available for $225.00, 
which includes $15.00 for shipping and handling. Version 25.0 of this 
manual, which will include the final FY 2008 DRG changes, will be 
available in hard copy for $250.00. Version 25.0 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.
9. Review of Procedure Codes in CMS DRGs 468, 476, and 477
    Each year, we review cases assigned to CMS DRG 468 (Extensive O.R. 
Procedure Unrelated to Principal Diagnosis), CMS DRG 476 (Prostatic 
O.R. Procedure Unrelated to Principal Diagnosis), and CMS DRG 477 
(Nonextensive O.R. Procedure Unrelated to Principal Diagnosis) to 
determine whether it would be appropriate to change the procedures 
assigned among these CMS DRGs. Under the MS-DRGs that we are proposing 
to adopt for FY 2008, discussed in section II.D. of the preamble of 
this proposed rule, CMS DRG 468 would have a three-way split and would 
become proposed MS-DRGs 981, 982, and 983 (Extensive O.R. Procedure 
Unrelated to Principal Diagnosis with MCC, with CC, and without CC/
MCC). CMS DRG 476 would become proposed MS-DRGs 984, 985, and 986 
(Prostatic O.R. Procedure Unrelated to Principal Diagnosis with MCC, 
with CC, and Without CC/MCC). CMS DRG 477 would become proposed MS-DRGs 
987, 988, and 989 (Nonextensive O.R. Procedure Unrelated to Principal 
Diagnosis with MCC, with CC, and without CC/MCC).
    Proposed MS-DRGs 981 through 983, 984 through 986, and 987 through 
989 (formerly CMS DRGs 468, 476, and 477, respectively) are reserved 
for those cases in which none of the O.R. procedures performed are 
related to the principal diagnosis. These CMS DRGs are intended to 
capture atypical cases, that is, those cases not occurring with 
sufficient frequency to represent a distinct, recognizable clinical 
group. Proposed MS-DRGs 984 through 986 (previously CMS DRG 476) are 
assigned to those discharges in which one or more of the following 
prostatic procedures are performed and are unrelated to the principal 
diagnosis:
     60.0, Incision of prostate
     60.12, Open biopsy of prostate
     60.15, Biopsy of periprostatic tissue
     60.18, Other diagnostic procedures on prostate and 
periprostatic tissue
     60.21, Transurethral prostatectomy
     60.29, Other transurethral prostatectomy
     60.61, Local excision of lesion of prostate
     60.69, Prostatectomy, not elsewhere classified
     60.81, Incision of periprostatic tissue
     60.82, Excision of periprostatic tissue
     60.93, Repair of prostate
     60.94, Control of (postoperative) hemorrhage of prostate
     60.95, Transurethral balloon dilation of the prostatic 
urethra
     60.96, Transurethral destruction of prostate tissue by 
microwave thermotherapy
     60.97, Other transurethral destruction of prostate tissue 
by other thermotherapy
     60.99, Other operations on prostate
    All remaining O.R. procedures are assigned to proposed MS-DRGs 981 
through 983 and 987 through 989 (previously CMS DRGs 468 and 477), with 
proposed MS-DRGs 987 through 989 (previously CMS DRG 477) assigned to 
those discharges in which the only procedures performed are 
nonextensive procedures that are unrelated to the principal 
diagnosis.\15\
    For FY 2008, we are not proposing to change the procedures assigned 
among these CMS DRGs.
---------------------------------------------------------------------------

    \15\ 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 place 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. In the FY 
2006 (70 FR 47317), we moved one procedure from DRG 468 and assigned 
it to DRG 477. In FY 2007, we moved one procedure from DRG 468 and 
assigned it to DRGs 479, 553, and 554.
---------------------------------------------------------------------------

a. Moving Procedure Codes From CMS DRG 468 (Proposed MS-DRGs 981 
Through 983) or CMS DRG 477 (Proposed MS-DRGs 987 Through 989) to MDCs
    We annually conduct a review of procedures producing assignment to 
CMS DRG 468 (proposed MS-DRGs 981 through 983) or CMS DRG 477 (proposed 
MS-DRGs 987 through 989) 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 in 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

[[Page 24740]]

year's review, we are not proposing to remove any procedures from CMS 
DRG 477 or CMS DRG 468 with assignment to one of the surgical DRGs.
b. Reassignment of Procedures Among CMS DRGs 468, 476, and 477 
(Proposed MS-DRGs 981 Through 983, 984 Through 986, and 987 Through 
989)
    We also annually review the list of ICD-9-CM procedures that, when 
in combination with their principal diagnosis code, result in 
assignment to CMS DRGs 468, 476, and 477 (proposed MS-DRGs 981 through 
983, 984 through 986, and 987 through 989, respectively), to ascertain 
whether 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.
    We are not proposing to move any procedure codes from CMS DRG 476 
(proposed MS-DRGs 984, 985, and 986) to CMS DRG 468 (proposed MS-DRGs 
981, 982, and 983) or to CMS DRG 477 (proposed MS-DRGs 987, 988, and 
989), or from CMS DRG 477 (proposed MS-DRGs 987, 988, and 989) to CMS 
DRGs 468 (proposed MS-DRGs 981, 982, and 983) or to CMS DRG 476 
(proposed MS-DRGs 984, 985, and 986) for FY 2008.
c. Adding Diagnosis or Procedure Codes to MDCs
    Based on our review this year, we are not proposing to add any 
diagnosis codes to MDCs for FY 2008.
10. Changes to the ICD-9-CM Coding System
    (If you choose to comment on issues in this section, please include 
the caption ``ICD-9-CM Coding System'' at the beginning of your 
comment.)
    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 
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 2008 at a public meeting held on September 28-29, 
2006, and finalized the coding changes after consideration of comments 
received at the meetings and in writing by December 4, 2006. Those 
coding changes are announced in Tables 6A through 6F in the Addendum to 
this proposed rule. The Committee held its 2007 meeting on March 22-23, 
2007. Proposed new codes for which there was a consensus of public 
support and for which complete tabular and indexing changes can be made 
by May 2007 will be included in the October 1, 2007 update to ICD-9-CM. 
Code revisions that were discussed at the March 22-23, 2007 Committee 
meeting could not be finalized in time to include them in the Addendum 
to this proposed rule. These additional codes will be included in 
Tables 6A through 6F of the final rule and are marked with an asterisk 
(*).
    Copies of the minutes of the procedure codes discussions at the 
Committee's September 28-29, 2006 meeting can be obtained from the CMS 
Web site at: http://cms.hhs.gov/ICD9ProviderDiagnosticCodes/03_meetings.asp. The minutes of the diagnosis codes discussions at the 
September 28-29, 2006 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, 2007. The new ICD-9-CM codes are listed, along 
with their DRG classifications, in Tables 6A and 6B (New Diagnosis 
Codes and New Procedure Codes, respectively) in the Addendum to this 
proposed rule. As we stated above, the code numbers and their titles 
were presented for public comment at the ICD-9-CM Coordination and 
Maintenance Committee meetings. Both oral and written comments were 
considered before the codes were approved. In this proposed rule, we 
are only soliciting

[[Page 24741]]

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, 2007. 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, 2007. 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 2008.
    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 Spring meeting as part of the 
code revisions effective the following October. As stated previously, 
ICD-9-CM codes discussed at the March 22-23, 2007 Committee meeting 
that received consensus and that were finalized by May 2007, will be 
included in Tables 6A through 6F of the Addendum to the final rule.
    Section 503(a) of Pub. L. 108-173 included a requirement for 
updating ICD-9-CM codes twice a year instead of a single update on 
October 1 of each year. This requirement was included as part of the 
amendments to the Act relating to recognition of new technology under 
the IPPS. Section 503(a) amended section 1886(d)(5)(K) of the Act by 
adding a clause (vii) which states that the ``Secretary shall provide 
for the addition of new diagnosis and procedure codes on 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 1886(d)(5)(K)(vii) of the Act 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 identify the new codes. Hospitals also have to obtain 
the new code books and encoder updates, and make other system changes 
in order to identify 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, 
is publicized on CMS and NCHS Web sites in May of each year. Publishers 
of coding books and software use this information to modify their 
products that are used by health care providers. This 5-month time 
period has proved to be necessary for hospitals and other providers to 
update their systems.
    A discussion of this timeline and the need for changes are included 
in the December 4-5, 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 
1886(d)(5)(K)(vii) of the Act, as added by section 503(a) of Pub. L. 
108-173, by developing a mechanism for approving, in time for the April 
update, diagnosis 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, 2007 implementation of an ICD-9-CM code at the 
September 28-29, 2006 Committee meeting. Therefore, there were no new 
ICD-9-CM codes implemented on April 1, 2007.
    We believe that this process captures the intent of section 
1886(d)(5)(K)(vii) of the Act. 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 identify 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 site at: http://www.cms.hhs.gov/icd9ProviderDiagnosticCodes/01_overview.asp#TopofPage. Information on ICD-9-CM diagnosis codes, along 
with the Official ICD-9-CM Coding Guidelines, can be found on the Web 
site 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

[[Page 24742]]

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. The code titles are adopted as 
part of the ICD-9-CM Coordination and Maintenance Committee process. 
Thus, although we publish the code titles in the IPPS proposed and 
final rules, they 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 
1886(d)(5)(K)(vii) of the Act as added 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.
11. Other Issues
    (If you choose to comment on issues in this section, please include 
the caption ``DRGs: Headaches and Seizures'' at the beginning of your 
comment.)
a. Seizures and Headaches
    After publication of the FY 2007 IPPS final rule (71 FR 47928), we 
received correspondence expressing concerns about the revisions we made 
to the seizure and headache DRGs effective on October 1, 2006. We 
created new DRGs 562 (Seizure Age >17 With CC), DRG 563 (Seizure Age 
>17 Without CC), and DRG 564 (Headaches Age >17) as an interim step to 
better recognize severity of illness among seizure and headache 
patients for FY 2007. Although national Medicare utilization data 
supported the revised DRGs, the commenter indicated that the change did 
not appropriately recognize hospital resources associated with the 
patients treated in the hospital's inpatient headache program. The 
commenter stated that patients who are admitted to the hospital's 
inpatient headache program suffer from chronic headache pain and 
require inpatient treatment that can last up to 12 days. The commenter 
noted that these patients are referred from around the country after 
several months of unsuccessful pain relief and treatment. The commenter 
indicated that the majority of patients treated at the hospital's 
inpatient headache program are drug dependent from being administered 
increasing dosages of pain relievers that have been unsuccessful in 
resolving chronic headache pain. Further, the commenter noted that the 
patients require detoxification before any headache treatment begins. 
The commenter urged CMS to subdivide the headache DRG to better 
recognize the higher level of severity associated with treating chronic 
headache patients in the hospital's program.
    Although we are sympathetic to the commenter, it is not feasible to 
design a DRG system that addresses concerns that may be unique to one 
facility. Other than this one commenter, we did not receive any concern 
about our decision to create separate DRGs for seizures and headaches. 
However, we agreed to review this issue as part of our effort to 
redesign the DRG system to better recognize severity of illness for FY 
2008.
    As discussed in section II.C. of the preamble of this proposed 
rule, we are proposing to adopt MS-DRGs for FY 2008. While our current 
DRG structure did not support splitting the headache DRG based on the 
presence or absence of a CC, the proposed MS-DRGs support the creation 
of a split for the headache DRGs based on whether the patient has an 
MCC as shown below:

----------------------------------------------------------------------------------------------------------------
                                                                     Number of    Average length      Average
                         Proposed MS-DRG                               cases          of stay         charges
----------------------------------------------------------------------------------------------------------------
MS-DRG 102 (Headaches with MCC).................................           1,268            5.04       19,077.33
MS-DRG 103 (Headaches without MCC)..............................          14,277            3.22       11,989.43
----------------------------------------------------------------------------------------------------------------

    (The criteria for determining whether to subdivide a DRG are 
described in detail earlier in section II.D. of the preamble of this 
proposed rule.) Thus, we are proposing to create two MS-DRGs for 
headaches under the MS-DRGs as shown below:
     Proposed MS-DRG 102 (Headaches With MCC)
     Proposed MS-DRG 103 (Headaches Without MCC)
    We believe this proposed structure would better recognize those 
headaches patients who are severely ill and require more resources as 
described by the commenter. We refer the readers to section II.D. of 
the preamble of this proposed rule for a detailed discussion of the MS-
DRG proposal.
    b. Devices That Are Replaced Without Cost or Where Credit for a 
Replaced Device Is Furnished to the Hospital
    (If you choose to comment on issues in this section, please include 
the caption ``Replaced Devices'' at the beginning of your comment.)
(1) Background
    We addressed the topic of Medicare payment for devices that are 
replaced without costs or where credit for a replaced device is 
furnished to the hospital in the FY 2007 IPPS final rule (71 FR 47962). 
In that final rule, we included the following background information:
    In recent years, there have been several field actions and recalls 
with regard to failure of implantable cardiac defibrillators (ICDs) and 
pacemakers. In many of these cases, the manufacturers have offered 
replacement devices without cost to the hospital or credit for the 
device being replaced if the patient required a more expensive device. 
In some circumstances, manufacturers have also offered, through a 
warranty package, to pay specified amounts for unreimbursed expenses to 
persons who had replacement devices implanted. Nonetheless, we believe 
that incidental device failures that are covered by manufacturer 
warranties occur routinely. While we understand that some device 
malfunctions may be inevitable as medical technology grows increasingly 
sophisticated, we believe that early recognition of problems would 
reduce the number of people who would be potentially adversely affected 
by these device problems. The medical community needs heightened and 
early awareness of patterns of device failures, voluntary field 
actions, and recalls so that it can take appropriate corrective action 
to care for patients. Systematic efforts must be undertaken by all 
interested and involved parties, including manufacturers, insurers, and 
the medical community, to ensure that

[[Page 24743]]

device problems are recognized, and are addressed as early as possible 
so that patients' quality of health care is protected and high quality 
medical care, equipment, and technologies are provided. We are taking 
several steps to assist in the early recognition and analysis of 
patterns of device problems to minimize the potential for harm from 
device-related defects to Medicare beneficiaries and the public in 
general.
    In recent years, CMS has recognized the importance of data 
collection as a condition of Medicare coverage for selected services. 
In 2005, we issued an NCD that expanded coverage of ICDs and also 
required registry participation when the devices were implanted for 
certain clinical indications. The NCD included this requirement in 
order to ensure that the medical care received by Medicare 
beneficiaries was reasonable and necessary and, therefore, that the 
provider or supplier would be appropriately paid. Presently, the 
American College of Cardiology--National Cardiovascular Data Registry 
(ACC-NCDR) collects these data and maintains the registry.
    In addition to ensuring appropriate payment of claims, collection, 
and ongoing analysis of ICD implantation, registry data can facilitate 
public response to the quality of health care issues in the event of 
future device recalls. Analysis of registry data may uncover patterns 
of device malfunction, device-related infection, or early battery 
depletion that would trigger a more specific investigation. Patterns 
found in registry data may identify problems in patient outcomes 
earlier than the currently available mechanisms, which do not 
systematically collect detailed information about each patient who 
receives an ICD.
    We encourage the medical community to work to develop additional 
registries for implantable devices, so that timely and comprehensive 
information is available regarding devices, recipients of those 
devices, and patients' quality of health care status and medical 
outcomes. While participation in an ICD registry is required as a 
Medicare condition of coverage for ICD implantation for certain 
clinical conditions, we believe that the potential benefits of other 
data collection extend well beyond their application in Medicare's 
specific NCDs. As medical technology continues to advance swiftly, data 
collection regarding the short-term and long-term medical outcomes of 
new technologies, especially concerning implanted devices that may 
remain in the bodies of patients for their lifetimes, will be essential 
to the timely recognition of any specific device-related problems, 
patterns of complications, and health-related outcomes. This 
information will facilitate early interventions to mitigate any harm 
potentially imposed upon Medicare beneficiaries and the public, and to 
improve the quality and efficiency of health care services provided.
    Moreover, published data from registries may further help the 
development of high quality, evidence-based clinical practice 
guidelines for the care of patients who may receive device implants. In 
turn, widespread use of evidence-based guidelines may reduce variation 
in medical practice, leading to improved personal care and overall 
public health. Registry information may also contribute to the 
development of more comprehensive and refined quality metrics that may 
be used to systematically assess the collected data, and then improve 
the safety and quality of health care provided to Medicare 
beneficiaries. Such improvements in the quality of care that result in 
better personal health will require the sustained commitment of 
industry, payers, health care providers, and others to progressively 
work towards that goal, and to ensure excellent and open communication 
and rapid systemwide responses.
    One strategy for this data collection involves adding information 
to the claims forms. CMS has a long history of collecting hemoglobin or 
hematocrit data from ESRD patients on the claims form. Modification of 
claims forms was necessary to do that. CMS is exploring the use of 
claims data to collect other types of clinical or technical data such 
as device manufacturer and model number. The systematic recording of 
model numbers can enhance knowledge of device-related outcomes and 
complications. We look forward to further discussions with the public 
about new strategies to both recognize device-related problems early as 
well as recognize health-related outcomes of new technologies.
    In addition, we believe that the routine identification of Medicare 
claims for certain device implantation procedures in situations where a 
payment adjustment is appropriate may enhance the medical community's 
recognition of device-related problems, potentially leading to more 
timely improvements in medical device technologies. This systematic 
approach, which enables hospitals to identify and then appropriately 
report selected services when devices are replaced without cost to the 
hospital, or with full or partial credit to the hospital for the cost 
of the replaced device, should provide comprehensive information 
regarding the hospitals' experiences with Medicare beneficiaries who 
have specific medical devices that are being replaced. Because Medicare 
beneficiaries are common recipients of implanted devices, the claims 
information may be particularly helpful in identifying patterns of 
device-related problems early in their natural history, so that 
appropriate strategies to reduce future problems may be developed. One 
possible strategy would be for the Medicare program to use information 
obtained through the use of bar coding of medical devices. The FDA 
issued a final rule in the Federal Register on February 26, 2004 (69 FR 
9119), that required bar codes for human drugs and biological product 
labels effective April 26, 2006. In the final rule, FDA deferred action 
on requiring bar codes for medical devices, noting the difficulty in 
standardizing medical devices, as compared to drugs and biologicals, 
which have the unique NDC numbering system. This rule can be reviewed 
on the Federal Register's Web site at: http://www.docket.access.gpo.gov/2004/04-4249.htm.
    We intend to monitor FDA's work in this area to determine how this 
technology could help CMS promote higher quality through better 
clinical decision making and, as discussed below, assist in improving 
the accuracy of the Medicare payment system.
    In addition to our concern for overall public health, we also have 
a fiduciary responsibility to the Medicare Trust Fund to ensure that 
Medicare pays only for covered services. Therefore, in the FY 2007 IPPS 
final rule, we indicated that we believe we need to consider whether it 
is appropriate to reduce the Medicare payment in cases in which an 
implanted device is replaced at reduced or no cost to the hospital or 
with partial or full credit for the removed device. Such consideration 
could cover certain devices for which credit for the replaced medical 
device is given, or medical devices that are replaced as a result of or 
pursuant to a warranty, field action, voluntary recall, or involuntary 
recall, and medical devices that are provided free of charge. We 
indicated that conveying this information to the Medicare beneficiary 
could provide for a reduction in the IPPS payment if we determine that 
the device is replaced without cost to the provider or beneficiary or 
when the provider receives full credit for the cost of a replaced 
device.
    In FY 2007 IPPS final rule, we indicated a need to develop a 
methodology to determine the amount of the reduction to the otherwise

[[Page 24744]]

payable IPPS payment for medical devices furnished to Medicare 
beneficiaries. We believe that this policy is appropriate because, in 
these cases, the full cost of the replaced device is not incurred and, 
therefore, an adjustment to the payment is necessary to remove the cost 
of the device.
(2) Current and Proposed Policies
    In the CY 2007 OPPS final rule (71 FR 68071 through 68077), we 
adopted a policy that requires a reduced payment to a hospital or 
ambulatory surgical center when a device is provided to them at no 
cost. From our experience with the OPPS, we understand that a 
manufacturer will often provide a credit or partial credit for the 
recalled device rather than a free replacement. In other situations, a 
manufacturer will provide either a full or partial credit for a device 
that needs to be replaced only during the manufacturer's warranty 
period. In either of these situations, the original implantation of the 
device was paid for either by Medicare, another third party on behalf 
of the beneficiary by making payment directly to the hospital, or the 
implantation was paid for directly by the beneficiary. Therefore, we 
believe that Medicare should not pay the hospital for the full cost of 
the replacement if the hospital is receiving a partial or full credit, 
either due to a recall or service during the warranty period. The 
device was already paid for at the time of initial implantation, and 
Medicare should retain the credit that is being provided to the 
hospital for service to a Medicare beneficiary.
    Moreover, we also believe that a proposed adjustment is consistent 
with section 1862(a)(2) of the Act, which excludes from Medicare 
coverage an item or service for which neither the beneficiary, nor 
anyone on his or her behalf, has an obligation to pay. Payment of the 
full IPPS payment amount in cases in which the device was replaced 
under warranty or in which there was a full or partial credit for the 
price of the recalled or failed device effectively results in Medicare 
payment for a noncovered item. Therefore, we are proposing to adjust 
the IPPS payment amount in these circumstances under the authority of 
section 1886(d)(5)(I) of the Act, which permits the Secretary to make 
``exceptions and adjustments to such payment amounts * * * as the 
Secretary deems appropriate.''
    Under the OPPS, we currently only apply the reduced payment amount 
in situations where the hospital received a replacement device at no 
cost or at full credit for the replacement device. Unlike the current 
OPPS policy, we are proposing for purposes of the IPPS to apply the 
policy for partial as well as full credit for a replacement device. As 
we indicated above, our experience with the OPPS suggests that the 
policy should be applied beyond full replacement of a recalled device. 
We are proposing to reduce the amount of the Medicare IPPS payment when 
a full or partial credit towards a replacement device is made or the 
device is replaced without cost to the hospital or with full credit for 
the removed device. However, we do not believe that the IPPS policy 
should apply to all DRGs and all situations in which a device is 
replaced without cost to the hospital for the device or with full or 
partial credit for the removed device. We recognize that, in many 
cases, the cost of the device is a relatively modest part of the IPPS 
payment. In other situations, we believe the amount of the credit will 
also be nominal. In these cases, we believe that the averaging nature 
of payments under the IPPS would incorporate any significant savings 
from a warranty replacement, field action, or recall into the payment 
rate for the associated DRG, and that no specific adjustment would be 
necessary or appropriate. For this reason, we are proposing to apply 
the policy only to those DRGs under the IPPS where the implantation of 
the device determines the base DRG assignment and situations where the 
hospital received a credit equal to 20 percent or more of the cost of 
the device. We believe a credit that is equal to or more than this 
percentage is substantial, and Medicare should not pay for the full 
cost of these replacement devices because hospitals have received 
significant savings from the manufacturer for its replacement costs. We 
are seeking comment on the application of this percentage amount. We 
further believe that it is appropriate to limit application of the 
policy only to those DRGs where implantation of the device determines 
the DRG assignment. In making a decision to assign a case based on 
whether a device was implanted, we recognized that the device cost was 
a significant portion of the overall costs faced by the hospital that 
treats the case. Therefore, we believe that Medicare should not make 
full payment for those DRGs where the assignment of the case is made 
based on implantation of the device when the hospital is receiving 
either a full or significant partial credit for the device. We have 
listed the CMS DRGs that would be subject to this proposed policy 
below. We have also listed, in parentheses after the CMS DRG title, the 
proposed new MS-DRG title to which these cases would be assigned.

                   CMS DRGs Subject to Proposed Policy
------------------------------------------------------------------------
          MDC             CMS DRG       Narrative Description of DRG
------------------------------------------------------------------------
PRE....................        103  Heart Transplant or Implant of Heart
                                     Assist System (Proposed MS-DRGs 1
                                     and 2, Heart Transplant or Implant
                                     of Heart Assist System With and
                                     Without MCC, respectively).
1......................          1  Craniotomy Age > 17 With CC
                                     (Proposed MS-DRG 25 and 26,
                                     Craniotomy and Endovascular
                                     Intracranial Procedure With MCC or
                                     Without CC, respectively).
1......................          2  Craniotomy Age > 17 Without CC
                                     (Proposed MS-DRGs 26 and 27,
                                     Craniotomy and Endovascular
                                     Intracranial Procedure Without CC/
                                     MCC).
1......................          7  Peripheral & Cranial Nerve & Other
                                     Nervous System Procedures With CC
                                     (Proposed MS-DRGs 40 and 41,
                                     Peripheral & Cranial Nerve & Other
                                     Nervous System Procedure With MCC
                                     or With CC, respectively).
1......................          8  Peripheral & Cranial Nerve & Other
                                     Nervous System Procedures Without
                                     CC (Proposed MS-DRG 42, Peripheral
                                     & Cranial Nerve & Other Nervous
                                     System Procedure Without CC/MCC).
1......................        543  Craniotomy With Major Device Implant
                                     or Acute Complex Central Nervous
                                     System Principal Diagnosis
                                     (Proposed MS-DRGs 23 and 24,
                                     Craniotomy with Major Device
                                     Implant or Acute Complex Central
                                     Nervous System Principal Diagnosis
                                     With and Without MCC,
                                     respectively).
3......................         49  Major Head & Neck Procedures
                                     (Proposed MS-DRGs 129 and 130,
                                     Major Head & Neck Procedures With
                                     CC/MCC or Major Device or Without
                                     CC/MCC, respectively).
5......................        104  Cardiac Valve & Other Major
                                     Cardiothoracic Procedures with
                                     Cardiac Catheterization (Proposed
                                     MS-DRGs 216, 217, and 218, Cardiac
                                     Valve & Other Major Cardiothoracic
                                     Procedure With Cardiac
                                     Catheterization With MCC, or
                                     Without CC, or Without CC/MCC,
                                     respectively).

[[Page 24745]]

 
5......................        105  Cardiac Valve & Other Major
                                     Cardiothoracic Procedures Without
                                     Cardiac Catheterization (Proposed
                                     MS-DRGs 219, 220, and 221, Cardiac
                                     Valve & Other Major Cardiothoracic
                                     Procedure Without Cardiac
                                     Catheterization With MCC, or With
                                     CC, or Without CC/MCC,
                                     respectively).
5......................        110  Major Cardiovascular Procedures With
                                     CC (Proposed MS-DRG 237, Major
                                     Cardiovascular Procedures With
                                     MCC).
5......................        111  Major Cardiovascular Procedures
                                     Without CC (Proposed MS-DRG 238,
                                     Major Cardiovascular Procedures
                                     Without MCC).
5......................        117  Cardiac Pacemaker Revision Except
                                     Device Replacement (Proposed MS-
                                     DRGs 260, 261, and 262, Cardiac
                                     Pacemaker Revision Except Device
                                     Replacement With MCC, or With CC,
                                     or Without CC/MCC, respectively).
5......................        118  Cardiac Pacemaker Device Replacement
                                     (Proposed MS-DRGs 258 and 259,
                                     Cardiac Pacemaker Device
                                     Replacement With MCC, and Without
                                     MCC, respectively).
5......................        515  Cardiac Defibrillator Implant
                                     Without Cardiac Catheterization
                                     (Proposed MS-DRGs 226 and 227,
                                     Cardiac Defibrillator Implant
                                     Without Cardiac Catheterization
                                     With MCC and Without MCC,
                                     respectively).
5......................        525  Other Heart Assist System Implant
                                     (Proposed MS-DRG 215, Other Heart
                                     Assist System Implant).
5......................        535  Cardiac Defibrillator Implant With
                                     Cardiac Catheterization With Acute
                                     Myocardial Infarction/Heart Failure/
                                     Shock (Proposed MS-DRGs 222 and
                                     223, Cardiac Defibrillator Implant
                                     With Cardiac Catheterization With
                                     Acute Myocardial Infarction/Heart
                                     Failure/Shock With MCC and Without
                                     MCC, respectively).
5......................        536  Cardiac Defibrillator Implant With
                                     Cardiac Catheterization Without
                                     Acute Myocardial Infarction/Heart
                                     Failure/Shock (Proposed MS-DRGs 224
                                     and 225, Cardiac Defibrillator
                                     Implant With Cardiac
                                     Catheterization Without Acute
                                     Myocardial Infarction/Heart Failure/
                                     Shock With MCC and Without MCC,
                                     respectively).
5......................        551  Permanent Cardiac Pacemaker Implant
                                     With Major Cardiovascular Diagnosis
                                     or AICD Lead or Generator (Proposed
                                     MS-DRGs 242, 243, and 244,
                                     Permanent Cardiac Pacemaker Implant
                                     With MCC, With CC, and Without CC/
                                     MCC, respectively).
5......................        552  Other Permanent Cardiac Pacemaker
                                     Implant Without Major
                                     Cardiovascular Diagnosis (Proposed
                                     MS-DRGs 242, 243, and 244,
                                     Permanent Cardiac Pacemaker Implant
                                     With MCC, With CC, and Without CC/
                                     MCC, respectively).
8......................        471  Bilateral or Multiple Major Joint
                                     Procedures of Lower Extremity
                                     (Proposed MS-DRGs 461 and 462,
                                     Bilateral or Multiple Major Joint
                                     Procedures of Lower Extremity With
                                     MCC, or Without MCC, respectively).
8......................        544  Major Joint Replacement or
                                     Reattachment of Lower Extremity
                                     (Proposed MS-DRGs 469 and 470,
                                     Major Joint Replacement or
                                     Reattachment of Lower Extremity
                                     With MCC or Without MCC,
                                     respectively).
8......................        545  Revision of Hip or Knee Replacement
                                     (Proposed MS-DRGs 466, 467, and
                                     468, Revision of Hip or Knee
                                     Replacement With MCC, With CC, or
                                     Without CC/MCC, respectively).
------------------------------------------------------------------------

    CMS has requested and received new condition codes from the 
National Uniform Billing Committee to describe claims where a provider 
has received a device or product without cost. We will use these 
condition codes to reduce payment when the hospital used a device for 
which full or partial credit is given, or the item was replaced as a 
result of or under a warranty, field action, voluntary recall, 
involuntary recall, or otherwise provided free of charge. On November 
4, 2005, we issued Change Request 4058, Transmittal 741, in the 
Medicare Claims Processing Manual. The effective date of this 
transmittal was April 1, 2006, and the implementation date was April 3, 
2006. This transmittal specifies that the following two new condition 
codes have been created. They are defined below:
     Condition Code 49--Product Replacement within Product 
Lifecycle. Replacement of a product earlier than the anticipated 
lifecycle due to an indication that the product is not functioning 
properly.
     Condition Code 50--Product Replacement for Known Recall of 
a Product. The manufacturer or the FDA has identified the product for 
recall and therefore replacement.
    Hospitals must report these codes on any claim for IPPS services 
that includes a replacement device or product for which they received 
full or partial credit. Hospital billing offices would report one of 
these condition codes in addition to the specific code for the type of 
procedure performed (for example, replacement of a defibrillator). When 
this code is received by Medicare and the discharge is assigned to a 
DRG that is subject to this policy, we are proposing to suspend the 
claim so that it does not automatically process and the fiscal 
intermediary (or, if applicable, the MAC) makes a manual payment 
determination. We are proposing to require the hospital to provide 
invoices or other information indicating its normal cost of the device 
and the amount of the credit it received.
    This transmittal can be accessed at the following Web site: http://www.cms.hhs.gov/Transmittals/downloads/R741CP.pdf.
    Under our policy, the fiscal intermediary (or, if applicable, the 
MAC) would manually process claims involving DRGs that are subject to 
this policy that include a device that is replaced without cost to the 
hospital for the device or with full or partial credit for the removed 
device as identified by condition codes 49 or 50. For a device provided 
to the hospital without cost, the fiscal intermediary (or, if 
applicable, the MAC) would subtract the cost of the device from the DRG 
payment. For a device for which the hospital received a full or partial 
credit, the fiscal intermediary (or, if applicable, the MAC) would 
subtract the amount credited from the DRG payment. We are proposing to 
require the hospital to provide invoices or other information 
indicating the cost of the device and the amount of credit it received. 
We are seeking comment on the best approach to making this payment 
adjustment and what types of documentation hospitals should provide to 
the fiscal intermediary or MAC.
    We are proposing to invoke our special exceptions and adjustment 
authority under section 1886(d)(5)(I)(i) of the Act to make this 
adjustment. The special exceptions and adjustment authority authorizes 
us to provide ``for such other exceptions and adjustments to [IPPS] 
payment amounts* * *as the Secretary deems appropriate.'' We believe it 
would be appropriate to adjust payments for surgical procedures to 
replace certain devices by providing payments to hospitals only for the 
nondevice-related procedural costs when such a device is replaced 
without cost to the hospital for the device or with full credit for the 
removed device.
    To codify in regulations the proposed policies for the IPPS 
discussed above, we are proposing to add a new paragraph (g) to Sec.  
412.2 and a new

[[Page 24746]]

Sec.  412.89 to 42 CFR Part 412, Subpart F. We are also proposing to 
make a technical, conforming change to the heading of Subpart F and to 
add an uncoded center heading before the proposed new Sec.  412.89.

H. Recalibration of DRG Weights

    (If you choose to comment on issues in this section, please include 
the caption ``Recalibration of DRG Weights'' at the beginning of your 
comment.)
    In section II.D.3. of the preamble of this proposed rule, we stated 
that we are proposing to continue to implement the cost-based DRG 
relative weights under a 3-year transition period such that, in FY 
2008, year two of the transition, the relative weights would be 
recalibrated using a blend of 67 percent of the cost relative weight 
and 33 percent of the charge relative weight. By FY 2009, the relative 
weights will be 100 percent cost-based. We are proposing a few minor 
changes to the cost-weighting methodology that we adopted in the FY 
2007 IPPS final rule (71 FR 47962 through 47971). However, in section 
II.E.2. of the preamble of this proposed rule, we request public 
comments about whether to adopt any of the short-term recommendations 
to the cost relative weighting methodology for FY 2008 made by RTI. 
Therefore, if we were to adopt any of the RTI recommendations based on 
public comment, our description of the cost-weighting methodology shown 
below would be modified accordingly in the IPPS final rule.
    In developing the FY 2008 proposed system of weights, we used two 
data sources: claims data and cost report data. As in previous years, 
the claims data source is the MedPAR file. This file is based on fully 
coded diagnostic and procedure data for all Medicare inpatient hospital 
bills. The FY 2006 MedPAR data used in this proposed rule include 
discharges occurring on October 1, 2005, through September 30, 2006, 
based on bills received by CMS through December 2006, 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 2006 MedPAR file used in calculating the 
relative weights includes data for approximately 11,748,387 Medicare 
discharges from IPPS providers. Discharges for Medicare beneficiaries 
enrolled in a Medicare Advantage managed care plan are excluded from 
this analysis. The data exclude CAHs, including hospitals that 
subsequently became CAHs after the period from which the data were 
taken. The second data source used in the cost relative weight 
methodology is the FY 2005 Medicare cost report data files from HCRIS, 
which represents the most recent full set of cost report data 
available. We used the December 31, 2006 update of the HCRIS cost 
report files for FY 2005 in setting the proposed relative cost based 
weights.
    Because we are implementing the relative weights on a transitional 
basis, it is necessary to calculate both charge-based and cost-based 
relative weights. The charge-based methodology used to calculate the 
DRG relative weights from the MedPAR data is the same methodology that 
was in place for FY 2006 and FY 2007 and was applied as follows:
     To the extent possible, all the claims were regrouped 
using the MS-DRGs being proposed for FY 2008, as discussed in section 
II.D. 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 (proposed MS-DRGs 001, 002, 005, 006, and 007, 
respectively; previously CMS DRGs 103, 480, and 495) were limited to 
those Medicare-approved transplant centers that have cases in the FY 
2005 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 IPPS rates, it was 
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.
     Total 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.
     Statistical outliers were eliminated by removing all cases 
that were beyond 3.0 standard deviations from the mean of the log 
distribution of both the standardized charges per case and the 
standardized charges per day for each DRG.
     The average charge for each DRG was then recomputed 
(excluding the statistical outliers). To compute the average DRG 
charge, we sum the standardized charges by DRG and divide by the 
transfer adjusted case count. 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. The average charge per DRG is then 
divided by the national average standardized charge per case to 
determine the relative weight.
    The new charge-based weights were then normalized by an adjustment 
factor of 1.50808 so that the average case weight after recalibration 
was equal to the average case weight before recalibration. This 
normalization adjustment is intended to ensure that recalibration by 
itself neither increases nor decreases total payments under the IPPS as 
required by section 1886(d)(4)(C)(iii) of the Act.
    The methodology we used to calculate the DRG cost-based weights 
from the FY 2006 MedPAR claims data and FY 2005 Medicare cost report 
data is as follows:
     To the extent possible, all the claims were regrouped 
using the FY 2008 proposed MS-DRG classifications discussed in section 
II.D. 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 (proposed MS-DRGs 001, 002, 005, 006, and 007, 
respectively; previously CMS DRGs 103, 480, and 495) were limited to 
those Medicare-approved transplant centers that have cases in the FY 
2006 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 cost for each DRG and before 
eliminating statistical outliers.
     Claims with total charges or total length of stay less 
than or equal to zero were deleted. Claims that had an amount in the 
total charge field that differed by more than $10.00 from the sum of 
the routine day charges, intensive care charges, pharmacy charges, 
special equipment charges, therapy services charges, operating

[[Page 24747]]

room charges, cardiology charges, laboratory charges, radiology 
charges, other service charges, labor and delivery charges, inhalation 
therapy charges and anesthesia charges were also deleted.
     At least 94 percent of the providers in the MedPAR file 
had charges for 10 of the 13 cost centers. Claims for providers that 
did not have charges greater than zero for at least 10 of the 13 cost 
centers were deleted.
     Statistical outliers were eliminated by removing all cases 
that were beyond 3.0 standard deviations from the mean of the log 
distribution of both the total charges per case and the total charges 
per day for each DRG.
    Once the MedPAR data were trimmed and the statistical outliers were 
removed, the charges for each of the 13 cost groups for each claim 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. Charges were then summed by DRG for each of the 13 cost 
groups such that each DRG had 13 standardized charge totals. These 
charges were then adjusted to cost by applying the national average 
CCRs developed from the FY 2005 cost report data.
    The 13 cost centers that we used in the relative weight calculation 
are shown in the following table. In addition, the table shows the 
lines on the cost report that we used to create the national cost 
center CCRs that we used to adjust the DRG charges to cost. For FY 
2008, we are proposing to make minor revisions to the Cardiology, 
Laboratory, Radiology, and Other Services CCRs we are using to 
calculate the DRG relative weights, as follows:
     The costs for cases involving Electroencephalography 
(EEG), cost report line 54, are currently in the Cardiology cost center 
group. However, MedPAR categorizes the claims data for EEG under 
Laboratory Charges (revenue codes 0740 and 0749). In order to maintain 
consistency with matching costs on the cost report to charges on MedPAR 
claims, we are proposing to move cost report line 54 for EEG out of the 
Cardiology cost center group into the Laboratory cost center group.
     In the FY 2007 IPPS proposed rule, we originally included 
the costs for Radioisotopes, cost report line 43, in the Radiology cost 
center group. However, in response to comments, we moved Radioisotopes 
to the Other Services cost center group. After researching this issue 
further over the past year, we believe that Radioisotopes is a 
radiology-related service that more appropriately belongs in the 
Radiology cost center group. Accordingly, for FY 2008, we are proposing 
to move the cost report line item for line 43, Radioisotopes, out of 
the Other Services cost center group and into the Radiology cost center 
group. The proposed version of the 13 cost center groupings are in the 
table below:
BILLING CODE 4120-01-P

[[Page 24748]]

[GRAPHIC] [TIFF OMITTED] TP03MY07.001


[[Page 24749]]


[GRAPHIC] [TIFF OMITTED] TP03MY07.002


[[Page 24750]]


[GRAPHIC] [TIFF OMITTED] TP03MY07.003


[[Page 24751]]


[GRAPHIC] [TIFF OMITTED] TP03MY07.004


[[Page 24752]]


[GRAPHIC] [TIFF OMITTED] TP03MY07.005


[[Page 24753]]


[GRAPHIC] [TIFF OMITTED] TP03MY07.006

BILLING CODE 4120-01-C
    We developed the national average CCRs as follows:
    Taking the FY 2005 cost report data, we removed CAHs, Indian Health 
Service hospitals, all-inclusive rate hospitals, and cost reports that 
represented time periods of less than 1 year (365 days). We included 
hospitals located in Maryland as we are including their charges in our 
claims database. We then created CCRs for each provider for each cost 
center (see prior table for line items used in the calculations) and 
removed any CCRs that were greater than 10 or less than 0.01. We 
normalized the departmental CCRs by dividing the CCR for each 
department by the total CCR for the hospital for the purpose of 
trimming the data. We then took the logs of the normalized cost center 
CCRs and removed any cost center CCRs where the log of the cost center 
CCR was greater or less than the mean log plus/minus 3 times the 
standard deviation for the log of that cost center CCR. Once the cost 
report data were trimmed, we calculated a Medicare-specific CCR. The 
Medicare-specific CCR was determined by taking

[[Page 24754]]

the Medicare charges for each line item from Worksheet D, Part 4 and 
deriving the Medicare specific costs by applying the hospital-specific 
departmental CCRs to the Medicare-specific charges for each line item 
from Worksheet D, Part 4. Once each hospital's Medicare-specific costs 
were established, we summed the total Medicare-specific costs and 
divided by the sum of the total Medicare-specific charges to produce 
national average, charge-weighted CCRs.
    After we multiplied the total charges for each DRG in each of the 
13 cost centers by the corresponding national average CCR, we summed 
the 13 ``costs'' across each DRG to produce a total standardized cost 
for the DRG. The average standardized cost for each DRG was then 
computed as the total standardized cost for the DRG divided by the 
transfer adjusted case count for the DRG. The average cost for each DRG 
was then divided by the national average standardized cost per case to 
determine the relative weight.
    The new cost-based weights were then normalized by an adjustment 
factor of 1.50988 so that the average case weight after recalibration 
was equal to the average case weight before recalibration. Since more 
trims were applied to the data under the cost-based weights methodology 
than under the charge-based methodology, a smaller universe of claims 
was used in the cost-based methodology. In this instance, the different 
universe of claims also resulted in a slightly higher cost-based 
normalization factor than the normalization factor derived for charge-
based weights. The normalization adjustment is intended to ensure that 
recalibration by itself neither increases nor decreases total payments 
under the IPPS as required by section 1886(d)(4)(C)(iii) of the Act.
    The 13 proposed national average CCRs for FY 2008 are as follows:

------------------------------------------------------------------------
                              Group                                 CCR
------------------------------------------------------------------------
Routine Days....................................................    0.52
Intensive Days..................................................    0.48
Drugs...........................................................    0.21
Supplies & Equipment............................................    0.34
Therapy Services................................................    0.42
Laboratory......................................................    0.17
Operating Room..................................................    0.30
Cardiology......................................................    0.19
Radiology.......................................................    0.18
Other Services..................................................    0.37
Labor & Delivery................................................    0.47
Inhalation Therapy..............................................    0.19
Anesthesia......................................................    0.14
------------------------------------------------------------------------

    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 2008. Using the FY 2006 MedPAR 
data set, there are 7 proposed MS-DRGs that contain fewer than 10 
cases. Under the proposed MS-DRGs, we have fewer low-volume DRGs than 
under the CMS DRGs because we no longer have separate DRGs for patients 
age 0 to 17 years. With the exception of newborns, we previously 
separated some DRGs based on whether the patient was age 0-17 or age 17 
and older. Other than the age split, cases grouping to these DRGs are 
identical. The DRGs for patients age 0 to 17 years generally have very 
low volumes because children are typically ineligible for Medicare. In 
the past, we have found that the low volume of cases for the pediatric 
DRGs could lead to significant year-to-year instability in their 
relative weights. Although we have always encouraged non-Medicare 
payers to develop weights applicable to their own patient populations, 
we have heard frequent complaints from providers about the use of the 
Medicare relative weights in the pediatric population. We believe that 
eliminating this age split in the proposed MS-DRGs will provide more 
stable payment for pediatric cases by determining their payment using 
adult cases that are much higher in total volume. All of the low-volume 
DRGs listed below are for newborns. Newborns are unique and require 
separate DRGs that are not mirrored in the adult population. Therefore, 
it remains necessary to retain separate DRGs for newborns. In FY 2008, 
because we do not have sufficient MedPAR data to set accurate and 
stable cost weights for these low-volume DRGs, we are proposing to 
compute weights for the low-volume DRGs by adjusting their FY 2007 
weights by the percentage change in the average weight of the cases in 
other DRGs. The crosswalk table we are proposing is shown below:

------------------------------------------------------------------------
   Low-volume DRG           DRG title              Crosswalk to DRG
------------------------------------------------------------------------
789................  Neonates, Died or       FY 2007 FR weight (adjusted
                      Transferred to          by percent change in
                      Another Acute Care      average weight of the
                      Facility.               cases in other DRGs).
790................  Extreme Immaturity or   FY 2007 FR weight (adjusted
                      Respiratory Distress    by percent change in
                      Syndrome, Neonate.      average weight of the
                                              cases in other DRGs).
791................  Prematurity With Major  FY 2007 FR weight (adjusted
                      Problems.               by percent change in
                                              average weight of the
                                              cases in other DRGs).
792................  Prematurity Without     FY 2007 FR weight (adjusted
                      Major Problems.         by percent change in
                                              average weight of the
                                              cases in other DRGs).
793................  Full-term Neonate With  FY 2007 FR weight (adjusted
                      Major Problems.         by percent change in
                                              average weight of the
                                              cases in other DRGs).
794................  Neonate With Other      FY 2007 FR weight (adjusted
                      Significant Problems.   by percent change in
                                              average weight of the
                                              cases in other DRGs).
795................  Normal Newborn........  FY 2007 FR weight (adjusted
                                              by percent change in
                                              average weight of the
                                              cases in other DRGs).
------------------------------------------------------------------------

I. Proposed MS-LTC-DRG Reclassifications and Relative Weights for LTCHs 
for FY 2008

    (If you choose to comment on issues in this section, please include 
the caption ``MS-LTC-DRGs'' at the beginning of your comment.)
1. Background
    In the June 6, 2003 LTCH PPS final rule (68 FR 34122), we changed 
the LTCH PPS annual payment rate update cycle to be effective July 1 
through June 30 instead of October 1 through September 30. In addition, 
because the patient classification system utilized under the LTCH PPS 
uses the same CMS DRGs as those currently 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. Therefore, we specified that we will continue to update 
the LTC-DRG

[[Page 24755]]

classifications and relative weights to be effective for discharges 
occurring on or after October 1 through September 30 each year. We 
further stated that we will publish the annual proposed and final 
update of the LTC-DRGs in same notice as the proposed and final update 
for the IPPS (69 FR 34125).
    In the past, the annual update to the IPPS CMS 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 2007 IPPS final rule (71 FR 47971 
through 47994) and in the Rate Year (RY) 2008 LTCH PPS proposed rule 
(72 FR 4783 through 4789), 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. 
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 improves the recognition of new technologies 
under the IPPS by accounting for those ICD-9-CM codes in the MedPAR 
claims data earlier than the agency had accounted for new technology in 
the past. In implementing the statutory change, the agency has provided 
that ICD-9-CM diagnosis and procedure codes for new medical technology 
may be created and assigned to existing CMS DRGs in the middle of the 
Federal fiscal year, on April 1. However, this policy change will not 
impact the DRG relative weights in effect for that year, which will 
continue to be updated only once a year (October 1), nor will it have 
any impact on Medicare payments. 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 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). Therefore, the ICD-9-CM codes currently used 
under both the IPPS and LTCH PPS may be updated as often as twice a 
year. This requirement is included as part of the amendments to the Act 
relating to recognition of new medical technology under the IPPS.
    Because we do not publish a midyear IPPS rule, any April 1 ICD-9-CM 
coding update will not be published midyear. 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 (as also discussed in section II.G.10. of this 
preamble). Any coding updates will be available through the Web sites 
provided in section II.G.10. of this preamble and through the Coding 
Clinic for ICD-9-CM, a product of the American Hospital Association. 
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.
    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 is an open process through the ICD-9-CM Coordination and 
Maintenance Committee. Requestors will be given the opportunity to 
present the merits for a new code and to 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 (as also 
discussed in section II.G.10. of this preamble).
    As we discussed in the RY 2008 LTCH PPS proposed rule (72 FR 4783 
through 4789), at the September 28, 2006 ICD-9-CM Coordination and 
Maintenance Committee meeting, there were no requests for an April 1, 
2007 implementation of ICD-9-CM codes. Therefore, the next update to 
the ICD-9-CM coding system will not occur until October 1, 2007 (FY 
2008). Because there were no coding changes suggested for an April 1, 
2007 update, the ICD-9-CM coding set implemented on October 1, 2006, 
will continue through September 30, 2007 (FY 2008). The update to the 
ICD-9-CM coding system for FY 2008 is discussed above in section 
II.G.10. of this preamble. Accordingly, in this proposed rule, as 
discussed in greater detail below, we are proposing to modify and 
revise the LTC-DRG classifications and relative weights, to be 
effective October 1, 2007 through September 30, 2008 (FY 2008). In 
addition, we will notify LTCHs of any revisions to the GROUPER software 
used under the IPPS and the LTCH PPS that may be implemented on April 
1, 2008. The proposed LTC-DRGs and proposed relative weights for FY 
2008 in this proposed rule are based on the proposed IPPS MS-DRGs 
(GROUPER Version 25.0) discussed in section II.B. of the preamble to 
this proposed rule.
2. Proposed Changes in the LTC-DRG Classifications
a. Background
    Section 123 of Pub. L. 106-113 specifically requires that the 
agency implement a PPS for LTCHs that is 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 123 of Pub. L. 106-113 as amended by 
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. As described in II.D. of 
the preamble of this proposed rule, we are proposing to adopt MS-DRGs 
under the IPPS because we believe that adopting this system will result 
in a significant improvement in the DRG system's recognition of 
severity of illness and resource usage. We believe these improvements 
in the DRG system would be equally applicable to the LTCH PPS. The 
changes we are currently proposing for the IPPS would be reflected in 
the FY 2008 GROUPER,

[[Page 24756]]

Version 25.0, to be effective for discharges occurring on or after 
October 1, 2007 through September 30, 2008. Currently, the LTC-DRGs 
used as the patient classification component of the LTCH PPS correspond 
to the current CMS DRGs applicable under the IPPS for acute care 
hospitals
    Consistent with our historical practice of having LTC-DRGs 
correspond to the DRGs applicable under the IPPS, under the broad 
authority of section 123(a) of Pub. L. 106-113, as modified by section 
307(b) of Pub. L. 106-554, we are proposing to use MS-LTC-DRGs which 
correspond to the proposed MS-DRGs. In addition, as stated above, we 
are proposing to use the FY 2008 GOUPER Version 25.0, to be effective 
for discharges occurring on or after October 1, 2007 through September 
30, 2008. The proposed changes to the current CMS DRG classification 
system used under the IPPS for FY 2008 (GROUPER Version 25.0) are 
discussed in section II.D. of the preamble to this proposed rule.
    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 has been updated annually 
as authorized by section 1886(d)(4)(C) of the Act and is effective for 
discharges occurring on or after October 1 through September 30 of each 
year. As such, the proposed updates to the CMS DRG classification 
system used under the IPPS for FY 2008 (GROUPER Version 25.0), 
discussed in section II.D. of the preamble of this proposed rule, would 
be applicable to updates under the LTCH PPS. In conjunction with the 
proposed changes to the existing CMS DRGs for the IPPS by adoption of 
the proposed MS-DRGs, we are proposing to adopt the MS-DRGs for the 
LTCH PPS, as both sets of DRGs are based on the same DRG structure. 
However, we refer to the proposed DRGs under the LTCH PPS as MS-LTC-
DRGs. This proposed conforming change, that is, to replicate the MS-
LTC-DRG structure after the proposed MS-DRG structure is appropriate in 
order to maintain consistency and uniformity among a number of 
stakeholders, such as acute care hospitals, LTCHs, epidemiologists, 
ratesetting organizations, and payors, among others.
    Under the LTCH PPS, as described in greater detail below, 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 characteristic of LTCH patients. (Unless 
otherwise noted in this proposed rule, our MS-LTC-DRG analysis is based 
on LTCH data from the December 2006 update of the FY 2006 MedPAR file, 
which contains hospital bills received through December 31, 2006, for 
discharges occurring in FY 2006.)
    LTCHs do not typically treat the full range of diagnoses as do 
acute care hospitals. Therefore, 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 final rule (70 FR 47324), we use low-volume quintiles 
in determining the LTC-DRG relative weights for LTC-DRGs with less than 
25 LTCH cases (low-volume LTC-DRGs). Specifically, we group those low-
volume LTC-DRGs into 5 quintiles based on average charges per 
discharge. (A listing of the composition of low-volume quintiles for 
the FY 2007 LTC-DRGs (based on FY 2005 MedPAR data) appears in section 
II.I.2.d. of the FY 2007 IPPS final rule (71 FR 47975 through 47978).) 
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.I.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 
have been classified into the proposed MS-DRGs for acute care hospitals 
under the IPPS (section II. of the preamble of this proposed rule), 
cases have been classified into proposed MS-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. Under the proposed MS-DRGs for the IPPS and the proposed MS-LTC-
DRGs for the LTCH PPS, these factors will not change.
    Section II.B. of the preamble of this proposed rule discusses the 
organization of the existing CMS DRGs, which we are proposing to 
maintain under the proposed MS-DRG and MS-LTC-DRG systems. As noted 
above, the patient classification system for the LTCH PPS is derived 
from the CMS DRGs and is similarly organized into 25 major diagnostic 
categories (MDCs). Most of these MDCs are based on a particular organ 
system of the body and the remainder involves 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. Under the present CMS DRGs, some 
surgical and medical DRGs are further differentiated based on the 
presence or absence of CCs. The existing LTC-DRGs are similarly 
categorized. (See section II.B. of the preamble of this proposed rule 
for further discussion of surgical DRGs and medical DRGs.)
    The proposed MS-DRGs and the proposed MS-LTC-DRGs contain base DRGs 
that have been subdivided into one, two, or three severity levels. The 
most severe level has at least one code that is a major CC, referred to 
as ``with MCC''. The next lower severity level contains cases with at 
least one CC, referred to as ``with CC''. Those DRGs without an MCC or 
a CC are referred to as ``without CC/MCC''. When data did not support 
the creation of three severity levels, the base DRG was divided into 
either two levels or the base was not subdivided. The proposed two-
level subdivisions consist of one of the following subdivisions:
     With CC/MCC
     Without CC/MCC
    In this type of subdivision, cases with at least one code that is 
on the CC or MCC list are assigned to the ``with CC/MCC'' DRG. Cases 
without a CC or an MCC are assigned to the ``without CC/MCC'' DRG.
    The other type of proposed two-level subdivision is as follows:
     With MCC
     Without MCC
    In this type of subdivision, cases with at least one code that is 
on the MCC list are assigned to the ``with MCC'' DRG. Cases that do not 
have an MCC are assigned to the ``without MCC'' DRG. This type of 
subdivision could include cases with a CC code, but no MCC.
    As under the present LTC-DRG system, we are proposing that the 
assignment of a case to a particular MS-LTC-DRG will determine the 
amount that is paid for the case. Therefore, it is important that the 
coding is accurate. Classifications and terminology used under the LTCH 
PPS are consistent with the ICD-9-CM and the Uniform Hospital Discharge 
Data Set (UHDDS), as recommended to the Secretary by the National 
Committee on Vital and Health Statistics (``Uniform Hospital Discharge 
Data: Minimum Data Set, National Center for Health Statistics, April 
1980'') and as revised in 1984 by the Health Information Policy Council 
(HIPC) of the U.S. Department of Health and Human Services. Again, we 
point

[[Page 24757]]

out 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. As 
under the present LTC-DRG system, inappropriate coding of cases under 
the proposed MS-LTC-DRG system could adversely affect the uniformity of 
cases in each proposed MS-LTC-DRG and produce inappropriate weighting 
factors at recalibration and result in inappropriate payments under the 
LTCH PPS. LTCHs are required to follow the same coding guidelines 
established under the IPPS, described in section II.G.10 of the 
preamble of this proposed rule established under the IPPS. It is 
mandatory that the coders continue to report the same principal 
diagnosis on all claims and include all diagnosis codes for conditions 
that coexist at the time of admission, for conditions that are 
subsequently developed, or for conditions that affect the treatment 
received. Similarly, all procedures performed in a LTCH, or paid for 
under arrangements by a LTCH (Sec.  412.509), during that stay are to 
be reported on each claim. Consistent with current practice, there will 
be only one proposed MS-LTC-DRG assigned to each discharge of the 
patient from a LTCH.
    Under the proposed MS-LTC-DRG classification system, as is required 
under existing policy, 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 fiscal intermediary (or, if applicable, MAC). The fiscal 
intermediary or MAC enters the clinical and demographic information 
into their claims processing systems and subject this information to a 
series of automated screening processes called the MCE. These screens 
are designed to identify cases that require further review before 
assignment into a LTC-DRG can be made.
    After screening through the MCE, each LTCH claim will be classified 
into the appropriate LTC-DRG by the Medicare LTCH GROUPER. The LTCH 
GROUPER is specialized computer software and is the same GROUPER used 
under the IPPS. After the LTC-DRG is assigned, the fiscal intermediary 
or MAC 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 or MAC and to submit additional 
information, if necessary, within a specified timeframe (Sec.  
412.513(c)). Under the proposed adoption of the MS-LTC-DRG, there would 
be no changes in this procedure.
    The LTCH GROUPER is used both to classify past cases in order to 
measure relative hospital resource consumption to establish the 
proposed MS-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.H. 
of the preamble of this proposed rule). The proposed MS-LTC-DRG 
relative weights are based on data for the population of LTCH 
discharges.
3. Development of the Proposed FY 2008 MS-LTC-DRG Relative Weights
a. General Overview of Development of the Proposed MS-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 
medical 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 have annually adjusted the LTCH PPS standard Federal prospective 
payment system rate by the applicable LTC-DRG relative weight in 
determining payment to LTCHs for each case. (As we have noted above, we 
are proposing to adopt the MS-LTC-DRGs for the LTCH PPS for FY 2008. 
However, this proposed change in the patient classification system does 
not affect the basic principles of the development of relative weights 
under a DRG-based prospective payment system. For purposes of clarity, 
in the general discussion below in which we describe the basic 
methodology of the patient classification system, in use since the 
start of the LTCH PPS, we use ``MS-LTC-DRG'' to specify the proposed 
DRG system to be used by the LTCH prospective payment system in FY 
2008.)
    Although the proposed adoption of the MS-LTC-DRGs will result in 
some modifications of existing procedures for assigning weights in 
cases of zero volume and/or nonmonotonicity, discussed in detail in the 
following sections, the basic methodology for developing the proposed 
FY 2008 MS-LTC-DRG relative weights in this proposed rule continue to 
be determined in accordance with the general methodology established in 
the August 30, 2002 LTCH PPS final rule (67 FR 55989 through 55991). 
(Therefore, as noted above, in this preamble, ``LTC-DRGs'' will be used 
in descriptions of the basic methodology established at the beginning 
of the LTCH PPS that will remain unchanged if we adopt the proposed MS-
LTC-DRGs. Use of ``MS-LTC-DRGs'' will indicate a discussion of 
specifics aspects of our proposed adoption of the severity-weighted 
patient classification system for FY 2008.)
    Under the LTCH PPS, relative weights for each proposed MS-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 proposed 
MS-LTC-DRG have access to an appropriate level of services and to 
encourage efficiency, we calculate a relative weight for each proposed 
MS-LTC-DRG that represents the resources needed by an average inpatient 
LTCH case in that proposed MS-LTC-DRG. For example, cases in a proposed 
MS-LTC-DRG with a relative weight of 2 will, on average, cost twice as 
much to treat as cases in a proposed MS-LTC-DRG with a weight of 1.
b. Data
    To calculate the proposed MS-LTC-DRG relative weights for FY 2008 
in his proposed rule, we obtained total Medicare allowable charges from 
FY 2006 Medicare LTCH bill data from the December 2006 update of the 
MedPAR file, which are the best available data at this time, and we 
used the proposed Version 25.0 of the CMS GROUPER used under the IPPS 
(as discussed in section II.B. of the preamble of this proposed rule) 
to classify cases. To calculate the final MS-LTC-DRG relative weights 
for FY 2008, we are proposing that, if more recent data are available 
(that is, data from the March 2007 update of the MedPAR file), we would 
use those data and the finalized Version 25.0 of the CMS GROUPER used 
under the IPPS.
    As we discussed in the FY 2007 IPPS final rule (71 FR 47974), we 
have excluded the data from LTCHs that are

[[Page 24758]]

all-inclusive rate providers and LTCHs that are reimbursed in 
accordance with demonstration projects authorized under section 402(a) 
of Pub. L. 90-248. Data from demonstration projects authorized under 
section 222(a) of Pub. L. 92-603 are also excluded. Therefore, in the 
development of the proposed FY 2008 MS-LTC-DRG relative weights in this 
proposed rule, 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 2006 MedPAR file.
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 proposed MS-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 (HSRV) method to calculate the 
proposed MS-LTC-DRG relative weights instead of the methodology used to 
determine the proposed CMS DRG relative weights under the IPPS 
described in section II.H. of the preamble this proposed rule. 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 HSRV 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, average 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 continue to 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.I.4. (step 
3) of the preamble of this proposed rule) 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 
proposed MS-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 at 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 at 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 at a LTCH with the same case-mix, but an average 
adjusted charge of $35,000. We believe that the adjusted charge of an 
individual case more accurately reflects actual resource use for an 
individual LTCH because the variation in charges due to systematic 
differences in the markup of charges among LTCHs is taken into account.
d. Proposed Treatment of Severity Levels in Developing Relative Weights
    With the implementation of the LTCH PPS for FY 2003, we established 
a procedure to address setting relative weights for LTC-DRG ``pairs'' 
that were differentiated on the presence or absence of CCs (71 FR 
47979). For FY 2008, we are proposing to adopt a severity-based patient 
classification system for the LTCH PPS, the MS-LTC-DRGs described 
above, which requires us to adapt our existing procedures for dealing 
with setting relative weights for the severity levels within a specific 
base DRG. We are also proposing to modify our existing methodology for 
maintaining monotonicity when setting relative weights for the proposed 
MS-LTC-DRGs.
    As under the existing procedure, under the proposed MS-LTC-DRGs, 
for purposes of the annual setting of the relative weights, there 
continue to be three different categories of DRGs based on volume of 
cases within specific LTC-DRGs. DRGs with at least 25 cases are each 
assigned a relative weight; low-volume proposed MS-LTC-DRGs (that is, 
proposed MS-LTC-DRGs that contain between one and 24 cases annually) 
are grouped into quintiles (described below) and assigned the weight of 
the quintile. Cases with no-volume proposed MS-LTC-DRGs (that is, no 
cases in the databases were assigned to those proposed MS-LTC-DRGs) are 
crosswalked to other proposed MS-LTC-DRGs based on the clinical 
similarities and assigned the weight of the quintile that is closest to 
the relative weight of the crosswalked proposed MS-LTC-DRG. (We provide 
in-depth discussions of our proposals regarding weightsetting for low-
volume MS-LTC-DRGs in section II.I.3.e. of the preamble of this 
proposed rule and for no-volume MS-LTC-DRGs, under Step 4 in section 
II.I.4. of the preamble of this proposed rule.)
    As described above, in response to the need to account for severity 
and pay appropriately for cases, we have developed a severity-adjusted 
patient classification system which we are proposing for both the IPPS 
and the LTCH PPS. As described in greater detail above, the proposed 
MS-LTC-DRG system can accommodate three severity levels: MCC (most 
severe); without CC/MCC (the least severe), and with CC, with each 
level assigned an individual MS-LTC-DRG number. In cases with two 
subdivisions, the levels are either with CC/MCC and without CC/MCC or 
with MCC and without MCC. Two parallel numbering systems have been 
developed, based on the MS-DRG patient classification system proposed 
under the IPPS, to describe proposed MS-LTC-DRGs. That is, while each 
severity level in each DRG category gets a unique MS-LTC-DRG number, in 
conjunction, each of the severity levels in a single DRG category are 
also assigned the same ``base-DRG'' number. We are proposing that the 
term ``base DRG'' is actually the MS-LTC-DRG number of the highest 
severity level and would be used when we refer to the MS-LTC-DRG 
category that encompasses all the levels of severity for that DRG. 
Therefore, under the proposed system, multiple sclerosis and cerebellar 
ataxia with MCC is MS-LTC-DRG 58; multiple sclerosis and

[[Page 24759]]

cerebellar ataxia with CC is MS-LTC-DRG 59; and multiple sclerosis and 
cerebellar ataxia without CC/MCC is MS-LTC-DRG 59, and the base MS-LTC-
DRG for each is 58.
    As noted above, for FY 2008, we are proposing to adopt the MS-DRGs 
for use in both the LTCH PPS and the IPPS. While the LTCH PPS and the 
IPPS use the same patient classification system, the methodology that 
is used to set the DRG weights for use in each payment system differs 
because the overall volume of cases in the LTCH PPS is much less than 
in the IPPS. As a general rule, we are proposing to set the weights for 
the MS-LTC-DRGs using the following steps: (1) If an MS-LTC-DRG has at 
least 25 cases, it is assigned its own relative weight; (2) if an MS-
LTC-DRGs has between 1 and 24 cases, it is assigned to a quintile to 
which we will assign a relative weight; and (3) if an MS-LTC-DRG has no 
cases, it is crosswalked to another DRG based upon clinical 
similarities and assigned the appropriate relative weight (as described 
in detail in Step 5, below).
    Theoretically, as with the existing LTC-DRG system, cases under the 
proposed MS-LTC-DRG system that are more severe require greater 
expenditure of medical care resources and will result in higher average 
charges. Therefore, in the three severity levels, weights should 
increase with severity, from lowest to highest. If the weights do not 
increase (that is, if based on the weight calculation, a proposed MS-
LTC-DRG with MCC would have a lower relative weight than one with CC, 
or the DRG without CC/MCC would have a higher relative weight than 
either of the others), there is a problem with monotonicity. Since the 
start of the LTCH PPS for FY 2003 (67 FR 55990), we have adjusted the 
setting of the LTC-DRG relative weight in order to maintain 
monotonicity by grouping both sets of cases together and establishing a 
new relative weight that is assigned to both LTC-DRGs. Similarly, we 
are proposing a procedure for dealing with nonmonotonicity under the 
proposed MS-LTC-DRG classification system that we describe in detail in 
our explanation of our methodology for setting the proposed FY 2008 
relative weights for the LTCH PPS, which is discussed in section II.F.4 
of the preamble of this proposed rule.
e. Low-Volume Proposed MS-LTC-DRGs
    In order to account for LTC-DRGs with low volume (that is, with 
fewer than 25 LTCH cases), under current policy, 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. For this FY 2008 IPPS proposed rule, we are proposing 
to continue to employ this treatment of low-volume proposed MS-LTC-DRGs 
with a modification to combine proposed MS-LTC-DRGs for the purpose of 
computing a relative weight in cases where necessary to maintain 
monotonicity in determining the proposed FY 2008 MS-LTC-DRG relative 
weights using the best available LTCH data. In this proposed rule, 
using LTCH cases from the December 2006 update of the FY 2006 MedPAR 
file, we identified 307 proposed MS-LTC-DRGs that contained between 1 
and 24 cases. This list of proposed MS-LTC-DRGs was then divided into 
one of the 5 low-volume quintiles, each containing a minimum of 61 
proposed MS-LTC-DRGs (307/5 = 61, with a remainder of 2 proposed MS-
LTC-DRGs). Consistent with our current methodology, we are proposing to 
make an assignment to a specific low-volume quintile by sorting the 
low-volume proposed MS-LTC-DRGs in ascending order by average charge. 
For this proposed rule, this results in a proposed assignment to a 
specific low-volume quintile of the sorted 307 low-volume proposed MS-
LTC-DRGs by ascending order by average charge. Because the number of 
low-volume proposed MS-LTC-DRGs for FY 2008 is not evenly divisible by 
five, to determine the composition of the low-volume quintiles in 
accordance with our established methodology, the average charge of the 
low-volume proposed MS-LTC-DRG was used to determine which low-volume 
quintile received the additional proposed MS-LTC-DRGs. After sorting 
the 307 low-volume proposed MS-LTC-DRGs in ascending order, we grouped 
the first fifth (1st through 61st) of low-volume proposed MS-LTC-DRGs 
(with the lowest average charge) into Quintile 1. Because the average 
charge of the 62nd proposed MS-LTC-DRG in the sorted list is closer to 
the 61st proposed MS-LTC-DRGs average charge (assigned to Quintile 1) 
than to the average charge of the 63rd proposed MS-LTC-DRG in the 
sorted list (to be assigned to Quintile 2), we placed the 62nd proposed 
MS-LTC-DRG into Quintile 1. This process was repeated through the 
remaining low-volume proposed MS-LTC-DRGs so that 2 low-volume 
quintiles contain 62 proposed MS-LTC-DRGs and 3 low-volume quintiles 
contain 61 proposed MS-LTC-DRGs. The highest average charge cases were 
grouped into Quintile 5.
    In order to determine the proposed relative weights for the 
proposed MS-LTC-DRGs with low-volume for FY 2008, based on the 
methodology established in the August 30, 2002 LTCH PPS final rule (67 
FR 55984), we are proposing to use the five low-volume quintiles 
described above. In addition, in cases where the initial assignment of 
the low-volume proposed MS-LTC-DRGs to quintiles results in 
nonmonotonicity within a base DRG, we are proposing to combine those 
proposed MS-LTC-DRGs for the purpose of computing a relative weight and 
set the same relative weight to each of the proposed MS-LTC-DRGs within 
the base DRG that required combining. The treatment of low-volume 
proposed MS-LTC-DRGs to preserve monotonicity is further discussed in 
detail in section II.I.4 (Step 6 of the methodology for determining the 
proposed FY 2008 MS-LTC-DRG relative weights). The composition of each 
of the proposed five low-volume quintiles shown in the chart below was 
used in determining the proposed MS-LTC-DRG relative weights for FY 
2008. We would determine a proposed relative weight and (geometric) 
average length of stay for each of the proposed five low-volume 
quintiles using the methodology that we apply to the regular proposed 
MS-LTC-DRGs (25 or more cases), as described below in section II.I.4. 
of the preamble of this proposed rule. We are proposing to assign the 
same relative weight and average length of stay to each of the proposed 
MS-LTC-DRGs that make up an individual proposed low-volume quintile. We 
note that, as this system is dynamic, it is possible that the number 
and specific type of MS-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 MS-LTC-DRGs and to calculate the relative 
weights based on our methodology. Therefore, we are proposing that, if 
we have updated data for the final rule, we will use that data to 
determine the finalized FY 2008 relative weights.

[[Page 24760]]



        Proposed Composition of Low-Volume Quintiles for FY 2008
------------------------------------------------------------------------
     Proposed MS-LTC-DRG            Proposed MS-LTC-DRG description
------------------------------------------------------------------------
                               QUINTILE 1
------------------------------------------------------------------------
30..........................  Spinal procedures w/o CC/MCC.
32..........................  Ventricular shunt procedures w CC.
33..........................  Ventricular shunt procedures w/o CC/MCC.
58..........................  Multiple sclerosis & cerebellar ataxia w
                               MCC*.
60..........................  Multiple sclerosis & cerebellar ataxia w/o
                               CC/MCC*.
66..........................  Intracranial hemorrhage or cerebral
                               infarction w/o CC/MCC.
67..........................  Nonspecific CVA & precerebral occlusion w/
                               o infarct w MCC.
68..........................  Nonspecific CVA & precerebral occlusion w/
                               o infarct w/o MCC.
69..........................  Transient ischemia.
72..........................  Nonspecific cerebrovascular disorders w/o
                               CC/MCC.
76..........................  Viral meningitis w/o CC/MCC.
79..........................  Hypertensive encephalopathy w/o CC/MCC.
88..........................  Concussion w MCC***.
133.........................   Other ear, nose, mouth & throat O.R.
                               procedures w CC/MCC***.
122.........................   Acute major eye infections w/o CC/MCC.
123.........................   Neurological eye disorders.
149.........................   Dysequilibrium.
153.........................   Otitis media & URI w/o MCC.
182.........................   Respiratory neoplasms w/o CC/MCC.
183.........................   Major chest trauma w MCC.
184.........................   Major chest trauma w CC**.
201.........................   Pneumothorax w/o CC/MCC.
261.........................  Cardiac pacemaker revision except device
                               replacement w CC.
262.........................  Cardiac pacemaker revision except device
                               replacement w/o CC/MCC.
313.........................  Chest pain.
328.........................  Stomach, esophageal & duodenal proc w/o CC/
                               MCC.
331.........................  Major small & large bowel procedures w/o
                               CC/MCC.
349.........................  Anal & stomal procedures w/o CC/MCC.
376.........................  Digestive malignancy w/o CC/MCC.
434.........................  Cirrhosis & alcoholic hepatitis w/o CC/
                               MCC*.
446.........................  Disorders of the biliary tract w/o CC/MCC.
505.........................  Foot procedures w/o CC/MCC.
512.........................  Shoulder, elbow or forearm proc, exc major
                               joint proc w/o CC/MCC.
544.........................  Pathological fractures & musculoskelet &
                               conn tiss malig w/o CC/MCC.
547.........................  Connective tissue disorders w/o CC/MCC.
563.........................  Fx, sprn, strn & disl except femur, hip,
                               pelvis & thigh w/o MCC.
598.........................  Malignant breast disorders w CC***.
630.........................  Other endocrine, nutrit & metab O.R. proc
                               w/o CC/MCC.
645.........................  Endocrine disorders w/o CC/MCC.
661.........................  Kidney & ureter procedures for non-
                               neoplasm w/o CC/MCC.
688.........................  Kidney & urinary tract neoplasms w/o CC/
                               MCC.
696.........................  Kidney & urinary tract signs & symptoms w/
                               o MCC.
714.........................  Transurethral prostatectomy w/o CC/MCC.
718.........................  Other male reproductive system O.R. proc
                               exc malignancy w/o CC/MCC.
724.........................  Malignancy, male reproductive system w/o
                               CC/MCC.
726.........................  Benign prostatic hypertrophy w/o MCC.
756.........................  Malignancy, female reproductive system w/o
                               CC/MCC.
759.........................  Infections, female reproductive system w/o
                               CC/MCC.
761.........................  Menstrual & other female reproductive
                               system disorders w/o CC/MCC.
825.........................  Lymphoma & non-acute leukemia w other O.R.
                               proc w/o CC/MCC.
836.........................  Acute leukemia w/o major O.R. procedure w/
                               o CC/MCC.
869.........................  Other infectious & parasitic diseases
                               diagnoses w/o CC/MCC.
876.........................  O.R. procedure w principal diagnoses of
                               mental illness.
881.........................  Depressive neuroses.
882.........................  Neuroses except depressive.
883.........................  Disorders of personality & impulse
                               control.
886.........................  Behavioral & developmental disorders.
894.........................  Alcohol/drug abuse or dependence, left
                               ama.
895.........................  Alcohol/drug abuse or dependence w
                               rehabilitation therapy.
906.........................  Hand procedures for injuries.
916.........................  Allergic reactions w/o MCC.
922.........................  Other injury, poisoning & toxic effect
                               diag w MCC.
923.........................  Other injury, poisoning & toxic effect
                               diag w/o MCC.
------------------------------------------------------------------------
                               QUINTILE 2
------------------------------------------------------------------------
75..........................  Viral meningitis w CC/MCC.
77..........................  Hypertensive encephalopathy w MCC.

[[Page 24761]]

 
78..........................  Hypertensive encephalopathy w CC**.
83..........................  Traumatic stupor & coma, coma >1 hr w CC.
84..........................  Traumatic stupor & coma, coma >1 hr w/o CC/
                               MCC.
99..........................  Non-bacterial infect of nervous sys exc
                               viral meningitis w/o CC/MCC.
102.........................  Headaches w MCC***.
113.........................  Orbital procedures w CC/MCC.
121.........................  Acute major eye infections w CC/MCC.
125.........................  Other disorders of the eye w/o MCC.
148.........................  Ear, nose, mouth & throat malignancy w/o
                               CC/MCC.
152.........................  Otitis media & URI w MCC.
156.........................  Nasal trauma & deformity w/o CC/MCC.
157.........................  Dental & Oral Diseases w MCC***.
158.........................  Dental & Oral Diseases w CC***.
184.........................  Major chest trauma w CC***.
188.........................  Pleural effusion w/o CC/MCC*.
200.........................  Pneumothorax w CC.
245.........................  AICD lead & generator procedures.
282.........................  Circulatory disorders w AMI, discharged
                               alive w/o CC/MCC.
285.........................  Circulatory disorders w AMI, expired w/o
                               CC/MCC*.
304.........................  Hypertension w MCC.
311.........................  Angina pectoris.
336.........................  Peritoneal adhesiolysis w CC.
382.........................  Complicated peptic ulcer w/o CC/MCC.
384.........................  Uncomplicated peptic ulcer w/o MCC.
390.........................  G.I. obstruction w/o CC/MCC.
433.........................  Cirrhosis & alcoholic hepatitis w CC*.
437.........................  Malignancy of hepatobiliary system or
                               pancreas w/o CC/MCC.
443.........................  Disorders of liver except malig, cirr, alc
                               hepa w/o CC/MCC.
499.........................  Local excision & removal int fix devices
                               of hip & femur w/o CC/MCC.
514.........................  Hand or wrist proc, except major thumb or
                               joint proc w/o CC/MCC.
534.........................  Fractures of femur w/o MCC.
535.........................  Fractures of hip & pelvis w MCC.
553.........................  Bone diseases & arthropathies w MCC.
555.........................  Signs & symptoms of musculoskeletal system
                               & conn tissue w MCC.
556.........................  Signs & symptoms of musculoskeletal system
                               & conn tissue w/o MCC.
578.........................  Skin graft &/or debrid exc for skin ulcer
                               or cellulitis w/o CC/MCC.
598.........................  Malignant breast disorders w CC**.
599.........................  Malignant breast disorders w/o CC/MCC**.
600.........................  Non-malignant breast disorders w CC/MCC.
601.........................  Non-malignant breast disorders w/o CC/MCC.
642.........................  Inborn errors of metabolism.
660.........................  Kidney & ureter procedures for non-
                               neoplasm w CC.
687.........................  Kidney & urinary tract neoplasms w CC.
693.........................  Urinary stones w/o ESW lithotripsy w MCC.
694.........................  Urinary stones w/o ESW lithotripsy w/o
                               MCC**.
723.........................  Malignancy, male reproductive system w CC.
730.........................  Other male reproductive system diagnoses w/
                               o CC/MCC.
744.........................  D&C, conization, laparoscopy & tubal
                               interruption w CC/MC
769.........................  Postpartum & post abortion diagnoses w
                               O.R. procedure.
803.........................  Other O.R. proc of the blood & blood
                               forming organs w CC.
815.........................  Reticuloendothelial & immunity disorders w
                               CC.
816.........................  Reticuloendothelial & immunity disorders w/
                               o CC/MCC**.
842.........................  Lymphoma & non-acute leukemia w/o CC/MCC.
848.........................  Chemotherapy w/o acute leukemia as
                               secondary diagnosis w/o CC/MCC.
864.........................  Fever of unknown origin.
897.........................  Alcohol/drug abuse or dependence w/o
                               rehabilitation therapy w/o MCC.
903.........................  Wound debridements for injuries w/o CC/
                               MCC.
905.........................  Skin grafts for injuries w/o CC/MCC.
917.........................  Poisoning & toxic effects of drugs w MCC.
918.........................  Poisoning & toxic effects of drugs w/o
                               MCC.
929.........................  Full thickness burn w skin graft or inhal
                               inj w/o CC/MCC.
956.........................  Limb reattachment, hip & femur proc for
                               multiple significant trauma.
964.........................  Other multiple significant trauma w CC.
965.........................  Other multiple significant trauma w/o CC/
                               MCC.
977.........................  HIV w or w/o other related condition.
------------------------------------------------------------------------
                               QUINTILE 3
------------------------------------------------------------------------
42..........................  Periph & cranial nerve & other nerv syst
                               proc w/o CC/MCC.
53..........................  Spinal disorders & injuries w/o CC/MCC.

[[Page 24762]]

 
78..........................   Hypertensive encephalopathy w CC***.
102.........................  Headaches w MCC**.
103.........................  Headaches w/o MCC.
133.........................  Other ear, nose, mouth & throat O.R.
                               procedures w CC/MCC**.
134.........................  Other ear, nose, mouth & throat O.R.
                               procedures w/o CC/MCC**.
157.........................  Dental & Oral Diseases w MCC**.
158.........................  Dental & Oral Diseases w CC**.
159.........................  Dental & Oral Diseases w/o CC/MCC**.
238.........................  Major cardiovascular procedures w/o MCC.
246.........................  Percutaneous cardiovascular proc w drug-
                               eluting stent w MCC.
250.........................  Perc cardiovasc proc w/o coronary artery
                               stent or AMI w MCC.
263.........................  Vein ligation & stripping.
284.........................  Circulatory disorders w AMI, expired w
                               CC*.
287.........................  Circulatory disorders except AMI, w card
                               cath w/o MCC.
294.........................  Deep vein thrombophlebitis w CC/MCC.
347.........................  Anal & stomal procedures w MCC.
348.........................  Anal & stomal procedures w CC.
352.........................  Inguinal & femoral hernia procedures w/o
                               CC/MCC.
354.........................  Hernia procedures except inguinal &
                               femoral w CC.
358.........................  Other digestive system O.R. procedures w/o
                               CC/MCC.
380.........................  Complicated peptic ulcer w MCC.
381.........................  Complicated peptic ulcer w CC.
383.........................  Uncomplicated peptic ulcer w MCC.
387.........................  Inflammatory bowel disease w/o CC/MCC*.
420.........................  Hepatobiliary diagnostic procedures w MCC.
421.........................  Hepatobiliary diagnostic procedures w CC.
424.........................  Other hepatobiliary or pancreas O.R.
                               procedures w CC.
425.........................  Other hepatobiliary or pancreas O.R.
                               procedures w/o CC/MCC.
494.........................  Lower extrem & humer proc except hip,
                               foot, femur w/o CC/MCC.
502.........................  Soft tissue procedures w/o CC/MCC.
504.........................  Foot procedures w CC.
507.........................  Major shoulder or elbow joint procedures w
                               CC/MCC.
517.........................  Other musculoskelet sys & conn tiss O.R.
                               proc w/o CC/MCC.
533.........................  Fractures of femur w MCC.
597.........................  Malignant breast disorders w MCC.
599.........................  Malignant breast disorders w/o CC/MCC***.
604.........................  Trauma to the skin, subcut tiss & breast w
                               MCC.
618.........................  Amputat of lower limb for endocrine,
                               nutrit, & metabol dis w/o CC/MCC.
619.........................  O.R. procedures for obesity w MCC.
620.........................  O.R. procedures for obesity w CC**.
624.........................  Skin grafts & wound debrid for endoc,
                               nutrit & metab dis w/o CC/MCC.
644.........................  Endocrine disorders w CC.
657.........................  Kidney & ureter procedures for neoplasm w
                               CC.
662.........................  Minor bladder procedures w MCC.
665.........................  Prostatectomy w MCC.
667.........................  Prostatectomy w/o CC/MCC.
694.........................  Urinary stones w/o ESW lithotripsy w/o
                               MCC***.
695.........................  Kidney & urinary tract signs & symptoms w
                               MCC.
711.........................  Testes procedures w CC/MCC***.
722.........................  Malignancy, male reproductive system w
                               MCC.
746.........................  Vagina, cervix & vulva procedures w CC/
                               MCC.
749.........................  Other female reproductive system O.R.
                               procedures w CC/MCC.
755.........................  Malignancy, female reproductive system w
                               CC.
809.........................  Major hematol/immune diag exc sickle cell
                               crisis & coagul w CC.
810.........................  Major hematol/immune diag exc sickle cell
                               crisis & coagul w/o CC/MCC.
816.........................  Reticuloendothelial & immunity disorders w/
                               o CC/MCC***.
821.........................  Lymphoma & leukemia w major O.R. procedure
                               w CC.
826.........................  Myeloprolif disord or poorly diff neopl w
                               maj O.R. proc w MCC.
834.........................  Acute leukemia w/o major O.R. procedure w
                               MCC.
835.........................  Acute leukemia w/o major O.R. procedure w
                               CC.
838.........................  Chemo w acute leukemia as sdx or w high
                               dose chemo agent w CC.
843.........................  Other myeloprolif dis or poorly diff neopl
                               diag w MCC***.
844.........................  Other myeloprolif dis or poorly diff neopl
                               diag w CC***.
855.........................  Infectious & parasitic diseases w O.R.
                               procedure w/o CC/MCC.
896.........................  Alcohol/drug abuse or dependence w/o
                               rehabilitation therapy w MCC.
963.........................  Other multiple significant trauma w MCC.
989.........................  Non-extensive O.R. proc unrelated to
                               principal diagnosis w/o CC/MCC.
------------------------------------------------------------------------
                               QUINTILE 4
------------------------------------------------------------------------
28..........................  Spinal procedures w MCC.

[[Page 24763]]

 
29..........................  Spinal procedures w CC.
38..........................  Extracranial procedures w CC.
39..........................  Extracranial procedures w/o CC/MCC.
88..........................  Concussion w MCC**.
89..........................  Concussion w CC.
124.........................   Other disorders of the eye w MCC.
168.........................   Other resp system O.R. procedures w/o CC/
                               MCC.
241.........................   Amputation for circ sys disorders exc
                               upper limb & toe w/o CC/MCC
242.........................   Permanent cardiac pacemaker implant w
                               MCC***.
244.........................   Permanent cardiac pacemaker implant w/o
                               CC/MCC.
254.........................  Other vascular procedures w/o CC/MCC.
257.........................  Upper limb & toe amputation for circ
                               system disorders w/o CC/MCC*.
286.........................  Circulatory disorders except AMI, w card
                               cath w MCC.
351.........................  Inguinal & femoral hernia procedures w CC.
368.........................  Major esophageal disorders w MCC.
369.........................  Major esophageal disorders w CC.
370.........................  Major esophageal disorders w/o CC/MCC**.
408.........................  Biliary tract proc except only cholecyst w
                               or w/o c.d.e. w MCC***.
407.........................  Pancreas, liver & shunt procedures w/o CC/
                               MCC.
412.........................  Cholecystectomy w c.d.e. w CC.
414.........................  Cholecystectomy except by laparoscope w/o
                               c.d.e. w MCC.
415.........................  Cholecystectomy except by laparoscope w/o
                               c.d.e. w CC.
418.........................  Laparoscopic cholecystectomy w/o c.d.e. w
                               CC.
423.........................  Other hepatobiliary or pancreas O.R.
                               procedures w MCC.
472.........................  Cervical spinal fusion w CC.
476.........................  Amputation for musculoskeletal sys & conn
                               tissue dis w/o CC/MCC*.
478.........................  Biopsies of musculoskeletal system &
                               connective tissue w CC.
479.........................  Biopsies of musculoskeletal system &
                               connective tissue w/o CC/MCC.
482.........................  Hip & femur procedures except major joint
                               w/o CC/MCC.
486.........................  Knee procedures w pdx of infection w CC.
487.........................  Knee procedures w pdx of infection w/o CC/
                               MCC.
490.........................  Back & neck procedures except spinal
                               fusion w CC/MCC or disc devices.
493.........................  Lower extrem & humer proc except hip,
                               foot, femur w CC.
497.........................  Local excision & removal int fix devices
                               exc hip & femur w/o CC/MCC.
503.........................  Foot procedures w MCC.
511.........................  Shoulder, elbow or forearm proc, exc major
                               joint proc w CC.
516.........................  Other musculoskelet sys & conn tiss O.R.
                               proc w CC.
562.........................  Fx, sprn, strn & disl except femur, hip,
                               pelvis & thigh w MCC.
576.........................  Skin graft &/or debrid exc for skin ulcer
                               or cellulitis w MCC.
577.........................  Skin graft &/or debrid exc for skin ulcer
                               or cellulitis w CC.
584.........................  Breast biopsy, local excision & other
                               breast procedures w CC/MCC.
620.........................  O.R. procedures for obesity w CC***.
659.........................  Kidney & ureter procedures for non-
                               neoplasm w MCC.
675.........................  Other kidney & urinary tract procedures w/
                               o CC/MCC.
709.........................  Penis procedures w CC/MCC.
711.........................  Testes procedures w CC/MCC**.
712.........................  Testes procedures w/o CC/MCC**.
717.........................  Other male reproductive system O.R. proc
                               exc malignancy w CC/MCC.
725.........................  Benign prostatic hypertrophy w MCC.
754.........................  Malignancy, female reproductive system w
                               MCC.
760.........................  Menstrual & other female reproductive
                               system disorders w CC/MCC.
776.........................  Postpartum & post abortion diagnoses w/o
                               O.R. procedure.
781.........................  Other antepartum diagnoses w medical
                               complications.
823.........................  Lymphoma & non-acute leukemia w other O.R.
                               proc w MCC.
824.........................  Lymphoma & non-acute leukemia w other O.R.
                               proc w CC.
843.........................  Other myeloprolif dis or poorly diff neopl
                               diag w MCC**.
844.........................  Other myeloprolif dis or poorly diff neopl
                               diag w CC**.
845.........................  Other myeloprolif dis or poorly diff neopl
                               diag w/o CC/MCC**.
880.........................  Acute adjustment reaction & psychosocial
                               dysfunction.
909.........................  Other O.R. procedures for injuries w/o CC/
                               MCC.
928.........................  Full thickness burn w skin graft or inhal
                               inj w CC/MCC.
933.........................  Extensive burns or full thickness burns w
                               MV 96+ hrs w/o skin graft.
958.........................  Other O.R. procedures for multiple
                               significant trauma w CC.
983.........................  Extensive O.R. procedure unrelated to
                               principal diagnosis w/o CC/MCC.
985.........................  Prostatic O.R. procedure unrelated to
                               principal diagnosis w CC.
986.........................  Prostatic O.R. procedure unrelated to
                               principal diagnosis w/o CC/MCC.
------------------------------------------------------------------------
                               QUINTILE 5
------------------------------------------------------------------------
12..........................  Tracheostomy for face, mouth & neck
                               diagnoses w CC.

[[Page 24764]]

 
26..........................  Craniotomy & endovascular intracranial
                               procedures w CC.
31..........................  Ventricular shunt procedures w MCC.
37..........................  Extracranial procedures w MCC.
131.........................  Cranial/facial procedures w CC/MCC.
134.........................  Other ear, nose, mouth & throat O.R.
                               procedures w/o CC/MCC***.
137.........................  Mouth procedures w CC/MCC.
139.........................  Salivary gland procedures.
159.........................  Dental & Oral Diseases w/o CC/MCC***.
164.........................  Major chest procedures w CC.
226.........................  Cardiac defibrillator implant w/o cardiac
                               cath w MCC.
227.........................  Cardiac defibrillator implant w/o cardiac
                               cath w/o MCC.
237.........................  Major cardiovascular procedures w MCC.
242.........................  Permanent cardiac pacemaker implant w
                               MCC**.
243.........................  Permanent cardiac pacemaker implant w CC.
248.........................  Percutaneous cardiovasc proc w non-drug-
                               eluting stent w MCC.
258.........................  Cardiac pacemaker device replacement w
                               MCC.
260.........................  Cardiac pacemaker revision except device
                               replacement w MCC.
327.........................  Stomach, esophageal & duodenal proc w CC.
329.........................  Major small & large bowel procedures w
                               MCC.
330.........................  Major small & large bowel procedures w CC.
335.........................  Peritoneal adhesiolysis w MCC.
350.........................  Inguinal & femoral hernia procedures w
                               MCC.
370.........................  Major esophageal disorders w/o CC/MCC***.
405.........................  Pancreas, liver & shunt procedures w MCC.
406.........................  Pancreas, liver & shunt procedures w CC.
408.........................  Biliary tract proc except only cholecyst w
                               or w/o c.d.e. w MCC**.
409.........................  Biliary tract proc except only cholecyst w
                               or w/o c.d.e. w CC.
417.........................  Laparoscopic cholecystectomy w/o c.d.e. w
                               MCC.
454.........................  Combined anterior/posterior spinal fusion
                               w CC.
456.........................  Spinal fusion exc cerv w spinal curv,
                               malig or 9+ fusions w MCC.
459.........................  Spinal fusion except cervical w MCC.
460.........................  Spinal fusion except cervical w/o MCC.
466.........................  Revision of hip or knee replacement w MCC.
467.........................  Revision of hip or knee replacement w CC.
469.........................  Major joint replacement or reattachment of
                               lower extremity w MCC.
470.........................  Major joint replacement or reattachment of
                               lower extremity w/o MCC.
471.........................  Cervical spinal fusion w MCC.
477.........................  Biopsies of musculoskeletal system &
                               connective tissue w MCC.
480.........................  Hip & femur procedures except major joint
                               w MCC.
481.........................  Hip & femur procedures except major joint
                               w CC.
485.........................  Knee procedures w pdx of infection w MCC.
488.........................  Knee procedures w/o pdx of infection w CC/
                               MCC.
492.........................  Lower extrem & humer proc except hip,
                               foot, femur w MCC.
498.........................  Local excision & removal int fix devices
                               of hip & femur w CC/MCC.
513.........................  Hand or wrist proc, except major thumb or
                               joint proc w CC/MCC.
582.........................  Mastectomy for malignancy w CC/MCC.
664.........................  Minor bladder procedures w/o CC/MCC.
668.........................  Transurethral procedures w MCC.
669.........................  Transurethral procedures w CC.
670.........................  Transurethral procedures w/o CC/MCC.
691.........................  Urinary stones w esw lithotripsy w CC/MCC.
712.........................  Testes procedures w/o CC/MCC***.
713.........................  Transurethral prostatectomy w CC/MCC.
715.........................  Other male reproductive system O.R. proc
                               for malignancy w CC/MCC.
802.........................  Other O.R. proc of the blood & blood
                               forming organs w MCC.
829.........................  Myeloprolif disord or poorly diff neopl w
                               other O.R. proc w CC/MCC.
837.........................  Chemo w acute leukemia as sdx or w high
                               dose chemo agent w MCC.
845.........................  Other myeloprolif dis or poorly diff neopl
                               diag w/o CC/MCC***.
957.........................  Other O.R. procedures for multiple
                               significant trauma w MCC.
969.........................  HIV w extensive O.R. procedure w MCC.
970.........................  HIV w extensive O.R. procedure w/o MCC.
984.........................  Prostatic O.R. procedure unrelated to
                               principal diagnosis w MCC
------------------------------------------------------------------------
* One of the original 307 low-volume proposed MS-LTC-DRGs initially
  assigned to this proposed low-volume quintile; removed from this
  proposed low-volume quintile in addressing nonmonotonicity (see step 6
  below).
** One of the original 307 low-volume proposed MS-LTC-DRGs initially
  assigned to a different proposed low-volume quintile but moved to this
  proposed low-volume quintile in addressing nonmonotonicity (see step 6
  below).
*** One of the original 307 low-volume proposed MS-LTC-DRGs initially
  assigned to this proposed low-volume quintile but moved to a different
  proposed low-volume quintile in addressing nonmonotonicity (see step 6
  below).


[[Page 24765]]

    We note that we will continue to monitor the volume (that is, the 
number of LTCH cases) in these low-volume quintiles to ensure that our 
proposed quintile assignment results in appropriate payment for such 
cases and does not result in an unintended financial incentive for 
LTCHs to inappropriately admit these types of cases.

4. Steps for Determining the Proposed FY 2008 MS-LTC-DRG Relative 
Weights

    As we noted previously, although the proposed adoption of the MS-
LTC-DRGs will result in some modifications of existing procedures for 
assigning weights in cases of zero volume and/or nonmonotonicity, 
described in detail elsewhere in this section, the proposed FY 2008 MS-
LTC-DRG relative weights in this proposed rule are based on the 
methodology established in the August 30, 2002 LTCH PPS final rule (67 
FR 55989 through 55991). In summary, for FY 2008, LTCH cases would be 
grouped to the appropriate MS-LTC-DRG, while taking into account the 
low-volume proposed MS-LTC-DRGs as described above, before the proposed 
FY 2008 MS-LTC-DRG relative weights can be determined. After grouping 
the cases to the appropriate proposed MS-LTC-DRG, we are proposing to 
calculate the proposed relative weights for FY 2008 by first removing 
statistical outliers and cases with a length of stay of 7 days or less, 
as discussed in greater detail below. Next, we are proposing to adjust 
the number of cases in each proposed MS-LTC-DRG for the effect of 
short-stay outlier cases under Sec.  412.529, as also discussed in 
greater detail below. The short-stay adjusted discharges and 
corresponding charges are used to calculate ``relative adjusted 
weights'' in each proposed MS-LTC-DRG using the HSRV method described 
above.
    Below we discuss in detail the steps for calculating the proposed 
FY 2008 MS-LTC-DRG relative weights. We note that, as we stated above 
in section II.I.3.b. of the preamble of this proposed rule, we have 
excluded the data of all-inclusive rate LTCHs and LTCHs that are paid 
in accordance with demonstration projects that had claims in the FY 
2006 MedPAR file.
    Step 1--Remove statistical outliers.
    The first step in the calculation of the proposed FY 2008 MS-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 proposed MS-LTC-DRG. These 
statistical outliers are removed prior to calculating the proposed 
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 proposed 
relative weights could result in an inaccurate relative weight that 
does not truly reflect relative resource use among the proposed MS-LTC-
DRGs.
    Step 2--Remove cases with a length of stay of 7 days or less.
    The proposed FY 2008 MS-LTC-DRG relative weights reflect the 
average of resources used on representative cases of a specific type. 
Generally, cases with a length of stay of 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 proposed FY 2008 MS-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, by including data from 
these very short-stays. Thus, as explained above, in determining the 
proposed FY 2008 MS-LTC-DRG relative weights, we remove LTCH cases with 
a length of stay of 7 days or less.
    Step 3--Adjust charges for the effects of short-stay outliers.
    After removing cases with a length of stay of 7 days or less, we 
are left with cases that have a length of stay of greater than or equal 
to 8 days. The next step in the calculation of the proposed FY 2008 MS-
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). (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 MS-LTC-DRG, 
in accordance with Sec.  412.529.)
    We make this adjustment by counting a short-stay outlier as a 
fraction of a discharge based on the ratio of the length of stay of the 
case to the average length of stay for the proposed MS-LTC-DRG for non-
short-stay outlier cases. This has the effect of proportionately 
reducing the impact of the lower charges for the short-stay outlier 
cases in calculating the average charge for the proposed MS-LTC-DRG. 
This process produces the same result as if the actual charges per 
discharge of a short-stay outlier case were adjusted to what they would 
have been had the patient's length of stay been equal to the average 
length of stay of the proposed MS-LTC-DRG.
    As we explained in the FY 2007 IPPS final (71 FR 47979), counting 
short-stay outlier cases as full discharges with no adjustment in 
determining the proposed MS-LTC-DRG relative weights would lower the 
proposed LTC-DRG relative weight for affected proposed MS-LTC-DRGs 
because the relatively lower charges of the short-stay outlier cases 
would bring down the average charge for all cases within a proposed MS-
LTC-DRG. This would result in an ``underpayment'' for nonshort-stay 
outlier cases and an ``overpayment'' for short-stay outlier cases. 
Therefore, we adjust for short-stay outlier cases under Sec.  412.529 
in this manner because it results in more appropriate payments for all 
LTCH cases.
    Step 4--Calculate the proposed FY 2008 MS-LTC-DRG relative weights 
on an iterative basis.
    The process of calculating the proposed MS-LTC-DRG relative weights 
using the HSRV methodology is iterative. First, for each LTCH case, we 
calculate a hospital-specific relative charge value by dividing the 
short-stay outlier adjusted charge per discharge (see step 3) of the 
LTCH case (after removing the statistical outliers (see step 1)) and 
LTCH cases with a length of stay of 7 days or less (see step 2) by the 
average charge per discharge for the LTCH in which the case occurred. 
The resulting ratio is then multiplied by the LTCH's case-mix index to 
produce an adjusted hospital-specific relative charge value for the 
case. An initial case-mix index value of 1.0 is used for each LTCH.
    For each proposed DRG, the proposed FY 2008 MS-LTC-DRG relative 
weight is calculated by dividing the average of the adjusted hospital-
specific relative charge values (from above) for the proposed MS-LTC-
DRG by the overall average hospital-specific relative charge value 
across all cases for all LTCHs. Using these proposed recalculated MS-
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 proposed MS-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

[[Page 24766]]

adjusted relative charge values are then used to calculate a new set of 
proposed MS-LTC-DRG relative weights across all LTCHs. In this proposed 
rule, this iterative process is continued until there is convergence 
between the weights produced at adjacent steps, for example, when the 
maximum difference is less than 0.0001.
    Step 5--Determine a proposed FY 2007 MS-LTC-DRG relative weight for 
proposed MS-LTC-DRGs with no LTCH cases.
    As we stated above, we determine the proposed relative weight for 
each proposed MS-LTC-DRG using total Medicare allowable charges 
reported in the December 2006 update of the FY 2006 MedPAR file. Of the 
745 proposed MS-LTC-DRGs for FY 2008, we identified 124 proposed MS-
LTC-DRGs for which there were no LTCH cases in the database. That is, 
based on data from the FY 2006 MedPAR file used in this proposed rule, 
no patients who would have been classified to those proposed MS-LTC-
DRGs were treated in LTCHs during FY 2006 and, therefore, no charge 
data were reported for those proposed MS-LTC-DRGs. Thus, in the process 
of determining the proposed MS-LTC-DRG relative weights, we are unable 
to determine weights for these 124 proposed MS-LTC-DRGs using the 
methodology described in Steps 1 through 4 above. However, because 
patients with a number of the diagnoses under these proposed MS-LTC-
DRGs may be treated at LTCHs beginning in FY 2008, for this proposed 
rule, we are proposing to assign relative weights to each of the 124 
no-volume proposed MS-LTC-DRGs based on clinical similarity and 
relative costliness to one of the remaining 621 (745-124 = 621) 
proposed MS-LTC-DRGs for which we are able to determine proposed 
relative weights, based on FY 2006 LTCH claims data. In general, we 
determined proposed relative weights for the 124 proposed MS-LTC-DRGs 
with no LTCH cases in the FY 2006 MedPAR file used in this proposed 
rule by crosswalking these proposed MS-LTC-DRGs to other proposed MS-
LTC-DRGs and then grouping them to the appropriate proposed low-volume 
quintile. This methodology is consistent with our methodology used in 
determining relative weights to account for the low-volume proposed MS-
LTC-DRGs described above.
    Our proposed methodology for determining the relative weights for 
the no-volume MS-LTC-DRGs is as follows: We crosswalk the no-volume 
proposed MS-LTC-DRG to a proposed MS-LTC-DRG for which there are LTCH 
cases in the FY 2006 MedPAR file and to which it is similar clinically 
and in 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, postoperative care, 
and length of stay. If the proposed MS-LTC-DRG to which it is 
crosswalked is grouped to one of the proposed low-volume quintiles, we 
assign the relative weight for the applicable low-volume quintile to 
the no volume proposed MS-LTC-DRG. However, if the proposed MS-LTC-DRG 
to which the no-volume proposed MS-LTC-DRG is crosswalked is not one of 
the proposed MS-LTC-DRGs in a low-volume quintile, we do the following: 
(1) compare the relative weight of the proposed MS-LTC-DRG to which the 
no-volume proposed MS-LTC-DRG is crosswalked to the relative weights of 
each of the five quintiles; (2) assign the no volume proposed MS-LTC-
DRG the relative weight of the low-volume quintile with the relative 
weight that is closest to the proposed MS-LTC-DRG to which the no 
volume proposed MS-LTC-DRG is crosswalked. (We note that in the 
infrequent case where nonmonotonicity involving a no volume proposed 
MS-LTC-DRG results, additional measures as described in Step 6 are 
required in order to maintain monotonically increasing relative 
weights.) or this proposed rule, a list of the no-volume proposed FY 
2008 MS-LTC-DRGs and the proposed FY 2008 MS-LTC-DRG to which it is 
crosswalked is shown in the chart below.

           No-Volume Proposed MS-LTC-DRG Crosswalk for FY 2008
------------------------------------------------------------------------
                                                              Proposed
   Proposed MS-LTC-DRG          Proposed MS-LTC-DRG       crosswalked MS-
                                    description               LTC-DRG
------------------------------------------------------------------------
9........................  Bone marrow transplant.......             823
20.......................  Intracranial vascular                      31
                            procedures w PDX hemorrhage
                            w MCC.
21.......................  Intracranial vascular                      32
                            procedures w PDX hemorrhage
                            w CC.
22.......................  Intracranial vascular                      33
                            procedures w PDX hemorrhage
                            w/o CC/MCC.
23.......................  Craniotomy w major device                  31
                            implant or acute complex CNS
                            PDX w MCC.
24.......................  Craniotomy w major device                  33
                            implant or acute complex CNS
                            PDX w/o MCC.
34.......................  Carotid artery stent                       37
                            procedure w MCC.
35.......................  Carotid artery stent                       38
                            procedure w CC.
36.......................  Carotid artery stent                       39
                            procedure w/o CC/MCC.
61.......................  Acute ischemic stroke w use                70
                            of thrombolytic agent w MCC.
62.......................  Acute ischemic stroke w use                71
                            of thrombolytic agent w CC.
63.......................  Acute ischemic stroke w use                72
                            of thrombolytic agent w/o CC/
                            MCC.
115......................  Extraocular procedures except             125
                            orbit.
116......................  Intraocular procedures w CC/              125
                            MCC.
117......................  Intraocular procedures w/o CC/            125
                            MCC.
129......................  Major head & neck procedures              146
                            w CC/MCC or major device.
130......................  Major head & neck procedures              148
                            w/o CC/MCC.
135......................  Sinus & mastoid procedures w              133
                            CC/MCC.
136......................  Sinus & mastoid procedures w/             133
                            o CC/MCC.
150......................  Epistaxis w MCC..............             152
151......................  Epistaxis w/o MCC............             153
215......................  Other heart assist system                 238
                            implant.
216......................  Cardiac valve & oth maj                   237
                            cardiothoracic proc w card
                            cath w MCC.
217......................  Cardiac valve & oth maj                   238
                            cardiothoracic proc w card
                            cath w CC.
218......................  Cardiac valve & oth maj                   250
                            cardiothoracic proc w card
                            cath w/o CC/MCC.
219......................  Cardiac valve & oth maj                   237
                            cardiothoracic proc w/o card
                            cath w MCC.
220......................  Cardiac valve & oth maj                   238
                            cardiothoracic proc w/o card
                            cath w CC.
221......................  Cardiac valve & oth maj                   250
                            cardiothoracic proc w/o card
                            cath w/o CC/MCC.

[[Page 24767]]

 
222......................  Cardiac defib implant w                   242
                            cardiac cath w AMI/HF/shock
                            w MCC.
223......................  Cardiac defib implant w                   243
                            cardiac cath w AMI/HF/shock
                            w/o MCC.
224......................  Cardiac defib implant w                   242
                            cardiac cath w/o AMI/HF/
                            shock w MCC.
225......................  Cardiac defib implant w                   243
                            cardiac cath w/oAMI/HF/shock
                            w/o MCC.
228......................  Other cardiothoracic                      252
                            procedures w MCC.
229......................  Other cardiothoracic                      253
                            procedures w CC.
230......................  Other cardiothoracic                      254
                            procedures w/o CC/MCC.
231......................  Coronary bypass w PTCA w MCC.             237
232......................  Coronary bypass w PTCA w/o                238
                            MCC.
233......................  Coronary bypass w cardiac                 237
                            cath w MCC.
234......................  Coronary bypass w cardiac                 238
                            cath w/o MCC.
235......................  Coronary bypass w/o cardiac               237
                            cath w MCC.
236......................  Coronary bypass w/o cardiac               238
                            cath w/o MCC.
296......................  Cardiac arrest, unexplained w             283
                            MCC.
297......................  Cardiac arrest, unexplained w             284
                            CC.
298......................  Cardiac arrest, unexplained w/            285
                            o CC/MCC.
332......................  Rectal resection w MCC.......             356
333......................  Rectal resection w CC........             357
334......................  Rectal resection w/o CC/MCC..             358
338......................  Appendectomy w complicated                371
                            principal diag w MCC.
339......................  Appendectomy w complicated                372
                            principal diag w CC.
340......................  Appendectomy w complicated                373
                            principal diag w/o CC/MCC.
341......................  Appendectomy w/o complicated              371
                            principal diag w MCC.
342......................  Appendectomy w/o complicated              372
                            principal diag w CC.
343......................  Appendectomy w/o complicated              373
                            principal diag w/o CC/MCC.
344......................  Minor small & large bowel                 371
                            procedures w MCC.
345......................  Minor small & large bowel                 372
                            procedures w CC.
346......................  Minor small & large bowel                 373
                            procedures w/o CC/MCC.
457......................  Spinal fusion exc cerv w                  456
                            spinal curv, malig or 9+
                            fusions w CC.
461......................  Bilateral or multiple major               480
                            joint procs of lower
                            extremity w MCC.
462......................  Bilateral or multiple major               482
                            joint procs of lower
                            extremity w/o MCC.
483......................  Major joint & limb                        480
                            reattachment proc of upper
                            extremity w CC/MCC.
484......................  Major joint & limb                        482
                            reattachment proc of upper
                            extremity w/o CC/MCC.
506......................  Major thumb or joint                      514
                            procedures.
509......................  Arthroscopy..................             505
537......................  Sprains, strains, &                       505
                            dislocations of hip, pelvis
                            & thigh w CC/MCC.
538......................  Sprains, strains, &                       505
                            dislocations of hip, pelvis
                            & thigh w/o CC/MCC.
614......................  Adrenal & pituitary                       629
                            procedures w CC/MCC.
615......................  Adrenal & pituitary                       630
                            procedures w/o CC/MCC.
625......................  Thyroid, parathyroid &                    628
                            thyroglossal procedures w
                            MCC.
626......................  Thyroid, parathyroid &                    629
                            thyroglossal procedures w CC.
627......................  Thyroid, parathyroid &                    630
                            thyroglossal procedures w/o
                            CC/MCC.
653......................  Major bladder procedures w                659
                            MCC.
654......................  Major bladder procedures w CC             660
655......................  Major bladder procedures w/o              661
                            CC/MCC.
666......................  Prostatectomy w CC...........             665
671......................  Urethral procedures w CC/MCC.             687
672......................  Urethral procedures w/o CC/               688
                            MCC.
697......................  Urethral stricture...........             688
707......................  Major male pelvic procedures              660
                            w CC/MCC.
708......................  Major male pelvic procedures              661
                            w/o CC/MCC.
734......................  Pelvic evisceration, rad                  717
                            hysterectomy & rad
                            vulvectomy w CC/MCC.
735......................  Pelvic evisceration, rad                  718
                            hysterectomy & rad
                            vulvectomy w/o CC/MCC.
736......................  Uterine & adnexa proc for                 754
                            ovarian or adnexal
                            malignancy w MCC.
737......................  Uterine & adnexa proc for                 755
                            ovarian or adnexal
                            malignancy w CC.
738......................  Uterine & adnexa proc for                 756
                            ovarian or adnexal
                            malignancy w/o CC/MCC.
739......................  Uterine,adnexa proc for non-              754
                            ovarian/adnexal malig w MCC.
740......................  Uterine,adnexa proc for non-              755
                            ovarian/adnexal malig w CC.
741......................  Uterine,adnexa proc for non-              756
                            ovarian/adnexal malig w/o CC/
                            MCC.
742......................  Uterine & adnexa proc for non-            755
                            malignancy w CC/MCC.
743......................  Uterine & adnexa proc for non-            756
                            malignancy w/o CC/MCC.
748......................  Female reproductive system                749
                            reconstructive procedures.
765......................  Cesarean section w CC/MCC....             744
766......................  Cesarean section w/o CC/MCC..             769
767......................  Vaginal delivery w                        769
                            sterilization &/or D&C.
768......................  Vaginal delivery w O.R. proc              769
                            except steril &/or D&C.
770......................  Abortion w D&C, aspiration                769
                            curettage or hysterotomy.
774......................  Vaginal delivery w                        769
                            complicating diagnoses.
775......................  Vaginal delivery w/o                      769
                            complicating diagnoses.
777......................  Ectopic pregnancy............             769

[[Page 24768]]

 
778......................  Threatened abortion..........             759
779......................  Abortion w/o D&C.............             759
780......................  False labor..................             759
782......................  Other antepartum diagnoses w/             759
                            o medical complications.
789......................  Neonates, died or transferred             761
                            to another acute care
                            facility.
790......................  Extreme immaturity or                     761
                            respiratory distress
                            syndrome, neonate.
791......................  Prematurity w major problems.             760
792......................  Prematurity w/o major                     761
                            problems.
793......................  Full term neonate w major                 760
                            problems.
794......................  Neonate w other significant               760
                            problems.
795......................  Normal newborn...............             761
799......................  Splenectomy w MCC............             423
800......................  Splenectomy w CC.............             424
801......................  Splenectomy w/o CC/MCC.......             425
827......................  Myeloprolif disord or poorly              823
                            diff neopl w maj O.R. proc w
                            CC.
887......................  Other mental disorder                     881
                            diagnoses.
927......................  Extensive burns or full                   933
                            thickness burns w MV 96+ hrs
                            w skin graft.
955......................  Craniotomy for multiple                    26
                            significant trauma.
------------------------------------------------------------------------

    To illustrate this methodology for determining the proposed 
relative weights for the 124 proposed MS-LTC-DRGs with no LTCH cases, 
we are providing the following example, which refers to the no volume 
proposed MS-LTC-DRGs crosswalk information for FY 2008 provided in the 
chart above.
    Example 1:
    There were no cases in the FY 2006 MedPAR file used for this 
proposed rule for proposed MS-LTC-DRG 22 (Intracranial vascular 
procedures w PDX hemorrhage w/o CC/MCC). We determined that proposed 
MS-LTC-DRG 33 (Ventricular shunt procedures w/o CC/MCC), which is 
assigned to low-volume Quintile 1 for the purpose of determining the 
proposed FY 2008 relative weights, is similar clinically and based on 
resource use to proposed MS-LTC-DRG 22. Therefore, we are proposing to 
assign the same relative weight of proposed MS-LTC-DRG 33 of 0.48011 
(Quintile 1) for FY 2008 (Table 11 in the Addendum to this proposed 
rule) to proposed MS-LTC-DRG 22.
    Furthermore, for FY 2008 we are proposing to establish proposed MS-
LTC-DRG relative weights of 0.0000 for the following transplant 
proposed MS-LTC-DRGs: Heart transplant or implant of heart assist 
system w MCC (proposed LTC-DRG 1); Heart transplant or implant of heart 
assist system w/o MCC (proposed LTC-DRG 2); Liver transplant w MCC or 
intestinal transplant (proposed LTC-DRG 5); Liver transplant w/o MCC 
(proposed LTC-DRG 6); Lung transplant (proposed LTC-DRG 7); 
Simultaneous pancreas/kidney transplant (proposed LTC-DRG 8); and 
Pancreas transplant (proposed LTC-DRG 10). This is 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 will 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.
    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 proposed MS-LTC-DRGs affected. At the 
present time, we would only include these seven proposed transplant MS-
LTC-DRGs in the GROUPER program for administrative purposes only. 
Because we use the same GROUPER program for LTCHs as is used under the 
IPPS, removing these proposed MS-LTC-DRGs would be administratively 
burdensome.
    Again, we note that, as this system is dynamic, it is entirely 
possible that the number of proposed MS-LTC-DRGs with no volume of LTCH 
cases based on the system will vary in the future. We used the most 
recent available claims data in the MedPAR file to identify no volume 
proposed MS-LTC-DRGs and to determine the proposed relative weights in 
this proposed rule.
    Table 11 in the Addendum to this proposed rule lists the proposed 
MS-LTC-DRGs and their respective proposed relative weights, geometric 
mean length of stay, and five-sixths of the geometric mean length of 
stay (to assist in the determination of short-stay outlier payments 
under Sec.  412.529) for FY 2008.
    Step 6--Adjust the proposed FY 2008 MS-LTC-DRG relative weights to 
account for nonmonotonically increasing relative weights.
    As explained in section II.B. of this preamble, the IPPS proposed 
FY 2008 MS-DRGs, on which the proposed FY 2008 MS-LTC-DRGs are based, 
provide a significant improvement in the DRG system's recognition of 
severity of illness and resource usage. The proposed MS-DRGs contain 
base DRGs that have been subdivided into one, two, or three severity 
levels. Where there are three severity levels, the most severe level 
has at least one code that is referred to as an MCC. The next lower 
severity level contains cases with at least one code that is a CC. 
Those cases without a MCC or a CC are referred to as without CC/MCC. 
When data did not support the creation of three severity levels, the 
base was divided into either two levels or the base was not subdivided. 
The two-level subdivisions could consist of the CC/MCC and the without 
CC/MCC. Alternatively, the other type of two level subdivision could 
consist of the MCC and without MCC. In base DRGs with two levels, cases 
classified into a ``without CC/MCC'' proposed MS-LTC-DRG are expected 
to have lower resource use

[[Page 24769]]

(and lower costs) than the ``with CC/MM'' and ``with MCC.''
    That is, theoretically, cases that are more severe typically 
require greater expenditure of medical care resources and will result 
in higher average charges. Therefore, in the three severity levels, 
relative weights should increase by severity, from lowest to highest. 
If the weights do not increase (that is, if within a base MS-LTC-DRG, a 
proposed MS-LTC-DRG with MCC has a lower relative weight than one with 
CC, or the proposed MS-LTC-DRG without CC/MCC has a higher relative 
weight than either of the others, they are nonmonotonic. We continue to 
believe that utilizing nonmonotonic relative weights to adjust Medicare 
payments would result in inappropriate payments. Consequently, we are 
proposing that, in general, we would combine proposed MS-LTC-DRG 
severity levels within a proposed base MS-LTC-DRG for the purpose of 
computing a relative weight when necessary to ensure that monotonicity 
is maintained. Specifically, under each of the example scenarios 
provided below, we would combine severity levels within a proposed base 
MS-LTC-DRG as follows:
    The first example of nonmonotonically increasing relative weights 
for MS-LTC-DRG pertains to base DRGs with a three-level split and each 
of the three levels has 25 or more LTCH cases and, therefore, did not 
fall into one of the proposed five low-volume quintiles. If 
nonmonotonicity is detected in the relative weights of proposed MS-LTC-
DRGs in adjacent severity levels (for example, the relative weight of 
the ``with MCC'' (the highest severity level) is less than the ``with 
CC'' (the middle level), or the ``with CC'' is less than the ``without 
CC/MCC''), we are proposing to combine the adjacent proposed MS-LTC-
DRGs and determine one relative weight based on the case-weighted 
average of the combined LTCH cases of the nonmonotonic proposed MS-LTC-
DRG. The case-weighted average charge is determined by dividing the 
total charges for all LTCH cases in both severity levels by the total 
number of LTCH cases for the combined proposed MS-LTC-DRGs. We are 
proposing to apply this relative weight to both affected levels of the 
proposed base MS-LTC-DRG. If nonmonotonicity remains an issue because 
the above process results in a relative weight that is still 
nonmonotonic to the remaining proposed MS-LTC-DRG, we are proposing to 
combine all three of the severity levels to determine one relative 
weight which is assigned to each of the proposed MS-LTC-DRG in that 
proposed base MS-LTC-DRG.
    A second scenario of nonmonotonically increasing relative weights 
for an MS-LTC-DRG pertains to the situation where one or more of the 
severity levels within a base DRG has less than 25 LTCH cases (that is, 
low volume). If nonmonotonicity occurs in the case where either the 
highest or lowest severity level (with MCC'' or ``without CC/MCC'') has 
25 LTCH cases or more and the other two severity levels are low volume 
(and therefore the other two severity levels would otherwise be 
assigned to quintiles), we are proposing to combine the data for the 
cases in the two adjacent low-volume proposed MS-LTC-DRGs for the 
purpose of determining a relative weight. If the combination results in 
at least 25 cases, we are proposing to calculate one relative weight 
and assign it to both of the proposed severity levels. If the 
combination results in less than 25 cases, based on the case-weighted 
average charge of the combined low-volume MS-LTC-DRGs, both MS-LTC-
DRGs, are assigned the relative weight of the quintile that has the 
closest relative weight to the case weighted average change of the 
combined low volume case. If nonmonotonicity persists, we are proposing 
to combine all three severity levels and one relative weight would be 
assigned to all three levels based on the case weighted average of the 
combined severity level. Similarly, in nonmonotonic cases where the 
middle level has 25 cases or more but either or both the lowest or 
highest severity level has less than 25 cases (that is, low volume), we 
are proposing to combine the nonmonotonic low-volume proposed MS-LTC-
DRG with the middle level proposed MS-LTC-DRG of the base DRG. We are 
proposing to calculate one relative weight and apply it to both of the 
affected proposed MS-LTC-DRGs. If the nonmonotonicity persists, we are 
proposing to combine all three levels for the purpose of determining a 
relative weight, and apply that relative weight to all three levels.
    A third scenario addresses nonmonotonicity in a base DRG where at 
least one of the severity levels has no cases. As discussed in greater 
detail in Step 5, based on clinical similarity, we would cross-walk the 
proposed MS-LTC-DRG to a proposed MS-LTC-DRG to which it is similar 
clinically and in intensity of resource use and then assign it to a 
quintile with the relative weight closest to that of the MS-LTC-DRG to 
which the no-volume MS-LTC-DRG had been cross-walked. If this results 
in nonmonotonicity, in the case where the no-volume proposed MS-LTC-DRG 
is either the lowest or highest severity level, we are proposing to 
assign to the no-volume proposed MS-LTC-DRG the same relative weight 
that is assigned to the middle level of the MS-LTC-DRG in that base 
DRG. If nonmonotonicity persists, we are proposing that all three 
severity levels be combined for the purpose of calculating one relative 
weight which is applied to each of the three levels. We note that this 
is a departure from our current treatment of no-volume LTC-DRGs which 
results in an ultimate assignment to a quintile. However, we propose 
that in the infrequent case where nonmonotonicity involves a no-volume 
proposed MS-LTC-DRG, we believe it is appropriate to resolve the 
nonmonotonicity by assigning the no-volume proposed MS-LTC-DRG the 
relative weight of the proposed MS-LTC-DRG(s) in the base DRG, 
regardless of whether the other proposed MS-LTC-DRG(s) is low volume 
(therefore assigned a relative weight of a quintile) or high volume 
(assigned its own relative weight). We believe this treatment achieves 
monotonically increasing relative weights while providing appropriate 
payment for the no-volume proposed MS-LTC-DRG because the relative 
weight assigned to the no-volume proposed MS-LTC-DRG is based on the 
average charges of services rendered within the same proposed base MS-
LTC-DRG, rather than a quintile which contains proposed MS-LTC-DRGs 
from different proposed base MS-LTC-DRGs.
    We are proposing to apply the same process where the proposed base 
MS-LTC-DRG contains a two-level split. For example, if nonmonotonicity 
occurs in a proposed base MS-LTC-DRG with two severity levels (that is, 
the higher severity level relative weight is less than the lower 
severity level), where both of the MS-LTC-DRGs have at least 25 cases 
or where one or both of the proposed MS-LTC-DRGs is low volume, we are 
proposing to combine the two proposed MS-LTC-DRGs of that proposed base 
MS-LTC-DRG for the purpose of determining a case-weighted relative 
weight. If the combination still results in at least 25 cases, we are 
proposing to calculate one relative weight and assign it to both of the 
proposed MS-LTC-DRGs. If the combination results in less than 25 cases, 
we determine the quintile assignment for both MS-LTC-DRGs based on the 
case-weighted average charge and assign both MS-LTC-DRGs the same 
relative weight of the appropriate quintile.
    Step 7--Calculate the proposed FY 2008 budget neutrality factor.

[[Page 24770]]

    As we stated in the FY 2008 LTCH PPS proposed rule (72 FR 4784 
through 4786), under the broad authority conferred upon the Secretary 
under section 123 of Pub. L. 106-113 as amended by section 307(b) of 
Pub. L. 106-554 to develop the LTCH PPS, we proposed that, beginning 
with the MS-LTC-DRG update for FY 2008, the annual update to the 
proposed MS-LTC-DRG classifications and relative weights would be done 
in a budget neutral manner such that estimated aggregate LTCH PPS 
payments would be unaffected, that is, would be neither greater than 
nor less than the estimated aggregate LTCH PPS payments that would have 
been made without the proposed MS-LTC-DRG classification and relative 
weight changes. Currently under Sec.  412.517, the LTC-DRG 
classifications and relative weights are adjusted annually to reflect 
changes in factors affecting the relative use of LTCH resources, such 
as treatment patterns, technology and number of discharges. In 
addition, there are currently no statutory or regulatory requirements 
that the annual update to the LTC-DRG classifications and relative 
weights be done in a budget neutral manner. Since the initial 
implementation of the LTCH PPS in FY 2003, we have updated the LTC-DRG 
relative weights each year without a budget neutrality adjustment based 
on the most recent available LTCH claims data, which reflect current 
LTCH patient mix and coding practices, and appropriately reflected more 
or less resource use than the previous year's LTC-DRG relative weights 
(71 FR 47991). Historically, we have not updated the LTC-DRGs in a 
budget neutral manner because we believed that past fluctuations in the 
LTC-DRG relative weights were primarily due to changes in LTCH coding 
practices. We believe that changes in the LTCH PPS payment rates, 
including the LTC-DRG relative weights, should accurately reflect 
changes in LTCHs' true cost of treating patients (real CMI increase), 
and should not be influenced by changes in coding practices (apparent 
CMI increase). Because LTCH 2006 claims data does not appear to 
significantly reflect changes in LTCH coding practices in response to 
the implementation of the LTCH PPS, we believe that it may be 
appropriate to update the LTC-DRGs so that estimated aggregate LTCH PPS 
payments would neither increase nor decrease. Thus, in the FY 2008 LTCH 
PPS proposed rule (72 FR 4784), we proposed that the annual update to 
the LTC-DRG classifications and relative weights be done in a budget 
neutral manner. (For a detailed discussion on updating the LTC-DRG 
classifications and relative weights in a budget neutral manner, refer 
to the FY 2008 LTCH PPS proposed rule (72 FR 4784 through 4786). 
Updating the LTC-DRGs in a budget neutral manner would result in an 
annual update to the individual LTC-DRG classifications and relative 
weights based on the most recent available data to reflect changes in 
relative LTCH resource use, and the LTC-DRG relative weights would be 
uniformly adjusted to ensure that estimated aggregate payments under 
the LTCH PPS would not be affected (that is, decreased or increased). 
Consistent with that proposal, we are proposing to update the proposed 
MS-LTC-DRG classifications and relative weights for FY 2008 based on 
the most recent available data and include a budget neutrality 
adjustment.
    To ensure budget neutrality in updating the MS-LTC-DRG 
classifications and relative weights under the proposed change to Sec.  
412.517, we are proposing to use a method that is similar to the 
methodology used under the IPPS. (A discussion of the IPPS DRG budget 
neutrality adjustment can be found in the FY 2007 IPPS final rule (71 
FR 47970).) Specifically, we are proposing that, after recalibrating 
the proposed MS-LTC-DRG relative weights, as we do under the 
methodology as described in detail in Steps 1 through 6 above, we would 
calculate and apply a normalization factor to the proposed MS-LTC-DRG 
relative weights to ensure that estimated payments are not influenced 
by changes in the composition of case types or changes made to the 
classification system. That is, the normalization adjustment is 
intended to ensure that the recalibration of the proposed MS-LTC-DRG 
relative weights (that is, the process itself) neither increases nor 
decreases total estimated payments. To calculate the normalization 
factor, we are proposing to use the most recent available claims data 
(FY 2006) and apply the proposed GROUPER (Version 25.0) to calculate 
the proposed relative weights. Furthermore, we are proposing to use the 
most recent available claims data in the analysis for the final rule. 
These weights are determined such that the average CMI value is 1.0. 
Then, we are proposing to group the same claims data (FY 2006) using 
the current GROUPER (Version 24.0) and current relative weights. The 
average CMI is calculated for the claims data using the current GROUPER 
and relative weights. Finally, the ratio of the average CMI of the 
claims data set under the current GROUPER and the proposed GROUPER is 
calculated as the proposed normalization factor. For FY 2008, based on 
the latest available data, the proposed normalization factor is 
estimated as 1.020302, which is applied to each proposed MS-LTC-DRG 
relative weight. (However, if more current data become available prior 
to publication of the final rule, we will use those data to determine 
the normalization factor.) That is, each proposed MS-LTC-DRG relative 
weight is multiplied by 1.020302 in the first step of the budget 
neutrality process. We are also proposing to ensure that estimated 
aggregate LTCH PPS payments (based on the most recent available LTCH 
claims data) after recalibration (the proposed relative weights) would 
be equal to estimated aggregate LTCH PPS payments (for the same most 
recent available LTCH claims data) before recalibration (the existing 
relative weights). Therefore, we are proposing to calculate the budget 
neutrality adjustment factor by simulating estimated payments under 
both sets of GROUPERs and relative weights. We are proposing to 
simulate total estimated payments under the current payment policies 
(RY 2007) using the most recent available claims data (FY 2006) and 
using the proposed GROUPER (Version 25.0), and normalized relative 
weights. Then, we are proposing to simulate estimated payments using 
the most recent available claims data (FY 2006) and apply the proposed 
GROUPER (Version 25.0). We next calculate payments using the same 
claims data (FY 2006) with the current GROUPER (Version 24.0). The 
ratio of the estimated average payment under the current GROUPER and 
the proposed GROUPER is calculated as the proposed budget neutrality 
factor. Then each of the proposed normalized relative weights is 
multiplied by the budget neutrality factor to determine the proposed 
budget neutral relative weight for each proposed MS-LTC-DRG. 
Accordingly, based on the most recent available data, we are proposing 
a budget neutrality factor of 1.003924 that is applied to the relative 
weights after normalizing. If more current data become available prior 
to publication of the final rule, we will use those data to determine 
the budget neutrality factor. The relative weights in Table 11 in the 
Addendum of this proposed rule reflect those budget neutral weights. 
If, as a result of comments, we decide not to finalize the proposed 
budget neutrality policy, the proposed weights in Table 11 of the 
Addendum to this proposed

[[Page 24771]]

rule change by the two factors discussed herein.
    Step 8--Apply the proposed case-mix budget neutrality factor to the 
proposed MS-LTC-DRG relative weight.
    As discussed under section II.D.6. of the preamble of this proposed 
rule, we are proposing a budget neutral adjustment for FY 2008 and FY 
2009 to eliminate the effect of changes in coding or classification of 
discharges that do not reflect real change in case-mix because we 
believe that adoption of the proposed MS-LTC-DRGs would create a risk 
of increased aggregate levels of payment as a result of increased 
documentation and coding. The additional step 8 would be necessary for 
FY 2008 and FY 2009 to ensure that estimated aggregate LTCH PPS 
payments would be neither greater than nor less than the estimated 
aggregate LTCH PPS payments that would have been made without the 
adoption of the proposed MS-LTC-DRG patient classification system. 
Accordingly, each of the relative weights in Table 11 of the Addendum 
to this proposed rule reflects this proposed adjustment. That is, each 
proposed MS-LTC-DRG relative weight is multiplied by a factor of 0.976 
to account for changes in coding or classification of discharges 
resulting from the adoption of the new patient classification system.

J. Proposed Add-On Payments for New Services and Technologies

    (If you choose to comment on issues in this section, please include 
the caption ``New Technology'' at the beginning of your comment.)
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 (sometimes collectively referred to in this section as 
``new 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 technologies 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 2006 are used to calculate the proposed FY 2008 DRG 
weights in this proposed rule. Section 412.87(b)(2) provides that, ``a 
medical service or technology may be considered new within 2 or 3 years 
after the point at which data begin to become available reflecting the 
ICD-9-CM code assigned to the new medical service or technology 
(depending on when a new code is assigned and data on the new medical 
service or technology become available for DRG recalibration). After 
CMS has recalibrated the DRGs based on available data to reflect the 
costs of an otherwise new medical service or technology, the medical 
service or technology will no longer be considered `new' under the 
criterion for this section.''
    The 2-year to 3-year period during which a medical service or 
technology 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 has 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 technologies ceases (Sec.  412.87(b)(2)). For example, an 
approved new technology that received FDA approval in October 2006 and 
entered the market at that time may be eligible to receive add-on 
payments as a new technology until FY 2010 (discharges occurring before 
October 1, 2009), when data reflecting the costs of the technology 
could be used to recalibrate the DRG weights. Because the FY 2009 DRG 
weights would be calculated using FY 2007 MedPAR data, the costs of 
such a new technology would be reflected in the FY 2009 DRG weights.
    Section 412.87(b)(3) further provides that new medical services or 
technologies must be inadequately paid otherwise under the DRG system 
to receive the add-on payment. To assess whether technologies would be 
inadequately paid under the DRGs, we establish thresholds to evaluate 
applicants for new technology add-on payments. In the FY 2004 IPPS 
final rule (68 FR 45385), we established the threshold at the geometric 
mean standardized charge for all cases in the DRG plus 75 percent of 1 
standard deviation above the geometric mean standardized charge (based 
on the logarithmic values of the charges and transformed back to 
charges) for all cases in the DRG to which the new medical service or 
technology is assigned (or the case-weighted average of all relevant 
DRGs, if the new medical service or technology occurs in many different 
DRGs).
    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. (Refer to section IV.D. of the 
preamble to the FY 2005 IPPS final rule (69 FR 49084) for a discussion 
of the revision of the regulations to incorporate the change made by 
section 503(b)(1) of Pub. L. 108-173.) Table 10 of the Addendum to the 
FY 2007 IPPS final rule (71 FR 48319) contained the final thresholds 
that are being used to evaluate applications for new technology add-on 
payments for FY 2008. An applicant must demonstrate that the cost 
threshold is met using information from inpatient hospital claims.
    We were recently asked to revisit the issue of whether the HIPAA 
Privacy Rule at 45 CFR Parts 160 and 164 applies to claims information 
that providers submit with applications for new technology add-on 
payments. We previously addressed this issue in the September 7, 2001 
final rule (66 FR 46917) that established the new technology add-on 
payment regulations. In the preamble to that final rule, we explained 
that health plans, including Medicare, and providers that conduct 
certain transactions electronically, including the hospitals that would 
be receiving payment under the FY 2001 IPPS final rule, are required to 
comply with the HIPAA Privacy Rule. We further explained how such 
entities could meet the applicable HIPAA

[[Page 24772]]

requirements by discussing how the HIPAA Privacy Rule permitted 
providers to share with health plans information needed to ensure 
correct payment, if they have obtained consent from the patient to use 
that patient's data for treatment, payment, or health care operations. 
We also explained that because the information to be provided within 
applications for new technology add-on payment would be needed to 
ensure correct payment, no additional consent would be required. The 
HHS Office of Civil Rights has since amended the HIPAA Privacy Rule, 
but the results remain. The HIPAA Privacy Rule no longer requires 
covered entities to obtain consent from patients to use or disclose 
individually identifiable health information for treatment, payment, or 
health care operations, and expressly permits such entities to use or 
to disclose individually identifiable health information to covered 
entities for any of these purposes (45 CFR Sec. Sec.  
164.502(a)(1)(ii), and 506(c)(1) and (c)(3); and the Standards for 
Privacy of Individually Identifiable Health Information published in 
the Federal Register on August 14, 2002 for a full discussion of 
changes in consent requirements).
    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 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. (Refer to 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 Congressional report language accompanying section 533 of Pub. 
L. 106-554 indicated Congress' intent to require the Secretary to 
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 have not been budget neutral.
    Applicants for add-on payments for new medical services or 
technologies for FY 2009 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. Complete application information, along with final deadlines 
for submitting a full application, will be available on our web site 
after publication of the IPPS FY 2008 final rule at: http://www.cms.hhs.gov/AcuteInpatientPPS/08_newtech.asp. To allow interested 
parties to identify the new medical services or technologies under 
review before the publication of the proposed rule for FY 2009, 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 clinical 
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 applications for add-on payments are 
pending.
     Accept comments, recommendations, and data from the public 
regarding whether a service or technology represents a substantial 
clinical improvement.
     Provide, before publication of a proposed rule, for a 
meeting at which organizations representing hospitals, physicians, 
manufacturers, and any other interested party may present comments, 
recommendations, and data regarding whether a new medical 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 2008 
before publication of the FY 2008 IPPS proposed rule, we published a 
notice in the Federal Register on December 22, 2006 (71 FR 77031), and 
held a town hall meeting at the CMS Headquarters Office in Baltimore, 
MD, on February 22, 2007. 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 discussion of the substantial clinical improvement criterion for 
each of the FY 2008 new medical service and technology add-on payment 
applications before the publication of the FY 2008 IPPS proposed rule.
    Approximately 70 individuals attended the town hall meeting in 
person, while additional participants listened over an open telephone 
line. Boston Scientific presented data on how its product 
(Wingspan[reg] Stent System with Gateway\TM\ PTA Balloon Catheter) 
meets the substantial clinical improvement criterion, as well as the 
need for additional payments to ensure its access to Medicare 
beneficiaries. No other attendees at the town hall meeting

[[Page 24773]]

made a presentation with regard to the Wingspan[reg] new technology 
add-on payment application.
    We considered Boston Scientific's presentation made at the town 
hall meeting, as well as written comments submitted with their 
application, in our evaluation of the Wingspan[reg] new technology 
application for FY 2008 in this proposed rule. We have summarized these 
comments under section I.4. of this preamble.
    We did not receive any other comments regarding substantial 
clinical improvement of Wingspan[reg]. However, there were a number of 
public comments made at the town hall meeting suggesting that CMS 
provide more specific detail about how it would apply the substantial 
clinical improvement criterion. For example, the public commenters at 
the town hall meeting suggested that CMS provide clear guidance with 
respect to the type of data that applicants should submit to support an 
application for add-on payments for new medical services and 
technologies. We were asked to work with stakeholders, including 
researchers, clinicians, representatives of patients, and 
manufacturers, to develop specific criteria and data quality standards 
that would make determinations of ``substantial clinical improvement'' 
more predictable and transparent.
    We welcome public comment on this issue. In particular, we are 
interested in any ``specific criteria or data quality standards'' that 
the commenters believe we should adopt to improve the new technology 
add-on application process, or any concerns or challenges that 
commenters believe we may encounter in undertaking this effort. Again, 
as we stated at the new technology town hall meeting, we are always 
interested in working with our stakeholders to improve the inpatient 
new technology add-on payment process. We are interested in ensuring 
that the latest medical technology that improves care for the Medicare 
patient population continues to be available to our beneficiaries.
3. FY 2008 Status of Technologies Approved for FY 2007 Add-On Payments
a. Endovascular Graft Repair of the Thoracic Aorta
    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 
manufacturer argued that endovascular stent-grafting of the descending 
thoracic aorta provides a less invasive alternative to the traditional 
open surgical approach required for the management of descending 
thoracic aortic aneurysms. 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 was initially identified using ICD-9-CM procedure code 39.79 
(Other endovascular repair (of aneurysm) of other vessels). The 
applicant also requested a unique ICD-9-CM procedure code. As noted in 
Table 6B of the FY 2006 IPPS final rule (70 FR 47637), new procedure 
code 39.73 (Endovascular implantation of graft in thoracic aorta) was 
assigned to this technology.
    In the FY 2006 IPPS final rule (70 FR 47356), we approved the GORE 
TAG device for new technology add-on payment for FY 2006. FDA approved 
GORE TAG on March 23, 2005. Because the technology remained within the 
2-to 3-year period during which it could be considered new for FY 2007, 
we continued add-on payments for the endovascular graft repair of the 
thoracic aorta in the FY 2007 IPPS final rule (71 FR 47999). GORE TAG 
will have been on the market for more than 3 years as of March 23, 
2008, or less than 6 months of FY 2008. Our practice has been to begin 
and end new technology add-on payments on the basis of a fiscal year. 
In general, we extend add-on payments for an additional year only if 
the 3-year anniversary date of the product's entry on the market occurs 
in the latter half of the fiscal year (70 FR 47362). Because the 3-year 
anniversary date of GORE TAG's entry onto the market was in the first 
half of the fiscal year, we are proposing to discontinue its new 
technology add-on payment for FY 2008.
b. Restore[supreg] Rechargeable Implantable Neurostimulator
    Medtronic Neurological submitted an application for new technology 
add-on payments for its Restore[supreg] Rechargeable Implantable 
Neurostimulator for FY 2006. The Restore[supreg] Rechargeable 
Implantable Neurostimulator is designed to deliver electrical 
stimulation to the spinal cord to block the sensation of pain. The 
technology standard for neurostimulators uses internal sealed batteries 
as the power source to generate the electrical current. These internal 
batteries have finite lives, and require replacement when their power 
has been completely discharged. According to the manufacturer, the 
Restore[supreg] Rechargeable Implantable Neurostimulator ``represents 
the next generation of neurostimulator technology, allowing the 
physician to set the voltage parameters in such a way that fully meets 
the patient's requirements to achieve adequate pain relief without fear 
of premature depletion of the battery.'' The applicant stated that the 
expected life of the Restore[supreg] rechargeable battery is 9 years, 
compared to an average life of 3 years for conventional neurostimulator 
batteries. We approved new technology add-on payments for all 
rechargeable, implantable neurostimulators for FY 2006 and FY 2007. 
Cases involving these devices, made by any manufacturer, are identified 
by the presence of newly created ICD-9-CM code 86.98 (Insertion or 
replacement of dual array rechargeable neurostimulator pulse 
generator).
    The FDA approved the Restore[supreg] Rechargeable Implantable 
Neurostimulator in 2005. However, as noted in the FY 2006 IPPS final 
rule (70 FR 47358), at least one similar product was approved by the 
FDA as early as April 2004. Because the Restore'' Rechargeable 
Implantable Neurostimulator will be beyond the 2- to 3-year period 
during which it can be considered new for FY 2008, we are proposing to 
discontinue add-on payments for the technology in FY 2008.
c. X STOP Interspinous Process Decompression System
    St. Francis Medical Technologies submitted an application for new 
technology add-on payments for the X STOP Interspinous Process 
Decompression System (X STOP) for FY 2007. Lumbar spinal stenosis 
describes a condition that occurs when the spaces between bones in the 
spine become narrowed due to arthritis and other age-related 
conditions. This narrowing, or stenosis, causes nerves coming from the 
spinal cord to be compressed, thereby causing symptoms including pain, 
numbness, and weakness. It particularly causes symptoms when the spine 
is in extension, when a patient stands fully upright or leans back. The 
X STOP device is inserted between the spinous processes of adjacent 
vertebrae in order to provide a minimally invasive alternative to 
conservative treatment (exercise and physical therapy) and invasive 
surgery (spinal fusion). It works by limiting the spine's extension 
that compresses the nerve's roots while still preserving as much motion 
as possible. The device is inserted in a relatively simple, primarily 
outpatient procedure using local anesthesia. However, in some 
circumstances, the physician may prefer to admit the

[[Page 24774]]

patient for an inpatient stay. The manufacturer described the device as 
providing ``a new minimally invasive, stand-alone alternative treatment 
for lumbar spinal stenosis.''
    The X STOP Interspinous Process Decompression system received pre-
market approval from the FDA on November 21, 2005. The device is 
currently described by ICD-9-CM code 84.58 (Implantation of 
Interspinous process decompression device) (excluding: Fusion of spine 
(codes 81.00 through 81.08, and 81.30 through 81.39)). This ICD-9-CM 
code went into effect on October 1, 2005.
    In the FY 2007 final rule, with respect to substantial clinical 
improvement, we noted our concern that, during the FDA approval 
process, the Center for Devices and Radiological Health Advisory Panel 
voted against pre-market approval of X STOP because of concerns about 
proper patient selection, as well as the lack of objective endpoints. 
The applicant addressed our concerns by demonstrating that the 
mechanism of effect on the spine in cadavers with in vivo clinical 
radiographic data. That is, the applicant was able to show that the X 
STOP device limits spine extension that compresses the nerve. Thus, we 
indicated that we believed the technology has promise for providing a 
less invasive alternative to procedures such as laminectomy or fusion 
for patients that have failed conservative treatment (exercise, 
physical therapy and medication). The X STOP system represents a new 
level of treatment on the continuum of care for patients with lumbar 
spinal stenosis that previously did not exist.
    Accordingly, after consideration of the comments received, we 
approved the X STOP Interspinous Process Decompression System for new 
technology add-on payment for FY 2007. Cases involving X STOP are 
identified by ICD-9-CM code 84.58 (Implantation of interspinous process 
decompression device). These cases are generally included in CMS-DRG 
499 (Back and Neck Procedures Except Spinal Fusion with CC) and CMS-DRG 
500 (Back and Neck Procedures Except Spinal Fusion without CC) for FY 
2007.
    The X STOP Interspinous Process Decompression System is still 
within the 2- to 3-year period during which it can be considered new 
for FY 2008. However, we are concerned that it may no longer meet the 
cost-threshold criterion. In section II.D. of the preamble of this 
proposed rule, we are proposing to adopt MS-DRGs for FY 2008 and assign 
cases with procedure codes 84.58 into proposed MS-DRG 490 (Back and 
Neck Procedures Except Spinal Fusion with CC or MCC or Disc Devices). 
Proposed MS-DRG 490 includes back and neck procedures except spinal 
fusion with a CC or MCC. As indicated earlier, we did a comprehensive 
review of the spinal fusion and nonspinal fusion DRGs. Based on this 
review, we are proposing to further modify MS-DRG 490 to also include 
the higher cost of cases where the patient receives a spinal disc 
device such as an artificial spinal disc prosthesis, or an interspinous 
process decompression system. Our earlier analysis of the spinal and 
nonspinal fusion DRGs showed that the average charge per case for cases 
involving X STOP is $29,162. The average charge per case for MS-DRG 490 
is $29,656. Therefore, cases that use X STOP have a lower average 
charge per case than all cases in MS-DRG 490. The data show that the 
technology is not inadequately paid under the revised MS-DRGs, and it 
no longer meets the cost threshold for new technology add-on payment. 
For this reason, we are proposing to discontinue new technology add-on 
payments for X STOP in FY 2008 and correlate the payments under MS-DRG 
490. The high costs for cases using X STOP that necessitated an add-on 
payment under the CMS DRGs will no longer be necessary because of the 
higher payment that would be made under the proposed MS-DRG 490.
4. FY 2008 Application for New Technology Add-On Payments
    Boston Scientific submitted an application for the Wingspan[reg] 
Stent System with Gateway PTA Balloon Catheter (Wingspan[reg]) for new 
technology add-on payments for FY 2008. The device is designed for the 
treatment of patients with significant intracranial arterial stenosis 
who are refractory to medical management. The device consists of the 
following: a self-expanding nitinol stent; a multilumen over wire 
delivery catheter; and a Gateway\TM\ PTA Balloon Catheter. The device 
is used to treat stenoses that occur in the intracranial vessels. Prior 
to stent placement, the Gateway\TM\ 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 August 3, 2005, the Wingspan[reg] was approved by the FDA as a 
Humanitarian Device Exemption (HDE). We note that the applicant 
submitted an application for new technology add-on payments in FY 2006 
but was not approved for add-on payments because it had not yet 
received FDA approval. In November 2006, we issued a national coverage 
determination (NCD) on intracranial stents. The NCD stated that the 
treatment of cerebral artery stenosis in patients with intracranial 
atherosclerotic disease with intracranial percutaneous transluminal 
angioplasty (PTA) and stenting is reasonable and necessary when 
furnished in accordance with the FDA-approved protocols governing 
Category B Investigational Device Exemption (IDE) clinical trials. 
Currently, there are no clinical trials in place for the Wingspan[reg]. 
However, because the technology is covered by Medicare, if it is used 
in the setting of a clinical trial, we will evaluate whether the 
Wingspan[reg] meets the criteria for an inpatient new technology add-on 
payment. The Wingspan[reg] has been available on the market since 
August 3, 2005. Therefore, we believe that the technology meets the 
newness criterion.
    The applicant noted in its application that cases of intracranial 
angioplasty and stenting cases are currently grouped to CMS DRGs 533 
(Extracranial Procedure with CC) and 534 (Extracranial Procedure 
Without CC). However, the applicant believes these cases should be 
assigned to CMS DRGs 1 (Craniotomy Age > 17 With CC), 2 (Craniotomy Age 
> 17 Without CC), and 543 (Craniotomy With Major Device Implant or 
Acute Complex Central Nervous System Principal Diagnosis) based on 
resource use and for clinical consistency with other endovascular 
intracranial procedures assigned to these DRGs. As discussed in section 
II.D. of the preamble of this proposed rule, we are proposing to move 
procedure code 00.62 to proposed MS-DRGs 25, 26, and 27 (Craniotomy & 
Endovascular Intracranial Procedures With MCC, With CC, and Without CC/
MCC, respectively) and proposed MS-DRGs 23 and 24 (Craniotomy With 
Major Device Implant or Acute Complex Central Nervous System Principal 
Diagnosis With MCC or Without MCC, respectively) under the proposed MS-
DRG system, which are comparable to DRGs 1, 2, and 543 under the 
current CMS-DRG system.
    To demonstrate that the Wingspan[reg] meets the cost threshold, the 
manufacturer submitted data from MedPAR and non-MedPAR databases. Using 
the FY 2005 MedPAR data, the applicant identified cases of intracranial 
angioplasty that had a procedure code of 39.50 (Angioplasty or 
atherectomy of

[[Page 24775]]

other noncoronary vessels) in combination with one of the following 
principal diagnosis codes: Any principal diagnosis code that begins 
with the prefix of 433 (Occlusion and stenosis of precerebral 
arteries), excluding 433.10 (Cartoid artery without mention of cerebral 
infarction) and 433.11 (Cartoid artery with cerebral infarction); any 
principal diagnosis code that begins with the prefix of 434 (Occlusion 
of cerebral arteries), 437.0 (Cerebral atherosclerosis), 437.1 (Other 
generalized ischemic cerebrovascular disease), or 437.9 (Unspecified). 
The applicant noted that procedure code 39.50 is the predecessor code 
for identifying cases of intracranial angioplasty. The applicant 
explained that, given the newness of procedure codes 00.62 and 00.65 
that were implemented beginning October 1, 2005, it believes there are 
still cases being coded with the predecessor procedure codes. Using 
this methodology, the applicant found 577 cases in DRG 533 and 179 
cases in DRG 534. The applicant noted that charges in the MedPAR file 
do not include the total costs of devices, drugs, and medical supplies 
associated with the Wingspan[reg], so the applicant conducted an 
estimate of the charges associated with the Wingspan[reg]. The 
applicant determined that costs associated with the Wingspan[reg] are 
approximately $10,073. Because we use charges to determine if a 
technology meets the threshold, it is necessary to inflate the costs to 
charges. Using the national average CCR of 0.47, the applicant inflated 
the costs associated with the Wingspan[reg] to $21,432 in charges. 
After adding the charges associated with the Wingspan[reg], the average 
standardized charge per case was $76,416 and $51,277 for DRGs 533 and 
534, respectively.
    We are concerned regarding whether the cases identified by the 
applicant are a useful proxy to identify cases of intracranial 
angioplasty. Procedure code 39.50 describes cases of angioplasty in any 
artery of the body except the heart. Intracranial angioplasty with 
stenting was not covered by Medicare in any circumstance prior to 
October 2006. Therefore, the Medicare cases submitted by the applicant 
under procedure code 39.50 should not involve intracranial angioplasty 
because they are neither described by the code nor covered by Medicare. 
Furthermore, procedure code 00.62 is assigned to the Non-Covered 
Procedure edit of the MCE. The applicant supplied Medicare data from FY 
2005 for claims coded with procedure code 00.62. It is unclear to us 
how these claims were processed despite the Non-Covered Procedure edit. 
Because these data appear to be based on claims that may not have been 
coded or processed correctly, we question the reliability and validity 
of these data. We are concerned that it may not be appropriate to rely 
on these data for purposes of determining whether the technology meets 
the cost threshold.
    As stated above, the applicant also submitted non-Medicare data. 
The applicant used the 2005 patient discharge data from California's 
Office of Statewide Health Planning and Development database for 
hospitals in California and the 2005 patient data from Florida's Agency 
for Health Care Administration for hospitals in Florida. Similar to the 
analysis above, the applicant identified cases of intracranial 
angioplasty using procedure code 39.50 in combination with the 
diagnosis codes listed above. The applicant identified 43 cases in DRG 
533, and 21 cases in DRG 534. Because these cases already include 
charges associated with Wingspan[supreg], it was not necessary to 
include the $21,432 in charges associated with Wingspan[supreg]. The 
average standardized charge per case was $89,697 and $40,475 for DRGs 
533 and 534, respectively. As discussed above, we are concerned about 
whether these cases actually represent cases of intracranial 
angioplasty. We also note that we are unable to validate these data 
because they are non-Medicare data. In addition, similar to the 
analysis described above, the applicant also identified cases of 
intracranial angioplasty using procedure code 00.62. The applicant 
found 30 cases in DRG 533, and 23 cases in DRG 534. The average 
standardized charge per case was $93,215 and $31,479 for DRGs 533 and 
534, respectively. Based on these data, the applicant maintains that 
the technology meets the cost threshold.
    As noted above, the applicant has requested that cases of the 
Wingspan[supreg] be reassigned to CMS DRGs 1, 2 and 543. In section 
II.G.2. of the preamble of this proposed rule, we are proposing to 
assign procedure code 00.62 to proposed MS-DRGs 23, 24, 25, 26 and 27, 
which replace DRGs 1, 2, and 543 of the current CMS DRGs. The 
thresholds in Table 10 of the Addendum of the FY 2007 IPPS final rule 
(as corrected at 71 FR 60040) for DRGs 1, 2 and 543 are $53,969, 
$37,116 and $64,397, respectively. Analyzing the same Medicare and non-
Medicare data that the applicant used to demonstrate that the 
Wingspan[supreg] exceeds the cost threshold for DRGs 533 and 534, the 
applicant compared the average standardized charge per case to the 
thresholds for DRGs 1, 2, and 543. The applicant maintains that the 
Wingspan[supreg] would still exceed the cost threshold even if it were 
reassigned to DRGs 1, 2, and 543.
    However, for the reasons described above, it is not clear whether 
Wingspan[supreg] meets the cost threshold for new technology add-on 
payment. We welcome public comments on this issue.
    The applicant also maintains that the technology meets the 
substantial clinical improvement criterion. In the past there has been 
no surgical or medical treatment available for recurrent strokes that 
occur despite optimal medical management. The applicant asserts that 
the Wingspan[supreg] provides a new treatment option for these 
patients. The applicant submitted three studies to support this 
position.
    First, the applicant cites data derived from a series of cases of 
45 patients who received the Wingspan[supreg] that demonstrate 4.4 
percent composite ipsilateral stroke or death at 30 days, 7.0 percent 
composite ipsilateral stroke or death at 6 months, and 9.3 percent 
ipsilateral stroke or death at 13 months. The applicant then used 
patients in the well known Warfarin-Aspirin Symptomatic Intracranial 
Disease (WASID) trial as a historical control against which to compare 
patients who received Wingspan[supreg]. The WASID trial compared the 
warfarin vs. aspirin therapy in treating symptomatic intracranial 
arterial stenosis, and it demonstrated a 23 percent stroke/death rate 
at one year in patients with severe (70 percent or greater) stenosis, 
and a 21 percent stroke/death rate at 2 years in patients with 50 
percent or greater stenosis. The applicant also submitted data from an 
ongoing Wingspan[supreg] registry of patients that demonstrate a 4.8 
percent stroke/death rate at 30 days, and a 9.7 percent stroke/death 
rate at 3 to 6 month follow up in 72 patients. In addition, the 
applicant submitted data from a multicenter NIH registry of 131 
patients with 70 percent or greater stenosis that demonstrate an 8.4 
percent rate of stroke, intracerebral hemorrhage or death at 30 days 
and a 9.9 percent rate of stroke and death at the mean 3.2 months 
followup.
    While we recognize that Wingspan[supreg] may represent a promising 
technology in patients with significant intracranial arterial stenosis 
who are refractory to medical management, we are concerned that, to 
date, there has been no controlled, randomized trial to demonstrate its 
clinical efficacy. We are also concerned that the Wingspan[supreg] data 
did not compare patients over the same followup periods as WASID. In 
addition, we are concerned over the use

[[Page 24776]]

of WASID patients as a control group against which to compare 
Wingspan[supreg] patients. The current FDA Humanitarian Device 
Exemption, in combination with the current CMS NCD, while providing 
access to this technology for very ill patients with generally poor 
prognoses who have few other options, also effectively designates the 
technology as investigational, and in need of further studies to prove 
its effectiveness. We would prefer that the product's effectiveness be 
demonstrated before we judge whether the product represents a 
substantial clinical improvement. For these reasons, we are concerned 
that there may not be sufficient evidence that Wingspan[supreg] 
represents an advance that substantially improves the diagnosis or 
treatment of Medicare beneficiaries. However, we welcome public 
comments that may pertain to this matter.
5. Technical Correction
    Section 1886(d)(5)(K)(i) of the Act requires that the Secretary 
establish a mechanism to recognize the costs of new medical services 
and technologies under subsection (d) of section 1886 of the Act. As 
made clear under section 1886(d)(1)(A) of the Act, subsection (d) 
provides the methodology for payment with respect to the operating 
costs of inpatient hospital services. Section 1886(g) of the Act 
provides for payment of capital costs of inpatient hospital services. 
Although it has always been our policy that new technology add-on 
payment is available only with respect to operating costs, Sec.  
412.88(a)(2) of our regulations does not specifically refer to 
operating costs or the operating CCR. Therefore, we are proposing to 
revise Sec.  412.88(a)(2) to clarify that the new technology add-on 
payment is available only for operating costs, and that we estimate the 
costs of a case by applying the hospital's operating CCR to the billed 
charges. This proposed correction would not have an impact on new 
technology add-on payments because, to the best of our knowledge, MACs 
already correctly apply only the operating CCR to calculate new 
technology add-on payments.

III. Proposed Changes to the Hospital Wage Index

A. Background

    Section 1886(d)(3)(E) of the Act requires that, as part of the 
methodology for determining prospective payments to hospitals, the 
Secretary must adjust the standardized amounts ``for area differences 
in hospital wage levels by a factor (established by the Secretary) 
reflecting the relative hospital wage level in the geographic area of 
the hospital compared to the national average hospital wage level.'' In 
accordance with the broad discretion conferred under the Act, we 
currently define hospital labor market areas based on the definitions 
of statistical areas established by the Office of Management and Budget 
(OMB). A discussion of the proposed FY 2008 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 must exclude the wages and wage-related costs incurred in 
furnishing skilled nursing services. This provision also requires us to 
make any updates or adjustments to the wage index in a manner that 
ensures that aggregate payments to hospitals are not affected by the 
change in the wage index. The proposed adjustment for FY 2008 is 
discussed in section II.B. of the Addendum to this proposed rule.
    As discussed below in section III.I. 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 
IPPS payment amounts. Under section 1886(d)(8)(D) of the Act, the 
Secretary is required to adjust the standardized amounts so as to 
ensure that aggregate payments under the IPPS after implementation of 
the provisions of sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the 
Act are equal to the aggregate prospective payments that would have 
been made absent these provisions. The proposed budget neutrality 
adjustment for FY 2008 is discussed in section II.A.4.b. of the 
Addendum to this proposed rule.
    Section 1886(d)(3)(E) of the Act also provides for the collection 
of data every 3 years on the occupational mix of employees for short-
term, acute care hospitals participating in the Medicare program, in 
order to construct an occupational mix adjustment to the wage index. A 
discussion of the occupational mix adjustment that we are proposing to 
apply beginning October 1, 2007 (the FY 2008 wage index) appears under 
section III.C. of this preamble.

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

    (If you choose to comment on issues in this section, please include 
the caption ``CBSAs'' at the beginning of your comments.)
    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). For a discussion of OMB's 
revised definitions of CBSAs and our implementation of the CBSA 
definitions, we refer readers to the preamble of the FY 2005 IPPS final 
rule (69 FR 49026 through 49032). The revised area designations 
established by OMB resulted in a higher wage index for some areas and a 
lower wage index for others. Further, some hospitals that were 
previously classified as urban became classified as rural. 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. As part of that transition, we allowed 
urban hospitals that became rural under the new definitions to maintain 
their assignment to the MSA where they were previously located for the 
3-year period of FY 2005, FY 2006, and FY 2007. For a discussion of the 
transition, we refer readers to the FY 2005 IPPS final rule (69 FR 
49032 through 49034).
    FY 2007 was the last year of the transition period for urban 
hospitals that became classified as rural. Therefore, for discharges on 
or after October 1, 2007 (FY 2008), these hospitals will receive their 
statewide rural wage index or their FY 2008 MGCRB reclassified age 
index. (These hospitals were and are eligible to apply for 
reclassification by the MGCRB both during the transition period and in 
subsequent years. These hospitals are considered rural for 
reclassification purposes.)
    Consistent with the FY 2005, FY 2006, and FY 2007 IPPS final rules, 
for FY 2008 we are proposing to provide that hospitals receive 100 
percent of their wage index based upon the CBSA configurations. 
Specifically, for each hospital, we will determine a wage index for FY 
2008 employing wage index data from FY 2004 hospital cost reports and 
using the CBSA labor market definitions. We consider CBSAs that are 
MSAs to be urban, and CBSAs that are Micropolitan Statistical Areas as 
well as areas outside of CBSAs to be rural. In addition, where an MSA 
has been divided into Metropolitan Divisions, we consider the 
Metropolitan

[[Page 24777]]

Division to comprise the labor market areas for purposes of calculating 
the wage index (69 FR 49029).
    On December 18, 2006, OMB announced the inclusion of two new CBSAs 
and the revision of designations for six areas (OMB Bulletin No. 07-
01). The new CBSAs are as follows:
     Lake Havasu-Kingman, Arizona (CBSA 29420). This CBSA comes 
from Mohave County, Arizona;
     Palm Coast, Florida (CBSA 37380). This CBSA comes from 
Flager County, Florida;
    The revised CBSA designations are as follows:
     Mauldin, South Carolina and Easley, South Carolina qualify 
as new principal cities of the Greenville-Mauldin-Easley, South 
Carolina CBSA;
     Conway, Arkansas qualifies as a new principal city of the 
Little Rock-North Little Rock-Conway, Arkansas CBSA;
     Goleta, California qualifies as a new principal city of 
the Santa Barbara-Santa Maria-Goleta, California CBSA;
     Franklin, Tennessee qualifies as a new principal city of 
the Nashville-Davidson-Murfreesboro-Franklin, Tennessee CBSA;
     Fort Pierce, Florida no longer qualifies as a principal 
city of the Port St. Lucie-Fort Pierce, Florida CBSA; the new 
designation is Port St. Lucie, Florida CBSA.
    (We note also that OMB renamed the Essex County, Massachusetts 
Metropolitan Division as the Peabody, Massachusetts Metropolitan 
Division. OMB also changed the CBSA code from 21604 to 37764.)
    The OMB bulletin is available on the OMB Web site at http://www.whitehouse.gov/OMB--go to ``Bulletins'' or ``Statistical Programs 
and Standards.'' CMS will apply these changes to the IPPS beginning 
October 1, 2007.

C. Proposed Occupational Mix Adjustment to the Proposed FY 2008 Wage 
Index

    (If you choose to comment on issues in this section, please include 
the caption ``Occupational Mix Adjustment'' at the beginning of your 
comment.)
    As stated earlier, section 1886(d)(3)(E) of the Act provides for 
the collection of data every 3 years on the occupational mix of 
employees for each short-term, acute care hospital participating in the 
Medicare program, in order to construct an occupational mix adjustment 
to the wage index, for application beginning October 1, 2004 (the FY 
2005 wage index). The purpose of the occupational mix adjustment is to 
control for the effect of hospitals' employment choices on the wage 
index. For example, hospitals may choose to employ different 
combinations of registered nurses, licensed practical nurses, nursing 
aides, and medical assistants for the purpose of providing nursing care 
to their patients. The varying labor costs associated with these 
choices reflect hospital management decisions rather than geographic 
differences in the costs of labor.
    1. Development of Data for the Proposed FY 2008 Occupational Mix 
Adjustment
    On October 14, 2005, we published a notice in the Federal Register 
(70 FR 60092) proposing to use a new survey, the 2006 Medicare Wage 
Index Occupational Mix Survey (the 2006 survey) to apply an 
occupational mix adjustment to the FY 2008 wage index. In the proposed 
2006 survey, we included several modifications based on the comments 
and recommendations we received on the 2003 survey, including (1) 
allowing hospitals to report their own average hourly wage rather than 
using BLS data; (2) extending the prospective survey period; and (3) 
reducing the number of occupational categories but refining the 
subcategories for registered nurses.
    We made the changes to the occupational categories in response to 
MedPAC comments to the FY 2005 IPPS final rule (69 FR 49036). 
Specifically, MedPAC recommended that CMS assess whether including 
subcategories of registered nurses would result in a more accurate 
occupational mix adjustment. MedPAC believed that including all 
registered nurses in a single category may obscure significant wage 
differences among the subcategories of registered nurses, for example, 
the wages of surgical registered nurses and floor registered nurses may 
differ. Also, to offset additional reporting burden for hospitals, 
MedPAC recommended that CMS should combine the general service 
categories that account for only a small percentage of a hospital's 
total hours with the ``all other occupations'' category because most of 
the occupational mix adjustment is correlated with the nursing general 
service category.
    In addition, in response to the public comments on the October 14, 
2005 notice, we modified the 2006 survey. On February 10, 2006, we 
published a Federal Register notice (71 FR 7047) that solicited 
comments and announced our intent to seek OMB approval on the revised 
occupational mix survey (Form CMS-10079 (2006)). OMB approved the 
survey on April 25, 2006.
    The 2006 survey provides for the collection of hospital-specific 
wages and hours data, a 6-month prospective reporting period (that is, 
January 1, 2006, through June 30, 2006), the transfer of each general 
service category that comprised less than 4 percent of total hospital 
employees in the 2003 survey to the ``all other occupations'' category 
(the revised survey focuses only on the mix of nursing occupations), 
additional clarification of the definitions for the occupational 
categories, an expansion of the registered nurse category to include 
functional subcategories, and the exclusion of average hourly rate data 
associated with advance practice nurses.
    The 2006 survey included only two general occupational categories: 
nursing and ``all other occupations.'' The nursing category has four 
subcategories: registered nurses, licensed practical nurses, aides, 
orderlies, attendants, and medical assistants. The registered nurse 
subcategory includes two functional subcategories: Management personnel 
and staff nurses or clinicians. As indicated above, the 2006 survey 
provided for a 6-month data collection period, from January 1, 2006 
through June 30, 2006. However, we allowed flexibility for the 
reporting period begin and end dates to accommodate some hospitals' bi-
weekly payroll and reporting systems. That is, the 6-month reporting 
period had to begin on or after December 25, 2005, and end before July 
9, 2006.
    We are proposing to use the 6-month 2006 survey data to calculate 
the occupational mix adjustment for the FY 2008 wage index. We used the 
1st quarter of 2006 survey data in the FY 2007 wage index to comply 
with a court decision in Bellevue Hosp. Center v. Leavitt, 443 F.3d 163 
(2nd Cir. 2006). For a discussion of our use of the 2006 survey data in 
the FY 2007 wage index, in compliance with the Bellevue decision, we 
refer readers to the FY 2007 IPPS final rule (71 FR 48007) as well as 
the FY 2007 IPPS final notice (71 FR 90886). However, as stated above, 
we are proposing to use the entire 6-month 2006 survey data (that is, 
from the period January 1, 2006 through June 30, 2006) to calculate the 
occupational mix adjustment for the FY 2008 wage index.
2. Timeline for the Collection, Review, and Correction of the 
Occupational Mix Data
    In a Joint-Signature Memorandum that we issued on April 21, 2006 
(JSM-06412), and in the FY 2007 IPPS final rule (71 FR 48008), we 
discussed the schedule for the 1st quarter 2006

[[Page 24778]]

occupational mix survey data that would be used in the FY 2007 wage 
index. The schedule included deadlines for--
     Hospitals to submit 1st quarter occupational mix data. The 
deadline was June 1, 2006.
     MAC review of the submitted 1st quarter data. The deadline 
was June 22, 2006.
     Availability of the submitted first quarter data on the 
CMS Web site. The deadline was June 29, 2006.
     Hospitals to submit requests to their MACs for corrections 
to their 1st quarter occupational mix data. The deadline was July 13, 
2006.
     MACs to submit corrected 1st quarter occupational mix 
survey data to CMS. The deadline was July 27, 2006.
    In the Joint-Signature Memorandum, we also indicated that hospitals 
were to submit their 2nd quarter 2006 occupational mix survey data to 
their intermediaries (MACs) by August 31, 2006. On October 6, we 
published on our web site both the audited 1st quarter and unaudited 
2nd quarter 2006 occupational survey data and Worksheet S-3 wage data 
to be used in calculating the FY 2008 wage index. In addition, we sent 
a letter to hospitals through their MACs (dated October 6, 2006) that 
discussed the timeframe for reviewing and correcting Worksheet S-3 wage 
data and the 2nd quarter 2006 survey data, and an opportunity for 
hospitals to request additional adjustments to their 1st quarter 2006 
survey data for the FY 2008 wage index. The revision and correction 
process for all of the data to be used for computing the FY 2008 wage 
index is discussed in detail in section III.K. of this preamble.
3. Calculation of the Proposed Occupational Mix Adjustment for FY 2008
    For FY 2008 (as we did for FY 2007), we are proposing to calculate 
the occupational mix adjustment factor using the following steps:
    Step 1--For each hospital, determine the percentage of the total 
nursing category attributable to a nursing subcategory by dividing the 
nursing subcategory hours by the total nursing category's hours 
(registered nurse management personnel and registered nurse staff 
nurses or clinicians are treated as separate nursing subcategories). 
Repeat this computation for each of the five nursing subcategories: 
registered nurse management personnel, registered nurse staff nurses or 
clinicians, licensed practical nurses; nursing aides, orderlies, and 
attendants; and medical assistants.
    Step 2--Determine a national average hourly rate for each nursing 
subcategory by dividing a subcategory's total salaries for all 
hospitals in the occupational mix survey database by the subcategory's 
total hours for all hospitals in the occupational mix survey database.
    Step 3--For each hospital, determine an adjusted average hourly 
rate for each nursing subcategory by multiplying the percentage of the 
total nursing category (from Step 1) by the national average hourly 
rate for that nursing subcategory (from Step 2). Repeat this 
calculation for each of the five nursing subcategories.
    Step 4--For each hospital, determine the adjusted average hourly 
rate for the total nursing category by summing the adjusted average 
hourly rate (from Step 3) for each of the nursing subcategories.
    Step 5--Determine the national average hourly rate for the total 
nursing category by dividing total nursing category salaries for all 
hospitals in the occupational mix survey database by total nursing 
category hours for all hospitals in the occupational mix survey 
database.
    Step 6--For each hospital, compute the occupational mix adjustment 
factor for the total nursing category by dividing the national average 
hourly rate for the total nursing category (from Step 5) by the 
hospital's adjusted average hourly rate for the total nursing category 
(from Step 4).
    If the hospital's adjusted average hourly rate is less than the 
national average hourly rate (indicating the hospital employs a less 
costly mix of nursing employees), the occupational mix adjustment 
factor would be greater than 1.0000. If the hospital's adjusted average 
hourly rate is greater than the national average hourly rate, the 
occupational mix adjustment factor would be less than 1.0000.
    Step 7--For each hospital, calculate the occupational mix adjusted 
salaries and wage-related costs for the total nursing category 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 total nursing category (using the occupational mix 
survey data, this percentage is determined by dividing the hospital's 
total nursing category salaries by the hospital's total salaries for 
``nursing and all other'') and by the total nursing category's 
occupational mix adjustment factor (from Step 6 above).
    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 by the occupational mix. A hospital's all 
other portion is determined by subtracting the hospital's nursing 
category percentage from 100 percent.
    Step 8--For each hospital, calculate the total occupational mix 
adjusted salaries and wage-related costs for a hospital by summing the 
occupational mix adjusted salaries and wage-related costs for the total 
nursing category (from Step 7) and the portion of the hospital's 
salaries and wage-related costs for all other employees (from Step 7).
    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 9--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 10--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.
    Step 11--To compute the occupational mix adjusted wage index, 
divide each area's occupational mix adjusted average hourly wage (Step 
9) by the national occupational mix adjusted average hourly wage (Step 
10).
    Step 12--To compute the Puerto Rico specific occupational mix 
adjusted wage index, follow Steps 1 through 11 above.
    The table below is an illustrative example of the proposed 
occupational mix adjustment.
BILLING CODE 4120-01-P

[[Page 24779]]

[GRAPHIC] [TIFF OMITTED] TP03MY07.007


[[Page 24780]]


[GRAPHIC] [TIFF OMITTED] TP03MY07.008

BILLING CODE 4120-01-C
    Because the occupational mix adjustment is required by statute, all 
hospitals that are subject to payments under the IPPS, or any hospital 
that

[[Page 24781]]

would be subject to the IPPS if not granted a waiver, must complete the 
occupational mix survey, unless the hospital has no associated cost 
report wage data that are included in the proposed FY 2008 wage index.
    For the FY 2007 wage index, if a hospital did not respond to the 
occupational mix survey, or if we determined that a hospital's 
submitted data were too erroneous to include in the wage index, we 
assigned the hospital the average occupational mix adjustment for the 
labor market area (71 FR 48013). We believed this method had the least 
impact on the wage index for other hospitals in the area. For areas 
where no hospital submitted data for purposes of calculating the 
occupational mix adjustment, we applied the national occupational mix 
factor of 1.0000 in calculating the area's FY 2007 occupational mix 
adjusted wage index. We indicated in the FY 2007 IPPS final rule that 
we reserve the right to apply a different approach in future years, 
including potentially penalizing nonresponsive hospitals.
    For the FY 2008 wage index, we are proposing to handle the data for 
hospitals that did not respond to the occupational mix survey (neither 
the 1st quarter nor 2nd quarter data) in the same manner as discussed 
above for the FY 2007 wage index. In addition, if a hospital submitted 
survey data for either the 1st quarter or 2nd quarter, but not for both 
quarters, we are proposing to use the data the hospital submitted for 
one quarter to calculate the hospital's FY 2008 occupational mix 
adjustment factor. Lastly, if a hospital submitted a survey(s), but 
that survey data could not be used because we determined it to be 
aberrant, we also assigned the hospital the average occupational mix 
adjustment for its labor market area. For example, if a hospital's 
individual nurse category average hourly wages were out of range (that 
is, unusually high or low), and the hospital did not provide sufficient 
documentation to explain the aberrancy, or the hospital did not submit 
any registered nurse staff salaries or hours data, we assigned the 
hospital the average occupational mix adjustment for the labor market 
area in which it is located.
    In calculating the average occupational mix adjustment factor for a 
labor market area, we replicated Steps 1 through 6 of the calculation 
for the occupational mix adjustment. However, instead of performing 
these steps at the hospital level, we aggregated the data at the labor 
market area level. In following these steps, for example, for CBSAs 
that contain providers that did not submit occupational mix survey 
data, the occupational mix adjustment factor ranged from a low of 
0.8972 (CBSA 39820, Redding, CA), to a high of 1.0728 (CBSA 19, Rural 
Louisiana). Also, in computing a hospital's occupational mix adjusted 
salaries and wage-related costs for nursing employees (Step 7 of the 
calculation), in the absence of occupational mix survey data, we 
multiplied the hospital's total salaries and wage-related costs by the 
percentage of the area's total workers attributable to the area's total 
nursing category. For FY 2008, there is one CBSA in which none of the 
providers submitted the occupational mix survey (CBSA 49740, Yuma, AZ). 
In the absence of any data in this labor market area, we applied an 
occupational mix adjustment factor of 1.0 to all provider(s).
    In the FY 2007 IPPS final rule, we also indicated that we would 
give serious consideration to applying a hospital-specific penalty if a 
hospital does not comply with regulations requiring submission of 
occupational mix survey data in future years. We stated that we believe 
that section 1886(d)(5)(I)(i) of the Act provides us with the authority 
to penalize hospitals that do not submit occupational mix survey data. 
That section authorizes us to provide for exceptions and adjustments to 
the payment amounts under IPPS as the Secretary deems appropriate. We 
also indicated that we would address this issue in the FY 2008 IPPS 
proposed rule.
    We are soliciting comments and suggestions for a hospital-specific 
penalty for hospitals that do not submit occupational mix survey. In 
response to the FY 2007 IPPS proposed rule, some commenters suggested a 
1-percent to 2-percent reduction in the hospital's wage index value or 
a set percentage of the standardized amount. Any penalty that we would 
determine for nonresponsive hospitals would apply to a future wage 
index, not the FY 2008 wage index.
4. Proposed 2007-2008 Occupational Mix Survey for the FY 2010 Wage 
Index
    As stated earlier, section 304(c) of Pub. L. 106-554 amended 
section 1886(d)(3)(E) of the Act to require CMS to collect data every 3 
years on the occupational mix of employees for each short-term, acute 
care hospital participating in the Medicare program. We are currently 
using occupational mix survey data collected in 2006 in the FY 2007 
IPPS. Since we implemented the 2006 survey, we received several public 
comments suggesting further improvements to the occupational mix survey 
instructions and definitions. Specifically, some commenters recommended 
that we include certain employees, such as surgical technicians and 
paramedics in the occupational mix adjustment. The commenters indicated 
that these occupations perform similar functions, and in some cases, 
are used as substitutes for nursing staff. Therefore, they recommended 
that CMS include these occupations with the nursing categories on the 
survey. (On the 2003 and 2006 surveys, these categories were included 
in the ``All Other Occupations'' category.) The commenters also 
recommended that CMS expand the list of cost centers for the survey to 
include additional cost centers that contain a significant number of 
nursing personnel.
    Some commenters suggested that CMS not collect occupational mix 
data for the ``Registered Nurse'' subcategories (that is, Management 
Personnel and Staff Nurse/Clinician). The commenters expressed concern 
that requiring the subcategories led to errors and inconsistencies in 
reporting, and added to the hospitals' collection burden. The 
commenters did not believe that this level of specificity significantly 
affects the adjustment. Therefore they recommended that CMS eliminate 
the RN subcategories.
    In addition, commenters recommended that CMS provide for a 1-year 
data collection period rather than a 6-month data collection period for 
the next survey collection. The commenters suggested that a 1-year data 
collection period would provide a better representation of a hospital's 
employment mix, which can vary during different times of the year. The 
commenters also indicated that a 1-year data collection period would 
allow hospitals to verify their wages and hours to year-end payroll 
reports and contractor invoices.
    In response to these suggestions we have modified the occupational 
mix survey. The revised 2007-2008 occupational mix survey will provide 
for the collection of hospital-specific wages and hours data for a 1-
year prospective reporting period from July 1, 2007, through June 30, 
2008, additional clarifications to the survey instructions, the 
elimination of the registered nurse subcategories, some refinements to 
the definitions of the occupational categories, and the inclusion of 
additional cost centers that typically provide nursing services. The 
revised 2007-2008 Medicare occupational mix survey will be applied 
beginning with the FY 2010 wage index.
    On February 2, 2007, we published a notice soliciting comments on 
the proposed revisions to the occupational mix survey (Form CMS-10079 
(2006))

[[Page 24782]]

(72 FR 5055). The comment period for the proposed survey ended on April 
3, 2007. A final notice is expected to be published in the Federal 
Register by July 1, 2007.

D. Worksheet S-3 Wage Data for the Proposed FY 2008 Wage Index

    (If you choose to comment on issues in this section, please include 
the caption ``Wage Data'' at the beginning of your comment.)
    The proposed FY 2008 wage index values (to be effective for 
hospital discharges occurring on or after October 1, 2007, and before 
October 1, 2008) in section II.B. of the Addendum to this proposed rule 
are based on the data collected from the Medicare cost reports 
submitted by hospitals for cost reporting periods beginning in FY 2004 
(the FY 2007 wage index was based on FY 2003 wage data).
1. Included Categories of Costs
    The proposed FY 2008 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.
2. Contract Labor for Indirect Patient Care Services
    In the FY 2003 IPPS final rule (67 FR 50022), we discussed the 
inclusion of contract labor cost in calculating the wage index. Our 
policy has evolved over the years with the increasing role of contract 
labor in meeting special personnel needs of hospitals. In response to 
suggestions that we further expand our definition of contract labor for 
the wage index, we indicated our intent to begin collecting data in 
future Medicare cost reports on the following overhead services: 
administrative and general (A&G); housekeeping; and dietary. We 
selected these three overhead services for consideration because they 
are provided at all hospitals, either directly or through contracts, 
and together they comprise about 60 percent of a hospital's overhead 
hours. Consistent with our consideration of contract A&G services, we 
also stated that we would begin collecting costs and hours data 
associated with other contract management services that would not be 
included on the cost report as overhead A&G and are not top management 
contracts (that is, the chief executive officer, chief financial 
officer, chief operating officer, and nurse administrator) that are 
included on Line 9 of Worksheet S-3, Part II.
    We revised the cost report, beginning October 1, 2003 (the FY 2004 
cost report), to provide for the collection of cost and hours data for 
the four identified contract indirect patient care services. We added 
four new line items to Worksheet S-3, Part II: Line 9.03 (Contract 
management and administrative services); Line 22.01 (Contract A & G 
services); Line 26.01 (Contract housekeeping services); and Line 27.01 
(Contract dietary services). We stated in the FY 2003 final rule that 
our decision on whether to include these costs in calculating the wage 
index would depend on our analyses of the data and public comments. The 
FY 2008 wage index, which is based on FY 2004 cost report data, is the 
first year that we can assess the impact of including these costs in 
the wage index.
    As part of the FY 2008 wage index desk review program, we required 
the fiscal intermediaries (or, if applicable, the MAC) to verify the 
accuracy of the data reported on the new Lines 9.03, 22.01, 26.01, and 
27.01. After the completion of these reviews, some hospitals continued 
to fail our edits for reasonableness: 12 hospitals (0.3 percent) failed 
edits for Line 9.03; 130 hospitals (3.6 percent) failed edits for Line 
22.01; 56 hospitals (1.6 percent) failed edits for Line 26.01; and 99 
hospitals (2.8 percent) failed edits for Line 27.01. Many of these edit 
failures are for wage data that are not to be included in the wage 
index and will be excluded through the wage index calculation. That is, 
as specified in the cost reporting instructions in the Provider 
Reimbursement Manual, Part II, section 3605.2, if a hospital's ratio of 
excluded area hours (Lines 8 and 8.0) on Worksheet S-3, Part II to 
total adjusted hours is less than 15 percent, Lines 21 through 35 of 
Part II should not be completed by hospitals. In addition, some of the 
aberrant data will be resolved by the final rule through the correction 
process described in section III.K. of the preamble of this proposed 
rule. Nevertheless, we believe that the amount of aberrant data on 
these new line items is minimal and will have little impact on area 
wage index values.
    In addition, we have simulated the effect of including these wage 
data for contract indirect patient care services on the wage index. 
Under this simulation, we found that the resulting average hourly wage 
would not affect 3,231 hospitals (90.2 percent), would decrease for 121 
hospitals (3.4 percent), and would increase for 229 hospitals (6.4 
percent). Only one hospital would experience a decrease of greater than 
1 percent (3 percent), and 19 hospitals would experience an increase of 
greater than 1 percent (the largest being 7.8 percent). At the labor 
market area level, we found that the resulting average hourly wage 
would not affect 316 areas (72.6 percent), would decrease for 28 areas 
(6.4 percent), and would increase for 91 areas (20.9 percent). No area, 
rural or urban, would experience an increase or decrease of greater 
than 0.6 percent in its wage index. We believe that the combined effect 
of including these costs in the wage index is negligible because the 
higher labor costs associated with contract management and A&G services 
are offset by the lower labor costs associated with contract 
housekeeping and dietary services.
    Public commenters have expressed interest in including in the wage 
index the costs and hours for contract management, A&G, housekeeping, 
and dietary services. We also believe that including a more 
comprehensive measure of area differences in the cost of labor will 
improve the accuracy of the wage index. For these reasons, we are 
proposing to include these contract services in the wage index, 
beginning with FY 2008. Although we invite public comment on whether we 
should revise a future cost report to collect contract labor data for 
the remaining indirect patient care cost centers on Worksheet S-3, Part 
II for possible inclusion in the wage index, we will consider these 
comments in the context of potential reforms of the IPPS wage index for 
FY 2009 and subsequent years. As indicated in section III.M. of the 
preamble of this proposed rule, section 106(b) of the MIEA-TRHCA (Pub. 
L. 109-432) requires the Secretary to consider a MedPAC study and nine 
specific aspects of the wage index in making one or more proposals for 
revisions in FY 2009.
3. Excluded Categories of Costs
    Consistent with the wage index methodology for FY 2007, the 
proposed wage index for FY 2008 also excludes the direct and overhead 
salaries and hours for services not subject to IPPS payment, such as 
SNF services, home health services, costs related to GME (teaching 
physicians and residents) and certified registered nurse anesthetists 
(CRNAs), and other subprovider components that are not paid under the 
IPPS. The proposed FY 2008 wage index

[[Page 24783]]

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).
4. Use of Wage Index Data by Providers Other Than Acute Care Hospitals 
under the IPPS
    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 IRFs, IPFs, and LTCHs, and for hospital 
outpatient services. We note that, in the IPPS rules, we do not address 
comments pertaining to the wage indices for non-IPPS providers. Such 
comments should be made in response to separate proposed rules for 
those providers.

E. Verification of Worksheet S-3 Wage Data

    (If you choose to comment on this section, please include the 
caption ``Wage Data'' at the beginning of your comment.)
    The wage data for the proposed FY 2008 wage index were obtained 
from Worksheet S-3, Parts II and III of the FY 2004 Medicare cost 
reports. Instructions for completing the Worksheet S-3, Parts II and 
III are in the Provider Reimbursement Manual, Part I, sections 3605.2 
and 3605.3. The data file used to construct the proposed wage index 
includes FY 2004 data submitted to us as of February 26, 2007 As in 
past years, we will perform an intensive review of the wage data, 
mostly through the use of edits designed to identify aberrant data.
    We asked our fiscal intermediaries/MACs to revise or verify data 
elements that resulted in specific edit failures. We identified and 
excluded 23 hospitals with data that was too aberrant to include in the 
proposed wage index, although if these data elements are corrected, we 
may include some of these providers in the FY 2008 final wage index. 
However, some unresolved data elements are included in the calculation 
of the proposed FY 2008 wage index. We instructed fiscal 
intermediaries/MACs to complete their data verification of questionable 
data elements and to transmit any changes to the wage data no later 
than April 13, 2007. We believe all unresolved data elements will be 
resolved by the date the final rule is issued. The revised data will be 
reflected in the final rule.
    In constructing the proposed FY 2008 wage index, we include the 
wage data for facilities that were IPPS hospitals in FY 2004, 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. For this proposed rule, we removed 18 hospitals that 
converted to CAH status between February 17, 2006, the cut-off date for 
CAH exclusion from the FY 2007 wage index, and February 16, 2007, the 
cut-off date for CAH exclusion from the FY 2008 wage index. After 
removing hospitals with aberrant data and hospitals that converted to 
CAH status, the proposed FY 2008 wage index is calculated based on 
3,581 hospitals.

F. Wage Index for Multicampus Hospitals

    (If you choose to comment on issues in this section, please include 
the caption ``Multicampus Hospitals'' at the beginning of your 
comment.)
    As discussed earlier under section III.B. of this preamble, 
effective October 1, 2004, for the IPPS, CMS implemented new labor 
market areas based on the CBSA definitions of MSAs. As a result of the 
new labor market areas, there are multicampus hospitals previously 
located in a single MSA that are now located in more than one CBSA. A 
multicampus hospital is a single integrated institution. For this 
reason, the multicampus hospital has one provider number and submits a 
single cost report that combines the total wages and hours of each of 
its campuses. When campuses of a multicampus hospital are located in 
the same CBSA, the wages and hours for the entire institution are 
included in the calculation of the wage index for that labor market 
area and there is no need to separate the data by campus. However, when 
a multicampus hospital has campuses located in different labor market 
areas, wages and hours are reported in a single CBSA even though the 
hospital's staff is working at campuses in more than one labor market 
area. The wage data are reported in the labor market area of the 
hospital campus associated with the provider number. Wages and hours 
are not reported separately for each campus and no data from the 
multicampus hospital are used in determining the wage index for the 
labor market area(s) where the other campus(es) are located. Under 
Sec.  412.64(b)(5) of our regulations, the wage-adjusted standardized 
amount is based on geographic location of the hospital facility at 
which the discharge occurred. Therefore, the wage index for each 
hospital campus used to make the IPPS payment is based on its 
geographic location, while the wage data from all of the campuses, 
including those that may be located in a different geographic area, are 
applied to one area only. We have received inquiries from several 
hospitals suggesting that we should adopt a policy that results in an 
allocation of a multicampus hospital's wages and hours across the 
different labor market areas where its campuses are located.
    The wage index was developed to adjust the IPPS standardized amount 
to reflect area differences in hospital wage levels in the hospital's 
geographic area compared to the national hospital wage level as 
required under section 1886(d)(3)(E) of the Act. Although we 
acknowledge that reporting the wage data into a single labor market 
area when individual campuses of a multicampus hospital are located in 
different labor market areas may not allocate wage data with exact 
precision, the Medicare cost report, in its current form, does not 
enable a multicampus hospital to separately report its costs by 
location. The fact that a multicampus hospital submits a single cost 
report reflects that it is an integrated institution with one 
accounting structure. Nevertheless, we agree with the comments brought 
to our attention that we should consider a policy that allocates a 
multicampus hospital's wages and hours among the different labor market 
areas where it is located. That is, rather than giving 100 percent of 
the hospital's wage data to the labor market area associated with its 
provider number, we believe that an allocation of its wage data should 
be made to each campus.
    We considered three alternative methods of apportionment: beds, 
discharges, or FTE staff. A hospital's number of discharges can 
fluctuate from year to year and may be an unstable data source to use 
in allocating a hospital's wages and hours among the different 
campuses. Alternatively, while a hospital's number of beds is a more 
static number, it likely does not correlate well with how a hospital 
incurs its wage costs. Furthermore, neither of these numbers is 
available on a campus-specific basis in Medicare's data systems. (While 
an individual

[[Page 24784]]

campus of a multicampus hospital located in a different labor market 
area than the remainder of the institution is required to indicate a 
suffix on its provider number when submitting a claim in order to 
receive payment using the wage index for its geographic location, the 
suffix is only used by the fiscal intermediary (or, if applicable, the 
MAC) and is not retained in Medicare's historical data files that we 
use to determine IPPS rates).
    Given the unavailability of beds and discharges and their 
respective drawbacks for allocating wages and hours across multiple 
campuses, we are proposing to apportion wages and hours for each campus 
of a multicampus hospital based on FTE staff. For example, a 
multicampus hospital may have three campuses located in two different 
labor market areas. Campuses A and B are located in labor market area 1 
and have 50 and 25 FTEs, respectively. Campus C is located in labor 
market area 2 and has an additional 25 FTEs. Therefore, 75 percent of 
the hospital's FTEs work in labor market 1 and 25 percent in labor 
market area 2. Under the proposed policy, we would apportion 75 percent 
of the hospital's occupational mix adjusted total salaries, wage-
related costs and hours to labor market 1 and 25 percent to labor 
market 2. We believe that the number of FTEs will provide the best 
method of apportioning wages and hours among the different campuses, 
thereby allowing the apportioned wage data to be included in each 
geographic area where the hospital has employees working.
    This proposed policy requires the identification of all multicampus 
hospitals located in more than one CBSA, the county, State, and zip 
code of each campus, and the campus-specific number of FTEs. Based on 
our comprehensive interactions with our fiscal intermediaries since 
adopting the revised labor market areas beginning in FY 2005, we are 
only aware of three multicampus hospitals that are located in more than 
one labor market area. We are beginning the process to make updates and 
refinements to the cost report for the future. We are currently 
planning to add additional lines to Worksheet S-2 of the cost report 
that will allow a multicampus hospital to report the locations of its 
different campuses (county, State, and zip code) and number of FTE 
staff by location so this information would become part of the cost 
report submission process. The effective date of the revised cost 
report is not expected until FY 2009. Therefore, we would not have data 
from multicampus hospitals under our normal wage data collection 
process to be able to allocate wages to each labor market area by FTEs 
until at least the FY 2013 wage index. In the interim, we will collect 
this information from multicampus hospitals on a small survey form 
through our fiscal intermediaries/MACs as part of the wage index desk 
review process beginning with the FY 2009 wage index. We will not be 
able to apply this policy to the FY 2008 wage index unless we have this 
information from multicampus hospitals prior to the close of the 
comment period on this proposed rule. Therefore, for the FY 2008 wage 
index, multicampus hospitals with campuses located in more than one 
geographic area should submit the information during the comment period 
on this proposed rule for the county, State, and zip code of its 
campuses, and the FTE number, including contract labor, per campus 
along with supporting documentation to: Centers for Medicare & Medicaid 
Services, Wage Index Team, C4-08-06, 7500 Security Boulevard, 
Baltimore, Maryland 21244, Attn: Kathy Ellingson.
    The hospitals should submit data from their FY 2004 cost reporting 
period to match the same data that will be used for the FY 2008 wage 
index. However, if unavailable, the hospital may submit the data for a 
subsequent cost reporting period that is closest to the FY 2004 
reporting period that provides the information in order to apportion 
the hospital's wage data among its campuses. These data will enable CMS 
to apportion the wages and hours of the multicampus hospital among its 
different campuses for use in the FY 2008 wage index calculations 
should this proposal become final. As stated earlier, we are only aware 
of three hospitals that would be affected by this proposed information 
collection request. As stipulated under 5 CFR 1320.3(c)(4), the 
proposed information collection request is exempt from the Paperwork 
Reduction Act (PRA) as it does not affect 10 or more persons within a 
12-month period. However, if during the IPPS rule comment period, we 
determine the number of affected persons surpasses the threshold of 10 
as specified in 5 CFR 1320.3(c)(4), we will not adopt the policy until 
FY 2009 in order for us to seek the requisite approval from OMB under 
the PRA.

G. Computation of the Proposed FY 2008 Unadjusted Wage Index

    (If you choose to comment on issues in this section, please include 
the caption ``Wage Index'' at the beginning of your comment.)
1. Method for Computing the Proposed FY 2008 Unadjusted Wage Index
    The method used to compute the proposed FY 2008 wage index without 
an occupational mix adjustment follows:
    Step 1--As noted above, we based the proposed FY 2008 wage index on 
wage data reported on the FY 2004 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, 2003, and before October 1, 2004. In addition, 
we include data from some hospitals that had cost reporting periods 
beginning before October 2003 and reported a cost reporting period 
covering all of FY 2004. These data are 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 2004 data. We note that, if a hospital 
had more than one cost reporting period beginning during FY 2004 (for 
example, a hospital had two short cost reporting periods beginning on 
or after October 1, 2003, and before October 1, 2004), we include 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 include 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 
subtract 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 exclude 
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 subtract from 
Line 1 the salaries for which no hours were reported. To determine 
total salaries plus wage-related costs, we add 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

[[Page 24785]]

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 are 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 compute 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 allocate overhead 
costs to areas of the hospital excluded from the wage index 
calculation. First, we determine 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 compute 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 compute the 
amounts of overhead wage-related costs to be allocated to excluded 
areas using three steps: (1) we determine 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 compute 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 
multiply the computed overhead wage-related costs by the above excluded 
area hours ratio. Finally, we subtract 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 adjust 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 estimate the 
percentage change in the employment cost index (ECI) for compensation 
for each 30-day increment from October 14, 2003, through April 15, 
2005, for private industry hospital workers from the BLS' 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. We also note that, since April 2006 with the 
publication of March 2006 data, the BLS' ECI uses a different 
classification system, the North American Industrial Classification 
System (NAICS), instead of the Standard Industrial Codes (SICs), which 
no longer exist. We have consistently used the ECI as the data source 
for our wages and salaries and other price proxies in the IPPS market 
basket and are not proposing to make any changes to the usage at this 
time. However, we are soliciting comments on our continued use of the 
BLS ECI data in light of the BLS change in system usage to the NAICS-
based ECI. 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
------------------------------------------------------------------------
         After                    Before             Adjustment Factor
------------------------------------------------------------------------
        10/14/2003               11/15/2003                  1.05743
        11/14/2003               12/15/2003                  1.05355
        12/14/2003               01/15/2004                  1.04964
        01/14/2004               02/15/2004                  1.04578
        02/14/2004               03/15/2004                  1.04198
        03/14/2004               04/15/2004                  1.03830
        04/14/2004               05/15/2004                  1.03482
        05/14/2004               06/15/2004                  1.03153
        06/14/2004               07/15/2004                  1.02821
        07/14/2004               08/15/2004                  1.02466
        08/14/2004               09/15/2004                  1.02086
        09/14/2004               10/15/2004                  1.01705
        10/14/2004               11/15/2004                  1.01344
        11/14/2004               12/15/2004                  1.01003
        12/14/2004               01/15/2005                  1.00671
        01/14/2005               02/15/2005                  1.00336
        02/14/2005               03/15/2005                  1.00000
        03/14/2005               04/15/2005                  0.99663
------------------------------------------------------------------------

    For example, the midpoint of a cost reporting period beginning 
January 1, 2004, and ending December 31, 2004, is June 30, 2004. An 
adjustment factor of 1.02821 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 2004 and covered a 
period of less than 360 days or more than 370 days, we annualize the 
data to reflect a 1-year cost report. Dividing the data by the number 
of days in the cost report and then multiplying the results by 365 
accomplishes annualization.
    Step 6--Each hospital is 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 add 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 divide 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 add the total adjusted salaries plus wage-related costs 
obtained in Step 5 for all hospitals in the Nation and then divide the 
sum by the national

[[Page 24786]]

sum of total hours from Step 4 to arrive at a national average hourly 
wage. Using the data as described above, the proposed national average 
hourly wage is $30.9298.
    Step 9--For each urban or rural labor market area, we calculate the 
hospital wage index value, unadjusted for occupational mix, 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 develop 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 add the total adjusted salaries plus wage-
related costs (as calculated in Step 5) for all hospitals in Puerto 
Rico and divide the sum by the total hours for Puerto Rico (as 
calculated in Step 4) to arrive at an overall proposed average hourly 
wage of $13.4729 for Puerto Rico. For each labor market area in Puerto 
Rico, we calculate 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 FY 2008, this change affects 239 hospitals in 
65 urban areas. The areas affected by this provision are identified by 
a footnote in Table 4A in the Addendum of this proposed rule.
2. Expiration of the Imputed Floor
    (If you choose to comment on issues in this section, please include 
the caption ``Imputed Floor'' at the beginning of your comment.)
    Section 4410 of Pub. L. 105-33 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 of that State (``the rural floor''). There are 
two States that have no rural areas (New Jersey and Rhode Island) and 
one State that has rural areas but no IPPS hospitals located in the 
rural areas of the State (Massachusetts). In the FY 2005 IPPS final 
rule (69 FR 49109), we adopted an ``imputed'' floor measure to address 
the concern that hospitals in all-urban States were disadvantaged by 
the absence of rural areas, because there is no floor within the State. 
We limited application of the policy to FYs 2005, 2006, and 2007 and 
indicated our intent to make additional changes to the policy or 
eliminate it for fiscal years after FY 2007.
    In FY 2008, the rural floor will apply to 239 hospitals in 25 
States. If the imputed rural floor were to continue into FY 2008, it 
would apply to an additional 28 hospitals in New Jersey. In FY 2007, 40 
hospitals in 10 urban areas received higher wage indices due to the 
imputed floor policy: Massachusetts (10 hospitals in 2 areas); New 
Jersey (30 hospitals in 8 areas); Rhode Island (no areas and no 
hospitals). In Massachusetts, the imputed rural floor will no longer 
apply even if it were to continue because one hospital acquired rural 
status under Sec.  412.103. We note that if a State has a hospital 
reclassified as rural under Sec.  412.103, the State will be considered 
to have IPPS hospitals located in rural areas because, in this case, 
the reclassified hospital is treated as being located in a rural area 
in accordance with section 1886(d)(8)(E) of the Act. This policy also 
accords with how we defined an ``all-urban State'' under Sec.  
412.64(h)(5) of the regulations, which specifies that ``A State with 
rural areas and with hospitals reclassified as rural under Sec.  
412.103 is not an all-urban State.'' Therefore, in the case where a 
State has no hospitals that are geographically located in its rural 
areas, and one or more hospitals in the State are reclassified as rural 
under Sec.  412.103, the data for the reclassified rural hospitals will 
be used to set the rural floor for the State until a new geographically 
located rural hospital opens and data are available from that hospital 
(as noted above, 4 years later) to compute the rural floor.
    We are proposing to discontinue the imputed floor policy after the 
FY 2007 wage index. After further considering the issue, we do not 
believe that it is necessary to have an ``imputed'' rural floor in 
States that have no rural areas or no rural hospitals. As discussed 
above, the imputed floor would not apply to two of the three States: it 
is not necessary for Rhode Island and is no longer necessary for 
Massachusetts. In addition, the imputed rural floor methodology creates 
a disadvantage in the application of the wage index to hospitals in 
States with rural hospitals but no urban hospitals receiving the rural 
floor. Because the application of a rural floor requires a transfer of 
payments from hospitals in States with rural hospitals but where the 
rural floor is not applied to hospitals in States where either a rural 
or imputed floor is applied, we believe the policy should apply only 
when required by statute. Thus, only States with both rural areas and 
hospitals located in such areas (including any hospital reclassified 
under Sec.  412.103) would benefit from the rural floor, as required by 
Congress.
    For all of the reasons stated above, we are not proposing to 
continue the imputed rural floor. Nevertheless, we recognize that we 
would still need a policy for determining the rural wage index when a 
new IPPS hospital opens in a State that has rural areas, but no IPPS 
hospitals. There is a lag between the time a hospital opens or becomes 
an IPPS provider and when the hospital's cost report wage data are 
available to include in calculating the area wage index. For example, 
if a hospital files its first Medicare cost report as an IPPS provider 
with a beginning date of January 1, 2007, and an ending date of 
December 31, 2007, the hospital's FY 2007 wage data would not be 
included in the wage index until the FY 2011 IPPS update. Therefore, 
when a rural IPPS hospital opens in a State that has rural areas, but 
no wage data are available to calculate a rural wage index, we are 
proposing to apply a wage index to that hospital using the same 
methodology that we currently use for home health and other post-acute 
care providers in rural Massachusetts (71 FR 65906). That is, we would 
use the unweighted average of the wage indices from all CBSAs that are 
contiguous to the rural counties of the State. (We define contiguous as 
sharing a border.)
    We would apply the wage index calculated above until the new IPPS 
hospital files a cost report for the base year that is used in 
calculating the wage index. (In the above example, the rural hospital's 
wage index would be calculated for FYs 2008, 2009, and 2010 using urban 
area data.) Further, under section 4410 of Pub. L. 105-33, the wage 
index for this rural hospital would become the State's rural floor. As 
stated above, however, if a State has rural areas, and a hospital is 
reclassified as rural under Sec.  412.103, then there would be no need 
to apply the above policy. The reclassified hospital would set the 
rural floor, and the wage data of the newly opened rural hospitals 
would be included in the calculation of the wage index of the rural 
area only once their wage data correlated with the survey year used to 
establish the wage index (4 years after wage data are reported).
3. CAHs Reverting Back to IPPS Hospitals and Raising the Rural Floor
    (If you choose to comment on issues in this section, please include 
the

[[Page 24787]]

caption ``Rural Floor'' at the beginning of your comment.)
    Medicare payments to CAHs are based on 101 percent of reasonable 
costs and are generally greater than the payments Medicare would make 
if the same hospitals were paid under the IPPS, which pays hospitals a 
fixed rate per discharge. Also, as a CAH, a hospital is guaranteed to 
recover is costs, while under the IPPS, it is not. We are aware of a 
situation where two rural hospitals in a State are considering 
converting from CAH status back to IPPS even though they continue to be 
CAH eligible. The CAHs would convert back to IPPS even though it would 
not directly benefit them. As IPPS providers, the hospitals' wage data 
would eventually set the rural floor for the State (that is, in 4 years 
when the hospitals' first IPPS cost reports would be included in a base 
year used in calculating the State's rural wage index). In this case, 
we are concerned that these hospitals are converting solely in order to 
take advantage of the rural floor provisions for the other hospitals in 
the State, but not for any reasons that are intrinsic to the two 
specific hospitals. Because the hospitals' wage levels are higher than 
most, if not all, of the urban IPPS hospitals in the State, including 
one hospital in the State that acquired rural status under Sec.  
412.103, the wage indices for most, if not all, of the State's urban 
hospitals would increase as a result of the rural floor provision if 
the CAHs convert to IPPS status. Such an arrangement would increase 
payments to the hospitals in the State at the expense of every other 
IPPS hospital in the nation. The two rural hospitals that are currently 
CAHs were last paid under the IPPS in FY 2003. We simulated the effect 
of allowing these two hospitals to set the State's rural floor with the 
same data used to calculate the FY 2003 wage index as would occur in FY 
2011 if these hospitals were to convert to IPPS status in FY 2007 and 
no other hospitals were to open in the rural area of the State. Based 
on this simulation, all hospitals except two would be paid using the 
rural floor, increasing payments in excess of $220 million for a single 
year. If the average hourly wage for these two hospitals increased 
faster than the national average, the increase in payments would be 
even higher. It seems likely that over 5 years, Medicare payments to 
hospitals in this State would increase by more than $1 billion. Again, 
these increased payments would be budget neutralized at the expense of 
all other IPPS hospitals nationwide. Given that the hospitals continue 
to be eligible for the higher paying CAH status, we are concerned that 
hospitals are converting to IPPS status solely in order to raise the 
State's rural floor. We are concerned about the propriety of such an 
arrangement if the intent is to manipulate the State's area wage index 
values to receive higher Medicare reimbursement.
    Section 1886(d)(5)(I)(i) of the Act allows the Secretary the 
authority to ``provide by regulation for such other exceptions and 
adjustments * * * as the Secretary deems appropriate.'' We are 
soliciting comments regarding whether it would be appropriate for CMS 
to establish a policy under this authority to preclude the arrangement 
described above and, if so, how such a policy would be applied. We 
believe that any policy should only apply to a CAH that continues to 
meet the CAH certification requirements and should not apply if a CAH 
no longer met those requirements and converted to an IPPS provider.
4. Application of Rural Floor Budget Neutrality
    Section 4410 of the Balanced Budget Act of 1997 (BBA) established 
the rural floor by requiring that the wage index for a hospital in any 
urban area cannot be less than the area wage index determined for the 
State's rural area. Since FY 1998, we have implemented the budget 
neutrality requirement of this provision by adjusting the standardized 
amounts. A discussion and illustration of the calculation of the 
standardized amounts is shown in the Addendum of every year's IPPS 
rule.\16\
---------------------------------------------------------------------------

    \16\ The BBA was enacted on August 5, 1997, and required 
application of the rural floor beginning with the FY 1998 IPPS. See 
the following for a description and calculation of the IPPS 
standardized amounts since that time: 62 FR 46038-46043, August 29, 
1997; 63 FR 41006-41010, July 31, 1998; 64 FR 41544-41549, July 30, 
1999; 65 FR 47111-47116, August 1, 2000; 66 FR 39939-39946, August 
1, 2001; 67 FR 50120-50126, August 1, 2002; 68 FR 45474-45480, 
August 1, 2003; 69 FR 49273-49282, August 11, 2004; 70 FR 47491-
47498, August 12, 2005; 71 FR 59889-58980, October 11, 2006.
---------------------------------------------------------------------------

    In this proposed rule, we are proposing a prospective change to how 
budget neutrality is applied to implement the rural floor for FY 2008 
and subsequent years. Section 4410(a) of the BBA indicates that ``the 
area wage index applicable * * * to any hospital which is not located 
in a rural area'may not be less than the area wage index applicable * * 
* to hospitals located in rural areas in the State in which the 
hospital is located.'' Section 4410(b) of the BBA imposes the budget 
neutrality requirement and states that the Secretary shall ``adjust the 
area wage index referred to in subsection (a) for hospitals not 
described in such subsection.''
    One possible interpretation of section 4410(b) of the BBA is that 
the budget neutrality adjustment would be applied only to those 
hospitals that do not receive the rural floor. In other words, the wage 
index of an urban hospital subject to the rural floor would be 
increased to the level of the rural wage index in the same State, but 
would not be adjusted for budget neutrality. Thus, urban hospitals 
receiving the rural floor would receive a higher wage index than the 
rural hospitals within the same State (because rural floor hospitals 
would not be subject to budget neutrality, whereas rural hospitals 
would be). We believe such a reading would not be in accordance with 
Congressional intent, which was to set a floor for urban hospitals, not 
to pay urban hospitals a wage index higher than the wage index 
applicable to rural hospitals.
    In order to avoid the apparent contradiction between raising an 
urban hospital's wage index to the rural floor and not applying budget 
neutrality to its wage index, we also believe the statute could be read 
to allow an iterative calculation of budget neutrality and wage 
indices. Under such iterative calculations (consistent with section 
4410(a) of the BBA), we would raise the wage index for urban hospitals 
to the level of the pre-budget neutrality rural wage index. Consistent 
with section 4410(b) of the BBA, we would adjust the wage index for all 
nonrural floor hospitals to achieve budget neutrality. However, such an 
adjustment would result in an urban hospital that would receive the 
rural floor having a higher wage index than a rural hospital in the 
same State. Therefore, we would then decrease wage indices for the 
rural floor hospitals so they are equal to the adjusted rural wage 
index in the same State. At this point, payments would be less in the 
aggregate than they were prior to applying the rural floor. 
Accordingly, a new budget neutrality adjustment would have to be 
calculated to raise the wage indices and total payments for rural 
hospitals and nonrural floor urban hospitals. The rural wage index 
would now be higher than the wage index for the rural floor hospitals 
in the same State. Therefore, the wage index for rural floor hospitals 
would then be increased again to the level of the State's rural wage 
index, leading to budget neutrality being recalculated again, the wage 
index reduced for rural floor hospitals, and so forth until the wage 
index and the budget neutrality adjustment stabilize.
    We have determined that the iterative method is substantively 
equivalent to

[[Page 24788]]

simply adjusting all area wage indices by a uniform percentage. We have 
performed the iterative calculation using provider-level data based on 
FY 2007 MedPAR data and the first half of FY 2007 wage index data. 
Using such data, we determined that the iterative method results in the 
same final wage indices through four decimal places that would result 
if a uniform budget neutrality factor were applied to all hospitals' 
wage indices. Furthermore, an iterative method, which requires 
adjusting only the wage index values of nonrural floor providers, 
reassigning the lowered rural floor value to rural floor providers, and 
reiterating the budget neutrality factor applied to the nonrural floor 
providers would require an excessive number of iterations and computer 
processing, which is not necessary if we simply apply a uniform budget 
neutrality adjustment to all wage index values. The latter method is 
accomplished more quickly, is less complex, and arrives at the same 
final wage index values. Because the IPPS schedule is relatively 
condensed, with a proposed rule issued in April, a 60-day comment 
period until June, and then only 2 months to analyze comments, respond 
to them, determine final policies and calculate final rates prior to 
the August 1 publication, we believe it would not be practical to 
require such multiple layers of calculations, when a uniform adjustment 
would produce substantively identical results. Therefore, we are 
proposing to implement the rural floor budget neutrality requirement by 
applying a uniform budget neutrality adjustment to all hospital wage 
indices rather than the more complicated iterative process illustrated 
below.
    The following hypothetical example, which includes a series of nine 
iterations, illustrates how the iterative process works. The example 
assumes three IPPS hospitals in one State. Hospital A is rural and 
Hospitals B and C are urban.

                                              Pre-Floor Wage Index
----------------------------------------------------------------------------------------------------------------
                                        Hospital A           Hospital B           Hospital C           Total
----------------------------------------------------------------------------------------------------------------
Wage Index.......................  0.9500.............  1.1700.............  0.8600.............  ..............
Relative Weights.................  100................  200................  150................  ..............
Location.........................  Rural..............  Urban..............  Urban..............  ..............
Standardized Amounts.............  $1,000.............  $1,000.............  $1,000.............  ..............
Payments.........................  $95,000............  $234,000...........  $129,000...........       $458,000
----------------------------------------------------------------------------------------------------------------
Note: Hospital C is urban and has a lower wage index than Hospital A which is rural.

Post-Floor Wage Index; Pre-Budget Neutrality

----------------------------------------------------------------------------------------------------------------
                                        Hospital A           Hospital B           Hospital C           Total
----------------------------------------------------------------------------------------------------------------
Wage Index.......................  0.9500.............  1.1700.............  0.9500.............  ..............
Relative Weights.................  100................  200................  150................  ..............
Location.........................  Rural..............  Urban..............  Urban..............  ..............
Standardized Amounts.............  $1,000.............  $1,000.............  $1,000.............  ..............
Payments.........................  $95,000............  $234,000...........  $142,500...........       $471,500
----------------------------------------------------------------------------------------------------------------
Note: Hospital C's wage index is raised to the same level as Hospital A.

Post Floor--Budget Neutrality Process
    Iteration 1:
    Step 1: Apply budget neutrality to Hospital A and Hospital B.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9110............  1.1220............  0.9500............  BN Factor.
Relative Weights................  100...............  200...............  150...............  0.95897.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $91,102...........  $224,398..........  $142,500..........  $458,000.
----------------------------------------------------------------------------------------------------------------

    Step 2: Reduce Hospital C's wage index to Hospital A's level.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9110............  1.1220............  0.9110............  BN Factor.
Relative Weights................  100...............  200...............  150...............  0.95897.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $91,102...........  $224,398..........  $136,653..........  $452,153.
----------------------------------------------------------------------------------------------------------------


[[Page 24789]]

    Iteration 2:
    Step 1: Apply budget neutrality to Hospital A and Hospital B.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9279............  1.1428............  0.9110............  BN Factor.
Relative Weights................  100...............  200...............  150...............  1.01853.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $92,790...........  $228,557..........  $136,653..........  $458,000.
----------------------------------------------------------------------------------------------------------------

    Step 2: Increase Hospital C's wage index to Hospital A's level.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9279............  1.1428............  0.9279............  BN Factor.
Relative Weights................  100...............  200...............  150...............  1.01854.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $92,790...........  $228,557..........  $139,185..........  $460,532.
----------------------------------------------------------------------------------------------------------------

    Iteration 3:
    Step 1: Apply budget neutrality to Hospital A and Hospital B.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9206............  1.1338............  0.9279............  BN Factor.
Relative Weights................  100...............  200...............  150...............  0.99212.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $92,059...........  $226,756..........  $139,185..........  $458,000.
----------------------------------------------------------------------------------------------------------------

    Step 2: Reduce Hospital C's wage index to Hospital A's level.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9206............  1.1338............  0.9206............  BN Factor.
Relative Weights................  100...............  200...............  150...............  0.99212.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $92,059...........  $226,756..........  $138,088..........  $456,903.
----------------------------------------------------------------------------------------------------------------

    Iteration 4:
    Step 1: Apply budget neutrality to Hospital A and Hospital B.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9238............  1.1377............  0.9206............  BN Factor.
Relative Weights................  100...............  200...............  150...............  1.00344.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $92,376...........  $227,536..........  $138,088..........  $458,000.
----------------------------------------------------------------------------------------------------------------

    Step 2: Increase Hospital C's wage index to Hospital A's level.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9238............  1.1377............  0.9238............  BN Factor.
Relative Weights................  100...............  200...............  150...............  1.00344.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $92,376...........  $227,536..........  $138,563..........  $458,475.
----------------------------------------------------------------------------------------------------------------


[[Page 24790]]

    Iteration 5:
    Step 1: Apply budget neutrality to Hospital A and Hospital B.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9224............  1.1360............  0.9238............  BN Factor.
Relative Weights................  100...............  200...............  150...............  0.99852.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $92,238...........  $227,198..........  $138,563..........  $458,000.
----------------------------------------------------------------------------------------------------------------

    Step 2: Reduce Hospital C's wage index to Hospital A's level.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9224............  1.1360............  0.9224............  BN Factor.
Relative Weights................  100...............  200...............  150...............  0.99852.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $92,238...........  $227,198..........  $138,358..........  $457,794.
----------------------------------------------------------------------------------------------------------------

    Iteration 6:
    Step 1: Apply budget neutrality to Hospital A and Hospital B.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9230............  1.1367............  0.9224............  BN Factor.
Relative Weights................  100...............  200...............  150...............  1.00064.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $92,298...........  $227,344..........  $138,358..........  $458,000.
----------------------------------------------------------------------------------------------------------------

    Step 2: Increase Hospital C's wage index to Hospital A's level.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9230............  1.1367............  0.9230............  BN Factor.
Relative Weights................  100...............  200...............  150...............  1.00064.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $92,298...........  $227,344..........  $138,447..........  $458,089.
----------------------------------------------------------------------------------------------------------------

    Iteration 7:
    Step 1: Apply budget neutrality to Hospital A and Hospital B.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9227............  1.1364............  0.9230............  BN Factor.
Relative Weights................  100...............  200...............  150...............  0.99972.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $92,272...........  $227,281..........  $138,447..........  $458,000.
----------------------------------------------------------------------------------------------------------------

    Step 2: Reduce Hospital C's wage index to Hospital A's level.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9227............  1.1364............  0.9227............  BN Factor.
Relative Weights................  100...............  200...............  150...............  0.99972.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $92,272...........  $227,281..........  $138,408..........  $457,961.
----------------------------------------------------------------------------------------------------------------


[[Page 24791]]

    Iteration 8:
    Step 1: Apply budget neutrality to Hospital A and Hospital B.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9228............  1.1365............  0.9227............  BN Factor.
Relative Weights................  100...............  200...............  150...............  1.00012.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $92,283...........  $227,308..........  $138,408..........  $458,000.
----------------------------------------------------------------------------------------------------------------

    Step 2: Increase Hospital C's wage index to Hospital A's level.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9228............  1.1365............  0.9228............  BN Factor.
Relative Weights................  100...............  200...............  150...............  1.00012.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $92,283...........  $227,308..........  $138,425..........  $458,016.
----------------------------------------------------------------------------------------------------------------

    Iteration 9:
    Step 1: Apply budget neutrality to Hospital A and Hospital B.

----------------------------------------------------------------------------------------------------------------
                                      Hospital A          Hospital B          Hospital C             Total
----------------------------------------------------------------------------------------------------------------
Wage Index......................  0.9228............  1.1365............  0.9228............  BN Factor.
Relative Weights................  100...............  200...............  150...............  0.99995.
Location........................  Rural.............  Urban.............  Urban.............  Target.
Standardized Amounts............  $1,000............  $1,000............  $1,000............  $458,000.
Payments........................  $92,279...........  $227,297..........  $138,425..........  $458,000.
----------------------------------------------------------------------------------------------------------------

    In the example above, the wage indices are shown only to the 4th 
decimal place even though they are not rounded. However, the actual 
wage indices that we calculate for the IPPS are rounded to 4 decimal 
places. In the 9th and final iteration of the budget neutrality 
adjustment shown above, there was no change to the wage indices through 
the 4th decimal place relative to the 8th iteration. Therefore, because 
the wage indices stopped changing, we could not obtain further 
precision in the budget neutrality and wage index calculations in the 
example shown above with further iterations. We note that the example 
above produces the same result as simply applying a uniform adjustment 
to hospital wage indices. Using the same data as the above hypothetical 
example, we show this result below:

                                              Pre-Floor Wage Index
----------------------------------------------------------------------------------------------------------------
                                        Hospital A           Hospital B           Hospital C           Total
----------------------------------------------------------------------------------------------------------------
Wage Index.......................  0.9500.............  1.1700.............  0.8600.............  ..............
Relative Weights.................  100................  200................  150................  ..............
Location.........................  Rural..............  Urban..............  Urban..............  ..............
Standardized Amounts.............  $1,000.............  $1,000.............  $1,000.............  ..............
Payments.........................  $95,000............  $234,000...........  $129,000...........       $458,000
----------------------------------------------------------------------------------------------------------------
Note: Hospital C is urban and has a lower wage index than Hospital A which is rural.

Post-Floor Wage Index; Pre-Budget Neutrality

----------------------------------------------------------------------------------------------------------------
                                        Hospital A           Hospital B           Hospital C           Total
----------------------------------------------------------------------------------------------------------------
Wage Index.......................  0.9500.............  1.1700.............  0.9500.............  ..............
Relative Weights.................  100................  200................  150................  ..............
Location.........................  Rural..............  Urban..............  Urban..............  ..............
Standardized Amounts.............  $1,000.............  $1,000.............  $1,000.............  ..............
Payments.........................  $95,000............  $234,000...........  $142,500...........       $471,500
----------------------------------------------------------------------------------------------------------------
Note: Hospital C's wage index is raised to the same level as Hospital A.


[[Page 24792]]

Post Floor--Budget Neutrality

----------------------------------------------------------------------------------------------------------------
                                        Hospital A           Hospital B           Hospital C           Total
----------------------------------------------------------------------------------------------------------------
Wage Index.......................  0.9228.............  1.1365.............  0.9228.............       BN Factor
Relative Weights.................  100................  200................  150................        0.971368
Location.........................  Rural..............  Urban..............  Urban..............          Target
Standardized Amounts.............  $1,000.............  $1,000.............  $1,000.............        $458,000
Payments.........................  $92,280............  $227,300...........  $138,420...........        $458,000
----------------------------------------------------------------------------------------------------------------

    We note that our proposed change would apply the budget neutrality 
adjustment to the wage index, and not to the standardized amount. In 
previous years, we applied a budget neutrality adjustment to the 
standardized amount to ensure that payments remained constant to 
payments that would have occurred in the absence of the rural floor 
requirement in section 4410 of the BBA. We believe such an adjustment 
is in keeping with the statute, which requires that the rural floor 
will not result in aggregate payments that are greater or less than 
those that would have been made in the absence of a rural floor. We 
believe that an adjustment to the wage index would result in a 
substantially similar payment as an adjustment to the standardized 
amount, as both involve multipliers to the standardized amount, and 
both would be based upon the same modeling parameters. We do note that 
because hospitals have different labor-related shares (62 percent for 
hospitals with wage indices less than or equal to 1; 69.7 percent for 
hospitals with wage indices greater than 1), an adjustment to the wage 
index would have slightly different effects from an adjustment to the 
standardized amount, as each wage index would be adjusted by a uniform 
percentage.
    For FY 2008, we are proposing to use FY 2006 discharge data and FY 
2008 wage indices to simulate IPPS payments without the rural floor. We 
would compare these simulated payments to simulated payments using the 
same data with a rural floor.
    We believe that the statute supports either an adjustment to the 
standardized amount or the wage indices because under either 
methodology, the rural floor would not result in aggregate payments 
that were greater or less than those that would have been made in the 
absence of a rural floor.

H. Analysis and Implementation of the Proposed Occupational Mix 
Adjustment and the Proposed FY 2008 Occupational Mix Adjusted Wage 
Index

    (If you choose to comment on issues in this section, please include 
the caption ``Occupational Mix Adjusted Wage Index'' at the beginning 
of your comment.)
    As discussed in section III.C. of this preamble, for FY 2008, we 
are proposing to apply the occupational mix adjustment to 100 percent 
of the FY 2008 wage index. We calculated the occupational mix 
adjustment using data from the 2006 occupational mix survey data, using 
the methodology described in section III.C.3. of this preamble.
    Using the first and second quarter occupational mix survey data and 
applying the occupational mix adjustment to 100 percent of the FY 2008 
wage index results in a proposed national average hourly wage of 
$30.9074 and a proposed Puerto Rico-specific average hourly wage of 
$13.4678. After excluding data of hospitals that either submitted 
aberrant data that failed critical edits, or that do not have FY 2004 
Worksheet S-3 cost report data for use in calculating the proposed FY 
2008 wage index, we calculated the proposed FY 2008 wage index using 
the occupational mix survey data from 3,368 hospitals. Using the 
Worksheet S-3 cost report data of 3,581 hospitals and occupational mix 
first and/or second quarter survey data from 3,368 hospitals represents 
a 94.1 percent survey response rate. The proposed FY 2008 national 
average hourly wages for each occupational mix nursing subcategory as 
calculated in Step 2 of the occupational mix calculation are as 
follows:

------------------------------------------------------------------------
                                                          Average hourly
          Occupational mix nursing subcategory                 wage
------------------------------------------------------------------------
National RN Management..................................        $38.6214
National RN Staff.......................................         33.4800
National LPN............................................         19.2485
National Nurse Aides, Orderlies, and Attendants.........         13.7267
National Medical Assistants.............................         15.7936
National Nurse Category.................................         28.7439
------------------------------------------------------------------------

    The proposed national average hourly wage for the entire nurse 
category as computed in Step 5 of the occupational mix calculation is 
$28.7439. Hospitals with a nurse category average hourly wage (as 
calculated in Step 4) of greater than the national nurse category 
average hourly wage receive an occupational mix adjustment factor (as 
calculated in Step 6) of less than 1.0. Hospitals with a nurse category 
average hourly wage (as calculated in Step 4) of less than the national 
nurse category average hourly wage receive an occupational mix 
adjustment factor (as calculated in Step 6) of greater than 1.0.
    Based on the January through June 2006 occupational mix survey 
data, we determined (in Step 7 of the occupational mix calculation) 
that the proposed national percentage of hospital employees in the 
Nurse category is 42.9 percent, and the proposed national percentage of 
hospital employees in the All Other Occupations category is 57.1 
percent. At the CBSA level, the percentage of hospital employees in the 
Nurse category ranged from a low of 27.3 percent in one CBSA, to a high 
of 85.3 percent in another CBSA.
    We compared the final FY 2007 occupational mix adjusted wage 
indices for each CBSA to the proposed FY 2008 wage indices adjusted for 
occupational mix. In proposing to implement an occupational mix 
adjusted wage index based on the above calculation using 6 months of 
survey data for FY 2008 as opposed to 3 months of survey data used for 
FY 2007, the final wage index values for 17 rural areas (36.2 percent) 
and 189 urban areas (48.7 percent) would decrease as a result of the 
adjustment. Nine rural areas (19.1 percent) and 127 urban areas (32.7 
percent) would experience a decrease of 1 percent or greater in their 
wage index values. The largest negative impacts would be 3.40 percent 
and 14.82 percent for a rural and urban area, respectively. In 
addition, 30 rural areas (63.8 percent) and 197 urban areas (50.8 
percent) would experience an increase in their wage index values. 
Twelve rural areas (25.5 percent) and 131 urban areas (33.8 percent) 
would experience an increase of 1 percent or greater in their wage 
index values. The largest increase for a rural area would be 10.75 
percent and the largest increase for an urban area would be 16.87 
percent. Two urban areas would be unaffected. These results indicate 
that a larger percentage of rural areas benefit from an occupational 
mix adjustment than do urban areas. However, as was the case with the 
FY 2007 occupational mix data, approximately a third of rural CBSAs 
(36.2 percent) continue to experience a decrease in their wage indices 
as a result of the occupational mix adjustment.

[[Page 24793]]

    The proposed wage index values for FY 2008 (except those for 
hospitals receiving wage index adjustments under section 1886(d)(13) of 
the Act) are shown in Tables 4A, 4B, 4C, and 4F in the Addendum to this 
proposed rule.
    Tables 3A and 3B in the Addendum to this proposed rule list the 3-
year average hourly wage for each labor market area before the 
redesignation of hospitals based on FYs 2006, 2007, and 2008 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 proposed rule includes the adjusted average hourly 
wage for each hospital from the FY 2002 and FY 2003 cost reporting 
periods, as well as the FY 2004 period used to calculate the proposed 
FY 2008 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 proposed wage index values in Tables 4A, 4B, 4C, and 4F and the 
average hourly wages in Tables 2, 3A, and 3B in the Addendum to this 
proposed rule include the proposed occupational mix adjustment as well 
as the budget neutrality adjustment for the rural floor.

I. Revisions to the Proposed Wage Index Based on Hospital 
Redesignations

    (If you choose to comment on issues in this section, please include 
the caption ``Hospital Reclassifications and Redesignations'' at the 
beginning of your comment.)
1. General
    Under section 1886(d)(10) of the Act, the Medicare Geographic 
Classification Review Board (MGCRB) considers applications by hospitals 
for geographic reclassification for purposes of payment under the IPPS. 
Hospitals must apply to the MGCRB to reclassify by September 1 of the 
year preceding the year during which reclassification is sought. 
Generally, hospitals must be proximate to the labor market area to 
which they are seeking reclassification and must demonstrate 
characteristics similar to hospitals located in that area. The MGCRB 
issues its decisions by the end of February for reclassifications that 
become effective for the following fiscal year (beginning October 1). 
The regulations applicable to reclassifications by the MGCRB are 
located in Sec. Sec.  412.230 through 412.280.
    Section 1886(d)(10)(D)(v) of the Act provides that, beginning with 
FY 2001, a MGCRB decision on a hospital reclassification for purposes 
of the wage index is effective for 3 fiscal years, unless the hospital 
elects to terminate the reclassification. Section 1886(d)(10)(D)(vi) of 
the Act provides that the MGCRB must use the 3 most recent years' 
average hourly wage data in evaluating a hospital's reclassification 
application for FY 2003 and any succeeding fiscal year.
    Section 304(b) of Pub. L. 106-554 provides that the Secretary must 
establish a mechanism under which a statewide entity may apply to have 
all of the geographic areas in the State treated as a single geographic 
area for purposes of computing and applying a single wage index, for 
reclassifications beginning in FY 2003. The implementing regulations 
for this provision are located at Sec.  412.235.
    Section 1886(d)(8)(B) of the Act requires the Secretary to treat a 
hospital located in a rural county adjacent to one or more urban areas 
as being located in the MSA to which the greatest number of workers in 
the county commute, if the rural county would otherwise be considered 
part of an urban area under the standards for designating MSAs 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.I.8. 
of this preamble.
2. Effects of Reclassification/Redesignation
    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, the wage index values were determined by 
considering the following:
     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.
    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.
    CMS has also adopted the following policies by regulation:
     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.
     In cases where urban hospitals have reclassified to rural 
areas under 42 CFR 412.103, the urban hospital wage data are: (a) 
Included in the rural wage index calculation, unless doing so would 
reduce the rural wage index; and (b) included in the urban area where 
the hospital is physically located.
3. FY 2008 MGCRB Reclassifications
    (If you choose to comment on issues in this section, please include 
the caption ``MGCRB'' at the beginning of your comment.)
    Under section 1886(d)(10) of the Act, the MGCRB considers 
applications by hospitals for geographic reclassification

[[Page 24794]]

for purposes of payment under the IPPS. The specific procedures and 
rules that apply to the geographic reclassification process are 
outlined in Sec.  412.230 through Sec.  412.280.
    At the time this proposed rule was constructed, the MGCRB had 
completed its review of FY 2008 reclassification requests. There were 
365 hospitals approved for wage index reclassifications by the MGCRB 
for FY 2008. Because MGCRB wage index reclassifications are effective 
for 3 years, hospitals reclassified during FY 2006 or FY 2007 are 
eligible to continue to be reclassified based on prior 
reclassifications to current MSAs during FY 2008. There were 299 
hospitals reclassified for wage index in FY 2006 and 214 hospitals 
reclassified for wage index in FY 2007. Some of the hospitals that 
reclassified for FY 2006 and FY 2007 have elected not to continue their 
reclassifications in FY 2008 because, under the revised 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 2006, FY 2007, and FY 2008, 866 hospitals are 
in a reclassification status for FY 2008.
    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 
rural referral centers and, effective for discharges occurring on or 
after October 1, 2006, MDHs 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). The exclusion of MDHs from the 12 
percent DSH cap under Pub. L. 109-171 was discussed under section 
IV.F.4. of the preamble of the FY 2007 IPPS final rule (71 FR 48066.)
    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 2008 must be received by 
the MGCRB within 45 days of the publication of this 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 or termination 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 will be incorporated into the wage index 
values published in the 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 2009 reclassifications are due to the MGCRB by 
September 4, 2007 (the first working day of September 2007). 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 2007, 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.
4. Hospitals That Applied for Reclassification Effective in FY 2008 and 
Reinstating Reclassifications in FY 2008
    Applications for FY 2008 reclassifications were due to the MGCRB by 
September 1, 2006. We note that this deadline also applied for 
canceling a previous wage index reclassification withdrawal or 
termination under Sec.  412.273(d). The MGCRB, in evaluating a 
hospital's request for reclassification for FY 2008 for the wage index, 
utilized the official data used to develop the FY 2007 wage index. The 
wage data used to support the hospital's wage comparisons were from the 
CMS hospital wage survey. Generally, the source for these data is the 
IPPS final rule to be published on or before August 1, 2006. However, 
the wage tables identifying the 3-year average hourly wage of hospitals 
were not available in time to include them in the FY 2007 IPPS final 
rule. Therefore, we made the data available subsequent to the 
publication of the FY 2007 IPPS final rule.
    Section 1886(d)(10)(C)(ii) of the Act indicates that a hospital 
requesting a change in geographic classification for a fiscal year must 
submit its application to the MGCRB not later than the first day of the 
13-month period ending on September 30 of the preceding fiscal year. 
Thus, the statute requires that FY 2008 reclassification applications 
were to be submitted to the MGCRB by no later than September 1, 2006. 
For this reason, we required hospitals to file an FY 2008 
reclassification application by the September 1, 2006 deadline even 
though the average hourly wage data used to develop the final FY 2007 
wage indices were not yet available. However, as outlined in Sec.  
412.256(c)(2), we also allowed hospitals with incomplete applications 
submitted by the deadline to request an extension beyond September 1, 
2006, to complete their applications. We also allowed hospitals 30 days 
from the date the final wage data were posted on the CMS Web site to 
request to cancel a withdrawal or termination in order to reinstate a 
reclassification for FY 2008 or FY 2009, or both fiscal years. For a 
more detailed discussion of the procedures used for the FY 2008 MGCRB 
applications we refer readers to the FY 2007 IPPS final rule (71 FR 
48022-48023).
5. Clarification of Policy on Reinstating Reclassifications
    Under Sec.  412.273(a) of our regulations, a hospital or group of 
hospitals may withdraw its application for reclassification at any time 
before the

[[Page 24795]]

MGCRB issues its decision or, if after the MGCRB issues its decision, 
within 45 days after publication of CMS's annual notice of proposed 
rulemaking for the upcoming fiscal year. In addition, a hospital may 
terminate a reclassification that is already in effect within 45 days 
after publication of the notice of proposed rulemaking for the upcoming 
fiscal year. Once a withdrawal or termination has been made, the 
hospital or group of hospitals will not be reclassified for purposes of 
the wage index to the same area for that year. The hospital also will 
not be reclassified to the withdrawn or terminated reclassification 
area in subsequent fiscal years unless the hospital subsequently 
cancels its withdrawal or termination. The procedures for making a 
withdrawal or termination, as well as for canceling a withdrawal or 
termination are specified at Sec.  412.273. In the FY 2003 IPPS final 
rule (67 FR 50065-50066), we clarified our existing policy stating that 
a previous 3-year reclassification may not be reinstated after a 
subsequent 3-year reclassification to another area takes effect. 
Therefore, a hospital can only have one active 3-year reclassification 
at a time.
    We have been asked whether a hospital (or group of hospitals) can 
reinstate the two remaining years of a previously approved 3-year 
reclassification to one area, while at the same time the individual 
hospital (or group) request a new 3-year reclassification from the 
MGCRB to a different area and be approved for both at the same time. In 
this case, the hospital or group of hospitals is permitted to apply to 
a different area than the previously approved reclassification but, as 
stated in Sec.  412.273(b)(2), once they accept a newly approved 
reclassification, a previously terminated and reinstated 3-year 
reclassification would be permanently terminated.
    Following the policy set forth at Sec.  412.273(d), a hospital may 
cancel a previous withdrawal or termination by submitting written 
notice of its intent to the MGCRB no later than September 1 for 
reclassifications effective at the start of the second following fiscal 
year 13 months later. At the same time (because the deadline for 
geographic reclassification applications for the second following 
fiscal year 13 months later is also September 1), a hospital or group 
of hospitals could apply for reclassification to a different area. If 
the application is denied, the hospital or group of hospitals can 
select between the reinstated geographic reclassification and the home 
area wage index for the following fiscal year. The hospital or group of 
hospitals must file a written request to the MGCRB within 45 days after 
publication of the notice of proposed rulemaking to terminate the 
reinstated reclassification and receive the home area wage index. If 
the hospital or group of hospitals takes no action, the pending 
geographic reclassification will go into effect. If the new geographic 
reclassification application is approved, the hospital or group of 
hospitals will have 45 days from publication of the notice of proposed 
rulemaking to accept either of the two pending geographic 
reclassifications or revert to the home area wage index. If the 
hospital or group of hospitals takes no action, the most recent 
approved geographic reclassification will go into effect and the prior 
reclassification will be permanently terminated. Alternatively, the 
hospital or group of hospitals can withdraw the most recent approved 
reclassification and accept the previously approved and reinstated 
reclassification within 45 days of publication of the notice of 
proposed rulemaking. Such an action will permanently terminate the most 
recently approved geographic reclassification. Finally, the hospital or 
group hospitals can write to the MGCRB within 45 days of publication of 
the notice of proposed rulemaking to withdraw both geographic 
reclassifications in order to receive the home area wage index. In this 
case, the hospital or group of hospitals can only reinstate one of the 
two geographic reclassifications. The other geographic reclassification 
is permanently terminated. Once a hospital or group of hospitals makes 
a decision for the following fiscal year within 45 days of publication 
of the notice of proposed rulemaking, the hospital or group of 
hospitals cannot change the decision for that fiscal year. It is also 
important to note that the reinstatement of a reclassification only 
applies to those withdrawals which were made after the MGCRB issued an 
approved 3-year decision, not a withdrawal made prior to the MGCRB 
issuing an approval decision.
    For example, a hospital has been reclassified to area ``A'' for FYs 
2007 through 2009. The hospital accepts this geographic 
reclassification for FY 2007. The hospital also applies for 
reclassification to a different area ``B'' for FYs 2008 through 2010 by 
September 1, 2006. If reclassification to area ``B'' is denied, the 
hospital can either withdraw or terminate its reclassification to area 
``A'' within 45 days of publication of the proposed rule for FY 2008 
and receive the home area wage index for FY 2008 or receive the 
reclassification to area ``A'' for FY 2008. If the hospital does 
nothing, it will receive the area ``A'' reclassification. If the 
hospital's reclassification application to area ``B'' is approved by 
the MGCRB, the hospital can (1) do nothing (and, therefore, receives 
the reclassification to area ``B'' for FY 2008, permanently terminating 
the reclassification to area ``A''); (2) within 45 days of publication 
of the notice of proposed rulemaking, withdraw the reclassification to 
area ``B'' and receive the reclassification to area ``A'' for FY 2008 
(permanently terminating the reclassification to area ``B''); or (3) 
withdraw or terminate both the reclassifications to both areas ``A'' 
and ``B'' and receive the home area wage index for FY 2008). If the 
latter option is selected, the hospital can only reinstate one of the 
withdrawn/terminated reclassifications by September 1, 2007 (to take 
effect for FY 2009). Upon the sunset of the 45-day window, the 
reclassification selection is final and the hospital will receive that 
wage index for the fiscal year, in this case for FY 2008.
6. ``Fallback'' Reclassifications
    As indicated in section III.I.3. of this preamble, the regulations 
at Sec.  412.273 provide the process that a hospital wishing to 
withdraw or terminate a reclassification must follow. If a hospital has 
an existing reclassification and then applies to the MGCRB to a second 
area and is approved, it has a choice between two reclassifications and 
its home area wage index for the following fiscal year. We have been 
asked a procedural question about how the hospital accepts its 
previously approved reclassification (its ``fall back'' 
reclassification) or how it can ``fall back'' to its home area wage 
index. As the example provided in the section III.I.5. of this preamble 
illustrates, a hospital will automatically be given its most recently 
approved reclassification (thereby permanently terminating any 
previously approved reclassifications) unless it provides written 
notice to the MGCRB within 45 days of publication of the notice of 
proposed rulemaking that it wishes to withdraw its most recently 
approved reclassification and ``fall back'' to either its prior 
reclassification or its home area wage index for the following fiscal 
year. If the hospital wishes to accept its home area wage index in 
preference to its previous ``fall back'' reclassification, the hospital 
must also state in its request to the MGCRB that it is not only 
withdrawing its most

[[Page 24796]]

recently approved reclassification but also terminating its previously 
approved reclassification.
7. Geographic Reclassification Issues for Multicampus Hospitals
    (If you choose to comments on issues in this section, please 
include the caption ``Multicampus Hospitals'' at the beginning of your 
comment.]
    In FY 2005, we modified the reclassification rules at Sec.  
412.230(d)(2)(iii) to allow campuses of multicampus hospitals located 
in separate wage index areas to support a reclassification application 
to the geographic area in which another campus is located using the 
average hourly wage data submitted on the cost report for the entire 
hospital. This special rule applies for applications for 
reclassifications effective in FYs 2006 through FY 2008. In the FY 2007 
IPPS final rule, we decided not to extend this special rule for 
multicampus hospitals. However, we believe that the proposed change to 
how we allocate a multicampus hospital's wage data has implications for 
multicampus hospitals' reclassification requests.
    As stated above, we are proposing to allocate the multicampus 
hospital's wage data across the different labor market areas where the 
campuses are located based upon FTEs. For this reason, an individual 
campus located in a geographic area distinct from the geographic area 
associated with the provider number of the multicampus hospital will 
now have published, hospital-specific wage data that it may use to 
support a request for individual reclassification. The campus's wage 
data will be included in the wage data public use file and also 
provided to the MGCRB. These data will be considered appropriate wage 
data under Sec.  412.230, because it will be part of the CMS hospital 
wage survey used to construct the wage index. We note, that where a 
multicampus hospital spanning two or more geographic areas does not 
provide us with appropriate FTE data, its campus-specific data will not 
be included in the public use files we use to construct the wage index. 
For this reason, unless a multicampus hospital has provided us with FTE 
data, we will not have appropriate campus-specific wage data that could 
be used to support an individual reclassification under Sec.  412.230, 
and the reclassification request for the individual campus would be 
denied. In this sense, our policy allowing the allocation of wage data 
using FTEs is somewhat different from our prior policy on multicampus 
hospitals.
    We note that when a multicampus hospital's wage data are divided by 
FTEs, the ratio of wages to hours remains constant. Thus, the effect of 
our policy, in some sense, is that the individual campus of a 
multicampus hospital effectively uses the average hourly wage of the 
entire multicampus institution to support its individual 
reclassification request. However, as stated in the paragraph above, 
appropriate wage data will exist, only if the hospital has provided FTE 
data that can be used to allocate institution-wide wages and hours.
    Under current policy, an individual campus of a multicampus 
hospital located in a different area than the one associated with the 
provider number does not have to provide any official wage index data 
to join a group reclassification. However, given that we are allocating 
a portion of the average hourly wage of the hospital's data to the 
labor market area that includes this campus, we are also proposing that 
this same data be used as part of a group reclassification application. 
Again, these data will be published in a public use file and will be 
considered appropriate wage data under Sec. Sec.  412.232 and 412.234. 
If a multicampus hospital spanning more than one geographic area has 
not provided us with FTE data, then, in accordance with our current 
policies for treating hospitals without official wage data, the 
individual campus would still be permitted to join the group 
application (and indeed would be required to join the application since 
all hospitals in a group must join in the application). In this case, 
the group application would omit the wage data from the individual 
campus of a multicampus hospital.
8. Redesignations of Hospitals Under Section 1886(d)(8)(B) of the Act
    Beginning October 1, 1988, section 1886 (d)(8)(B) of the Act 
required us to treat a hospital located in a rural county adjacent to 
one or more urban areas as being located in the MSA if certain criteria 
were met. Prior to FY 2005, the rule was that a rural county adjacent 
to one or more urban areas would be treated as being located in the MSA 
to which the greatest number of workers in the county commute, if the 
rural county would otherwise be considered part of an urban area under 
the standards published in the Federal Register on January 3, 1980 (45 
FR 956) for designating MSAs (and New England County Metropolitan Areas 
(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.
    Effective beginning FY 2005, we use 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. Hospitals located in these counties have been known 
as ``Lugar'' hospitals and the counties themselves are often referred 
to as ``Lugar'' counties. We provide the chart below with the listing 
of the rural counties designated as urban under section 1886(d)(8)(B) 
of the Act that we are proposing to use for FY 2008. For discharges 
occurring on or after October 1, 2007, 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.

 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.

[[Page 24797]]

 
Clinton, IN............................  Lafayette, IN.
Henry, IN..............................  Indianapolis-Carmel, IN.
Spencer, IN............................  Evansville, IN-KY.
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.
------------------------------------------------------------------------

    As in the past, hospitals redesignated under section 1886(d)(8)(B) 
of the Act are also eligible to be reclassified to a different area by 
the MGCRB. Affected hospitals are permitted to compare the reclassified 
wage index for the labor market area in Table 4C in the Addendum to 
this proposed rule into which they have been reclassified by the MGCRB 
to the wage index for the area to which they are redesignated under 
section 1886(d)(8)(B) of the Act. Hospitals may withdraw from an MCGRB 
reclassification within 45 days of the publication of this proposed 
rule.
9. Reclassifications Under Section 1886(d)(8)(B) of the Act
    We have been asked whether Lugar hospitals and counties (discussed 
above in section III.H.8. of this preamble) are considered urban or 
rural for MGCRB reclassification purposes. As stated in the regulations 
at 42 CFR 412.64(b)(3), as well as in section 1886(d)(8)(C) of the Act, 
Lugar hospitals and counties are deemed to be located in an urban area. 
Therefore, because they are physically located in a rural area and are 
deemed urban, they receive the reclassified wage index (Table 4C in the 
Addendum to this proposed rule) for the urban area to which they have 
been redesignated. Because Lugar hospitals are treated like 
reclassified hospitals, when they are seeking reclassification by the 
MCGRB, they are subject to the rural reclassification rules set forth 
at Sec.  412.230. The procedural rules set forth at Sec.  412.230 list 
the criteria which a hospital must meet in order to reclassify as a 
rural hospital. Lugar hospitals would be subject to the proximity 
criteria and payment thresholds that apply to rural hospitals. 
Specifically, the hospital would have to be no more than 35 miles from 
the area to which it seeks reclassification (Sec.  412.230(b)(1)); the 
hospital would have to show that its average hourly wage is at least 
106 percent of the average hourly wage of all other hospitals in the 
area in which the hospital is located (Sec.  412.230(d)(1)(iii)(C)); 
and the hospital would have to demonstrate that its average hourly wage 
is equal to at least 82 percent of the average hourly wage of hospitals 
in the area to which it seeks redesignation (Sec.  
412.230(d)(1)(iv)(C)).
    Hospitals not located in a Lugar county seeking reclassification to 
the urban area where the Lugar hospitals have been redesignated are not 
permitted to measure to the Lugar county to demonstrate proximity (no 
more than 15 miles for an urban hospital, and no more than 35 miles for 
a rural hospital or the closest urban or rural area for RRCs or SCHs) 
in order to be reclassified to such urban area. These hospitals must 
measure to the urban area exclusive of the Lugar County to meet the 
proximity or nearest urban or rural area requirement.
10. New England Deemed Counties
    Our regulations at 42 CFR 412.64(b)(1)(ii)(B) list New England 
counties that are deemed to be parts of urban areas under section 
601(g) of the Social Security Amendments of 1983 (Pub. L. 98-21, 42 
U.S.C. 1395ww(note)). These counties include Litchfield County, 
Connecticut; York County, Maine; Sagadahoc County, Maine; Merrimack 
County, New Hampshire; and Newport County, Rhode Island. OMB standards 
designate and define two categories of CBSAs: Metropolitan Statistical 
Areas (MSAs) and Micropolitan Statistical Areas (65 FR 82235). For our 
labor market area definitions, we treat micropolitan areas as rural.
    Of these five counties, three (York County, Sagadahoc County, and 
Newport County) are also included in metropolitan areas by OMB, whereas 
the remaining two, Litchfield County and Merrimack County, are located 
in micropolitan statistical areas and would

[[Page 24798]]

be treated as rural under our labor market area definitions were they 
not deemed urban under Sec.  412.64(b)(1)(ii)(B) of the regulations. 
Litchfield County and Merrimack County have been listed as being part 
of urban CBSA 25540 Hartford-West Hartford-East Hartford, CT, and urban 
CBSA 31700 Manchester-Nashua, NH, respectively. Even though hospitals 
located in Litchfield County and Merrimack County are in micropolitan 
statistical areas, they have been treated as urban for reclassification 
purposes. Under our regulations, we have deemed both of these two New 
England counties and the hospitals within them as urban. Because the 
counties themselves were deemed urban, the hospitals within them have 
also been treated as urban for reclassification purposes, even though 
Litchfield and Merrimack counties are in micropolitan statistical 
areas. However, upon further consideration of this issue, we believe 
the hospitals located within these New England counties should be 
treated the same as Lugar hospitals. That is, the area would be 
considered rural but the hospitals within them would be deemed to be 
urban. Therefore, we are proposing to change our policy and consider 
Litchfield County and Merrimack County as rural but would continue to 
consider the hospitals within them as being redesignated to urban CBSA 
25540 Hartford-West Hartford-East Hartford, CT, and urban CBSA 31700 
Manchester-Nashua, NH, respectively. Under our proposal, hospitals 
located in these counties--like the Lugar hospitals described in 
section III.I.8. of this preamble--must meet the rural requirements set 
forth at Sec.  412.230 for individual reclassifications and Sec.  
412.232 for group reclassifications. We are proposing to revise Sec.  
412.64(b)(1)(ii)(B) accordingly. Hospitals not located inside one of 
these deemed New England counties are not permitted to measure to these 
counties to demonstrate close proximity in order to be reclassified to 
the CBSA(s) to which the hospitals in Litchfield and Merrimack counties 
are redesignated. We note that Tables 2, 3A, 3B, 4A, and 4B in the 
Addendum to this proposed rule do not reflect this proposed change; 
rather, they reflect the wage index based on the current policy.
11. Reclassifications Under Section 508 of Pub. L. 108-173
    (If you choose to comment on issues in this section, please include 
the caption ``508 Reclassifications'' at the beginning of your 
comment.)
    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 
were applicable to discharges occurring during the 3-year period 
beginning April 1, 2004, and ending March 31, 2007. Section 106(a) of 
the MIEA-TRHCA (Pub. L. 109-432), extended any geographic 
reclassifications of hospitals that were made under section 508 and 
that would expire on March 31, 2007, by 6 months until September 30, 
2007. On March 23, 2007, we published a notice in the Federal Register 
(72 FR 13799) that indicated how we are implementing section 106(a) of 
the MIEA-TRHCA through September 30, 2007. Because the section 508 
provision will expire on September 30, 2007, and will not be applicable 
in FY 2008, in this proposed rule, we are not making any proposals 
related to the provision.
12. Other Issues
    We have been advised of a reclassification scenario of concern to a 
particular hospital. In this scenario, two hospitals were approved by 
the Medicare Geographic Classification Review Board (MGCRB) for a 3-
year group reclassification. Prior to the second year of the 3-year 
reclassification, one of the hospitals reclassified individually to 
another area. Consistent with our policy, the second hospital retained 
its group geographic reclassification for the two remaining years (see 
66 FR 39888, August 1, 2001). However, once the group reclassification 
expires, the second hospital does not qualify to reclassify 
individually to another area. We have been asked to consider potential 
regulatory options that would allow this hospital to either reclassify 
or receive a declining blend of its home area and reclassified wage 
index as a transition to its post-reclassified wage index.
    There are no options under our current regulations that would allow 
this hospital to reclassify individually or as a group. The hospital 
does not meet the well established wage data comparison criteria to 
reclassify as an individual hospital. In order for a group 
reclassification to be approved, all hospitals in the county must apply 
as a group. We have been informed that one hospital will not join the 
group reclassification because it qualifies individually to reclassify 
to a different area with a higher wage index than where the group 
applied.
    We considered whether to change our regulations for this type of 
situation. However, we decided not to propose a change to our 
regulations given the need to gather additional information and better 
understand the policy issues in such a case. In this regard, we would 
be interested in receiving comments on whether such a situation is 
consistent with the purpose of reclassification. In particular, we 
would like to receive comments on how a hospital that is applying to 
reclassify would demonstrate similarity to hospitals in the neighboring 
area when the hospital would qualify to be part of a group 
reclassification if all other hospitals in the county the hospital is 
located agreed to apply.
    In addition, we would be interested in comments on how we could 
make a determination that a hospitals own area wage index is 
inappropriate when the hospital does not meet the current criteria for 
reclassification on its own, but would meet the criteria for a group 
reclassification in the event all hospitals in the county in which the 
hospital is located would agree to submit a group application. Finally, 
given that reclassifications are in effect for three years, we request 
comments on whether or how we could address this situation while 
simultaneously maintaining the distinction between group and individual 
reclassifications--particularly the rule that all members of a group 
must apply for a group reclassification.
    For all the above reasons, we decided, as noted, not to propose 
changes to the regulations to address the situation brought to our 
attention. Rather, we think it is appropriate to gather additional 
information and seek comment on this or similar situations. If 
commenters wish to raise issues with the points described in this 
section or comment on other issues we did not consider in the questions 
raised above, we welcome such public comments.

J. Proposed FY 2008 Wage Index Adjustment Based on Commuting Patterns 
of Hospital Employees

    (If you choose to comment on issues in this section, please include 
the caption ``Out-Migration Adjustment'' at the beginning of your 
comment.)
    In accordance with the broad discretion under section 1886(d)(13) 
of the Act, as added by section 505 of Pub. L. 108-173, beginning with 
FY 2005, we established a process to make adjustments to the hospital 
wage index based on commuting patterns of hospital employees. The 
process,

[[Page 24799]]

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 budget neutrality requirements under 
section 1886(d)(3)(E) of the Act.
    Hospitals located in counties that qualify for the wage index 
adjustment are to receive an increase in the wage index that is equal 
to the average of the differences between the wage 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. To date, we have used pre-reclassified 
wage indices when determining the out-migration adjustment. In the FY 
2005 IPPS final rule (69 FR 49061 through 49063), we stated that it was 
reasonable to interpret the term ``wage index'' in section 
1886(d)(13)(D) of the Act to mean the pre-reclassified, pre-adjusted 
wage index. At the time, we stated that it was unclear whether to use 
the pre- or post-reclassified wage index as the basis for comparison to 
determine the out-migration adjustment. We also cited complicating 
factors such as the use of blended wage indices as a result of the 
labor market area transition as another reason to base the out-
migration adjustment on the pre-reclassified wage index. However, we 
indicated that we will continue to examine the possibility of employing 
post-reclassification wage indexes as we refine our policy for future 
adjustments.
    We have reconsidered our policy in this proposed rule and are 
proposing to calculate the out-migration adjustment using the post-
reclassified wage index. First, the labor-market area transition has 
ended and the use of blended wage indexes is no longer a complicating 
factor in determining whether to use pre- or post-reclassified wage 
indexes to determine the out-migration adjustment. Second, we are 
proposing to apply budget neutrality for application of the rural floor 
to area wage indices rather than to the standardized amount beginning 
in FY 2008. The budget neutrality adjustment for the rural floor is 
being applied to the post-reclassification wage indices and is a 
component of the wage index that is being used to adjust for area 
differences in wages. Therefore, we believe the out-migration 
adjustment should be determined using post-reclassified wage index that 
reflects the budget neutrality adjustment for application of the rural 
floor.
    We are proposing to use the same formula described in the FY 2005 
final rule (69 FR 49064), with the addition of now using the post-
reclassified wage indices, to calculate the out-migration adjustment. 
This adjustment is calculated as follows:
    Step 1. Subtract the wage index for the qualifying county from the 
wage index of each of the higher wage area(s) to which hospital workers 
commute.
    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. For each of the 
higher wage areas, 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.
    These adjustments will be effective for each county for a period of 
3 fiscal years. Hospitals that received the adjustment in FY 2007 will 
be eligible to retain that same adjustment for FY 2008. 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, 2007.
    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 unless they waive the out-
migration adjustment. Consistent with our FY 2005, 2006, and 2007 final 
rules, we are proposing that hospitals redesignated under section 
1886(d)(8) of the Act or reclassified under section 1886(d)(10) of the 
Act will be deemed to have chosen to retain their redesignation or 
reclassification. Section 1886(d)(10) hospitals that wish to receive 
the out-migration adjustment, rather than their reclassification, 
should follow the termination/withdrawal procedures specified in 42 CFR 
412.273 and section III.I.3. of the preamble of this proposed rule. 
Otherwise, they will be deemed to have waived the out-migration 
adjustment. Hospitals redesignated under section 1886(d)(8) of the Act 
will be deemed to have waived the out-migration adjustment, unless they 
explicitly notify CMS that they elect to receive the out-migration 
adjustment instead within 45 days from the publication of this proposed 
rule. These notifications should be sent to the following address: 
Centers for Medicare and Medicaid Services, Center for Medicare 
Management, Attention: Wage Index Adjustment Waivers, Division of Acute 
Care, Room C4-08-06, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    Table 4J in the Addendum to this proposed rule lists the proposed 
out-migration wage index adjustments for FY 2008. Hospitals that are 
not otherwise reclassified or redesignated under section 1886(d)(8) or 
section 1886(d)(10) of the Act will automatically receive the listed 
adjustment. In accordance with the procedures discussed above, 
redesignated/reclassified hospitals will be deemed to have waived the 
out-migration adjustment unless CMS is otherwise notified. 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 proposed rule. Hospitals should carefully review the wage index 
adjustment that they would receive under this provision (as listed in 
Table 4J) and the area wage index value as listed in Table 4A (both 
included in the Addendum to this proposed rule) in comparison to the 
wage index value that they would receive under the MGCRB 
reclassification (Table 4C in the Addendum to this proposed rule).

K. Process for Requests for Wage Index Data Corrections

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

[[Page 24800]]

    The preliminary Worksheet S-3 wage data and occupational mix survey 
data files (1st and 2nd quarter 2006) for the FY 2008 wage index were 
made available on October 6, 2006, through the Internet on the CMS Web 
site at: http://cms.hhs.gov/AcuteInpatientPPS/. In a memorandum dated 
October 6, 2006, we instructed all 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 6, 2006 wage and occupational mix data files, the hospital 
was to submit corrections along with complete, detailed supporting 
documentation to its fiscal intermediary by December 4, 2006. 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, 2006 memorandum referenced above.
    In the October 6, 2006 memorandum, we also specified that a 
hospital could request revisions to 1st and/or 2nd quarter occupational 
mix survey data if they missed the previous deadlines (June 1, 2006, 
for the 1st quarter data collection and August 31, 2006, for the 2nd 
quarter collection) for submitting occupational mix survey data to 
their fiscal intermediaries. A hospital requesting revisions to its 1st 
and/or 2nd quarter occupational mix survey data was to copy its 
record(s) from the CY 2006 occupational mix preliminary files posted to 
our website in October, highlight the revised cells on its spreadsheet, 
and submit its spreadsheet(s) and complete documentation to its fiscal 
intermediary no later than December 4, 2006.
    The fiscal intermediaries (or, if applicable, the MAC) notified the 
hospitals by mid-February 2007 of any changes to the wage index data as 
a result of the desk reviews and the resolution of the hospitals' 
early-December revision requests. The fiscal intermediaries or MAC also 
submitted the revised data to CMS by mid-February 2007. CMS published 
the proposed wage index public use files that included hospitals' 
revised wage data on February 23, 2007. In a memorandum also dated 
February 23, 2007, we instructed fiscal intermediaries and the MAC 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 12, 2007 to submit requests to the fiscal intermediaries or the 
MAC for reconsideration of adjustments made by the fiscal 
intermediaries or the MAC as a result of the desk review, and to 
correct errors due to CMS's or the fiscal intermediary's (or, if 
applicable, the MAC'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 or the MAC are to transmit any additional revisions 
resulting from the hospitals' reconsideration requests by April 13, 
2007. The deadline for a hospital to request CMS intervention in cases 
where the hospital disagreed with the fiscal intermediary's (or, if 
applicable, the MAC's) policy interpretations is April 20, 2007.
    Hospitals should also examine Table 2 in the Addendum to this 
proposed rule. Table 2 of this 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 2004 data used to construct the 
proposed FY 2008 wage index. We note that the hospital average hourly 
wages shown in Table 2 only reflect changes made to a hospital's data 
and transmitted to CMS by February 21, 2007.
    We will release the final wage index data public use files in early 
May 2007 on the Internet at http:/www.cms.hhs.gov/AcuteInpatientPPS/. 
The May 2007 public use files will be made available solely for the 
limited purpose of identifying any potential errors made by CMS or the 
fiscal intermediary or MAC in the entry of the final wage index data 
that result from the correction process described above (revisions 
submitted to CMS by the fiscal intermediaries or the MAC by April 13, 
2007). If, after reviewing the May 2007 final files, a hospital 
believes that its wage or occupational mix data are incorrect due to a 
fiscal intermediary or MAC or CMS error in the entry or tabulation of 
the final data, the hospital should send a letter to both its fiscal 
intermediary or MAC and CMS that outlines why the hospital believes an 
error exists and to provide all supporting information, including 
relevant dates (for example, when it first became aware of the error). 
CMS and the fiscal intermediaries (or, if applicable, the MAC) must 
receive these requests no later than June 08, 2007. Requests mailed to 
CMS should be sent to: Centers for Medicare & Medicaid Services, Center 
for Medicare Management, Attention: Wage Index Team, Division of Acute 
Care, C4-08-06, 7500 Security Boulevard, Baltimore, MD 21244-1850.
    Each request also must be sent to the fiscal intermediary or the 
MAC. The fiscal intermediary or the MAC will review requests upon 
receipt and contact CMS immediately to discuss its findings.
    At this point in the process, that is, after the release of the May 
2007 wage index data files, changes to the wage and occupational mix 
data will only made in those very limited situations involving an error 
by the fiscal intermediary or the MAC or CMS that the hospital could 
not have known about before its review of the final wage index data 
files. Specifically, neither the fiscal intermediary or the MAC nor CMS 
will approve the following types of requests:
     Requests for wage index data corrections that were 
submitted too late to be included in the data transmitted to CMS by 
fiscal intermediaries or the MAC on or before April 13, 2007.
     Requests for correction of errors that were not, but could 
have been, identified during the hospital's review of the February 23, 
2007 wage index public use files.
     Requests to revisit factual determinations or policy 
interpretations made by the fiscal intermediary or the MAC or CMS 
during the wage index data correction process.
    Verified corrections to the wage index data received timely by CMS 
and the fiscal intermediaries or the MAC (that is, by June 08, 2007) 
will be incorporated into the final wage index to be published by 
August 1, 2007, to be effective October 1, 2007.
    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 2008 payment rates. Accordingly, 
hospitals that do not meet the procedural deadlines set forth above 
will not be afforded a later opportunity to submit wage index data 
corrections or to dispute the fiscal intermediary's (or, if applicable 
the MAC'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

[[Page 24801]]

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 and occupational mix data to the fiscal intermediary's (or, 
if applicable, the MAC's) attention. Moreover, because hospitals will 
have access to the final wage index data by early May 2007, they have 
the opportunity to detect any data entry or tabulation errors made by 
the fiscal intermediary or the MAC or CMS before the development and 
publication of the final FY 2008 wage index by August 1, 2007, and the 
implementation of the FY 2008 wage index on October 1, 2007. If 
hospitals avail themselves of the opportunities afforded to provide and 
make corrections to the wage and occupational mix 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 08, 2007, 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 the 
MAC 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 index 
data available to hospitals on the CMS Web site prior to publishing 
both the proposed and final IPPS rules, and the fiscal intermediaries 
or the MAC notify hospitals directly of any wage index data changes 
after completing their desk reviews, we do not expect that midyear 
corrections will 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 final rule (70 FR 47385), we revised Sec.  
412.64(k)(2) to specify that, effective on October 1, 2005, that is 
beginning with the FY 2006 wage index, 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, if applicable, the MAC) 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 (or if applicable the MAC) and CMS correct the error using 
the established process and within the established schedule for 
requesting corrections to the wage index data, before the beginning of 
the fiscal year for the applicable IPPS update (that is, by the June 
08, 2007 deadline for the FY 2008 wage index); and (3) CMS agreed that 
the fiscal intermediary (or if applicable, the MAC) or CMS made an 
error in tabulating the hospital's wage index data and the wage index 
should be corrected.
    In those circumstances where a hospital requests a correction to 
its wage index data before CMS calculates the final wage index (that 
is, by the June deadline), and CMS acknowledges that the error in the 
hospital's wage index data was caused by CMS's or the fiscal 
intermediary's (or, if applicable, the MAC'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 provision is not be available to a hospital 
seeking to revise another hospital's data. In addition, the provision 
cannot be used to correct prior years' wage index data; it can only be 
used for the current Federal fiscal year. In other situations where our 
policies would allow midyear corrections, we continue to believe that 
it is appropriate to make prospective-only corrections to the 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 index data revision request.

L. Labor-Related Share for the Proposed Wage Index for FY 2008

    (If you choose to comment on issues in this section, please include 
the caption ``Labor-Related Share'' at the beginning of your comment.)
    Section 1886(d)(3)(E) of the Act directs the Secretary to adjust 
the proportion of the national prospective payment system base payment 
rates that are attributable to wages and wage-related costs by a factor 
that reflects the relative differences in labor costs among geographic 
areas. It also directs the Secretary to estimate from time to time the 
proportion of hospital costs 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 portion of hospital costs attributable to wages and wage-related 
costs as the labor-related share. The labor-related share of the 
prospective payment rate is adjusted by an index of relative labor 
costs, which is referred to as the wage index.
    Section 403 of Pub. L. 108-173 amended section 1886(d)(3)(E) of the 
Act to provide that the Secretary must employ 62 percent as the labor-
related share unless this ``would result in lower payments to a 
hospital than would otherwise be made.'' However, this provision of 
Pub. L. 108-173 did not change the legal requirement that the Secretary 
estimate ``from time to time'' the proportion of hospitals' costs that 
are ``attributable to wages and wage-related costs.'' We believe that 
this reflected Congressional intent that hospitals receive payment 
based on either a 62-percent labor-related share, or the labor-related 
share estimated from time to time by the Secretary, depending on which 
labor-related share resulted in a higher payment.
    We have continued our research into the assumptions employed in 
calculating the labor-related share. Our research involves analyzing 
the compensation share 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.
    In the FY 2006 IPPS final rule (70 FR 47392), we presented our 
analysis and conclusions regarding the frequency and methodology for 
updating the labor-related share for FY 2006. We also recalculated a 
labor-related share of 69.731 percent, using the FY 2002-based PPS 
market basket for discharges occurring on or after October 1, 2005. In 
addition, we implemented this revised and rebased labor-related share 
in a

[[Page 24802]]

budget neutral manner, but consistent with section 1886(d)(3)(E) of the 
Act, we did not take into account the additional payments that would 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.
    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. 
In this proposed rule, we are not proposing to make any changes to 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 are proposing to continue 
to use a labor-related share of 69.731 percent for discharges occurring 
on or after October 1, 2007. Tables 1A and 1B will reflect this 
proposed labor-related share. 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 to a 
hospital than would otherwise be made.''
    We also are proposing to continue to use a labor-related share for 
the Puerto Rico-specific standardized amounts of 58.7 percent for 
discharges occurring on or after October 1, 2007. Consistent with our 
methodology for determining the national labor-related share, we added 
the Puerto Rico-specific relative weights for wages and salaries, 
fringe benefits, contract labor, nonmedical professional fees, and 
other labor-intensive services to determine the labor-related share. 
Puerto Rico hospitals are paid based on 75 percent of the national 
standardized amounts and 25 percent of the Puerto Rico-specific 
standardized amounts. For Puerto Rico hospitals, the national labor-
related share will always be 62 percent because the wage index for all 
Puerto Rico hospitals is less than 1.0. A Puerto Rico-specific wage 
index is applied to the Puerto Rico-specific portion of payments to the 
hospitals. The labor-related share of a hospital's Puerto Rico-specific 
rate will be either 62 percent or the Puerto Rico-specific labor-
related share depending on which results in higher payments to the 
hospital. If the hospital has a Puerto Rico-specific wage index of 
greater than 1.0, we will set the hospital's rates using a labor-
related share of 62 percent for the 25 percent portion of the 
hospital's payment determined by the Puerto Rico standardized amounts 
because this amount will result in higher payments. Conversely, a 
hospital with a Puerto Rico-specific wage index of less than 1.0 will 
be paid using the Puerto Rico-specific labor-related share of 58.7 
percent of the Puerto Rico-specific rates because the lower labor-
related share will result in higher payments. The Puerto Rico labor-
related share of 58.7 percent for FY 2007 is reflected in the Table 1C 
of the Addendum to this proposed rule.

M. Wage Index Study Required Under Pub. L. 109-432

    Section 106(b)(1) of the MIEA-TRHCA (Pub. L. 109-432) requires 
MedPAC to submit to Congress, not later than June 30, 2007, a report on 
the Medicare wage index classification system applied under the 
Medicare Prospective Payment System. Section 106(b) of MIEA-TRHCA 
requires the report to include any alternatives that MedPAC recommends 
to the method to compute the wage index under section 1886(d)(3)(E) of 
the Act.
    In addition, section 106(b)(2) of Pub. L. 109-432 instructs the 
Secretary of Health and Human Services, taking into account MedPAC's 
recommendations on the Medicare wage index classification system, to 
include in the FY 2009 IPPS proposed rule one or more proposals to 
revise the wage index adjustment applied under section 1886(d)(3)(E) of 
the Act for purposes of the IPPS. The proposal (or proposals) must 
consider each of the following:
     Problems associated with the definition of labor markets 
for the wage index adjustment;
     The modification or elimination of geographic 
reclassifications and other adjustments;
     The use of Bureau of Labor of Statistics data or other 
data or methodologies to calculate relative wages for each geographic 
area;
     Minimizing variations in wage index adjustments between 
and within MSAs and statewide rural areas;
     The feasibility of applying all components of CMS' 
proposal to other settings;
     Methods to minimize the volatility of wage index 
adjustments while maintaining the principle of budget neutrality;
     The effect that the implementation of the proposal would 
have on health care providers on each region of the country;
     Methods for implementing the proposal(s) including methods 
to phase in such implementations; and
     Issues relating to occupational mix such as staffing 
practices and any evidence on quality of care and patient safety 
including any recommendation for alternative calculations to the 
occupational mix.
    We look forward to reviewing the MedPAC report on the wage index 
later this year. As required by the law, we will consider MedPAC's 
recommendations and each of the factors specified above in making a 
proposal (or proposals) in the FY 2009 IPPS proposed rule.

N. Proxy for the Hospital Market Basket

    (If you choose to comment on issues in this section, please include 
the caption ``Hospital Market Basket'' at the beginning of your 
comment.)
    In the FY 2006 IPPS final rule (70 FR 47387), we changed the base 
year cost structure for the IPPS hospital index for the hospital market 
basket for operating costs from FY 1997 to FY 2002. As discussed in 
that final rule, the IPPS hospital index primarily uses the BLS data as 
price proxies, which are grouped in one of the three BLS categories. 
The categories are Producer Price Indexes (PPIs), Consumer Price 
Indexes (CPIs), and Employment Cost Indexes (ECIs), discussed in detail 
in the FY 2006 IPPS final rule (70 FR 47388 through 47391). We evaluate 
the price proxies using the criteria of reliability, timeliness, 
availability, and relevance. The PPIs, CPIs, and ECIs selected by us 
and used for this proposed rule meet these criteria as described in the 
FY 2006 IPPS final rule. We believe they continue to be the best 
measures of price changes for the cost categories.
    Beginning April 2006 with the publication of March 2006 data, the 
BLS' ECI began using a different classification system, the North 
American Industrial Classification System (NAICS), instead of the 
Standard Industrial Codes (SIC), which no longer exists. We have 
consistently used the ECI as the data source for our wages and salaries 
and other price proxies in the IPPS market basket and are not making 
any changes to the usage at this time. Thus, we propose to use the BLS-
NAICS-based ECIs as price proxies in the market basket.

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

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

    (If you choose to comment on issues in this section, please include 
the caption ``Hospital Quality Data'' at the beginning of your 
comment.)
1. Background
    Section 5001(a) of the Deficit Reduction Act of 2005, Pub. L. 109-
171

[[Page 24803]]

(DRA), set out new requirements for the Reporting Hospital Quality Data 
for Annual Payment Update (RHQDAPU) program. We established the RHQDAPU 
program in order to implement section 501(b) of Pub. L. 108-173. It 
builds on our ongoing voluntary Hospital Quality Initiative which is 
intended to empower consumers with quality of care information to make 
more informed decisions about their health care while also encouraging 
hospitals and clinicians to improve their quality of care.
    Section 5001(a) of the DRA revised the mechanism used to update the 
standardized amount for payment for hospital inpatient operating costs. 
Specifically, sections 1886(b)(3)(B)(viii)(I) and (II) of the Act 
provide that the payment update for FY 2007 and each subsequent fiscal 
year will be reduced by 2.0 percentage points for any ``subsection (d) 
hospital'' (that is, a hospital paid under the IPPS) that does not 
submit certain quality data in a form and manner, and at a time, 
specified by the Secretary.
    Sections 1886(b)(3)(B)(viii)(III) and (IV) of the Act required that 
we expand the ``starter set'' of 10 quality measures established by the 
Secretary as of November 1, 2003, provided certain requirements were 
met. In expanding this set of measures, section 1886(b)(3)(B)(viii)(IV) 
of the Act provides that we must begin to adopt the baseline set of 
performance measures as set forth in a 2005 report issued by the 
Institute of Medicine (IOM) of the National Academy of Sciences under 
section 238(b) of the MMA,\17\ effective for payments beginning with FY 
2007.
---------------------------------------------------------------------------

    \17\ Institute of Medicine, ``Performance Measurement: 
Accelerating Improvement,'' December 1, 2005, available at http://www.iom.edu/CMS/3809/19805/31310.aspx.
---------------------------------------------------------------------------

    The IOM measures include: Hospital Quality Alliance (HQA) quality 
measures (the HQA is a public-private collaboration to improve the 
quality of care provided by the nation's hospitals by measuring and 
publicly reporting on that care), the HCAHPS patient perspective 
survey, and three structural measures. The structural measures are: (1) 
Implementation of computerized provider order entry for prescriptions, 
(2) staffing of intensive care units with intensivists, and (3) 
evidence-based hospital referrals. These structural measures constitute 
the Leapfrog Group's original ``three leaps,'' and are part of the 
National Quality Forum's 30 Safe Practices for Better Healthcare.
    Sections 1886(b)(3)(B)(viii)(V) and (VI) of the Act require that, 
effective for payments beginning with FY 2008, we add other quality 
measures that reflect consensus among affected parties, and provide the 
Secretary with the discretion to replace any quality measures or 
indicators in appropriate cases, such as where all hospitals are 
effectively in compliance with a measure, or the measures or indicators 
have been subsequently shown to not represent the best clinical 
practice. Thus, the Secretary has broad discretion to replace measures 
on the basis that they are not appropriate.
    Section 1886(b)(3)(B)(viii)(VII) of the Act requires that we 
establish procedures for making quality data available to the public 
after ensuring that a hospital has the opportunity to review, in 
advance, its data that are to be made public. In addition, this section 
requires that we report quality measures of process, structure, 
outcome, patients' perspective on care, efficiency, and costs of care 
that relate to services furnished in inpatient settings on the CMS Web 
site.
    Section 1886(b)(3)(B)(viii)(I) of the Act also provides that any 
reduction in a hospital's payment update will apply only with respect 
to the fiscal year involved, and will not be taken into account for 
computing the applicable percentage increase for a subsequent fiscal 
year.
    The starter set of 10 quality measures we established as of 
November 1, 2003 are as follows:
    Heart Attack (Acute Myocardial Infarction or AMI)
     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 (HF)
     Did the patient get an assessment of his or her heart 
function?
     Was an ACE inhibitor given to the patient?
    Pneumonia (PNE)
     Was an antibiotic given to the patient in a timely way?
     Had the patient received a pneumococcal vaccination?
     Was the patient's oxygen level assessed?
    We adopted these measures after the Secretary of HHS joined in a 
partnership with several collaborators intended to promote hospital 
quality improvement and public reporting of hospital quality 
information. These collaborators included the American Hospital 
Association, the Federation of American Hospitals, the Association of 
American Medical Colleges, the Joint Commission on Accreditation of 
Healthcare Organizations (the Joint Commission), the National Quality 
Forum (NQF), the American Medical Association, the Consumer-Purchaser 
Disclosure Project, the AARP, the American Federation of Labor-Congress 
of Industrial Organizations, the Agency for Healthcare Research and 
Quality (AHRQ), as well as CMS and others. This collaboration, 
originally known as the National Voluntary Hospital Reporting 
Initiative, is now known as the HQA.
    This starter set of 10 quality measures was endorsed by the NQF. 
NQF is a voluntary consensus standard-setting organization established 
to standardize health care quality measurement and reporting through 
its consensus development process. In addition, this starter set is a 
subset of measures currently collected for The Joint Commission as part 
of its certification program.
    We chose these 10 quality measures in order to collect data that 
will: (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.
    Hospitals submit quality data through the QualityNet Exchange 
secure Web site (http://www.qnetexchange.org). We believe that this Web 
site meets or exceeds all current Health Insurance Portability and 
Accountability Act requirements for security of personal health 
information. Data from this initiative are used to populate the 
Hospital Compare Web site, http://www.hospitalcompare.hhs.gov. This Web 
site assists beneficiaries and the general public by providing 
information on hospital quality of care for consumers who need to 
select a hospital. It further serves to encourage consumers to work 
with their doctors and hospitals to discuss the quality of care they 
provide to patients, thereby providing an additional incentive to 
improve their quality of that care.
    In the FY 2007 IPPS final rule (71 FR 48137), we amended our 
regulations at Sec.  412.64(d)(2) to reflect the 2.0 percentage point 
reduction in the payment update for FY 2007 and subsequent fiscal years 
for hospitals that do not comply with requirements for reporting 
quality data as provided for under section 5001(a) of the DRA. We also 
added 11 additional quality

[[Page 24804]]

measures to the 10 measure starter set to establish an expanded set of 
21 quality measures (71 FR 48029 through 48037). These 21 measures are 
as follows:

------------------------------------------------------------------------
                 Topic                           Quality measure
------------------------------------------------------------------------
Heart Attack (Acute Myocardial            Aspirin at arrival.*
 Infarction).
                                          Aspirin prescribed at
                                          discharge.*
                                          ACE inhibitor (ACE-I)
                                          or Angiotensin Receptor
                                          Blocker (ARBs) for left
                                          ventricular systolic
                                          dysfunction.*
                                          Beta blocker at
                                          arrival.*
                                          Beta blocker
                                          prescribed at discharge.*
                                          Thrombolytic agent
                                          received within 30 minutes of
                                          hospital arrival.
                                          Percutaneous Coronary
                                          Intervention (PCI) received
                                          within 120 minutes of hospital
                                          arrival.
                                          Adult smoking
                                          cessation advice/counseling.
Heart Failure (HF).....................   Left ventricular
                                          function assessment.*
                                          ACE inhibitor (ACE-I)
                                          or Angiotensin Receptor
                                          Blocker (ARBs) for left
                                          ventricular systolic
                                          dysfunction.*
                                          Discharge
                                          instructions.
                                          Adult smoking
                                          cessation advice/counseling.
Pneumonia (PNE)........................   Initial antibiotic
                                          received within 4 hours of
                                          hospital arrival.*
                                          Oxygenation
                                          assessment.*
                                          Pneumococcal
                                          vaccination status.*
                                          Blood culture
                                          performed before first
                                          antibiotic received in
                                          hospital.
                                          Adult smoking
                                          cessation advice/counseling.
                                          Appropriate initial
                                          antibiotic selection.
                                          Influenza vaccination
                                          status.
Surgical Care Improvement Project         Prophylactic
 (SCIP)--named SIP for discharges prior   antibiotic received within 1
 to July 2006 (3Q06).                     hour prior to surgical
                                          incision.
                                          Prophylactic
                                          antibiotics discontinued
                                          within 24 hours after surgery
                                          end time.
------------------------------------------------------------------------
*Measure included in 10 measure starter set.

    In addition, in the FY 2007 IPPS final rule (71 FR 48031 through 
48044), we set out RHQDAPU program procedures for data submission, 
program withdrawal, data validation, attestation, public display of 
hospitals' quality data, and reconsiderations. In response to public 
comments, we required that reporting of the expanded quality measures 
begin with discharges occurring on or after the third calendar quarter 
of 2006 (July through September discharges). We also responded to 
public comments regarding whether we should establish more structured 
reconsideration procedures for FY 2008 and what such procedures might 
include.
    Under section 1886(b)(3)(B)(viii)(V) of the Act, for payments 
beginning with FY 2008, we are required to add other measures that 
reflect consensus among affected parties, and, to the extent feasible 
and practicable, we must include measures set forth by one or more 
national consensus building entities.
2. FY 2008 Quality Measures
    Commenters on the FY 2007 IPPS proposed rule requested that we 
notify the public as far in advance as possible of any proposed 
expansions of the measurement set and program procedures in order to 
encourage broad collaboration and to give hospitals time to prepare for 
any anticipated change. Taking these concerns into account, in the CY 
2007 OPPS final rule (71 FR 68201), we adopted additional quality 
measures for the FY 2008 update. The six additional measures we adopted 
are as follows:

 HCAHPS survey
 SCIP Quality Measures
    --SCIP-VTE 1: Venous thromboembolism (VTE) prophylaxis ordered for 
surgery patient
    --SCIP-VTE 2: VTE prophylaxis within 24 hours pre/post surgery
    --SCIP Infection 2: Prophylactic antibiotic selection for surgical 
patients
 Mortality (Medicare Patients)
    --Acute Myocardial Infarction 30-day mortality Medicare patients
    --Heart Failure 30-day mortality Medicare patients

    For the FY 2008 payment determination, hospitals are required to 
report the following 27 measures:

------------------------------------------------------------------------
                 Topic                           Quality measure
------------------------------------------------------------------------
Heart Attack (Acute Myocardial            Aspirin at arrival.*
 Infarction).
                                          Aspirin prescribed at
                                          discharge.*
                                          ACE inhibitor (ACE-I)
                                          or Angiotensin Receptor
                                          Blocker (ARBs) for left
                                          ventricular systolic
                                          dysfunction.*
                                          Beta blocker at
                                          arrival.*
                                          Beta blocker
                                          prescribed at discharge.*
                                          Thrombolytic agent
                                          received within 30 minutes of
                                          hospital arrival.**
                                          Percutaneous Coronary
                                          Intervention (PCI) received
                                          within 120 minutes of hospital
                                          arrival.**
                                          Adult smoking
                                          cessation advice/counseling.**
Heart Failure (HF).....................   Left ventricular
                                          function assessment.*
                                          ACE inhibitor (ACE-I)
                                          or Angiotensin Receptor
                                          Blocker (ARBs) for left
                                          ventricular systolic
                                          dysfunction.*

[[Page 24805]]

 
                                          Discharge
                                          instructions.**
                                          Adult smoking
                                          cessation advice/counseling.**
Pneumonia (PNE)........................   Initial antibiotic
                                          received within 4 hours of
                                          hospital arrival.*
                                          Oxygenation
                                          assessment.*
                                          Pneumococcal
                                          vaccination status.*
                                          Blood culture
                                          performed before first
                                          antibiotic received in
                                          hospital.**
                                          Adult smoking
                                          cessation advice/counseling.**
                                          Appropriate initial
                                          antibiotic selection.**
                                          Influenza vaccination
                                          status.**
Surgical Care Improvement Project         Prophylactic
 (SCIP)--named SIP for discharges prior   antibiotic received within 1
 to July 2006 (3Q06).                     hour prior to surgical
                                          incision.**
                                          Prophylactic
                                          antibiotics discontinued
                                          within 24 hours after surgery
                                          end time.**
                                          SCIP-VTE 1: Venous
                                          thromboembolism (VTE)
                                          prophylaxis ordered for
                                          surgery patients.***
                                          SCIP-VTE 2: VTE
                                          prophylaxis within 24 hours
                                          pre/post surgery.***
                                          SCIP Infection 2:
                                          Prophylactic antibiotic
                                          selection for surgical
                                          patients.***
Mortality Measures (Medicare patients).   Acute Myocardial
                                          Infarction 30-day mortality
                                          Medicare patients.***
                                          Heart Failure 30-day
                                          mortality Medicare
                                          patients.***
Patients' Experience of Care...........   HCAHPS patient
                                          survey.***
------------------------------------------------------------------------
*Measure included in 10 measure starter set.
**Measure included in 21 measure expanded set.
*** Measure added in CY 2007 OPPS final rule.

    We did not adopt any other new RHQDAPU measures for FY 2008.
3. New Quality Measures and Program Requirements for FY 2009 and 
Subsequent Years
a. Proposed New Quality Measures for FY 2009 and Subsequent Years
    We are proposing to add 1 outcome measure and 4 process measures to 
the existing 27 measure set to establish a new set of 32 quality 
measures to be used for the FY 2009 annual payment determination. We 
plan to adopt these measures a year in advance in order to provide 
additional time for hospitals to prepare for changes related to the 
RHQDAPU program. We are proposing to add the following quality measures 
for the FY 2009 RHQDAPU program.
     Pneumonia 30-day Mortality (Medicare patients)
     SCIP Infection 4: Cardiac Surgery Patients with Controlled 
6AM Postoperative Serum Glucose
     SCIP Infection 6: Surgery Patients with Appropriate Hair 
Removal
     SCIP Infection 7: Colorectal Patients with Immediate 
Postoperative Normothermia
     SCIP Cardiovascular 2: Surgery Patients on a Beta-Blocker 
Prior to Arrival Who Received a Beta-Blocker During the Perioperative 
Period
    The above measures reflect our continuing commitment to quality 
improvement in both clinical care and patient safety. These additional 
measures also demonstrate our commitment to include in the RHQDAPU 
program only those quality measures that reflect consensus among the 
affected parties and that have been reviewed by a consensus building 
process. The proposed measures have been put forth by the HQA for 
inclusion in its public reporting set, contingent on endorsement by the 
NQF. (In the case of SCIP Infection 7, the HQA recently withdrew its 
previous support unless the measure receives NQF endorsement.) We 
anticipate that the NQF will endorse these measures prior to the 
publication of the FY 2008 IPPS final rule. Any measure that has not 
been endorsed by that time will not be finalized in that rule.
    CMS requests public comment on these five measures, as well as 
whether to add other measures to the RHQDAPU program measure set for FY 
2009 and subsequent years. CMS may, based on comments received, include 
one or more of the measures discussed below in the RHQDAPU program 
measure set for FY 2009 payments. We will finalize the FY 2009 RHQDAPU 
measure set in the FY 2008 IPPS final rule.
    The following table contains a list of 18 measures and 8 measure 
sets from which additional quality measures could be selected for 
inclusion in the RHQDAPU program. It includes measures and measure sets 
that highlight CMS' interest in improving patient safety and outcomes 
of care, with a particular focus on the quality of surgical care and 
patient outcomes. In order to engender a broad review of potential 
performance measures, the list includes measures that have not yet been 
considered for approval by the HQA or endorsement by the NQF consensus 
review process for public reporting. It also includes measures 
developed by organizations other than CMS as well as measures that are 
to be derived from administrative data (such as claims) that may need 
to be modified for specific use by the Medicare program if implemented 
under the RHQDAPU program.
    We hope to receive comment from a broad set of stakeholders on the 
measures and measure sets that are listed, as well as any critical gaps 
or ``missing'' measures or measure sets. We specifically requests input 
concerning the following:
     Which of the measures or measure sets should be included 
in the FY 2009 RHQDAPU program or in subsequent years?
     What challenges for data collection and reporting are 
posed by the identified measures and measure sets? What improvements 
could be made to data collection or reporting that might offset or 
otherwise address those challenges?

[[Page 24806]]



 Possible Measures and Measure Sets for the RHQDAPU Program for FY 2009
                          and Subsequent Years
------------------------------------------------------------------------
                                                            Clinical
                             Measure                       condition
------------------------------------------------------------------------
            Intensive Care Unit (ICU) Critical Care Measures
------------------------------------------------------------------------
1........  Stress Ulcer Disease Prophylaxis..........  ICU/critical
                                                        care.
2........  Urinary Catheter-Associated Urinary Tract   ICU/critical
            Infection For Intensive Care Unit (ICU)     care.
            Patients.
------------------------------------------------------------------------
                          Readmission Measures
------------------------------------------------------------------------
3........  Readmission Heart Failure (HF) Within 30    Efficiency/HF.
            Days Rate--Medicare Only (CMS
            Methodology).
4........  Readmission (same hospital) Acute           Efficiency/AMI.
            Myocardial Infarction (AMI) Within 30
            Days Rate.
5........  Readmission (same hospital) PNE Within 30   Efficiency/PNE.
            Days Rate.
6........  Readmission Within 30 Days Of Surgery--     Surgical Care.
            Medicare Only (SCIP Global-2).
------------------------------------------------------------------------
      NQF--Nursing Sensitive Condition Set (Outcomes Measures Only)
------------------------------------------------------------------------
7........  Failure To Rescue--Nursing Sensitive        Patient centered.
            Measure.
8........  Pressure Ulcer Prevalence--Nursing          Patient centered.
            Sensitive Measure.
9........  Patient Falls Prevalence--Nursing           Patient centered.
            Sensitive Measure.
10.......  Patient Falls With Injury--Nursing          Patient centered.
            Sensitive Measure.
------------------------------------------------------------------------
                       Cancer (Inpatient) Measures
------------------------------------------------------------------------
11.......  Patients With Early Stage Breast Cancer     Cancer--Breast.
            Who Have Evaluation Of The Axilla.
12.......  College Of American Pathologists Breast     Cancer--Breast.
            Cancer Protocol.
13.......  Surgical Resection Includes At Least 12     Cancer--Colon.
            Nodes (ACOS-02).
14.......  College Of American Pathologists Colon And  Cancer--Colon.
            Rectum Protocol.
15.......  Completeness Of Pathologic Reporting (CCO-  Cancer--Colon.
            04).
------------------------------------------------------------------------
       Leapfrog Leaps, identified by IOM and Deficit Reduction Act
------------------------------------------------------------------------
16.......  Use Of Computerized Physician Order Entry   Patient safety.
            (CPOE) Systems.
17.......  Use of Intensivists in ICUs/ICU Physician   Patient safety.
            Staffing (IPS).
18.......  Evidence-Based Hospital Referrals.........  Patient Safety.
------------------------------------------------------------------------
Measure Sets of Potential Interest (Individual measures not specified in
                          this proposed rule)
        Sets Under Active Review by National Quality Forum (NQF)
------------------------------------------------------------------------
1........  Healthcare-Associated Infection measures--  Patient Safety.
            under consideration by the NQF National
            Voluntary Consensus Standards for
            Reporting of Healthcare-associated
            Infections Data Project.
2........  Readmission Rates by Condition--under       Efficiency.
            consideration by NQF National Voluntary
            Consensus Standards for Hospital Care:
            Additional Priorities, 2007 Project.
3........  Average Length of Stay (ALOS) by            Efficiency.
            Condition--under consideration by NQF
            National Voluntary Consensus Standards
            for Hospital Care: Additional Priorities,
            2007 Project.
4........  AHRQ Quality Indicators, including Patient  Patient Safety,
            Safety Indicators--under consideration by   various
            NQF National Voluntary Consensus            conditions.
            Standards for Hospital Care: Additional
            Priorities, 2007 Project.
------------------------------------------------------------------------
            Measure Sets/Practices Previously Endorsed by NQF
------------------------------------------------------------------------
5........  Safe Practices for Better Healthcare......  Patient Safety.
6........  Serious Reportable Events in Healthcare     Patient Safety.
            (``Never Events'').
------------------------------------------------------------------------
                       Other Hospital Measure Sets
------------------------------------------------------------------------
7........  Hospital Emergency Department Measures....  Various.
8........  Vascular Surgery Complications (for         Surgical Care.
            Carotid Endarterectomy, Lower Extremity
            Bypass, Open Surgery Abdominal Aortic
            Aneurysm Repair, Endovascular Abdominal
            Aortic Aneurysm Repair).
------------------------------------------------------------------------

b. Data Submission
    In order to be eligible for the full FY 2009 market basket update, 
we are proposing that hospitals will be required to submit data on 32 
measures (the 27 existing measures plus the 5 proposed new measures). 
The technical specifications for this requirement are published in the 
CMS/Joint Commission Specifications Manual for National Hospital 
Quality Measures. This manual can be found on the QualityNet.org Web 
site.
    For the additional SCIP measures that we are proposing to add 
through this rule, (SCIP Infection 4, 6, and 7 and SCIP-Card-2), 
hospitals will be required to submit data to the QIO Clinical Warehouse 
starting with discharges that occur in CY 2008. We are proposing that 
the deadline for hospitals to submit this data for first calendar 
quarter of 2008 would be August 15, 2008. Data must be submitted for 
each subsequent quarter by 4.5 months after the end of the quarter.
    We are proposing this time period to allow hospitals sufficient 
time to prepare for the data collection. The three SCIP Infection 
measures that we are proposing to include for FY 2009 were added to the 
Manual in version 2.0, effective with third calendar quarter of 2006 
(3Q06) and the proposed SCIP Cardiovascular measure was added in 
version 2.1d of the Manual, effective with fourth calendar quarter of 
2006

[[Page 24807]]

(4Q06). Hospitals may report data on these measures for discharges 
prior to CY 2008 discharges, if they so choose.
    For the proposed Pneumonia 30-day Mortality measure, we are 
proposing to use claims data that are already being collected for index 
hospitalizations to calculate the mortality rates. As is the case with 
the other 30-day mortality (outcome) measures already associated with 
the RHQDAPU program (AMI, HF), hospitals need not submit additional 
data. Claims data submitted to CMS for index hospitalizations occurring 
from July 2006 through June 2007 (3Q06 through 2Q07) will be used to 
calculate the Pneumonia 30-day mortality rate that will be used for FY 
2009 annual payment determination.
    All measures that we have previously finalized, and that we 
finalize in the future through the rulemaking process, will be required 
for the RHQDAPU program annual payment determination each year until 
further notice. CMS, working in conjunction with The Joint Commission, 
maintains the specifications for the set of measures used both for the 
RHQDAPU program and for reporting under the HQA initiative. The 
specifications are updated semiannually and changes are made 
prospectively, except in exceptional circumstances. Revised 
specifications can be found at http://www.qualitynet.org.
4. Retiring or Replacing RHQDAPU Program Quality Measures
    Over time, CMS expects that the set of measures used for the 
RHQDAPU program will evolve and change. New measures will be added to 
reflect clinical and other program goals. Measures that are no longer 
supported by clinical evidence would be modified or dropped. Through 
its public reporting and RHQDAPU program activities, CMS seeks to 
balance the competing goals of assuring the development of a 
comprehensive yet parsimonious set of quality measures while reducing 
reporting burden on hospitals. Section 1886(b)(3)(B)(viii)(VI) of the 
Act gives the Secretary authority to replace any measures or indicators 
in appropriate cases, such as where all hospitals are effectively in 
compliance or the measures or indicators have been subsequently shown 
not to represent the best clinical practice. CMS recognizes the need to 
develop a process related to the retirement and/or replacement of 
measures that comprise the RHQDAPU program measure set. In this 
proposed rule, we solicit public comment and suggestions concerning the 
criteria and mechanism for a process that would identify and, where 
appropriate, retire or replace measures that comprise the RHQDAPU 
program measure set.
5. Procedures for the RHQDAPU Program for FY 2008 and FY 2009
a. Procedures for Participating in the RHQDAPU Program
    The ``Reporting Hospital Quality Data for Annual Payment Update 
Reference Checklist'' section of the QualityNet Exchange Web site 
contains all of the forms to be completed by hospitals participating in 
the program. In order to participate in the hospital reporting 
initiative for FY 2008, hospitals must follow these steps:
     Identify a QualityNet Exchange Administrator who follows 
the registration process and submits the information through the QIO 
Clinical Warehouse. This must be done regardless of whether the 
hospital uses a vendor for transmission of data.
     Complete the revised ``Reporting Hospital Quality Data for 
Annual Payment Update Notice of Participation'' form. These hospitals 
must send this form to their QIO, no later than August 15, 2007. In 
effort to alleviate the burden associated with submitting this form 
annually, we are proposing that a hospital that submits this form will 
be considered an active RHQDAPU program participant until such time as 
the hospital submits a withdrawal form to CMS.
    In addition, before participating hospitals initially begin 
reporting data, they must register with the QualityNet Exchange, 
regardless of the method used for submitting data.
     Collect and report data for 24 of the 27 required measures 
(listed in Table--under the following headings: Acute Myocardial 
Infarction, Heart Failure, Pneumonia and SCIP). A hospital must report 
this data for discharges occurring in or after first quarter CY 2007. 
Hospitals must submit the data to the QIO Clinical Warehouse either 
using the CMS Abstraction & Reporting Tool (CART), the JCAHO ORYX[reg] 
Core Measures Performance Measurement System, or using another third-
party vendor tool that has met the measurement specification 
requirements for data transmission to QualityNet Exchange. All 
submissions will be executed through QualityNet Exchange. Because the 
information in the QIO Clinical Warehouse is considered QIO 
information, it is subject to the stringent QIO confidentiality 
regulations in 42 CFR part 480. The QIO Clinical Warehouse will submit 
the data to CMS on behalf of the hospitals.
     For each quality measure that requires hospitals to 
collect and report data, submit complete data regarding the quality 
measures in accordance with the joint CMS/Joint Commission sampling 
requirements located on the QualityNet Exchange Web site. These 
requirements specify that hospitals must submit a random sample or 
complete population of cases for each of topics covered by the quality 
measures. Hospitals must meet these sampling requirements for these 
quality measures for discharges in each quarter.
     Submit aggregate population and sample size counts for 
Medicare and non-Medicare discharges for the four topic areas (AMI, HF, 
PNE, and SCIP) on a quarterly basis to CMS.
     Continuously collect HCAHPS data beginning with July 2007 
discharges in accordance with the HCAHPS Quality Assurance Guidelines, 
Version 2.0, located at http://www.hcahpsonline.org. The CY 2007 OPPS 
rule required HCAHPS-eligible hospitals to participate in the March 
2007 dry run of the HCAHPS survey, if they have not already 
participated in a previous dry run. Hospitals must submit HCAHPS dry 
run data to the QIO Clinical Warehouse by July 13, 2007. As part of the 
March 2007 dry run, hospitals were required to survey HCAHPS-eligible 
discharges between 48 hours and 6 weeks following hospital discharge.
     For the AMI 30-day and HF 30-day mortality measures, CMS 
will use Part A and Part B claims for Medicare fee-for-service patients 
to calculate the mortality measures. For FY 2008, hospital inpatient 
claims (Part A) from July 1, 2005 to June 30, 2006 will be used to 
identify the relevant patients and the index hospitalizations. 
Inpatient claims for the index hospitalization and Part A and Part B 
claims for all inpatient, outpatient and physician services received 
one year prior to the index hospitalizations are used to determine 
patient comorbidity, which is used in the risk adjustment calculation 
(see http://www.qualitynet.org/dcs/ContentServer?cid=1163010398556&pagename=QnetPublic%2FPage%2FQnetTier2&c=Page). No other hospital data submission is required to calculate the 
mortality rates.
b. Procedures for Participating in the RHQDAPU Program for FY 2009
    For FY 2009, the requirements for FY 2008 discussed above will 
apply, except that hospitals will be required to collect and report 
data on any additional measures that we finalize through the rulemaking 
process and for which we specify that data submission is required. 
Mortality measures will be expanded to

[[Page 24808]]

include pneumonia pending final NQF endorsement.
c. Chart Validation Requirements
(1) FY 2008 Validation Requirements
    For the FY 2008 update, and until further notice, we will continue 
to require that hospitals meet the chart validation requirements that 
we implemented in the FY 2006 IPPS final rule. There were no chart-
audit validation criteria in place for FY 2005. Based upon our 
experience with the FY 2005 submissions and our requirement for 
reliable and validated data, in the FY 2006 IPPS final rule we 
discussed additional requirements that we had established for the data 
that hospitals were required to submit in order to receive the full FY 
2006 payment update (70 FR 47421 and 47422). These requirements, as 
well as additional information on validation requirements, will 
continue and are being placed on the QualityNet Exchange Web site.
    For the FY 2008 payment update, and until further notice, hospitals 
must pass our validation requirement of a minimum of 80 percent 
reliability, based upon our chart-audit validation process, for the 
first three quarters of data from CY 2006. These data are due to the 
QIO Clinical Warehouse by August 15, 2006 (first quarter CY 2006 
discharges), November 15, 2006 (second quarter CY 2006 discharges), and 
February 15, 2007 (third quarter CY 2006 discharges).
    We use confidence intervals to determine if a hospital has achieved 
an 80-percent reliability aggregated over the three quarters. The use 
of confidence intervals allows us to establish an appropriate range 
below the 80-percent reliability threshold that demonstrates a 
sufficient level of reliability to allow the data to still be 
considered validated. 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.
    We are using the design-specific estimate of the variance for the 
confidence interval calculation, which, in this case, is a stratified 
single stage cluster sample, with unequal cluster sizes. (For 
reference, see Cochran, William G.: Sampling Techniques, John Wiley & 
Sons, New York, chapter 3, section 3.12 (1977); and Kish, Leslie.: 
Survey Sampling, John Wiley & Sons, New York, chapter 3, section 3.3 
(1964).) Each quarter is treated as a stratum for variance estimation 
purposes.
    We will 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 proceed to the second 
step and restrict the comparison to those variables associated with 
payment. For first and second quarter CY 2006 discharges (1Q06, 2Q06), 
that means we limit the calculations to the 10-measure starter set. For 
third quarter CY 2006 discharges (3Q06), we include 21 measures. 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 program.
    Due to time constraints, we will not apply the validation 
requirement for the FY 2008 update to 3 SCIP measures that are included 
in the RHQDAPU measure set, Infection 2, VTE 1 and VTE 2.
    For HCAHPS, hospitals and survey vendors must participate in a 
quality oversight process conducted by the HCAHPS project team. Prior 
to July 2007, the purpose of the oversight activities will be to 
provide feedback to hospitals and survey vendors on data collection 
procedures. Starting in July 2007, we may ask hospitals/survey vendors 
to correct any problems that are found and provide follow-up 
documentation of corrections for review within a defined time period. 
If the HCAHPS project team finds that the hospital has not made these 
corrections, CMS may determine that the hospital is not submitting 
appropriate HCAHPS data for the RHQDAPU program. As part of these 
activities, HCAHPS project staff will review and discuss with survey 
vendors and hospitals self-administering the survey their specific 
Quality Assurance Plans, survey management procedures, sampling and 
data collection protocols, and data preparation and submission. This 
review may take place in-person or through other means of 
communication.
(2) FY 2009 Chart Validation Requirements
    For the FY 2009 update, all 2008 requirements apply, except for the 
following modifications. We will modify the validation requirement to 
pool the quarterly validation estimates for 4th quarter CY 2006 through 
3rd quarter 2007 discharges. We will also expand the list of validated 
measures in the FY 2009 update to add SCIP Infection-2, SCIP VTE-1, and 
SCIP VTE-2 starting with 4th quarter CY 2006 discharges. We will also 
drop the current two-step process to determine if the hospital is 
submitting valid data. We propose for the FY 2009 update to pool 
validation estimates covering the 4 quarters (4th quarter CY 2006 
discharges through 3rd quarter 2007 discharges) in a similar manner to 
the current 3 quarter pooled confidence interval.
(3) Validation and Submission Requirements
    We plan to apply the validation and submission requirements for FY 
2008 and FY 2009 payment determination for the quality measures. For 
the validation and submission requirements for the FY 2008 payment 
year, we plan to use the following:
     The 10 measure starter set for both submission and 
validation for 1st through 3rd quarters CY 2006 discharges.
     The additional 11 measures that make up the expanded 
measure set for both submission and validation for 3rd quarter CY 2006 
discharges.
     SCIP VTE 1, 2, and SCIP Infection 2 submission only for 1Q 
2007 discharges only.
     HCAHPS measures, both submission of dry run data and 
continuous submission beginning with July 2007 discharges.
     AMI and HF 30-day mortality measures as described 
previously. For FY 2009 payment year, we plan to use the following:
     The 21 expanded measure set for submission and validation 
starting with fourth quarter CY 2006 (4Q06) through third quarter CY 
2007 discharges.
     SCIP VTE 1, 2, and SCIP Infection 2 submission and 
validation second quarter CY 2007 and 3rd Quarter CY 2007 discharges.
     HCAHPS measures, continuous submission.
     AMI, HF, and PN 30-day mortality measures as described 
previously.
    As additional measures are finalized for inclusion in the FY 2009 
payment decision, we anticipate making changes to the above plan to 
incorporate those measures.
c. Data Validation and Attestation
    For the FY 2008 update and in subsequent years, we will revise and 
post up-to-date confidence interval information on the QualityNet 
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

[[Page 24809]]

verify expectations about the volume of the data received.
    We will require for FY 2008 and subsequent years that hospitals 
attest each quarter to the completeness and accuracy of their data, 
including the volume of data, submitted to the QIO Clinical Warehouse 
in order to improve aspects of the validation checks. We will provide 
additional information to explain this attestation requirement, as well 
as provide the relevant form to be completed on the QualityNet Exchange 
Web site.
d. Public Display
    We will continue to display quality information for public viewing 
as required by section 1886(b)(3)(B)(viii)(VII) of the Act. Before we 
display this information, hospitals will be permitted to review their 
information as recorded in the QIO Clinical Warehouse.
    Currently, hospitals that share the same Medicare Provider Number 
(MPN) must combine data collection and submission across their multiple 
campuses (for both clinical measures and for HCAHPS). These measures 
are then publicly reported as if they apply to a single hospital. We 
estimate that approximately 5 to 10 percent of the hospitals reported 
on the Hospital Compare Web site share MPNs. For FY 2008 and subsequent 
years, we are proposing to require hospitals to begin to report the 
name and address of each hospital that shares the same MPN. This 
information will be gathered through the RHQDAPU program Notice of 
Participation form, which hospitals will submit to their QIOs by August 
15, 2007. To increase transparency in public reporting and improve the 
usefulness of Hospital Compare, CMS plans to note on the Web site where 
publicly reported measures combine results from two or more hospitals.
e. Reconsideration and Appeal Procedures
    If we deny a hospital the full market basket update, the hospital 
may submit a letter requesting that we reconsider our decision that the 
hospital did not meet the RHQDAPU program requirements. For FY 2008, a 
hospital must submit such a request for reconsideration on or before 
November 1, 2007. We also are establishing additional procedural rules 
that will govern RHQDAPU program reconsiderations. We will post these 
rules on the QualityNet Exchange Web site.
    If a hospital is dissatisfied with the result of a RHQDAPU program 
reconsideration, the hospital may file a claim under 42 CFR Part 405, 
Subpart R (a Provider Reimbursement Review Board (PRRB) appeal).
    In this proposed rule we are again soliciting public comment and 
suggestions related to reconsideration.
f. RHQDAPU Program Withdrawal Requirements
    For the FY 2008 update, hospitals may withdraw from the RHQDAPU 
program at any time up to August 15, 2007. If a hospital withdraws from 
the program, it will receive a 2.0 percentage point reduction in its 
payment update.
6. Electronic Medical Records
    In the FY 2006 IPPS final rule, we encouraged hospitals to take 
steps toward the adoption of electronic medical records (EMRs) that 
will allow for reporting of clinical quality data from the EMRs 
directly to a CMS data repository (70 FR 47420). We intend 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 continues to work cooperatively with other Federal 
agencies in the development of Federal health architecture data 
standards. We encouraged 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.
    Due to the low volume of comments we received on this issue in 
response to the FY 2006 proposed IPPS rule, in the proposed IPPS rule 
for FY 2007 (71 FR 24095), we again invited comments on these 
requirements and options. In the FY 2007 IPPS final rule, we summarized 
and addressed the additional comments we received. We would welcome 
additional comments on this issue.
7. New Hospitals
    In addition, we are proposing a minor change to our policies 
regarding new hospitals. In the FY 2006 IPPS final rule, we noted that 
a new hospital should begin collecting and reporting data immediately 
and complete the registration requirements for the RHQDAPU. (70 FR 
47421 and 47428). We also explained that a new hospital would 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. We also stated that fiscal intermediaries would 
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.
    We believe that some new hospitals have found it difficult to start 
reporting RHQDAPU measures immediately after signing up to participate 
in the RHADAPU program. Therefore, we are proposing a modification to 
our policy to reduce burden on new hospitals. We are proposing that the 
fiscal intermediary would continue to provide information on the new 
hospital to the QIO in the state in which the hospital is located as 
soon as possible so that the QIO could enter the provider information 
into its PRS and follow through with ensuring provider participation 
with the requirements for quality data reporting. However, for a new 
hospital that receives a provider number on or after October 1st of 
each year (beginning with October 1, 2007), we are proposing that the 
hospital would be required to report RHQDAPU data beginning with the 
first day of the quarter following the date the hospital registers to 
participate in the RHQDAPU program. For example, a hospital that 
receives its MPN on October 2, 2007 and signs up to participate in 
RHQDAPU on November 1, 2007 will be expected to meet all data 
submission requirements for discharges on or after January 1, 2008.

B. Development of the Medicare Hospital Value-Based Purchasing Plan

    (If you choose to comment on issues in this section, please include 
the caption ``Value-Based Purchasing Plan'' at the beginning of your 
comment.)
    Section 5001(b) of the DRA specifies that CMS develop a plan to 
implement a Value-Based Purchasing (VBP) Program for payments under the 
Medicare program for subsection (d) hospitals beginning with FY 2009. 
Congress specified that the ``plan'' include consideration of the 
following issues:
     The ongoing development, selection, and modification 
process for measures of quality and efficiency in hospital inpatient 
settings.

[[Page 24810]]

     The reporting, collection, and validation of quality data.
     The structure of value-based payment adjustments, 
including the determination of thresholds or improvements in quality 
that would substantiate a payment adjustment, the size of such 
payments, and the sources of funding for the value-based payments.
     The disclosure of information on hospital performance.
    In developing the plan, we must consult with relevant affected 
parties and consider experience with demonstrations that are relevant 
to the value-based purchasing program.
    We have created an internal Hospital Pay-for-Performance Workgroup 
that is charged with developing the VBP Plan for Medicare hospital 
services. The workgroup is organized into four subgroups to address 
each of the required planning issues: (1) measures; (2) data collection 
and validation; (3) incentive structure; and (4) public reporting. The 
workgroup has been charged with preparing a set of design options, 
narrowing the set of design options to prepare a draft plan, and 
preparing the final plan for implementing VBP for Medicare hospital 
services that will be provided to Congress.
    CMS is hosting two public ``Listening Sessions'' in early 2007 to 
solicit comments from relevant affected parties on outstanding design 
questions associated with development of the final plan. The first 
listening session was held on January 17, 2007, to consider design 
questions posed in an issues paper that has been posted since December 
22, 2006, on the Medicare Web site, Hospital Center, under Spotlights 
at: http://www.cms.hhs.gov/center/hospital.asp. An audio download of 
the listening session and the PowerPoint slides used during the session 
are also posted on this Web site.
    The second listening session will be held on April 12, 2007, to 
consider the draft plan, which will be posted on the Medicare Web site, 
Hospital Center, on March 22, 2007. A notice announcing this listening 
session was published in the Federal Register on February 23, 2007 (71 
FR 8179). It is hoped that hospitals, hospital associations, and other 
interested parties will attend and make comments on the draft plan in 
person. It will also be possible to participate by teleconference, and 
limited time will be allocated for verbal comments by telephone 
participants. Registration to participate in person or by telephone is 
open until April 5, 2007. The agenda and PowerPoint slides for the 
session will be posted by April 9, 2007. An audio download of the 
second listening session will be posted by April 17, 2007. Written 
comments are welcomed and will be accepted until 5 PM EDT on April 19, 
2007. The perspectives expressed during this session and in writing 
will assist CMS in making revisions to the draft plan to create the 
final Medicare Hospital Value-Based Purchasing Plan expected to be 
completed by June 2007.
    While section 5001(b) of the DRA authorized development of this 
plan, additional legislation will be required to establish and 
implement the Medicare Hospital Value-Based Purchasing Program. As 
described in the draft plan, we proposed that the current RHQDAPU 
Program will provide the foundation for and be incorporated into the 
new Medicare Hospital Value-Based Purchasing Program.

C. Rural Referral Centers (RRCs) (Sec.  412.96)

    (If you choose to comment on issues in this section, please include 
the caption ``RRCs'' at the beginning of your comment.)
    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 an RRC. For discharges 
occurring before October 1, 1994, RRCs 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, RRCs 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 RRCs. Other rural hospitals 
with less than 500 beds are subject to a 12-percent cap on DSH 
payments. RRCs are not subject to the 12-percent cap on DSH payments 
that is applicable to other rural hospitals (with the exception of 
rural hospitals with 500 or more beds). RRCs 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 an RRC by the Secretary * * * for fiscal year 1991 shall 
be classified as such an RRC for fiscal year 1998 and each subsequent 
year.'' In the August 29, 1997 final rule with comment period (62 FR 
45999), we also reinstated RRC status for all hospitals that lost the 
status due to triennial review or MGCRB reclassification, but not to 
hospitals that lost RRC 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 an RRC and lost their status due to OMB redesignation of 
the county in which they are located from rural to urban to be 
reinstated as an RRC. Otherwise, a hospital seeking RRC status must 
satisfy the applicable criteria. We used the definitions of ``urban'' 
and ``rural'' specified in Subpart D of 42 CFR Part 412.
    1. Proposed Annual Update of RRC Status Criteria
    One of the criteria under which a hospital may qualify as a RRC 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 an RRC if the hospital meets two mandatory prerequisites (a minimum 
CMI 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 an RRC if--
     The hospital's CMI is at least equal to the lower of the 
median CMI for urban hospitals in its census region, excluding 
hospitals with approved teaching programs, or the median CMI 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.)
a. Case-Mix Index
    Section 412.96(c)(1) provides that CMS will establish updated 
national and regional CMI values in each year's annual notice of 
prospective payment rates for purposes of determining RRC status. The 
methodology we use to determine the national and regional CMI values is 
set forth in regulations at Sec.  412.96(c)(1)(ii). The proposed 
national

[[Page 24811]]

median CMI value for FY 2008 includes all urban hospitals nationwide, 
and the regional values for FY 2008 are the median CMI 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(f)). These 
values are based on discharges occurring during FY 2006 (October 1, 
2005 through September 30, 2006) and include bills posted to CMS' 
records through December 2006.
    We are proposing that, in addition to meeting other criteria, if 
they are to qualify for initial RRC status for cost reporting periods 
beginning on or after October 1, 2007, rural hospitals with fewer than 
275 beds must have a CMI value for FY 2006 that is at least--
     1.2258; or
     The median CMI value (not transfer-adjusted) for urban 
hospitals (excluding hospitals with approved teaching programs as 
identified in Sec.  412.105(f)) calculated by CMS for the census region 
in which the hospital is located.
    The proposed median CMI values by region are set forth in the 
following table:

------------------------------------------------------------------------
                                                         Case-mix index
                        Region                                value
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)...............            1.2389
2. Middle Atlantic (PA, NJ, NY).......................            1.2675
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)            1.3524
4. East North Central (IL, IN, MI, OH, WI)............            1.3499
5. East South Central (AL, KY, MS, TN)................            1.2909
6. West North Central (IA, KS, MN, MO, NE, ND, SD)....            1.2780
7. West South Central (AR, LA, OK, TX)................            1.4013
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)..........            1.4260
9. Pacific (AK, CA, HI, OR, WA).......................            1.3722
------------------------------------------------------------------------

    The preceding numbers will be revised in the final rule to the 
extent required to reflect the updated FY 2006 MEDPAR file, which will 
contain data from additional bills received through March 2007.
    Hospitals seeking to qualify as RRCs or those wishing to know how 
their CMI value compares to the criteria should obtain hospital-
specific CMI values (not transfer-adjusted) from their fiscal 
intermediaries. Data are available on the Provider Statistical and 
Reimbursement (PS&R) System. In keeping with our policy on discharges, 
these CMI values are computed based on all Medicare patient discharges 
subject to the IPPS DRG-based payment.
b. 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 RRC 
status. As specified in section 1886(d)(5)(C)(ii) of the Act, the 
national standard is set at 5,000 discharges. We are proposing to 
update the regional standards based on discharges for urban hospitals' 
cost reporting periods that began during FY 2004 (that is, October 1, 
2003 through September 30, 2004), which is the latest available cost 
report data we have at this time.
    Therefore, we are proposing that, in addition to meeting other 
criteria, a hospital, if it is to qualify for initial RRC status for 
cost reporting periods beginning on or after October 1, 2007, must have 
as the number of discharges for its cost reporting period that began 
during FY 2004 a figure that is at least--
     5,000 (3,000 for an osteopathic hospital); or
     The median number of discharges for urban hospitals in the 
census region in which the hospital is located, as indicated in the 
following table:

------------------------------------------------------------------------
                                                            Number of
                        Region                             discharges
------------------------------------------------------------------------
1. New England (CT, ME, MA, NH, RI, VT)...............             7,749
2. Middle Atlantic (PA, NJ, NY).......................            10,603
3. South Atlantic (DE, DC, FL, GA, MD, NC, SC, VA, WV)            10,562
4. East North Central (IL, IN, MI, OH, WI)............             9,209
5. East South Central (AL, KY, MS, TN)................             7,596
6. West North Central (IA, KS, MN, MO, NE, ND, SD)....             7,963
7. West South Central (AR, LA, OK, TX)................             7,167
8. Mountain (AZ, CO, ID, MT, NV, NM, UT, WY)..........             9,116
9. Pacific (AK, CA, HI, OR, WA).......................             8,420
------------------------------------------------------------------------

    These numbers will be revised in the FY 2008 IPPS final rule based 
on the latest available cost report data.
    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 RRC 
status for cost reporting periods beginning on or after October 1, 
2007, the hospital would be required to have at least 3,000 discharges 
for its cost reporting period that began during FY 2004.
2. Acquired Rural Status and RRCs (Sec.  412.103(g))
    With the following exceptions, a hospital must be rural to qualify 
as an RRC:
     Consistent with section 4202(b) of Pub. L. 105-33, any 
hospital designated as an RRC in FY 1991 retains that status for FY 
1998 and each subsequent year.
     Hospitals located in a rural county that would have lost 
their RRC status as a result of an OMB redesignation of the area from 
rural to urban were permitted to remain as RRCs (69 FR 49056).
     Hospitals located in urban areas that apply for 
reclassification as rural under Sec.  412.103 (that is, the hospital is 
located in an urban area but it

[[Page 24812]]

``acquires'' rural status under the regulations) also may qualify as 
RRCs.
    Under Sec.  412.103(g), a hospital may cancel its rural 
reclassification by submitting a written request to the CMS Regional 
Office no less than 120 days prior to the end of its current cost 
reporting period. A hospital may choose to cancel its acquired rural 
status if it determines it may be more financially beneficial to return 
to urban status and the associated IPPS payments rather than remain 
rural and receive the special treatments of certain rural providers 
such as RRCs, SCHs and CAHs. The hospital's acquired rural status is 
canceled beginning with its next cost reporting period. We have 
received inquiries asking whether a hospital retains its RRC status 
once it voluntarily cancels its acquired rural status.
    As indicated above, a hospital generally must be rural to be 
classified as an RRC. However, a hospital may retain its RRC status 
only in the special circumstances where it would have lost status due 
to OMB redesignation of its area from rural to urban, or where it was 
already designated as an RRC in 1991. In these situations, there were 
either special statutory provisions that require the hospital to retain 
its RRC status or the hospital's geographic status changed from rural 
to urban through no action of its own. We do not believe that an urban 
hospital that acquires rural status under Sec.  412.103 and 
subsequently is approved as an RRC should be able to retain the 
benefits of being an RRC when it voluntarily cancels that acquired 
rural status. For this reason, Medicare's policy has been that a 
hospital cannot continue to be an RRC once it cancels acquired rural 
status under Sec.  412.103. It follows from the requirement that an RRC 
must be located in a rural area that cancellation of acquired rural 
status negates a hospital's RRC designation.
    In this proposed rule, we are clarifying our current policy that a 
hospital that cancels its acquired rural status, received under Sec.  
412.103, would also lose its RRC designation under Sec.  412.96. In 
this situation, the hospital would lose its RRC designation under Sec.  
412.96 as of the date the cancellation of its acquired rural status 
takes effect. As indicated above, RRCs are not subject to a maximum DSH 
adjustment of 12 percent that applies to other rural hospitals with 
less than 500 beds. Further, RRCs are not subject to the proximity 
criteria when applying for geographic reclassification (Sec.  
412.230(a)(3)), and they do not have to meet certain wage comparison 
tests for reclassification (Sec.  412.230(d)(1)(iii)). A hospital 
located in an urban area that cancels its acquired rural status under 
Sec.  412.103 loses its RRC status and would become subject to a 12-
percent cap on the DSH adjustment applicable to urban hospitals with 
less than 100 beds (if the hospital has 100 beds or more, it would not 
be subject to the cap on the DSH adjustment). Further, the hospital 
would also have to meet the proximity requirement for geographic 
reclassification at Sec.  412.230(a)(3).
    We note that the hospital would maintain the benefit of being 
exempt from the average hourly wage criterion for geographic 
reclassification requiring the comparison of the hospital's wages to 
the wages of the area in which it is located, as stated in section 
1886(d)(10)(D)(iii) of the Act.
    We are also proposing to revise the regulations at Sec.  412.103(g) 
with respect to when cancellation of acquired rural status becomes 
effective. Currently, Sec.  412.103(g)(2) states ``The hospital's 
cancellation of the classification is effective beginning with the 
hospital's next full cost reporting period following the date of its 
request for cancellation.'' While this policy is appropriate for 
hospitals paid under reasonable costs, such as CAHs, it is inconsistent 
with the IPPS that makes changes prospectively on the basis of a 
Federal fiscal year. In addition, to address concerns that some IPPS 
hospitals are acquiring rural status solely to benefit from 
reclassification rules applying to hospitals that were once RRCs and 
then canceling that rural status within a short period of time, such as 
a few months, we are proposing to require IPPS hospitals to retain 
acquired rural status for at least one 12-month cost reporting period. 
If the hospital chooses to cancel its rural reclassification, the 
effective date of that cancellation would occur both after at least one 
12-month cost reporting period and at the start of the next Federal 
fiscal year. Thus, for example, if a hospital with a cost reporting 
period from July 1, 2008, to June 30, 2009, becomes rural on May 30, 
2008, its acquired rural status under Sec.  412.103 would remain in 
effect from May 30, 2008, through at least September 30, 2009 (that is, 
the date it acquired rural status through the end of the fiscal year 
containing a full cost reporting period). We believe this policy is 
reasonable, given that acquired rural status for IPPS hospitals should 
be a considered decision for hospitals that truly wish to be considered 
as rural, and not purely as a mechanism for reclassifying. We are not 
proposing a duration requirement for hospitals paid under cost 
reimbursement because we are not aware of similar manipulations of 
rural status in these cases. Therefore, we are proposing to change our 
current policy by revising Sec.  412.103(g) to specify that a 
hospital's cancellation of its acquired rural status under Sec.  
412.103 is effective for hospitals under reasonable cost reimbursement 
(such as CAHs) with the hospital's next cost reporting period and for 
hospitals under the IPPS after at least one 12-month cost reporting 
period as rural and not until the beginning of a Federal fiscal year 
following both the request for cancellation and the 12-month cost 
reporting period. Under the proposed revised regulations, an IPPS 
hospital (such as an RRC or SCH) that cancels its acquired rural status 
would continue to be paid as rural until the beginning of the next 
fiscal year after at least one 12-month cost reporting period as rural. 
In addition, for these IPPS hospitals, the deadline for seeking 
cancellation of the acquired rural status would be not less than 120 
days before the end of the fiscal year.

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

    (If you choose to comment on issues in this section, please include 
the caption ``IME Adjustment'' at the beginning of your comment.)
1. Background
    Section 1886(d)(5)(B) of the Act provides that prospective payment 
hospitals that have residents in an approved graduate medical education 
(GME) program receive an additional payment to reflect the higher 
indirect patient care 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 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.
2. IME Adjustment Factor for FY 2008
    The IME adjustment to the DRG payment is based in part on the

[[Page 24813]]

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.
    Section 502(a) of Pub. L. 108-173 modified the formula multiplier 
(c) to be used in the calculation of the IME adjustment. Prior to the 
enactment of Pub. L. 108-173, the formula multiplier was fixed at 1.35 
for discharges occurring during FY 2003 and thereafter. Section 502(a) 
modified the formula multiplier beginning midway through FY 2004 and 
provided for a new schedule of formula multipliers for FY 2005 and 
thereafter. In the FY 2005 IPPS rule, we announced the schedule of 
formula multipliers to be used in the calculation of the IME adjustment 
and incorporated the schedule in our regulations at Sec.  
412.105(d)(3)(viii) through (d)(3)(xii). In this proposed rule, we are 
specifying that, for any discharges occurring during FY 2008, the 
statutorily mandated formula multiplier is 1.35. Previously, for 
discharges occurring during FY 2007, the mandated formula multiplier 
was 1.32. We estimate that application of the mandated formula 
multiplier for FY 2008 will result in an increase of 5.5 percent in IME 
payment for every approximately 10-percent increase in the resident-to-
bed ratio.
3. Time Spent by Residents on Vacation or Sick Leave and in Orientation
a. Background
    In the FY 2007 IPPS final rule (71 FR 48080), we clarified our 
policy with respect to the time that residents spend in nonpatient care 
activities (such as conferences and seminars) as part of approved 
residency programs. We amended our regulations concerning the FTE 
resident count at 42 CFR 412.105(f)(1)(iii)(C) to state, ``In order to 
be counted, a resident must be spending time in patient care 
activities, as defined in Sec.  413.75(b) * * *'' The regulations at 
Sec.  413.75(b) define patient care activities as ``the care and 
treatment of particular patients, including services for which a 
physician or other practitioner may bill.'' In light of this 
clarification, during the past year, we have received questions from 
the teaching hospital community as to whether the time that residents 
spend on vacation or sick leave, and in orientation activities that 
typically occur at the beginning of a residency training program, is 
counted for IME payment purposes.
    Historically, time spent by residents on vacation or sick leave and 
in initial orientation activities has been included in the FTE resident 
count for IME and direct GME. (The sick leave we are referring to 
throughout this discussion is sick leave that does not require the 
resident to make up for his or her absence by adding additional 
training time at the end of the program.) The practice of allowing 
vacation and sick leave to be included in the IME count appears to be 
based on a provision in the Provider Reimbursement Manual, Part I, at 
section 2405.3.H.2. This manual provision discusses the treatment of 
residents who are on vacation or sick leave in the context of our prior 
``one day count'' policy for counting residents for IME payment. 
Generally, effective with cost reporting periods beginning on or after 
October 1, 1984, and before July 1, 1991, residents were counted for 
IME purposes on a uniform reporting date of September 1. A hospital's 
FTE residents were counted based on their assignment to that hospital's 
IPPS or outpatient areas on September 1 of an academic year. Because it 
was possible that a resident might not actually be present in the 
hospital on September 1 because he or she was on approved vacation or 
sick leave, to ensure that the hospital's IME FTE count would not be 
understated for the entire year, section 2405.3.H.2 of the PRM-I states 
that ``interns and residents using vacation and sick leave on the day 
of the count may be included in the count.'' Although the regulations 
were changed effective for cost reporting periods beginning on or after 
July 1, 1991 (55 FR 36059) to reflect the current resident-counting 
methodology (that is, to count the number of FTE residents based on the 
amount of time required to fill a residency slot as specified at Sec.  
412.105(f)(1)(iii)(A)), the fiscal intermediary (or MAC) have continued 
to include time spent by residents on vacation and sick leave in the 
FTE resident counts for purposes of both IME and direct GME payments.
    Orientation time is time spent by residents in activities that 
typically take place at the beginning of a resident's training program, 
and include orientation regarding hospital employment, the hospital's 
policies and procedures in general, as well as policies and procedures 
specific to the residency training program. As is the case for vacation 
and sick leave, time spent by residents in orientation has continued to 
be included by intermediaries/MACs in the FTE resident counts for 
purposes of both IME and direct GME.
    We understand why we have received numerous questions regarding 
whether FTE resident time spent on vacation or sick leave, or in 
orientation activities, should be counted for purposes of IME payment. 
The time a resident spends on vacation or sick leave is not addressed 
within the current definition of ``patient care activities'' at Sec.  
413.75(b). In fact, time spent on vacation or sick leave would not be 
spent at the hospital location at all, so no patient care activities 
would occur during this time. Time spent in orientation might be spent 
in the hospital complex (or at a nonhospital setting), but would not 
involve the care and treatment of particular patients. Thus, although 
time spent by residents on vacation or sick leave or in orientation has 
historically been included in the IME and direct GME FTE counts, it 
seems apparent that this time should be carefully considered in light 
of our clarified policy and current regulations. We believe these types 
of activities (vacation time, sick leave, and orientation) are 
inherently different from the types of ``patient care activities'' and 
``nonpatient care activities'' we have discussed in depth in previous 
rules, and most recently in the FY 2007 IPPS final rule. We believe the 
aforementioned activities should be distinguished from other 
activities, patient care or otherwise, in which the resident 
participates as part of the approved program.
b. Vacation and Sick Leave Time
    We believe that approved vacation time and sick leave are not 
appropriately categorized as patient care activities, or as didactic, 
research, or other nonpatient care activities. In addition, although 
the Accreditation Council for Graduate Medical Education (ACGME) has 
some rules regarding resident duty hours and work environment, the 
ACGME is not explicit regarding resident vacation and sick leave 
policies. Rather, vacation and sick leave policies are determined by 
the resident's employer and can vary by residency training program. 
Consequently, although vacation and sick leave are fringe benefits to 
which every employee, hospital or otherwise, is typically entitled, 
vacation and sick leave are not, in fact, part of the training time 
spent by residents in an approved program. Therefore, we believe 
vacation and sick leave are not properly considered as either patient 
care time or nonpatient care time, but are within a distinct third 
category of time. As we noted above, it has been our policy to include 
the time spent by residents on

[[Page 24814]]

vacation or sick leave in the FTE resident count for IME and direct 
GME. However, we do not believe the continuation of this policy is 
appropriate in light of our current policy as clarified in the FY 2007 
IPPS final rule and expressed in revised regulations that permit only 
time spent by residents in patient care activities to be counted for 
purposes of IME. We initially considered proposing a policy to no 
longer count the time spent by residents on vacation or sick leave for 
purposes of IME on the ground that this time is not spent in patient 
care activities in accordance with our regulations. However, we do not 
believe such a policy would have recognized the unique character of 
vacation and sick time as time that is not spent in any aspect of 
residency training--patient care or nonpatient care. Because we believe 
time spent by residents on vacation and sick leave is not properly 
considered patient care time or nonpatient care time, but fit within a 
distinct third category of time that is neither patient care nor 
nonpatient care, we believe it would be more appropriate to remove the 
time altogether from the FTE calculation for each resident for both IME 
and direct GME payment purposes. Accordingly, we are proposing to 
remove vacation and sick leave from the total time considered to 
constitute an FTE resident for purposes of IME payment effective for 
cost reporting periods beginning on or after October 1, 2007. Further, 
in order to have a consistent conception of an FTE resident for 
purposes of IME and direct GME payment, we are proposing to remove 
vacation and sick leave from the total FTE resident time for purposes 
of direct GME payment as well effective for cost reporting periods 
beginning on or after October 1, 2007. We acknowledge that removing 
vacation and sick leave time from the denominator of the FTE count for 
both IME and direct GME could have some impact on the FTE count, but 
the impact is fact-specific. In some cases, it would result in a lower 
FTE count, and in some cases, it would result in a higher FTE count. In 
addition, we note that under our current policy, residents who are on 
maternity leave or other approved sick leave of extended duration that 
prolongs the total time a resident is participating in the approved 
program beyond the normal duration of the program are not counted while 
they are out on extended sick or maternity leave. This is because the 
FTE time spent by such residents is counted in accordance with our FTE 
counting policies during the training time they spend to make up for 
their absence. For example, a resident in an internal medicine program 
who takes 3 months of approved maternity leave and, therefore, must 
stay an additional 3 months beyond the normal 3 years to complete her 
training, would not be counted while she is on maternity leave for IME 
and direct GME payment purposes. Rather, time spent during the 
additional 3 months of training in which she must participate to make 
up for her 3 month absence will be counted in accordance with our FTE-
counting policies for IME and direct GME. We are not proposing to 
change our policy with respect to time spent by residents on maternity 
leave or other approved sick leave of extended duration.
c. Orientation Activities
    As discussed above, we believe that orientation activities in which 
residents participate, often prior to the start of their residency 
training program, are also distinct from the typical ``patient care'' 
and ``nonpatient care'' activities in which residents participate as 
part of their training program. For example, before residents begin 
training in an approved residency program, the hospital (or in many 
cases, the medical school as the employer of the residents) is required 
to provide orientation for their residents. Most of these orientation 
activities involve neither patient care nor the typical didactic or 
research activities that comprise the residency training program. 
Instead, such orientation consists of basic informational sessions in 
which all new employees, residents and other staff, must participate at 
the beginning of employment. There could also be other orientation 
activities designed specifically to prepare residents to furnish 
patient care in a particular setting or to participate in a particular 
approved residency training program. We recognize that certain portions 
of orientation activities are specific to residents in particular 
approved programs and are required by the accrediting organizations. 
Other components of orientation relate to employment and are common to 
all employees. Still other components of orientation may involve 
training regarding particular hospital policies and procedures, some of 
which would relate to patient care and safety. In many ways, these 
orientation activities resemble ``didactic'' activities. However, we 
believe there are important differences between the ``didactic'' 
activities that are part of orientation and the other conferences and 
seminars in which the residents engage throughout the course of their 
training. That is, we do not envision orientation activities as 
including scholarly didactic activities such as conferences or seminars 
that may occur throughout a residency training program. Rather, we 
believe orientation activities would occur either at the beginning of a 
particular specialty program, or when a resident goes to another 
facility for training. In orientation sessions, much of the information 
being imparted to the residents is essential knowledge for the 
residents in order to furnish patient care services in a particular 
hospital facility or approved program. Thus, the information furnished 
during orientation is not information that merely enhances the 
resident's patient care delivery knowledge and skills during the 
residency program, but it is a necessary prerequisite for the residents 
as they commence (or continue) their training program and is often 
required as a term of employment. Because we recognize the distinct 
character of orientation activities as essential to the provision of 
patient care by residents, and the fundamental differences between 
orientation and the typical didactic activities in which a resident may 
participate throughout a residency training program, we are proposing 
to continue to count the time spent by residents in orientation 
activities, whether they occur in the hospital or nonhospital setting, 
and are proposing to amend our regulations accordingly. (We note that 
orientation activities in the hospital setting have historically been 
counted for direct GME payment purposes in accordance with the 
regulations at Sec.  413.78(a) which state ``Residents in an approved 
program working in all areas of the hospital complex may be counted.'') 
We are proposing to amend Sec.  413.75(b) to add a definition of the 
term ``orientation activities,'' to mean ``activities that are 
principally designed to prepare an individual for employment as a 
resident in a particular setting, or for participation in a particular 
specialty program and patient care activities associated with that 
particular specialty program.'' We understand that orientation 
activities typically occur at the beginning of a resident's first 
program year. However, we are interested in hearing from commenters on 
whether orientation activities typically occur during other times 
during an approved residency training program. We are proposing to 
amend the definition of ``patient care activities'' at Sec.  413.75(b) 
as follows: ``the care and treatment of particular patients, including 
services for which a physician or other practitioner may bill, and

[[Page 24815]]

orientation activities as defined at Sec.  413.75(b).'' In addition, we 
are proposing to amend the regulations at Sec. Sec.  
412.105(f)(1)(iii)(A) and 413.78(b) to specify that ``Vacation and sick 
leave are not included in the determination of full-time equivalency.''
d. Proposed Regulation Changes
    In summary, we are proposing, for cost reporting periods beginning 
on or after October, 1, 2007, for direct GME and IME, that time spent 
by residents on vacation or sick leave would not be included in the 
determination of what constitutes an FTE resident (or would be removed 
from both the numerator and denominator of the FTE count) for both IME 
and direct GME payment purposes. In addition, we are proposing to 
continue to count time spent by residents in orientation activities for 
both IME and direct GME payment purposes. We are proposing to amend the 
regulations at Sec. Sec.  412.105(f)(1)(iii)(A) and 413.78(b). Lastly, 
we are proposing to amend Sec.  413.75(b) to include the definition of 
the term ``orientation activities'' and to amend the definition of 
``patient care activities'' to add ``orientation activities.''

E. Hospital Emergency Services Under EMTALA (Sec.  489.24)

    (If you choose to comment on issues in this section, please include 
the caption ``EMTALA'' at the beginning of your comments.)
1. Background
    Sections 1866(a)(1)(I), 1866(a)(1)(N), and 1867 of the Act impose 
specific obligations on certain Medicare-participating hospitals and 
CAHs. (Throughout this section of this proposed rule, when we reference 
the obligation of a ``hospital'' under these sections of the Act and in 
our regulations, we mean to include CAHs as well.) These obligations 
concern individuals who come to a hospital emergency department and 
request examination or treatment for medical conditions, and apply to 
all of these individuals, regardless of whether they are beneficiaries 
of any program under the Act.
    The statutory provisions cited above are frequently referred to as 
the Emergency Medical Treatment and Labor Act (EMTALA), also known as 
the patient antidumping statute. EMTALA was passed in 1986 as part of 
the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), 
Pub. L. 99-272. Congress enacted these antidumping provisions in the 
Social Security Act to ensure that individuals with emergency medical 
conditions are not denied essential lifesaving services because of a 
perceived inability to pay.
    Under section 1866(a)(1)(I)(i) of the Act, a hospital that fails to 
fulfill its EMTALA obligations under these provisions may be liable for 
termination of its Medicare provider agreement, which would result in 
loss of all Medicare and Medicaid payments.
    Section 1867 of the Act sets forth requirements for medical 
screening examinations for individuals who come to the hospital and 
request examination or treatment for a medical condition. The section 
further provides that if a hospital finds that such an individual has 
an emergency condition, it is obligated to provide that individual with 
either necessary stabilizing treatment or an appropriate transfer to 
another medical facility where stabilization can occur.
    The EMTALA statute also outlines the obligation of hospitals to 
receive appropriate transfers from other hospitals. Section 1867(g) of 
the Act states that a participating hospital that has specialized 
capabilities or facilities (such as burn units, shock-trauma units, 
neonatal intensive care units or (with respect to rural areas) regional 
referral centers as identified by the Secretary in regulation) shall 
not refuse to accept an appropriate transfer of an individual who 
requires these specialized capabilities or facilities if the hospital 
has the capacity to treat the individual.
    The regulations implementing section 1867 of the Act are found at 
42 CFR 489.24.
2. Recent Legislation Affecting EMTALA Implementation
a. Secretary's Authority To Waive Requirements During National 
Emergencies
    Section 1135 of the Act authorizes the Secretary to temporarily 
waive or modify the application of several requirements of titles 
XVIII, XIX, or XXI of the Act (the Medicare, Medicaid, and State 
Children's Health Insurance Program provisions) and their implementing 
regulations in an emergency area during an emergency period. Section 
1135(g)(1) of the Act defines an ``emergency area'' as the geographical 
area in which there exists an emergency or disaster declared by the 
President pursuant to the National Emergencies Act or the Robert T. 
Stafford Disaster Relief and Emergency Assistance Act (subsection A) 
and a public health emergency declared by the Secretary pursuant to 
section 247d of Title 42 of the United States Code. Section 1135(g)(1) 
of the Act also defines an ``emergency period'' as the period during 
which such a disaster exists.
    Section 1135(b) of the Act lists the actions for which the 
otherwise applicable statutory provisions and implementing regulations 
may be waived. Included among these actions are, in subparagraph 
(b)(3)(A), a transfer of an individual who has not been stabilized in 
violation of the EMTALA requirements restricting transfer until an 
individual has been stabilized (section 1867(c) of the Act) and, in 
subparagraph (b)(3)(B), the direction or relocation of an individual to 
receive medical screening in an alternate location, in accordance with 
an appropriate State emergency preparedness plan.
    Section 1135(b) of the Act further states that a waiver or 
modification provided for under section 1135(b)(3) of the Act shall be 
limited to a 72-hour period beginning upon implementation of a hospital 
disaster protocol. All other waivers arising out of section 1135(b) of 
the Act (except for section 1135(b)(7)) ordinarily may continue in 
effect for the duration of the declaration of emergency or disaster, or 
the declaration of a public health emergency, or for 60-day periods as 
described in section 1135(e)(1) of the Act.
    To take into account the effect of section 1135 waivers on the 
EMTALA requirements, Sec.  489.24(a)(2) of our regulations specifies 
that sanctions under the EMTALA regulations for inappropriate transfer 
during a national emergency do not apply to a hospital with a dedicated 
emergency department located in an emergency area, as specified in 
section 1135(g)(1) of the Act.
    For further information about section 1135 of the Act and its 
applicability, we refer readers to the CMS Web site: http://www.cms.hhs.gov/Emergency/02_Hurricanes.asp.
b. Provisions of the Pandemic and All-Hazards Preparedness Act
    On December 19, 2006, Congress enacted the Pandemic and All-Hazards 
Preparedness Act, Pub. L. 109-417. Section 302(b) of Pub. L. 109-417 
makes two specific changes that affect EMTALA implementation in 
emergency areas during an emergency period.
    As noted above, section 1135(b)(3) of the Act authorizes the 
Secretary to waive sanctions for either the transfer of an unstabilized 
individual in violation of the requirements of section 1867(c) of the 
Act where such transfer is necessitated by the circumstances of the 
declared emergency in the emergency area during the emergency period or 
the direction or relocation of an individual to receive medical 
screening in an

[[Page 24816]]

alternate location in accordance with an appropriate State emergency 
preparedness plan. Section 302(b)(1)(A) of Pub. L. 109-417 amended 
section 1135(b)(3)(B) of the Act to state that sanctions for the 
direction or relocation of an individual for screening may be waived 
where, in the case of a public health emergency that involves a 
pandemic infectious disease, that direction or relocation occurs 
pursuant to a State pandemic preparedness plan or to an appropriate 
State emergency preparedness plan. In addition, sections 302(b)(1)(B) 
and (b)(1)(C) of Pub. L. 109-417 amended section 1135(b) of the Act to 
state that, if a public health emergency involves a pandemic infectious 
disease (such as pandemic influenza), the duration of a waiver or 
modification for such emergency shall be determined in accordance with 
section 1135(e) of the Act as that subsection applies to public health 
emergencies. The amendments to section 1135(b) of the Act made by 
section 302(b) of Pub. L. 109-417 are effective as of the date of 
enactment of that legislation (December 19, 2006) and apply to public 
health emergencies declared pursuant to section 247(d) of Title 42 of 
the United States Code.
c. Proposed Revisions to the EMTALA Regulations
    Currently, the EMTALA regulation at 42 CFR 489.24(a)(2) specifies 
that sanctions under this section (Sec.  489.24) for inappropriate 
transfer during a national emergency do not apply to a hospital with a 
dedicated emergency department located in an emergency area, as 
specified in section 1135(g)(1) of the Act. To implement the changes 
made by section 302(b) of Pub. L. 109-417 and to ensure that our 
regulations accurately reflect section 1135 of the Act, we are 
proposing to make two changes to paragraph (a)(2) of Sec.  489.24. 
First, we would specify that the sanctions that do not apply are those 
for either the inappropriate transfer of an individual who has not been 
stabilized or those for the direction or relocation of an individual to 
receive medical screening at an alternate location. We also are 
proposing to revise Sec.  489.24 by adding a second sentence to 
paragraph (a)(2) to state that a waiver of these sanctions for EMTALA 
violations is limited to a 72-hour period beginning upon the 
implementation of a hospital disaster protocol, except that if a public 
health emergency involves a pandemic infectious disease (such as 
pandemic influenza), the duration of the waiver will be determined in 
accordance with subsection (e) of section 1135 of the Act as that 
subsection applies to public health emergencies. This proposed change 
would clarify that, in the case of public health emergencies involving 
pandemic infectious diseases, the waiver of EMTALA sanctions is not 
limited to 72 hours, but will remain in effect until the termination of 
the applicable declaration of a public health emergency as described in 
section 1135(e)(1)(B) of the Act.

F. Disclosure of Physician Ownership in Hospitals and Patient Safety 
Measures

1. Disclosure of Physician Ownership in Hospitals
    (If you choose to comment on issues in this section, please include 
the caption ``Physician Ownership in Hospitals'' at the beginning of 
your comment.)
    Section 1866 of the Act states that any provider of services 
(except a fund designated for purposes of section 1814(g) and section 
1835(e) of the Act) shall be qualified to participate in the Medicare 
program and shall be eligible for Medicare payments if it files a 
Medicare provider agreement and abides by the requirements applicable 
to Medicare provider agreements. These requirements are incorporated 
into our regulations in 42 CFR part 489, subparts A and B (Provider 
Agreements and Supplier Approval). Section 1861(e) of the Act defines 
the term ``hospital.'' Section 1861(e)(9) of the Act defines a hospital 
and authorizes the Secretary to establish requirements as he finds 
necessary in the interest of patient health and safety. Section 
1820(e)(3) of the Act authorizes the Secretary to establish criteria 
necessary for an institution to be certified as a critical access 
hospital.
    Section 5006 of Pub. L. 109-171 (DRA) required the Secretary to 
develop a ``strategic and implementing plan'' to address certain issues 
related to physician investment in ``specialty hospitals.'' In the 
strategic and implementing plan included in our ``Final Report to the 
Congress and Strategic and Implementing Plan Required under Section 
5006 of the Deficit Reduction Act of 2005'' issued on August 8, 2006 
(page 69), available on our Web site at: http://www.cms.hhs.gov/PhysicianSelfReferral/06a_DRA_Reports.asp (hereinafter referred to as 
the ``DRA Report to Congress''), we stated that our plan for addressing 
issues related to physician investment in specialty hospitals involved 
promoting transparency of investment. Consistent with that approach, we 
stated that we would adopt a disclosure requirement that would require 
hospitals to disclose to patients whether they are physician-owned, and 
if so, disclose the names of the physician owners. Accordingly, we are 
proposing changes to regulations governing Medicare provider agreements 
to effectuate this change, under our authority at sections 1861(e)(9), 
1820(e) and 1866 of the Act and under our rulemaking authority at 
sections 1871 and 1102 of the Act. We are seeking comment as to whether 
these changes best effectuated through changes to the Medicare provider 
agreement regulations or whether it would be more appropriate to 
include these changes in the conditions of participation requirements 
applicable to hospitals and critical access hospitals.
    Specifically, we are proposing to amend Sec.  489.3 to define a 
``physician-owned hospital'' as any participating hospital (as defined 
in Sec.  489.24) in which a physician or physicians have an ownership 
or investment interest. We solicit comments on whether, for purposes of 
the ownership disclosure requirements only, the definition of 
``physician-owned hospital'' should exclude certain physician ownership 
or investment interests based on the nature of the interest or the 
relative size of the interest or the entity's assets (for example, 
whether the interest would satisfy the exception at Sec.  4111.356(a) 
for physician ownership or investment interest in public-traded 
securities and mutual funds).
    We are proposing to add a new provision at Sec.  489.20(u)(1) to 
require that patients be given written notice that a hospital is 
physician-owned and that the list of physician owners is available upon 
request. We are proposing to require that the notice, in a manner 
reasonably designed to be understood by all patients, disclose the fact 
that the hospital meets the Federal definition of a ``physician-owned 
hospital'' and that patients will be provided the list of the 
hospital's physician owners upon request. In addition, we are proposing 
to add a new provision at Sec.  489.20(u)(2) which will require 
hospitals to require that all physician owners who are also members of 
the hospital's medical staff disclose, in writing, their ownership 
interest in the hospital to all patients they refer to the hospital, as 
a condition of continued medical staff membership. Patient disclosure 
would be required at the time a physician makes a referral. We believe 
that these provisions are in the interest of the health and safety of 
individuals who are furnished services in these institutions. This 
notice requirement will permit individuals to make more informed 
decisions regarding their treatment and to

[[Page 24817]]

evaluate whether the existence of a financial relationship, in the form 
of an ownership interest, suggests a conflict of interest that is not 
in their best interest.
    In order to enforce these proposed requirements, we are proposing 
to amend Sec.  489.12 to deny a provider agreement to a hospital that 
does not have procedures in place to notify patients of physician 
ownership in the hospital. In addition, we are proposing to amend Sec.  
489.53 to permit CMS to terminate a provider agreement with a 
physician-owned hospital if the hospital fails to comply with the 
requirements of Sec.  489.20(u).
2. Patient Safety Measures
    (If you choose to comment on issues in this section, please include 
the caption ``Patient Safety Measures'' at the beginning of your 
comment.)
    In the DRA Report to Congress (page 67), we stated that it was 
appropriate to issue further guidance on what we expect of all 
hospitals with respect to the appraisal, initial treatment, and 
referral, when appropriate, of patients with medical emergencies. The 
Medicare hospital conditions of participation regulations at 42 CFR 
part 482 impose requirements on hospitals that have emergency 
departments, as well as requirements on hospitals without emergency 
departments. We believe that hospitals should be required to disclose 
to patients at the time of inpatient admission or registration for an 
outpatient service information concerning whether a physician is 
available on the premises 24 hours a days, 7 days a week. Under the 
authority at sections 1861(e)(9), 1820(e)(3), 1866, 1871, and 1102 of 
the Act (described previously), we are proposing to add a new provision 
at Sec.  489.20(v)(1) to require that hospitals furnish all patients 
notice at the beginning of their hospital stay or outpatient service if 
a doctor of medicine or a doctor of osteopathy is not present in the 
hospital 24 hours per day, 7 days a week, and to describe how the 
hospital will meet the medical needs of any patient who develops an 
emergency medical condition, at a time when no physician is present in 
the hospital. We are seeking comment as to whether this change best 
effectuated through changes to the Medicare provider agreement 
regulations or whether it would be more appropriate to include this 
change in the conditions of participation requirements applicable to 
hospitals and critical access hospitals.
    It has also come to our attention that some hospitals have called 
9-1-1 when a patient has gone into respiratory arrest, a physician has 
not been on the premises, and the onsite clinical personnel have lacked 
the requisite equipment or training to provide the required assessment, 
initial treatment, and referral that are required of all hospitals. In 
some cases, required interventions to initiate emergency treatment may 
be outside the scope of practice of the clinical personnel onsite. This 
has occurred even in hospitals that operate emergency departments. 
Therefore, in this proposed rule, we are soliciting comments on whether 
current requirements for emergency service capability in hospitals with 
or without emergency departments should be strengthened in certain 
areas. Specifically, we are seeking feedback on whether present 
regulatory provisions should be expanded with respect to the type of 
clinical personnel that must be present at all times in hospitals with 
and without emergency departments; the competencies that such personnel 
must demonstrate, such as training in Advanced Cardiac Life Support, or 
successful completion of specified professional training programs; the 
type of emergency response equipment that must be available and the 
manner in which it must be available, such as in each emergency 
department, or inpatient unit, among others; and whether emergency 
departments must be operated 24 hours/day, 7 days a week. After 
evaluating the comments we receive, we will consider whether we should 
amend the Medicare hospital conditions of participation related to 
provision of emergency services in hospitals with and without emergency 
departments.

G. Rural Community Hospital Demonstration Program

    (If you choose to comment on issues in this section, please include 
the caption ``Rural Community Hospital Demonstration'' at the beginning 
of your comments.)
    In accordance with the requirements of section 410A(a) of Pub. L. 
108-173, the Secretary has established a 5-year demonstration program 
(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 is treated as being located in a rural 
area under section 1886(d)(8)(E) of the Act;
     Has fewer than 51 beds (excluding beds in a distinct part 
psychiatric or rehabilitation unit) as reported in its most recent cost 
report;
     Provides 24-hour emergency care services; and
     Is not designated or eligible for designation as a CAH.
    As we indicated in the FY 2005 IPPS final rule (69 FR 49078), in 
accordance with sections 410A(a)(2) and (a)(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). Nine rural community hospitals 
located within these States are currently participating in the 
demonstration program for FY 2008. (Of the 13 hospitals that 
participated in the first 2 years of the demonstration program, 4 
hospitals located in Nebraska have withdrawn from the program; they 
have become CAHs.)
    Under the demonstration program, 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. 
Payments to the participating hospitals will be the lesser amount of 
the 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 are inpatient hospital services 
(defined in section 1861(b) of the Act), and include 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

[[Page 24818]]

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 program on a budget neutral basis, the 
demonstration program is budget neutral in its own terms; in other 
words, the 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 program. This form of budget neutrality is 
viable when, by changing payments or aligning incentives to improve 
overall efficiency, or both, a demonstration program may reduce the use 
of some services or eliminate the need for others, resulting in reduced 
expenditures for the demonstration program's participants. These 
reduced expenditures offset increased payments elsewhere under the 
demonstration program, thus ensuring that the demonstration program as 
a whole is budget neutral or yields savings. However, the small scale 
of this demonstration program, in conjunction with the payment 
methodology, makes it extremely unlikely that this demonstration 
program could be viable under the usual form of budget neutrality. 
Specifically, cost-based payments to the nine participating 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 program 
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 
program for FY 2008, we are proposing to adjust the national inpatient 
PPS rates by an amount sufficient to account for the added costs of 
this demonstration program. We are proposing to apply budget neutrality 
across the payment system as a whole rather than merely across the 
participants in this demonstration program. As we discussed in the FY 
2005, FY 2006, and FY 2007 IPPS final rules (69 FR 49183; 70 FR 47462; 
and 71 FR 48100), 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 2008, using cost report 
data for FY 2003, adjusted to account for the increased estimated costs 
for the remaining nine participating hospitals, we estimate that the 
adjusted amount would be $9,681,893. This proposed estimated adjusted 
amount reflects the estimated difference between the participating 
hospitals' costs and the IPPS payment based on data from the hospitals' 
cost reports. We discuss the proposed payment rate adjustment that 
would be required to ensure the budget neutrality of the demonstration 
program for FY 2008 in section II.A.4. of the Addendum to this proposed 
rule.

V. Proposed Changes to the IPPS for Capital-Related Costs

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

A. Background

    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 prospective payment system established by the 
Secretary.'' Under the statute, the Secretary has broad authority in 
establishing and implementing the IPPS for acute care hospital 
inpatient capital-related costs. We initially implemented the IPPS 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 (FFY) 2001 was the last year of the 10-year 
transition period established to phase in the IPPS for hospital 
inpatient capital-related costs. For cost reporting periods beginning 
in FY 2002, capital IPPS 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 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 IPPS 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).)

[[Page 24819]]

    Under the IPPS 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, we refer readers to the August 30, 1991 final 
rule (56 FR 43418).) During the 10-year transition period, a new 
hospital was exempt from the capital IPPS 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 
Medicare allowable 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. (We refer readers 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 IPPS, we compute a 
separate payment rate specific to Puerto Rico hospitals using the same 
methodology used to compute the national Federal rate for capital-
related costs. In general, hospitals located in Puerto Rico are paid a 
blend of the applicable capital IPPS Puerto Rico rate and the 
applicable capital IPPS Federal rate.
    Prior to FY 1998, hospitals in Puerto Rico were paid a blended 
capital IPPS rate that consisted of 75 percent of the capital IPPS 
Puerto Rico specific rate and 25 percent of the capital IPPS Federal 
rate. However, effective October 1, 1997 (FY 1998), in conjunction with 
the change to the operating IPPS blend percentage for Puerto Rico 
hospitals required by section 4406 of Pub. L. 105-33, we revised the 
methodology for computing capital IPPS payments to hospitals in Puerto 
Rico to be based on a blend of 50 percent of the capital IPPS Puerto 
Rico rate and 50 percent of the capital IPPS Federal rate. Similarly, 
in conjunction with the change in operating IPPS 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 IPPS payments to 
hospitals in Puerto Rico to be based on a blend of 25 percent of the 
capital IPPS Puerto Rico rate and 75 percent of the capital IPPS 
Federal rate effective for discharges occurring on or after October 1, 
2004.

B. Proposed Policy Change

    As we have noted above, the Secretary has broad authority under the 
statute in establishing and implementing the IPPS for hospital 
inpatient capital-related costs. We initially exercised that authority 
in the August 30, 1991 IPPS final rule (56 FR 43358). Among other 
provisions of that rule, we established the 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). The purpose 
of that lengthy transition was to allow hospitals sufficient time to 
adjust to payment under a fully prospective system based on a uniform 
national rate. In that rule, we also established the initial standard 
Federal payment rate for capital-related costs, as well as the 
mechanism for updating that rate in subsequent years. 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.
    Since the implementation of the IPPS for hospital inpatient 
capital-related costs, we have carefully monitored the adequacy of the 
standard Federal payment rate for capital-related costs and the updates 
provided under the existing regulations. On several occasions, the 
standard Federal payment rate has been adjusted. Section 1886(g)(1)(A) 
of the Act required a 7.4 percent reduction to the capital rate for 
discharges occurring after September 30, 1993. (We implemented that 
reduction to the rate in Sec.  412.308(b)(2) of our regulations, 
effective in FY 1994.) Section 412.308(b)(3) of the regulations 
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 be 
reduced by 17.78 percent (above the previous statutory reduction of 7.4 
percent). (As a result of that reduction, the FY 1998 standard Federal 
payment rate for capital-related costs was $371.51, compared to $438.92 
in FY 1997.) As we discussed in the FY 2003 IPPS final rule (67 FR 
50102) and implemented in Sec.  412.308(b)(6), a small part of that 
reduction was restored effective October 1, 2002.
    In general, under a PPS, standard payment rates should reflect the 
costs that an average, efficient provider would bear to provide the 
services required for quality patient care. Payment rate updates should 
also account for the changes necessary to continue providing such 
services. Updates should reflect, for example, the increased costs that 
are necessary to provide for the introduction of new technology that 
improves patient care. Updates should also take into account the 
productivity gains that, over time, allow providers to realize the 
same, or even improved, quality outcomes with reduced inputs and lower 
costs. Hospital margins, the difference between the costs of actually 
providing services and the payments received under a particular system, 
thus provide some evidence concerning whether payment rates have been 
established and updated at an appropriate level over time for efficient 
providers to provide necessary services. All other factors being equal, 
sustained substantial positive margins may suggest that payment rates 
and updates have exceeded what is required to provide those services. 
It is to be expected, under a PPS, that highly efficient providers 
might regularly realize positive margins, while less efficient 
providers might regularly

[[Page 24820]]

realize negative margins. However, a PPS that is correctly calibrated 
should not necessarily experience sustained periods in which providers 
generally realize substantial positive Medicare margins.
    Under the capital IPPS in particular, it seems especially 
appropriate that there should not be sustained significant positive 
margins across the system as a whole. Prior to the implementation of 
the capital IPPS, Congress mandated that the Medicare program pay only 
85 percent of hospitals' inpatient Medicare capital costs. During the 
first 5 years of the capital IPPS, Congress also mandated a budget 
neutrality adjustment, under which the standard Federal capital rate 
was set each year so that payments under the system as a whole equaled 
90 percent of estimated hospitals' inpatient Medicare capital costs for 
the year. Finally, as we discussed above, Congress has twice adjusted 
the standard Federal capital rate (a 7.4 percent reduction beginning in 
FY 1994, followed by a 17.78 percent reduction beginning in FY 1998). 
On the second occasion in particular, the specific congressional 
mandate was ``to apply the budget neutrality factor used to determine 
the Federal capital payment rate in effect on September 30, 1995 * * * 
to the unadjusted standard Federal capital payment rate'' for FY 1998 
and beyond. (The designated budget neutrality factor constituted a 
17.78 percent reduction.) This statutory language indicates that 
Congress considered the payment levels in effect during FYs 1992 
through 1995, established under the budget neutrality provision to pay 
90 percent of hospitals' inpatient Medicare capital costs in the 
aggregate, appropriate for the capital IPPS. The statutory history of 
the capital IPPS thus suggests that the system in the aggregate should 
not provide for continuous, large positive margins.
    In analyzing the adequacy of the existing capital IPPS rates, we 
recently conducted a comprehensive review of hospital experience under 
the IPPS for hospital inpatient capital-related costs, with particular 
attention to the relationship between acute care hospital capital 
Medicare costs and payments under the capital IPPS. Specifically, we 
examined the relationship between the Medicare inpatient capital costs 
of hospitals that are paid under the IPPS for hospital inpatient 
capital-related costs and their payments under that system over a 
number of years. We derived both cost and revenue data from the 
Medicare cost report. Specifically, cost data were derived from 
Worksheet D, Part I, columns 10 and 12 and Part II, columns 6 and 8, 
and revenue data from Worksheet E, Part A, Lines 9 and 10. We began our 
analysis with FY 1996, the year in which the statutory budget 
neutrality provision expired. (As we have discussed, for FYs 1992 
through 1995, section 1886(g)(1)(A) of the Act 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. As discussed in section III. of the Addendum to this proposed 
rule, we employed an 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 
reasonable cost in order to determine the required budget neutrality 
adjustment. As a result of the expiration of the budget neutrality 
provision, the standard Federal payment rate for capital-related costs 
increased to $461.96 in FY 1996 from $376.83 in FY 1995.) Our analysis 
extended through FY 2004, the most recent year for which we have 
relatively complete cost report information. We examined data across 
all hospitals subject to the capital IPPS and across the categories of 
hospitals (for example, urban and rural, and teaching and nonteaching) 
that we normally employ in conducting impact analyses. Specifically, we 
looked at the difference between aggregate hospital revenues from the 
capital IPPS and hospitals' aggregate Medicare inpatient capital costs. 
We determined the inpatient hospital Medicare capital margins for each 
year of the period from FY 1996 through FY 2004. (A margin is 
calculated as the difference between payments and costs, divided by 
payments.) We similarly calculated the aggregate margins for the period 
(the aggregate difference between payments and costs over the period, 
divided by total payments over the period). We also calculated 
aggregate margins for the period FY 1998 through FY 2004 (excluding FY 
1996 and 1997). As a result of the expiration of the statutory budget 
neutrality provision, the capital standard Federal rate increased to 
$461.96 in FY 1996 from $376.83 in FY 1995. The capital standard 
Federal rate was $438.92 in FY 1997, before it was reduced to $371.51 
in FY 1998 under section 4402 of Pub. L. 105-33, which required that 
the unadjusted capital standard Federal rate be reduced by 17.78 
percent. The capital standard Federal rates for FYs 1996 and 1997 were 
thus substantially higher than the rates for the periods immediately 
preceding those years, and in the subsequent years (FY 1998 and 
beyond). The margins for those years are correspondingly higher than 
the margins for the other years in the period, and thus it could be 
argued that the margins for FYs 1996 and 1997 are unrepresentative. The 
table below summarizes the findings of this analysis.

                                                       Hospital Inpatient Medicare Capital Margins
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                         1996    1997    1998    1999    2000    2001    2002    2003    2004    1996-2004    1998-2004*
--------------------------------------------------------------------------------------------------------------------------------------------------------
U.S...................................................    17.5    13.4     7.0     6.8     7.3     7.9     8.7     7.7     5.1          9.0          7.2
    URBAN.............................................    17.6    13.8     7.8     7.4     8.3     8.9    10.3     9.1     6.3          9.9          8.3
    RURAL.............................................    17.2    11.1     2.0     2.7     1.3     1.5    -1.7    -1.2    -2.9          3.4         0.26
No DSH Payments.......................................    16.2    11.8     4.4     4.4     5.6     5.6     5.0     4.8    -0.9          6.9          4.2
Has DSH Payments......................................    18.3    14.4     8.5     8.1     8.2     8.7     9.9     8.6     6.7          9.9          8.4
    $1-$249,999.......................................    14.5    12.9    -0.4     3.1     1.6     4.2     2.5     0.6    -3.5          3.3          1.8
    $250,000-$999,999.................................    15.5     9.3     2.2     1.5     3.0     2.5    -1.2     0.2    -3.8          2.9          0.5
    $1,000,000-$2,999,999.............................    16.8    12.8     8.5     9.2     8.6     7.2     9.0     4.6     3.0          8.7          7.1
    $3,000,000 or more................................    20.1    16.6    10.4     9.1     9.7    11.6    13.4    12.5    10.1         12.4         11.1
TEACHING..............................................    19.4    15.7     9.8     9.7    11.1    11.7    13.9    13.2    11.3         12.9         11.6
NON-TEACHING..........................................    15.3    10.5     3.3     2.9     2.2     2.8     1.6     0.2    -3.2          3.9          1.3
Census Division:
    New England (1)...................................    26.9    25.8    17.0    15.1    18.2    20.5    21.3    21.2    20.5         20.9         19.3
    Middle Atlantic (2)...............................    19.1    15.5    11.0    11.5    13.8    16.3    18.4    17.9    15.0         15.5         15.0
    South Atlantic (3)................................    17.9    13.9     5.8     3.9     5.9     5.2     6.3     7.5     4.9          7.9          5.7
    East North Central (4)............................    18.2    12.7     6.2     7.2     8.8     8.6     6.3     8.1     7.1          9.2          7.5

[[Page 24821]]

 
    East South Central (5)............................    14.8    11.1     3.3     4.1     3.4     2.9     3.0    -1.8    -4.2          3.9          1.4
    West North Central (6)............................    14.2     6.9     0.0    -0.4    -1.6     1.9     2.6     3.3     1.1          3.2          1.1
    West South Central (7)............................    13.3     8.3     3.4     3.1     0.6     0.1     1.4    -1.2    -4.2          2.5          0.3
    Mountain (8)......................................    17.3    14.8     8.4     7.6     7.4     6.4     3.2     3.1     0.7          7.2          4.9
    Pacific (9).......................................    20.5    16.1    12.4    11.3    11.5    12.8    15.5    12.8     9.2         13.5         12.2
    Code 99...........................................    24.1    26.1    14.9    16.7    20.0    20.9    20.6    25.2    22.3         21.4         20.3
Bed Size:
    < 100 beds........................................    17.7    13.0     4.7     3.5     2.8     2.5    -1.7    -1.3    -5.6          3.5          0.5
    100-249 beds......................................    15.1    10.6     3.5     4.5     4.7     6.0     6.1     4.5     1.1          6.2          4.4
    250-499 beds......................................    18.9    14.0     8.7     8.3    10.4    10.5    11.7    11.6    10.6         11.7         10.4
    500-999 beds......................................    19.7    17.5    11.1    10.3    10.7    10.4    12.5    10.3     6.8         12.0         10.2
    >= 1000 beds......................................     8.2    13.8     2.1     0.2    -6.6    -3.5     8.7     6.3     1.4          3.1         1.8
--------------------------------------------------------------------------------------------------------------------------------------------------------
Notes:
* Excluding 1996 and 1997.
Based on Medicare Cost Report hospital data updated as of the 4th quarter of 2006.
Revenue are from Worksheet E, Part A, Lines 9 and 10.
Expenses are from Worksheet D, Part I, columns 10 and 12 and Part II, columns 6 and 8.
We apply the outlier trimming methodology developed by MedPAC.

    As the table shows, hospital inpatient Medicare capital margins 
have been very high across all hospitals during the period from FY 1996 
through FY 2004. The margin for the entire period was 9.0 percent (7.2 
percent, excluding FYs 1996 and 1997). For particular years, margins 
across all hospitals ranged from a high of 17.5 percent in FY 1996 to a 
low 5.1 percent in FY 2004. While the margins fell after a high in FY 
1996 of 17.5 to 6.8 percent in FY 1999, they rose again to 8.7 percent 
in FY 2002 before declining modestly to 5.1 percent in FY 2004.
    There are similar results among most types of hospitals and 
groupings of hospitals by geographic region. For example, teaching 
hospitals have realized margins of 12.9 percent (11.6 percent, 
excluding FYs 1996 and 1997) during the period from FY 1996 through FY 
2004, with a high margin of 19.4 percent in FY 1996 and a low margin of 
9.7 percent in FY 1999. Urban hospitals realized margins of 9.9 percent 
during the period from FY 1996 through FY 2004 (8.3 percent, excluding 
FYs 1996 and 1997). DSH hospitals realized margins of 9.9 percent over 
the period (8.4 percent, excluding FYs 1996 and 1997), while non-DSH 
had aggregate margins of 6.9 percent (4.2 percent, excluding FYs 1996 
and 1997).
    During the period from FY 1996 through FY 2004, every type of 
hospital and geographic grouping of hospitals has realized a positive 
aggregate margin from their capital IPPS payments. Of course, the 
aggregate capital margins for some types of hospitals have been lower 
than the margins for others. In particular, inpatient hospital Medicare 
capital margins for rural hospitals have lagged considerably behind the 
margins for urban hospitals. The aggregate margin for rural hospitals 
during the period from FY 1996 through FY 2004 was 3.4 percent (0.2 
percent, excluding FYs 1996 and 1997), compared to 9.9 percent for 
urban hospitals and 9.0 percent for all hospitals. Rural hospitals have 
even experienced negative margins during several years of the period (-
1.7 percent in FY 2002, -1.2 percent in FY 2003, and -2.9 percent in FY 
2004). Similarly, nonteaching hospitals have experienced lower margins 
than teaching hospitals. Teaching hospitals have experienced an 
aggregate margin of 12.9 percent during the period from FY 1996 through 
FY 2004 (11.6 percent, excluding FYs 1996 and 1997). However, 
nonteaching hospitals have experienced an aggregate margin of 3.9 
percent during that period (1.3 percent, excluding FYs 1996 and 1997).
    There may be various factors reflected in these margins. For 
example, one factor in the lower margins experienced by rural hospitals 
may be the transition of many rural hospitals to CAHs that are paid 
outside the IPPS. The number of rural hospitals in our analysis fell 
from 2,243 in FY 1996 to 1,211 in FY 2004, as the inpatient Medicare 
capital margins realized by rural hospitals fell from 17.2 percent to -
2.9 percent. This suggests that more rural hospitals with relatively 
higher inpatient Medicare capital margins have made the transition to 
CAH status. However, it remains to be seen whether this trend in 
inpatient Medicare capital margins will continue as the relative 
numbers of CAHs and rural hospitals subject to the IPPS stabilize. The 
low aggregate for nonteaching hospitals is largely a function of the 
effect of the low, and for some years even negative, margin of the 
rural hospitals, as discussed earlier.
    We believe that there could be a number of reasons for the 
relatively high margins that most IPPS hospitals have realized under 
the capital IPPS. One possibility is that the updates to the capital 
IPPS rates have been higher than the actual increases in Medicare 
inpatient capital costs that hospitals have experienced in recent 
years. As we discuss in section III. of the Addendum to this proposed 
rule, we update the capital standard Federal rate 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. Under the 
framework that we have been using, the update factor for FY 2008 would 
be 0.8 percent, based on the best data available at this time. That 
update factor is derived from a projected 1.2 percent increase in the 
CIPI, a 0.0 percent adjustment for intensity, a 0.0 percent adjustment 
for case-mix, a -0.4 percent adjustment for the FY 2005 DRG 
reclassification and recalibration, and a forecast error correction of 
0.0 percent. We discuss this update framework, and the computation of 
the policy adjustment factors, in section III. of the Addendum to this 
proposed rule.
    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 believe that the update framework successfully captures several 
factors that should be taken into account in determining appropriate 
updates for hospitals subject to the capital IPPS. However, there may 
be factors affecting the rate-of-increase in

[[Page 24822]]

capital costs that are not yet captured in our analytical framework. 
For example, hospitals may be experiencing productivity gains in their 
use of capital equipment. As productivity increases, hospitals would be 
able to reduce the number of inputs required to produce a unit of 
service. MedPAC has taken the position that payment ``rate for health 
care providers should be set so that the Federal Government benefits 
from providers' productivity gains, just as private purchasers of goods 
in competitive markets benefit from the productivity gains of their 
suppliers.'' MedPAC has, therefore, included a productivity improvement 
target in its framework for updating Medicare hospital payments on the 
grounds that ``as a prudent purchaser, Medicare should also require 
some productivity gains each year from its providers.'' (MedPAC, Report 
to Congress, March 2006, p. 66) While we have not as yet included a 
specific productivity factor, such as MedPAC's productivity improvement 
target, in our analytical frameworks for updating the IPPS payment 
rates, we will continue to study the appropriateness of adopting such a 
measure.
    Another possible reason for the relatively high margins of most 
capital IPPS hospitals may be that the payment adjustments provided 
under the system are too high, or perhaps even unnecessary. 
Specifically, the adjustments for teaching hospitals, disproportionate 
share hospitals, and large urban hospitals appear to be contributing to 
excessive payment levels for these classes of hospitals. Since the 
inception of the capital IPPS in FY 1992, the system has provided 
adjustments for teaching hospitals (the IME adjustment factor, under 
Sec.  412.322 of the regulations), disproportionate share hospitals 
(the DHS adjustment factor, under Sec.  412.320), and large urban 
hospitals (the large urban location adjustment factor, under Sec.  
412.316((b)). The classes of hospitals eligible for these adjustments 
have been realizing much higher margins than other hospitals under the 
system. Specifically, teaching hospitals (11.6 percent for FYs 1998 
through 2004), urban hospitals (8.3 percent), and disproportionate 
share hospitals (8.4 percent) have significant positive margins. Other 
classes of hospitals have experienced much lower margins, especially 
rural hospitals (0.2 percent for FYs 1998 through 2004) and nonteaching 
hospitals (1.3 percent). The three groups of hospitals that have been 
realizing especially high margins under the capital IPPS are, 
therefore, classes of hospitals that are eligible to receive one or 
more specific payment adjustments under the system. We believe that the 
evidence indicates that these adjustments have been contributing to the 
significantly large positive margins experienced by the classes of 
hospitals eligible for these adjustments.
    We believe that the data on inpatient hospital Medicare capital 
margins, as discussed above, provide sufficient evidence that some 
adjustment of the updates under the capital IPPS is warranted at this 
time. In light of the significant disparities in the margin 
performances of different classes of hospitals, we do not believe that 
an adjustment to the updates for FYs 2008 and 2009 should apply equally 
to all hospitals that are paid under the capital IPPS. In particular, 
an adjustment to the updates should take into account the much lower 
margins of rural hospitals (0.2 percent for the period from FY 1998 
through FY 2004) compared to urban hospitals (8.3 percent during that 
period). We also believe that any initial adjustment to the rate should 
be relatively modest. One reason is that any adjustment should avoid 
unwarranted disruption to hospital finances: because of the nature of 
capital spending, long periods of time can be necessary for hospitals 
to adjust adequately to significant changes in payment. Therefore, for 
FYs 2008 and 2009, we are proposing that the update to the capital 
standard Federal rate for urban hospitals will be 0.0 percent, in place 
of the 0.8 percent update that would otherwise be provided in FY 2008 
under the update framework that we have been employing. (We have not 
yet determined the update that would be provided for FY 2009 under the 
framework.) However, in light of the margin analysis, we are also 
proposing to give rural hospitals the full 0.8 percent update 
determined by the update framework in FY 2008. We anticipate that we 
will provide the full update to rural hospitals in FY 2009 as well, 
once we have determined what the update would be under the update 
framework. We are proposing to revise Sec.  412.308(c)(1) of the 
regulations accordingly. For purposes of the update in FYs 2008 and 
2009, an urban hospital is any hospital located in an area that meets 
the definitions under Sec.  412.64(b)(1)(ii)(A) or (b)(1)(ii)(B), or 
Sec.  412.64(b)(3). A rural hospital is any hospital that does not meet 
those definitions, or that is reclassified as rural under Sec.  
412.103. For subsequent years, we will continue to analyze the data 
concerning the adequacy of payments under the capital IPPS, and we may 
propose additional adjustments, positive or negative, as they are 
warranted. We will also continue to study our update framework and will 
consider whether adoption of additional or revised adjustments to 
account for other factors affecting capital cost changes may be 
warranted.
    In addition, we are also proposing to eliminate, for FYs 2008 and 
beyond, one of the payment adjustments that has been provided under the 
capital IPPS. Specifically, we are proposing to discontinue the 3.0 
percent additional payment that has been provided to hospitals located 
in large urban areas. The consistent and significant positive margin of 
hospitals located in urban areas is strong evidence that it is not 
necessary to continue this adjustment. Therefore, we are proposing to 
amend Sec.  412.316(b) of the regulations to provide that, effective 
for discharges on or after October 1, 2007, there will no longer be any 
additional payment for hospitals located in large urban areas, as 
currently provided under that section. When the payment adjustments 
were instituted at the inception of the program, the initial standard 
Federal payment rate was adjusted in a budget-neutral fashion to 
account for the expenditures that would be required by these 
adjustments. However, in light of the strong overall positive margins 
across the system, we are proposing not to increase the standard 
capital rate to account for expenditures otherwise payable due to this 
adjustment (approximately $147 million). Rather, in light of the 
excessive capital IPPS payments over the period of FYs 1996 through 
2004, we believe that it is appropriate for the program to realize 
savings from this proposal.
    We will also continue to study the adequacy of payments under the 
capital IPPS, and will consider whether it is appropriate to make 
further adjustments to the standard Federal capital rate and updates of 
the rate. While we are formally proposing an update of 0.0 percent for 
urban hospitals, an update of 0.8 percent for rural hospitals in FY 
2008, and elimination of the large urban add-on, we are also soliciting 
comment on additional adjustments to the capital payment structure. As 
we have noted above, the margin analysis indicates that several classes 
of hospitals have continuous, significant positive margins. The 
analysis indicates that the existing payment adjustments for teaching 
hospitals and disproportionate share hospitals are contributing to 
excessive payment levels for these classes of hospitals. Therefore, it 
may be appropriate to reduce these adjustments significantly, or even 
to eliminate them altogether, within the capital IPPS.

[[Page 24823]]

These payment adjustments, unlike the parallel adjustments under the 
operating IPPS, were not mandated by the Act. Rather, they were 
included within the original design of the capital IPPS under the 
Secretary's broad authority under sections 1886(g)(1)(A) and (g)(1)(B) 
of the Act to include appropriate adjustments and exceptions within a 
capital IPPS. Therefore, we are considering whether it may be 
appropriate to develop a proposal to reduce or to terminate these 
payment adjustments in the near future. It is difficult to justify 
indefinite continuation of these adjustments in the light of the 
continuous, substantial positive margins realized by the classes of 
hospitals that qualify for them. When the payment adjustments were 
instituted at the inception of the program, the initial standard 
Federal payment rate was adjusted in a budget-neutral fashion to 
account for the expenditures that would be required by these 
adjustments. Therefore, if we decide to propose to reduce or eliminate 
these adjustments, we will also consider whether we should similarly 
adjust the Federal capital payment rate to account for all or a portion 
of these adjustments, effectively increasing the base payment rate for 
all hospitals (including rural, nonteaching, and non-DSH hospitals that 
do not benefit from these adjustments), while removing these special 
adjustments for the hospitals that have been eligible to receive them. 
We are also considering whether, in light of the substantial positive 
margins experienced by these teaching and DSH hospitals, the 
discontinuation of these adjustments should not result in a change to 
the standard capital rate and should instead result in savings to the 
program. We welcome comments on these potential proposals and on other 
means of appropriately adjusting and targeting payments under the 
capital IPPS, as well as on the proposals that we are formally making 
in this proposed rule.

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

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

A. Payments to Existing and New Excluded Hospitals and Hospital Units

    Historically, hospitals and hospital units excluded from the 
prospective payment system 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 (now referred to as IRFs), 
psychiatric hospitals and units (now referred to as IPFs), LTCHs, 
children's hospitals, and cancer hospitals).
    Payment for children's hospitals and cancer hospitals that are 
excluded from the IPPS continues to be subject to the rate-of-increase 
ceiling 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. IRFs, IPFs, and LTCHs were paid 
previously under the reasonable cost methodology. However, the statute 
was amended to provide for the implementation of prospective payment 
systems for IRFs, IPFs, and LTCHs. In general, the prospective payment 
systems for IRFs, IPFs, and LTCHs provide(d) transition periods of 
varying lengths during which time a portion of the prospective payment 
is (was) based on cost-based reimbursement rules under Part 413 
(certain providers do not receive a transition period or may elect to 
bypass the transition as applicable under Subparts N, O, and P). We 
note that the various transition periods provided for under the IRF 
PPS, IPF PPS, and LTCH PPS have ended or will soon end.)
    For cost reporting periods beginning on or after October 1, 2002, 
all IRFs are paid 100 percent of the adjusted Federal rate under the 
IRF PPS. Therefore, for cost reporting periods beginning on or after 
October 1, 2002, no portion of an IRF PPS payment is subject to Part 
413. Similarly, for cost reporting periods beginning on or after 
October 1, 2006, all LTCHs are paid 100 percent of the adjusted Federal 
rate under the LTCH PPS. Therefore, for cost reporting periods 
beginning on or after October 1, 2006, no portion of the LTCH PPS 
payment is subject to 42 CFR part 413. However, except as provided in 
Sec.  412.426(c), IPFs remain under a blend methodology for cost 
reporting periods beginning on or after January 1, 2005, and before 
January 1, 2008.
    For IPFs paid under the blend methodology, the portion of the IPF 
PPS payment that is based on reasonable cost principles is subject to 
the rules of 42 CFR part 413. In order to calculate the portion of the 
PPS payment that is based on reasonable cost principles, it is 
necessary to determine whether the IPF would be considered ``existing'' 
for purposes of section 1886(b)(3)(H) of the Act or ``new'' for 
purposes of section 1886(b)(7) of the Act. We note that readers should 
not confuse an IPF that is considered ``new'' for purposes of section 
1886(b)(7) of the Act and Sec.  413.40(f)(2)(ii) of the regulations 
with an IPF that is considered ``new'' under Sec.  412.426(c) of the 
reguations. Any IPF that, under present or previous ownership or both, 
has its first cost reporting period as an IPF beginning on or after 
January 1, 2005, is considered ``new'' for purposes of Sec.  
412.426(c). An IPF that is considered ``new'' under Sec.  412.426(c) is 
paid based on 100 percent of the Federal per diem payment amount. 
Consequently, only those IPFs considered ``new'' under section 
1886(b)(7) of the Act, but not ``new'' under Sec.  412.426(c) of the 
regulations will be paid under a PPS blended payment methodology. An 
IPF considered ``new'' for purposes of Sec.  413.40(f)(2)(ii) would 
have its ``reasonable cost-based'' portion of its prospective payment 
subject to Sec.  413.40(f)(2)(ii) and Sec.  413.40(c)(4)(v), as 
applicable. An IPF considered ``new'' for purposes of section 
1886(b)(7) of the Act has the target amount for its third cost 
reporting period determined in accordance with sections 
1886(b)(7)(A)(ii) and 1886(b)(3)(A)(ii) of the Act. For the fourth and 
subsequent cost reporting periods, the target amount is calculated in 
accordance with section 1886(b)(3)(A)(ii) of the Act. An IPF that would 
be considered ``existing'' for purposes of section 1886(b)(3)(H) of the 
Act has the target amount for the ``reasonable cost-based'' portion of 
its prospective payment determined in accordance with section 
1886(b)(3)(A)(ii) of the Act and the regulations at Sec.  
413.40(c)(4)(ii).
    We are proposing that the applicable percentage increase to update 
the target amount for the reasonable cost-based portion of the PPS 
payment of an IPF that is considered existing under section 
1886(b)(3)(H) of the Act or new under section 1886(b)(7) of the Act, 
but not new under Sec.  412.426(c), is 3.4 percent. (However, if more 
current data become available prior to publication of the final rule, 
we will use those data for updating the market basket.)

B. Separate PPS for IRFs

    Section 1886(j) of the Act, as added by section 4421(a) of Pub. L. 
105-33,

[[Page 24824]]

provided for a phase-in of a case-mix adjusted PPS for inpatient 
hospital services furnished by 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 
IRFs, 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.

C. Separate PPS for LTCHs

    On August 30, 2002, we issued 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. Except for a 
LTCH that made an election under Sec.  412.533(c) or a LTCH that is 
defined as new under Sec.  412.23(e)(4), there was a transition period 
for cost reporting periods beginning on or after October 1, 2002, and 
ending before October 1, 2007. For cost reporting periods beginning on 
or after October 1, 2006, total LTCH PPS payments are based on 100 
percent of the Federal rate.

D. Separate PPS for IPFs

    In accordance with section 124 of Pub. L. 106-113 and section 
405(g)(2) of Pub. L. 108-173, we established a PPS for inpatient 
hospital services furnished in 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, days 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 COLAs 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.

E. Determining Proposed LTCH Cost-to-Charge Ratios (CCRs) Under the 
LTCH PPS

    (If you choose to comment on the issues in this section, please 
include the caption ``LTCH PPS CCRs and Outlier Payments'' at the 
beginning of your comment.)
    In determining both high-cost outlier and short-stay outlier 
payments under the LTCH PPS (at Sec.  412.525(a) and Sec.  412.529, 
respectively), we calculate the estimated cost of the case by 
multiplying the LTCH's overall CCR by the Medicare allowable charges 
for the case. Under the LTCH PPS, a single prospective payment per 
discharge is made for both inpatient operating and capital-related 
costs, and, therefore, we compute a single ``overall'' or ``total'' 
LTCH-specific CCR based on the sum of LTCH operating and capital costs 
(as described in Chapter 3, section 150.24, of the Medicare Claims 
Processing Manual (CMS Pub. 100-4)) as compared to total charges. 
Specifically, a LTCH's CCR is calculated by dividing a LTCH's total 
Medicare costs (that is, the sum of its operating and capital inpatient 
routine and ancillary costs) by its total Medicare charges (that is, 
the sum of its operating and capital inpatient routine and ancillary 
charges) (72 FR 48117).
    In the June 9, 2003 IPPS high-cost outlier final rule (68 FR 
34498), we made revisions to our policies concerning the determination 
of LTCHs' CCRs and the reconciliation of high-cost outlier and short-
stay outlier payments under the LTCH PPS. As we stated in that final 
rule (68 FR 34507), because the LTCH PPS high-cost outlier and short-
stay outlier policies are modeled after the IPPS outlier policy, we 
believe they are susceptible to the same payment vulnerabilities.
    In the FY 2007 IPPS final rule (71 FR 48115 through 48122), we 
amended our regulations and, for discharges occurring on or after 
October 1, 2006, refined the methodology for determining the annual CCR 
ceiling and statewide average CCRs. We also codified, with 
modifications and editorial clarifications, our policy for the 
reconciliation of high-cost outlier and short-stay outlier payments 
under the LTCH PPS. We indicated that because, historically, updates to 
the LTCH PPS CCR ceiling and statewide average CCRs have been effective 
on October 1, we would make these updates (and include relevant impact 
data) as a part of the IPPS rulemaking cycle.
    Specifically, in the FY 2007 IPPS final rule (71 FR 48117 through 
48121), under the broad authority of section 123 of Pub. L. 106-113 and 
section 307(b)(1) of Pub. L. 106-554, we established under the LTCH PPS 
high-cost outlier policy at Sec.  412.525(a)(4)(iv)(C) and the LTCH PPS 
short-stay outlier policy at Sec.  412.529(c)(3)(iv)(C), for discharges 
occurring on or after October 1, 2006, that the fiscal intermediary (or 
currently the MAC, if applicable) may use a statewide average CCR, 
which is established annually by CMS, if it is unable to determine an 
accurate CCR for a LTCH in one of the following three circumstances: 
(1) new LTCHs that have not yet submitted their first Medicare cost 
report (for this purpose, a new LTCH is defined as an entity that has 
not accepted assignment of an existing hospital's provider agreement in 
accordance with Sec.  489.18); (2) LTCHs whose CCR is in excess of the 
LTCH CCR ceiling; and (3) other LTCHs for whom data with which to 
calculate a CCR are not available (for example, missing or faulty 
data). (Other sources of data that the fiscal intermediary (or, if 
applicable, the MAC) may consider in determining a LTCH's CCR include 
data from a different cost reporting period for the LTCH, data from the 
cost reporting period preceding the period in which the hospital began 
to be paid as a LTCH (that is, the period of at least 6 months that it 
was paid as a short-term acute care hospital), or data from other 
comparable LTCHs, such as LTCHs in the same chain or in the same 
region.)
    As noted above, a LTCH is assigned the applicable statewide average 
CCR if, among other things, a LTCH's CCR is found to be in excess of 
the applicable maximum CCR threshold (that is, the LTCH CCR ceiling). 
As we explained in the FY 2007 IPPS final rule (71 FR 48117), CCRs 
above this threshold are

[[Page 24825]]

most likely due to faulty data reporting or entry, and, therefore, 
these CCRs should not be used to identify and make payments for outlier 
cases. Such data are clearly errors and should not be relied upon. 
Thus, under our established policy, if a LTCH's calculated CCR is above 
the applicable ceiling, the applicable LTCH PPS statewide average CCR 
is assigned to the LTCH instead of the CCR computed from its most 
recent (settled or tentatively settled) cost report data.
    We revised our methodology for determining the annual CCR ceiling 
and statewide average CCRs under the LTCH PPS effective October 1, 
2006, as we explained in the FY 2007 IPPS final rule (71 FR 48117 
through 48121), because we believe that those changes are consistent 
with the LTCH PPS single payment rate for inpatient operating and 
capital costs. Therefore, under the broad authority of section 123 of 
Pub. L. 106-113 and section 307(b)(1) of Pub. L. 106-554, in that same 
final rule, we revised our methodology used to determine the LTCH CCR 
ceiling. For discharges occurring on or after October 1, 2006, we 
established that the LTCH CCR ceiling specified under Sec.  
412.525(a)(4)(iv)(C)(2) for high-cost outliers and under Sec.  
412.529(c)(3)(iv)(C)(2) for short-stay outliers is calculated as 3 
standard deviations above the corresponding national geometric mean 
total CCR (established and published annually by CMS). (The fiscal 
intermediary (or, if applicable, the MAC) may use a statewide average 
CCR if, among other things, a LTCH's CCR is in excess of the LTCH CCR 
ceiling.) The LTCH total CCR ceiling is determined based on IPPS CCR 
data, by first calculating the ``total'' (that is, operating and 
capital) IPPS CCR for each hospital and then determining the average 
``total'' IPPS CCR for all IPPS hospitals. (Our rationale for using 
IPPS hospital data is discussed in the FY 2007 IPPS final rule (71 FR 
48117).) The LTCH CCR ceiling is then established at 3 standard 
deviations from the corresponding national geometric mean total CCR. 
(For further detail on our methodology for annually determining the 
LTCH CCR ceiling, we refer readers to the FY 2007 IPPS final rule (71 
FR 48117 through 48119).)
    We also established that the LTCH ``total'' CCR ceiling used under 
the LTCH PPS will continue to be published annually in the IPPS 
proposed and final rules, and the public should continue to consult the 
annual IPPS proposed and final rules for changes to the LTCH total CCR 
ceiling that would be effective for discharges occurring on or after 
October 1 of each year. Accordingly, in the FY 2007 IPPS final rule (71 
FR 48119), we established a FY 2007 LTCH PPS total CCR ceiling of 
1.321, effective for discharges occurring on or after October 1, 2006.
    In this proposed rule, in accordance with Sec.  
412.525(a)(4)(iv)(C)(2) for high-cost outliers and Sec.  
412.529(c)(3)(iv)(C)(2) for short-stay outliers, using our established 
methodology for determining the LTCH total CCR ceiling (described 
above), based on IPPS total CCR data from the December 2006 update to 
the Provider-Specific File, we are proposing a total CCR ceiling of 
1.273 under the LTCH PPS that would be effective October 1, 2007. 
Furthermore, we are proposing that, if more recent data are available, 
we will use such data to determine the final total CCR ceiling under 
the LTCH PPS for FY 2008 using our established methodology described 
above.
    In addition, under the broad authority of section 123 of Pub. L. 
106-113 and section 307(b)(1) of Pub. L. 106-554, in the FY 2007 IPPS 
final rule (71 FR 48120), we revised our methodology to determine the 
statewide average CCRs under Sec.  412.525(a)(4)(iv)(C) for high-cost 
outliers and under Sec.  412.529(c)(3)(iv)(C) for short-stay outliers 
for use under the LTCH PPS in a manner similar to the way we compute 
the ``total'' CCR ceiling using IPPS CCR data. Specifically, we first 
calculate the total (that is, operating and capital) CCR for each IPPS 
hospital. We then calculate the weighted average ``total'' CCR for all 
IPPS hospitals in the rural areas of the State and the weighted average 
``total'' CCR for all IPPS hospitals in the urban areas of the State. 
(For further detail on our methodology for annually determining the 
LTCH urban and rural statewide average CCRs, we refer readers to the FY 
2007 IPPS final rule (71 FR 48119 through 48121).) We also established 
that the applicable statewide average ``total'' (operating and capital) 
CCRs used under the LTCH PPS will continue to be published annually in 
the IPPS proposed and final rules, and the public should continue to 
consult the annual IPPS proposed and final rules for changes to the 
applicable statewide average total CCRs that would be effective for 
discharges occurring on or after October 1 each year. Accordingly, in 
the FY 2007 IPPS final rule (71 FR 48122), the FY 2007 LTCH PPS 
statewide average total CCRs for urban and rural hospitals, effective 
for discharges occurring on or after October 1, 2006, were presented in 
Table 8C of the Addendum of that final rule (71 FR 48303).
    In this proposed rule, in accordance with Sec.  
412.525(a)(4)(iv)(C) for high-cost outliers and Sec.  
412.529(c)(3)(iv)(C) for short-stay outliers, using our established 
methodology for determining the LTCH statewide average CCRs (described 
above), based on the most recent complete IPPS total CCR data from the 
December 2006 update of the Provider-Specific File, the proposed LTCH 
PPS statewide average total CCRs for urban and rural hospitals that 
would be effective October 1, 2007, are presented in Table 8C of the 
Addendum to this proposed rule. Furthermore, we are proposing that, if 
more recent data are available, we would use such data to determine the 
final statewide average total CCRs for urban and rural hospitals under 
the LTCH PPS for FY 2008 using our established methodology described 
above.
    We note that, for this proposed rule, as we established when we 
revised our methodology for determining the applicable LTCH statewide 
average CCRs in the FY 2007 IPPS final rule (71 FR 48119 through 
48121), and as is the case under the IPPS, all areas in the District of 
Columbia, New Jersey, Puerto Rico, and Rhode Island are classified as 
urban, and therefore there are no proposed rural statewide average 
total CCRs listed for those jurisdictions in Table 8C of the Addendum 
to this proposed rule. In addition, as we established when we revised 
our methodology for determining the applicable LTCH statewide average 
CCRs in that same final rule, and as is the case under the IPPS, 
although Massachusetts has areas that are designated as rural, there 
are no short-term acute care IPPS hospitals or LTCHs located in those 
areas as of December 2006. Therefore, there is no proposed rural 
statewide average total CCR listed for rural Massachusetts in Table 8C 
of the Addendum of this proposed rule. As we also established when we 
revised our methodology for determining the applicable LTCH statewide 
average CCRs in the FY 2007 IPPS final rule (71 FR 48120 through 
48121), in determining the urban and rural statewide average total CCRs 
for Maryland LTCHs paid under the LTCH PPS, we used, as a proxy, the 
national average total CCR for urban IPPS hospitals and the national 
average total CCR for rural IPPS hospitals, respectively. We use this 
proxy because we believe that the CCR data on the Provider-Specific 
File for Maryland hospitals may not be accurate (as discussed in 
greater detail in that same final rule (71 FR 48120)).

VII. Services Furnished to Beneficiaries in Custody of Penal 
Authorities

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

[[Page 24826]]

caption ``Beneficiaries in Custody'' at the beginning of your comment.)
    Section 1862(a)(2) of the Act prohibits payment under Medicare Part 
A or Part B for any items or services for which the beneficiary has no 
legal obligation to pay, and which no other person or organization 
(such as a prepayment plan of which the beneficiary is a member) has a 
legal obligation to provide or pay for the service. Our current 
regulations at Sec.  411.4(b) specify the special conditions when 
Medicare payment may be made for services furnished to individuals in 
custody of penal authorities. These regulatory conditions include: (1) 
State or local law requires those individuals or groups of individuals 
to repay the cost of medical services they receive while in custody; 
and (2) the State or local government entity enforces the requirement 
to pay by billing all such individuals, whether or not covered by 
Medicare or any other health insurance, and by pursuing collection of 
the amounts they owe in the same way and with the same vigor that it 
pursues the collection of other debts.
    However, Sec.  411.4(b) does not define ``custody'' and does not 
clearly state that CMS will not defer to a particular State or local 
government's definition (or interpretation) of what constitutes 
``custody.'' In this proposed rule, we are proposing to specify that, 
for purposes of Medicare payment, individuals who are in ``custody'' 
include, but are not limited to, individuals who are under arrest, 
incarcerated, imprisoned, escaped from confinement, under supervised 
release, required to reside in mental health facilities, required to 
reside in halfway houses, required to live under home detention, or 
confined completely or partially in any way under a penal statute or 
rule. We believe that this proposed definition of ``custody'' is in 
accordance with how custody has been defined by Federal courts for 
purposes of the habeas corpus protections of the Constitution. For 
example, the term ``custody'' is not limited solely to physical 
confinement. (Sanders v. Freeman, 221 F.3d 846, 850-51 (6th Cir. 
2000).) Individuals on parole, probation, bail, or supervised release 
may be ``in custody.''

VIII. MedPAC Recommendations

    (If you choose to comment on issues in this section, please include 
the caption ``MedPAC Update Recommendation'' at the beginning of your 
comment.)
    We are required by section 1886(e)(4)(B) of the Act to respond to 
MedPAC's IPPS recommendations in our annual proposed IPPS rule. We have 
reviewed MedPAC's March 2007 ``Report to the Congress: Medicare Payment 
Policy'' and have given it careful consideration in conjunction with 
the proposed policies set forth in this document. MedPAC's 
Recommendation 2A-1 states that, ``The Congress should increase payment 
rates for the acute inpatient and outpatient prospective payment 
systems in 2008 by the projected rate of increase in the hospital 
market basket index, concurrent with implementation of a quality 
incentive payment program.'' This recommendation is discussed in 
Appendix B to this proposed rule.
    Recommendation 2A-2: MedPAC recommended that, ``Concurrent with 
implementation of severity adjustment to Medicare's diagnosis related 
group payments, the Congress should reduce the indirect medical 
education adjustment in fiscal year 2008 by 1 percentage point to 4.5 
percent per 10 percent increment in the resident-to-bed ratio. The 
funds obtained from reducing the indirect medical education adjustment 
should be used to fund a quality incentive payment system.'' MedPAC 
further states that the IME adjustment is ``set above the empirical 
level which contributes to the large differences between teaching and 
nonteaching hospitals in financial performance under Medicare.'' MedPAC 
asserts that since there is no accountability for how IME funds are 
used, and teaching hospitals will benefit from implementation of the 
severity adjusted DRGs the IME adjustment should be reduced in FY 2008.
    Response: We note that, MedPAC stated in its March 2007 Report that 
Congress made a conscious decision to fund the IME adjustment above the 
empirical level due to the concern for how teaching hospitals would 
fare under the PPS. Because the IME adjustment is set by Congress, as 
cited in section 1886(d)(5)(B) of the Act, any change to the IME 
adjustment, whether it is a 1 percentage point reduction or reduction 
of the IME adjustment to its empirical level, would require a statutory 
change. Therefore, absent a change to the IME provision in the Medicare 
statute for FY 2008, the IME adjustment will remain at the current 
level required by the statute, as specified in section IV.D. of this 
preamble.
    Recommendation 2A-3: MedPAC recommended that, ``The Secretary 
should improve the form and accompanying instructions for collecting 
data on uncompensated care in the Medicare cost report and require 
hospitals to report using the revised form as soon as possible.'' 
MedPAC indicated that ``accurate data on hospitals'' charity care and 
bad debts are crucial to any effort to help develop a federal payment 
mechanism to help hospitals with their uncompensated care.''
    Response: MedPAC convened an ``Expert Panel on Measuring 
Uncompensated Care'' on May 5, 2005, to address concerns raised by 
stakeholders on the usefulness of the S-10 Worksheet data. CMS' 
representatives participated in the discussions on this expert panel, 
and listened carefully to the concerns of MedPAC and the stakeholders 
about the S-10 Worksheet. MedPAC is recommending that we adopt the list 
of recommended changes to the S-10 Worksheet that resulted from the 
panel's discussion. CMS is currently undertaking a major update of the 
hospital cost report and will be making changes to the S-10 Worksheet 
form and accompanying instructions based on the panel's discussions 
with MedPAC.
    In sections II.C. through E. of the preamble of this proposed rule, 
we further address the recommendations included in Recommendation 1 and 
Recommendation 3 in the March 2005 Report to Congress on Physician-
Owned Specialty Hospitals. Recommendation 1 relates to refining the 
DRGs used under the IPPS 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; and basing the 
weights on the national average of hospitals' relative values in each 
DRG. Recommendation 3 recommended that the Secretary implement MedPAC's 
recommended policies over a transition period.
    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 website at: http://www.medpac.gov.

IX. Other Required Information

A. Requests for Data from the Public

    In order to respond promptly to public requests for data related to 
the prospective payment system, we have established a process under 
which commenters can gain access to raw data on an expedited basis. 
Generally, the data are available in computer tape or cartridge format; 
however, some files are available on diskette as well as on the 
Internet at: http://www.cms.hhs.gov/providers/hipps. Data files and the 
cost for each file, if applicable, are listed below. Anyone wishing to 
purchase

[[Page 24827]]

data tapes, cartridges, or diskettes should submit a written request 
along with a company check or money order (payable to CMS-PUF) to cover 
the cost to the following address: Centers for Medicare & Medicaid 
Services, Public Use Files, Accounting Division, P.O. Box 7520, 
Baltimore, MD 21207-0520, (410) 786-3691. Files on the Internet may be 
downloaded without charge.
1. CMS Wage Data Public Use File
    This file contains the hospital hours and salaries from Worksheet 
S-3, Parts II and Parts III from FY 2004 cost reports used to create 
the proposed FY 2008 IPPS wage index. The file is typically available 
by the end of February each year for the NPRM and will be available by 
the beginning of May for the final rule.

------------------------------------------------------------------------
                                                                  PPS
                  Processing year                   Wage data    fiscal
                                                       year       year
------------------------------------------------------------------------
2007..............................................       2004       2008
2006..............................................       2003       2007
2005..............................................       2002       2006
------------------------------------------------------------------------

    Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage.
    Periods Available: FY 2006 through 2008 IPPS Updates.
2. CMS Occupational Mix Data Public Use File
    This file contains the occupational mix survey data to be used to 
compute the occupational mix adjusted wage indexes. The file is 
typically available by the end of February each year for the NPRM and 
will be available by the beginning of May for the final rule.
    Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage.
    Periods Available: FY 2008 PPS Update.
3. Final AHWs for FY 2007 and Proposed AHWs for FY 2008 by CBSA Public 
Use File
    This file includes CBSAs, and the AHWs by CBSA for FY 2007 (final 
data) and FY 2008 (proposed data). This file is typically available by 
the end of February each year for the NPRM.
    Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage.
    Periods Available: FY 2008 IPPS Proposed Rule Update.
4. FY 2008 Occupational Mix Adjusted and Unadjusted AHWs by Provider
    This file is available after publication of each IPPS NPRM and 
final rule, and includes provider number, CBSA, the provider's 
unadjusted and occupational mix adjusted AHW, and the percent 
difference between the two.
    Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage.
    Periods Available: FY 2008 IPPS Update.
5. FY 2008 Occupational Mix Adjusted and Unadjusted AHWs and Pre-
Reclass Wage Indexes by CBSA
    This file is available after publication of each IPPS NPRM and 
final rule, and is organized by CBSA, and contains total CBSA 
occupational mix wages, total CBSA hours, CBSA occupational mix 
adjusted AHWs, CBSA occupational mix adjusted pre-reclass wage indexes, 
total CBS unadjusted wages, CBSA unadjusted AHWs, and unadjusted pre-
reclass wage indexes.
    Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage.
    Periods Available: FY 2008 IPPS Update.
6. FY 2008 Occupational Mix Factor by Provider Public Use File
    This file is available after publication of each IPPS NPRM and 
final rule, and is organized by provider, and includes occupational mix 
adjusted and unadjusted wages, occupational mix adjusted and unadjusted 
AHWs, the nurse occupational mix adjustment factor, and the CBSA nurse 
occupational mix adjustment factor.
    Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage.
    Periods Available: FY 2008 IPPS Update.
7. FY 2008 Average Hourly Wage by Provider and CBSA Public Use File
    This file is available after publication of each IPPS NPRM and 
final rule, and includes occupational mix adjusted wages, hours, 
occupational mix adjusted AHWs, and pre-reclass occupational mix 
adjusted wage indexes, by provider and CBSA.
    Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage.
    Periods Available: FY 2008 IPPS Update.
8. IPPS SSA/FIPS CBSA State and County Crosswalk
    This file contains a crosswalk of State and county codes used by 
the Social Security Administration (SSA) and the Federal Information 
Processing Standards (FIPS), county name, Core Based Statistical Area 
(CBSA), and the historical list of Metropolitan Statistical Areas 
(MSAs).
    Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/FFD/list.asp#TopOfPage.
    Periods Available: FY 2008 IPPS Update.
9. FY 2008 Proposed Rule AHW by Provider Area Listing
    This file contains a spreadsheet with two tabs: One for providers 
that are geographically located in an area, and one for providers that 
are reclassifying. The first tab includes the pre-reclass occupational 
mix adjusted total wages and AHWs by provider and CBSA, and the second 
tab lists the providers that are reclassifying and their post-reclass 
occupational mix adjusted total wages and AHWs by provider and CBSA. 
This file is typically posted after publication of the IPPS NPRM each 
year.
    Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage.
    Periods Available: FY 2008 IPPS Proposed Rule Update.
10. PPS-IV to PPS-XII Minimum Data Set
    The Minimum Data Set contains cost, statistical, financial, and 
other information from Medicare hospital cost reports. The data set 
includes only the most current cost report (as submitted, final 
settled, or reopened) submitted for a Medicare participating hospital 
by the Medicare fiscal intermediary to CMS. This data set is updated at 
the end of each calendar quarter and is available on the last day of 
the following month.
    Media: Compact Disc (CD).
    File Cost: $100.00 per year.

------------------------------------------------------------------------
                                                  Periods
                                                 beginning    and before
                                                on or after
------------------------------------------------------------------------
PPS-IV........................................     10/01/86     10/01/87
PPS-V.........................................     10/01/87     10/01/88
PPS-VI........................................     10/01/88     10/01/89
PPS-VII.......................................     10/01/89     10/01/90
PPS-VIII......................................     10/01/90     10/01/91
PPS-IX........................................     10/01/91     10/01/92
PPS-X.........................................     10/01/92     10/01/93
PPS-XI........................................     10/01/93     10/01/94
PPS-XII.......................................     10/01/94    10/01/95
------------------------------------------------------------------------
(Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII, PPS-
  XIX PPS-XX, PPS-XXI, and PPS-XX-II Minimum Data Sets are part of the
  PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII, PPS-XIX, PPS-
  XX, PPS-XXI, and PPS-XXII Hospital Data Set Files (refer to item 10
  below).)

11. PPS-XIII to PPS-XXII Hospital Data Set
    The file contains cost, statistical, financial, and other data from 
the Medicare Hospital Cost Report. The data set includes only the most 
current cost

[[Page 24828]]

report (as submitted, final settled, or reopened) submitted for a 
Medicare-certified hospital by the Medicare fiscal intermediary to CMS. 
The data set is updated at the end of each calendar quarter and is 
available on the last day of the following month.
    Media: Compact Disc (CD).
    File Cost: $100.00.

------------------------------------------------------------------------
                                                  Periods
                                                 beginning    and before
                                                on or after
------------------------------------------------------------------------
PPS-XIII......................................     10/01/95     10/01/96
PPS-XIV.......................................     10/01/96     10/01/97
PPS-XV........................................     10/01/97     10/01/98
PPS-XVI.......................................     10/01/98     10/01/99
PPS-XVII......................................     10/01/99     10/01/00
PPS-XVIII.....................................     10/01/00     10/01/01
PPS-XIX.......................................     10/01/01     10/01/02
PPS-XX........................................     10/01/02     10/01/03
PPS-XXI.......................................     10/01/03     10/01/04
PPS-XXII......................................     10/01/04     10/01/05
------------------------------------------------------------------------

12. Provider-Specific File
    This file is a component of the PRICER program used in the fiscal 
intermediary's system to compute DRG payments for individual bills. The 
file contains records for all prospective payment system eligible 
hospitals, including hospitals in waiver States, and data elements used 
in the prospective payment system recalibration processes and related 
activities. Beginning with December 1988, the individual records were 
enlarged to include pass-through per diems and other elements.
    Media: Internet at http://www.cms.hhs.gov/ProspMedicareFeeSvcPmtGen/Downloads/INP_psf0107.zip.
    Periods Available: FY 2008 PPS Update.
13. CMS Medicare Case-Mix Index File
    The Medicare case-mix indexes by provider number are published in 
table 2 of each year's update of the Medicare hospital inpatient 
prospective payment system. The case-mix index is a measure of the 
costliness of cases treated by a hospital relative to the cost of the 
national average of all Medicare hospital cases, using DRG weights as a 
measure of relative costliness of cases. Two versions of this file are 
created each year.
    They support the following:
     NPRM published in the Federal Register.
     Final rule published in the Federal Register.
    Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/WIFN/list.asp#TopOfPage.
    Periods Available: FY 2006 through FY 2008.
14. DRG Relative Weights (Table 5 DRG)
    This file contains a listing of DRGs, DRG narrative descriptions, 
relative weights, and geometric and arithmetic mean lengths of stay as 
published in the Federal Register. There are two versions of this file 
as published in the Federal Register:
     NPRM.
     Final rule.
    Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/FFD/list.asp#TopOfPage.
    Periods Available: FY 2006 through FY 2008 PPS Update.
15. PPS Payment Impact File
    This file contains data used to estimate payments under Medicare's 
hospital inpatient prospective payment systems for operating and 
capital-related costs. The data are taken from various sources, 
including the Provider-Specific File, Minimum Data Sets, and prior 
impact files. The data set is abstracted from an internal file used for 
the impact analysis of the changes to the prospective payment systems 
published in the Federal Register.
    Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/FFD/list.asp#TopOfPage and http://www.cms.hhs.gov/AcuteInpatientPPS/HIF/list.asp#TopOfPage.
    Periods Available: FY 1994 through FY 2008 PPS Update
16. AOR/BOR Tables
    This file contains data used to develop the DRG relative weights. 
It contains mean, maximum, minimum, standard deviation, and coefficient 
of variation statistics by DRG for length of stay and standardized 
charges. The BOR tables are ``Before Outliers Removed'' and the AOR is 
``After Outliers Removed.'' (Outliers refer to statistical outliers, 
not payment outliers.)
    Two versions of this file are created each year. They support the 
following:
     NPRM published in the Federal Register.
     Final rule published in the Federal Register.
    Media: Internet at http://www.cms.hhs.gov/AcuteInpatientPPS/FFD/list.asp#TopOfPage.
    Periods Available: FY 2008 PPS Update.
17. Prospective Payment System (PPS) Standardizing File
    This file contains information that standardizes the charges used 
to calculate relative weights to determine payments under the 
prospective payment system. Variables include wage index, cost-of-
living adjustment (COLA), case-mix index, disproportionate share, and 
the Metropolitan Statistical Area (MSA). The file supports the 
following:
     NPRM published in the Federal Register.
     Final rule published in the Federal Register.
    Media: Internet.
    Periods Available: FY 2008 PPS Update.
    For further information concerning these data tapes, contact the 
CMS Public Use Files Hotline at (410) 786-3691.
    Commenters interested in obtaining or discussing any other data 
used in constructing this proposed rule should contact Mark Hartstein 
at (410) 786-4548.

B. Collection of Information Requirements

    Under the Paperwork Reduction Act of 1995 (PRA), we are required to 
provide 60-day notice in the Federal Register and solicit public 
comment before a collection of information requirement is submitted to 
the Office of Management and Budget (OMB) for review and approval. In 
order to fairly evaluate whether an information collection should be 
approved by OMB, section 3506(c)(2)(A) of the PRA 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.
    We are soliciting public comment on each of these issues for the 
following sections of this document that contain information collection 
requirements.

Section 412.103 Special Treatment: Hospitals Located in Urban Areas and 
That Apply for Reclassifications as Rural

    Section 412.103(g)(1) states that (1) for a hospital paid on the 
basis of reasonable costs, the hospital may cancel its rural 
reclassification by submitting a written request to the CMS Regional 
Office not less than 120 days prior to the end of its current cost 
reporting period, and (2) for a hospital paid under the hospital 
inpatient prospective payment system, the hospital may cancel its rural 
reclassification by submitting a written request to the CMS Regional 
Office not less than 120 days prior to the end of a Federal fiscal year 
and after being paid as rural for at least one 12-month cost reporting 
period.

[[Page 24829]]

    The burden associated with these requirements is the time and 
effort required for a hospital to develop, draft, and submit its 
written request for the cancellation of its rural reclassification. 
While these requirements are subject to the PRA, we believe the burden 
is exempt under 5 CFR 1320.3(c)(4). We believe that the information 
collection requirements in Sec.  412.103(g)(1) and Sec.  421.103(g)(2), 
respectively, will impact less than 10 entities. The notices will be 
submitted by individual hospitals and will be reviewed on a case-by-
case basis.

Section 489.20 Basic Commitments

    Proposed Sec.  489.20(u)(1) would require physician-owned 
hospitals, as defined in Sec.  489.3, to furnish notice to all patients 
that the hospital is a physician-owned hospital. The notice must be 
furnished at the beginning of their hospital stay or outpatient visit. 
The burden associated with the aforementioned requirements is the time 
and effort associated with a physician-owned hospital developing a 
generic notice and providing notice to the patients. Approximately 175 
physician-owned hospitals must comply with this requirement. We 
estimate that it will require a hospital's general counsel 4 hours to 
develop a standard notice to be furnished to all patients upon 
admission as an inpatient or an outpatient.
    In addition, we estimate that it will take 30 seconds to provide 
the notice to a patient and it will take another 30 seconds to maintain 
a copy of the disclosure in the patient's medical record. On average, 
each hospital will be required to make 1,092 disclosures per year. The 
total burden associated with the requirements in Sec.  489.20(u)(1) is 
3,885 annual burden hours.
    Proposed Sec.  489.20(v) would require all hospitals, as defined in 
Sec.  489.24(b), to furnish all patients notice, in accordance with 
Sec.  482.13(b)(2), at the beginning of their hospital stay or 
outpatient visit if a doctor of medicine or a doctor of osteopathy is 
not present in the hospital 24 hours per day, 7 days per week. The 
notice must indicate how the hospital will meet the medical needs of 
any inpatient who develops an emergency medical condition, as defined 
in Sec.  489.24(b), at a time when there is no physician present in the 
hospital. The burden associated with this requirement is the time and 
effort necessary for each hospital to develop a standard notice to 
furnish to its patients. We believe 2,504 hospitals will be required to 
comply with this requirement. Complying with the requirement will 
require a hospital's general counsel 4 hours to develop a standard 
notice. In addition, we estimate that it will take 30 seconds to 
provide the notice to a patient, and it will take another 30 seconds to 
maintain a copy of the disclosure in the patient's medical record. On 
average, each hospital will be required to make 1,092 disclosures per 
year. The total burden associated with the requirements in Sec.  
489.20(v)(1) is 55,588 annual burden hours.

                               Estimated Annual Reporting and Recordkeeping Burden
----------------------------------------------------------------------------------------------------------------
                                                                                                        Total
                                                                                        Burden  per     annual
           Requirements             OMB control number    Respondents      Responses      response      burden
                                                                                          (hours)      (hours)
----------------------------------------------------------------------------------------------------------------
Sec.   489.20(u)(1)..............  0938-New...........             175              75            4          700
                                   ...................             175         191,100      .016667        3,185
Sec.   489.20(v)(1)..............  0938-New...........           2,504           2,504            4       10,016
                                   ...................           2,504       2,734,368      .016667       45,572
                                  ------------------------------------------------------------------------------
    Total........................  ...................  ..............  ..............  ...........       59,473
----------------------------------------------------------------------------------------------------------------

    This proposed rule imposes collection of information requirements 
as outlined in the regulation text and specified above. However, this 
proposed rule also makes reference to several associated information 
collections that are not discussed in the regulation text. The 
following is a discussion of these collections, which have already 
received the Office of Management and Budget's (OMB) approval.

Proposed Add-on Payments for New Services and Technologies

    Section II.I.1 of the preamble of this proposed rule discusses 
proposed add-on payments for new services and technologies. 
Specifically, this section states that applicants for add-on payments 
for new medical services or technologies for FY 2009 must submit a 
formal request. A formal request includes 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. In 
addition, the request must contain a significant sample of the data to 
demonstrate that the medical service or technology meets the high-cost 
threshold.
    We also detailed the burden associated with this requirement in a 
final rule published in the Federal Register on September 7, 2001 (66 
FR 46902). As stated in that final rule, we believe the associated 
burden is exempt from the PRA as stipulated under 5 CFR 1320.3(h)(6). 
Collection of the information for this requirement will be conducted on 
individual case-by-case basis.

Occupational Mix Adjustment to the FY 2008 Index (Hospital Wage Index 
Occupational Mix Survey)

    Section III. of the preamble of this proposed rule details the 
proposed changes to the hospital wage index. Specifically, section 
III.C addresses the proposed occupational mix adjustment to the 
proposed FY 2008 index. While the preamble does not contain any new 
information collection requirements, it is important to note that there 
is an OMB approved collection associated with the hospital wage index.
    As stated in section III.C. of the preamble of this proposed rule, 
section 304(c) of Pub. L. 106-554 amended section 1886(d)(3)(E) of the 
Act to require CMS to collect data at least once 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. We collect the data via 
the occupational mix survey.
    The burden associated with this information collection request is 
the time and effort required to collect and submit the data in the 
Hospital Wage Index Occupational Mix Survey to CMS. While this burden 
is subject to the PRA, it is already approved under OMB control number 
0938-0907, with an expiration date of May 31, 2009.

[[Page 24830]]

Revisions to the Wage Index Based on Hospital Redesignations (Medicare 
Geographic Classification Review Board)

    As noted in section III.I of the preamble of this proposed rule, 
section 1886(d)(10) of the Act established the MGCRB, an entity that 
has the authority to accept IPPS hospital applications requesting 
geographic reclassification for wage index or standardized payment 
amounts and to issue decisions on these requests. It is important for 
CMS to ensure the accuracy of the MGCRB decisions and remain apprised 
of potential payment impacts. Our regulations at Sec.  412.256 require 
a hospital to submit a copy of its MGCRB application to CMS.
    The burden associated with this requirement is the time and effort 
associated with a hospital compiling and submitting a copy of its MGCRB 
application to CMS. While this requirement is subject to the PRA, the 
burden is approved under OMB control number 0938-0573, with an 
expiration date of November 30, 2008.

Reporting of Hospital Quality Data for Annual Hospital Payment Update

    As noted in section IV.A.1 of the preamble of this proposed rule, 
section 5001(a) of the DRA sets out new requirements for the RHQDAPU 
program. The RHQDAPU program was established to implement section 
501(b) of Pub. L. 108-173, thereby expanding our Hospital Quality 
Initiative. The RHQDAPU program originally consisted of a ``starter 
set'' of 10 quality measures. Hospitals participating in the hospital 
quality initiative submit their quality data on the 10 measures to 
receive an increase in their Medicare Annual Payment Update. The Office 
of Management and Budget approved the collection of data associated 
with the original starter set of quality measures under OMB control 
number 0938-0918, with an expiration date of January 31, 2010.
    However, we recently submitted a new information collection request 
containing additional quality measures to OMB for approval. The new 
measures collect data for the Surgical Care Improvement Project (SCIP) 
and mortality measures. We announced and sought public comment on the 
information collection request in both 60-day and 30-day Federal 
Register notices that published on October 13, 2006 (71 FR 60532), and 
December 22, 2006 (71 FR 77026), respectively. The revised information 
collection request is currently under review at OMB.
    Section IV.A.1 of the preamble of this proposed rule also discusses 
the use of the HCAHPS survey to capture quality data. The survey is 
designed to produce comparable data on the patient's perspective on 
care that allows objective and meaningful comparisons between hospitals 
on domains that are important to consumers. The HCAHPS survey is 
currently approved under OMB control number 0938-0981, with an 
expiration date of December 31, 2007.
    Section IV.A.2.h of the preamble of this proposed rule addresses 
the reconsideration and appeal procedures for a hospital that we 
believe did not meet the RHQDAPU program requirements. If a hospital 
disagrees with our determination, it may submit a written request to us 
requesting that we reconsider our decision. The hospital's letter must 
explain the reasons it believes it did meet the RHQDAPU program 
requirements. While this is a reporting requirement, the burden 
associated with it is not subject to the PRA under 5 CFR 1320.4(a)(2). 
The burden associated with information collection requirements imposed 
subsequent to an administrative action is not subject to the PRA.
    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 Group, Attn: 
William N. Parham, III, CMS-1533-P, Room C4-26-05, 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: Carolyn Lovett, CMS Desk Officer, CMS-1533-P, [email protected]. Fax (202) 395-6974.

C. Response to Comments

    Because of the large number of comments we normally receive on 
Federal Register documents, we are not able to acknowledge or respond 
to them individually. We will consider all comments we receive by the 
date and time specified in the DATES section of this preamble, and, 
when we proceed with a subsequent document, we will respond to the 
comments in the preamble to that document.

List of Subjects

42 CFR Part 411

    Kidney diseases, Medicare, Physician referral, Reporting and 
recordkeeping requirements.

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 489

    Health facilities, Medicare, Reporting and recordkeeping 
requirements.

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

PART 411--EXCLUSIONS FROM MEDICARE AND LIMITATIONS ON MEDICARE 
PAYMENT

    1. The authority citation for Part 411 continues to read as 
follows:

    Authority: Secs. 1102, 1860D-4(e)(6), 1871, and 1877(b)(4) and 
(5) of the Social Security Act (42 U.S.C. 1302, 1395w-10(e)(6), 
1395hh, and 1395nn(b)(4) and (5).

    2. Section 411.4 is amended by revising the introductory text of 
paragraph (b) to read as follows:


Sec.  411.4  Services for which neither the beneficiary nor any other 
person is legally obligated to pay.

* * * * *
    (b) Special conditions for services furnished to individuals in 
custody of penal authorities. Individuals who are in custody include, 
but are not limited to, individuals who are under arrest, incarcerated, 
imprisoned, escaped from confinement, under supervised release, 
required to reside in mental health facilities, required to reside in 
halfway houses, required to live under home detention, or confined 
completely or partially in any way under a penal statute or rule. 
Payment may be made for services furnished to individuals or groups of 
individuals who are in the custody of police or other penal authorities 
or in the custody of a government agency under a penal statute only if 
the following conditions are met.
* * * * *

[[Page 24831]]

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL 
SERVICES

    3. The authority citation for Part 412 is revised to read as 
follows:

    Authority: Secs. 1102 and 1871 of the Social Security Act (42 
U.S.C. 1302 and 1395hh), and sec. 124 of Pub. L. 106-113 (113 Stat. 
1501A-332).

    4. Section 412.2 is amended by adding a new paragraph (g) to read 
as follows:


Sec.  412.2  Basis for payment.

* * * * *
    (g) Payment adjustment for certain replaced devices. CMS makes a 
payment adjustment for certain replaced devices, as provided under 
Sec.  412.89.
    5. Section 412.4 is amended by--
    a. Revising paragraphs (d)(3)(ii)(B) and (d)(3)(ii)(C).
    b. Adding a new paragraph (d)(3)(ii)(D).
    c. Revising paragraph (f)(3).
    d. Revising the introductory text of paragraph (f)(5).
    e. Revising paragraph (f)(5)(i).
    f. Revising paragraph (f)(5)(iv).
    g. Adding a new paragraph (f)(6).
    The revisions and additions read as follows:


Sec.  412.4  Discharges and transfers.

* * * * *
    (d) * * *
    (3) * * *
* * * * *
    (ii) * * *
    (B) The proportion of short-stay discharges to postacute care to 
total discharges in the DRG exceeds the 55th percentile for all DRGs;
    (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 paragraphs (d)(3)(ii)(A) and 
(d)(3)(ii)(B) of this section; and
    (D) In the case of MS-DRGs that share the same base MS-DRG, if one 
MS-DRG meets the criteria specified under paragraph (d)(3)(ii)(B) of 
this section, every MS-DRG that shares the same base MS-DRG is a 
qualifying DRG.
* * * * *
    (f) * * *
    (3) Transfer assigned to DRG for newborns that die or are 
transferred to another hospital. If a transfer is classified into CMS 
DRG 385 (Neonates, Died or Transferred) prior to October 1, 2007, or 
into MS-DRG 789 (Neonates, Died or Transferred to Another Acute Care 
Facility) on or after October 1, 2007, the transferring hospital is 
paid in accordance with Sec.  412.2(b).
* * * * *
    (5) Special rule for DRGs meeting specific criteria. For discharges 
occurring on or after October 1, 2005, and prior to October 1, 2007, a 
hospital that transfers an inpatient under the circumstances described 
in paragraph (c) of this section is paid using the provisions of 
paragraphs (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)(ii) of this section.
* * * * *
    (iv) If a DRG is 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 paragraphs (f)(5)(i) through 
(f)(5)(iii) of this section, that DRG will also be paid under the 
provisions of paragraphs (f)(2)(i) and (f)(2)(ii) of this section.
    (6) Special rule for DRGs meeting specific criteria. For discharges 
occurring on or after October 1, 2007, a hospital that transfers an 
inpatient under the circumstances described in paragraph (c) of this 
section is paid using the provisions of paragraphs (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)(ii) 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.
    (iv) If a DRG is part of an MS-DRG group that meets the criteria 
specified in paragraphs (f)(6)(i) through (f)(6)(iii) of this section, 
that DRG will also be paid under the provisions of paragraphs (f)(2)(i) 
and (f)(2)(ii) of this section.
    6. Section 412.64 is amended by--
    a. Revising paragraph (b)(1)(ii)(B).
    b. In paragraph (b)(3), designating the existing text as (b)(3)(i) 
and adding a new paragraph (b)(3)(ii).
    c. Adding a new paragraph (e)(3).
    d. Revising paragraph (i)(2).
    The revisions read as follows:


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

* * * * *
    (b) * * *
    (1) * * *
    (ii) * * *
    (B) For discharges occurring on or after October 1, 1983, and 
before October 1, 2007, the following New England counties, which are 
deemed to be parts of urban areas under section 601(g) of the Social 
Security Amendments of 1983 (Public Law 98-21, 42 U.S.C. 1395ww (note); 
Litchfield County, Connecticut; York County, Maine; Sagadahoc County, 
Maine; Merrimack County, New Hampshire; and Newport County, Rhode 
Island.
* * * * *
    (3)(i) * * *
    (ii) For discharges occurring on or after October 1, 2007, 
hospitals in the following New England counties, if not already located 
in an urban area, are deemed to be located in urban areas under section 
601(g) of the Social Security Amendments of 1983 (Public Law 98-21, 42 
U.S.C. 1395ww (note)): Litchfield County, Connecticut; York County, 
Maine; Sagadahoc County, Maine; Merrimack County, New Hampshire; and 
Newport County, Rhode Island.
* * * * *
    (e) * * *
    (3) To the extent CMS determines that changes to the DRG 
classification and recalibrations of the DRG relative weights for a 
previous year (or estimates that such adjustments for a future fiscal 
year) did (or are likely to) result in a change in aggregate payments 
under this subsection during the fiscal year that are a result of 
changes in coding or classification of discharges that do not reflect 
real changes in case mix, CMS may adjust the standardized amount for 
subsequent fiscal years so as to eliminate the effect of such coding 
and classification changes.
    (i) * * *
    (2) Amount of adjustment. A hospital located in a county that meets 
the criteria under paragraphs (i)(1)(i) through (i)(1)(iii) of this 
section will receive an increase in its wage index that is equal to a 
weighted average of the difference between the postreclassified wage 
index of the MSA (or MSAs) with the higher wage index (or wage indices) 
and the postreclassified wage index of the MSA or rural statewide area 
in which the qualifying county is located, weighted by the overall 
percentage of the hospital employees residing in the qualifying county 
who are employed in any MSA with a higher wage index.
* * * * *
    7. The heading of Subpart F is revised to read as follows:

[[Page 24832]]

Subpart F--Payments for Outlier Cases, Special Treatment Payment 
for New Technology, and Payment Adjustment for Certain Replaced 
Devices

    8. Section 412.88 is amended by revising the introductory text of 
paragraph (a)(2) to read as follows:


Sec.  412.88  Additional payment for new medical service or technology.

    (a) * * *
    (2) If the costs of the discharge (determined by applying the 
operating cost-to-charge ratios as described in Sec.  412.84(h)) exceed 
the full DRG payment, an additional amount equal to the lesser of--
* * * * *
    9. A new undesignated center heading and a new Sec.  412.89 are 
added under Subpart F following Sec.  412.88 to read as follows:

Payment Adjustment for Certain Replaced Devices


Sec.  412.89  Payment adjustment for certain replaced devices.

    (a) General rule. For discharges occurring on or after October 1, 
2007, the amount of payment for a discharge described in paragraph (b) 
of this section is reduced when--
    (1) A device is replaced without cost to the hospital;
    (2) The provider received full credit for the cost of a device; or
    (3) The provider receives a credit equal to 20 percent or more of 
the cost of the device.
    (b) Discharges subject to payment adjustment. (1) Payment is 
reduced in accordance with paragraph (a) of this section only if the 
implantation of the device determines the DRG assignment.
    (2) CMS lists the DRGs that qualify under paragraph (b)(1) of this 
section in the annual final rule for the hospital inpatient prospective 
payment system.
    (c) Amount of reduction. (1) For a device provided to the hospital 
without cost, the cost of the device is subtracted from the DRG 
payment.
    (2) For a device for which the hospital received a full or partial 
credit, the amount credited is subtracted from the DRG payment.
    10. Section 412.103 is amended by revising paragraph (g) to read as 
follows:


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

* * * * *
    (g) Cancellation of classification--(1) Hospitals paid on basis of 
reasonable costs. For a hospital paid on the basis of reasonable 
costs--
    (i) A hospital may cancel its rural reclassification by submitting 
a written request to the CMS Regional Office not less than 120 days 
prior to the end of its current cost reporting period.
    (ii) The hospital's cancellation of the classification is effective 
beginning with the next full cost reporting period.
    (2) Hospitals paid under the hospital inpatient prospective payment 
system. For a hospital paid under the hospital inpatient prospective 
payment system--
    (i) A hospital may cancel its rural reclassification by submitting 
a written request to the CMS Regional Office not less than 120 days 
prior to the end of a Federal fiscal year and after being paid as rural 
for at least one 12-month cost reporting period.
    (ii) The hospital's cancellation of the classification is not 
effective until it has been paid as rural for at least one 12-month 
cost reporting period, and not until the beginning of the Federal 
fiscal year following such 12-month cost reporting period.
    11. Section 412.105 is amended by adding a sentence at the end of 
paragraph (f)(1)(iii)(A) to read as follows:


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

* * * * *
    (f) * * *
    (1) * * *
    (iii) * * *
    (A) * * * Effective for cost reporting periods beginning on or 
after October 1, 2007, vacation leave and sick leave (that do not 
prolong the total time a resident is participating in the approved 
program beyond the normal duration of the program) are not included in 
the determination of full-time equivalency.
* * * * *
    12. Section 412.308 is amended by--
    a. Revising paragraph (c)(1)(ii).
    b. Adding new paragraphs (c)(1)(iii) and (c)(1)(iv).
    The revision and addition read as follows:


Sec.  412.308  Determining and updating the Federal rate.

* * * * *
    (c) * * *
    (1) * * *
    (ii) Effective FY 1996. Except as specified in paragraph 
(c)(1)(iii) of this section, effective FY 1996, the standard Federal 
rate is updated based on an analytical framework. The framework 
includes a capital input price index, which measures the annual change 
in the prices associated with capital-related costs during the year. 
CMS adjusts the capital input price index rate of change to take into 
account forecast errors, changes to the case-mix index, the effect of 
changes to DRG classification and relative weights, and allowable 
changes in the intensity of hospital services.
    (iii) Effective FY 2008. Effective FY 2008, the update to the 
standard Federal rate for urban hospitals equals 0 and the update for 
rural hospitals is determined based on an analytical framework as 
described in paragraph (c)(1)(ii) of this section.
    (iv) Definition of urban and rural hospital. For purposes of 
paragraph (c)(1)(iii) of this section, an urban hospital is a hospital 
located in an area that meets the definition under Sec.  
412.64(b)(1)(ii)(A) or Sec.  412.64(b)(1)(ii)(B) or that is deemed to 
be located in an urban area under Sec.  412.64(b)(3). A rural hospital 
includes a hospital reclassified under Sec.  412.103.
* * * * *
    13. Section 412.316 is amended by--
    a. Revising the introductory text of paragraph (b).
    b. Revising paragraph (b)(2).
    c. Revising paragraph (b)(3).
    The revisions read as follows:


Sec.  412.316  Geographic adjustment factor.

* * * * *
    (b) Large urban location. For discharges occurring on or before 
September 30, 2007, CMS provides an additional payment to a hospital 
located in a large urban area equal to 3.0 percent of what would 
otherwise be payable to the hospital based on the Federal rate.
* * * * *
    (2) For discharges occurring on or after October 1, 2004, and 
before October 1, 2007, the definition of large urban areas under Sec.  
412.63(c)(6) continues to be in effect for purposes of the payment 
adjustment under this section, based on the geographic classification 
under Sec.  412.64, except as provided for in paragraph (b)(3) of this 
section.
    (3) For purposes of this section, the geographic classifications 
specified under Sec.  412.64 apply, except that, effective for 
discharges occurring on or after October 1, 2006, and before October 1, 
2007, for an urban hospital that is reclassified as rural as set forth 
in Sec.  412.103, the geographic classification is rural.
* * * * *
    14. Section 412.517 is amended by--
    a. Redesignating the introductory text and paragraphs (a), (b), 
(c), and (d) as paragraphs (a) introductory text, (a)(1), (a)(2), 
(a)(3), and (a)(4), respectively.
    b. Reserving paragraph (b).
    c. Adding a new paragraph (c).

[[Page 24833]]

    The additions read as follows:


Sec.  412.517  Revision of LTC-DRG group classifications and weighting 
factors.

* * * * *
    (b) [Reserved]
    (c) To the extent CMS determines that changes to the DRG 
classifications and recalibrations of the DRG relative weights for a 
previous year (or estimates that such adjustments for a future fiscal 
year) did (or are likely to) result in a change in aggregate payments 
under this subpart during the fiscal year that are a result of changes 
in coding or classification of discharges that do not reflect real 
changes in case mix, CMS may adjust the DRG relative weights for 
subsequent fiscal years so as to eliminate the effect of such coding 
and classification changes.

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

    15. The authority citation for Part 413 is revised to read as 
follows:

    Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and 
(n), 1861(v), 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), 
1395x(v), 1395hh, 1395rr, 1395tt, and 1395ww); and sec. 124 of Pub. 
L. 106-133 (113 Stat. 1501A-332).

    16. Section 413.75(b) is amended by--
    a. Adding in alphabetical order a definition of ``orientation 
activities''.
    b. Revising the definition of ``patient care activities''.
    The addition and revision read as follows:


Sec.  413.75  Direct GME payments: General requirements.

* * * * *
    (b) * * *
    Orientation activities means activities that are principally 
designed to prepare an individual for employment as a resident in a 
particular setting, or for participation in a particular specialty 
program and patient care activities associated with that particular 
specialty program.
    Patient care activities means the care and treatment of particular 
patients, including services for which a physician or other 
practitioner may bill, and orientation activities as defined in this 
section.
* * * * *
    17. Section 413.78 is amended by adding a sentence at the end of 
paragraph (b) to read as follows:


Sec.  413.78  Direct GME payments: Determination of the total number of 
FTE residents.

* * * * *
    (b) * * * Effective for cost reporting periods beginning on or 
after October 1, 2007, vacation leave and sick leave (that do not 
prolong the total time a resident is participating in the approved 
program beyond the normal duration of the program) are not included in 
the determination of full-time equivalency.
* * * * *

PART 489--PROVIDER AGREEMENTS AND SUPPLIER APPROVAL

    18. The authority citation for part 489 is amended to read as 
follows:

    Authority: Secs. 1102, 1819, 1820(e), 1861, 1864(m), 1866, 1869, 
and 1871 of the Social Security Act (41 U.S.C. 1302, 1395i-3, 1395x, 
1395aa(m), 1395cc, 1395ff, and 1395hh)

    19. Section 489.3 is amended by adding a definition of ``physician-
owned hospital'' in alphabetical order to read as follows:


Sec.  489.3  Definitions.

* * * * *
    Physician-owned hospital means any participating hospital (as 
defined in Sec.  489.24) in which a physician or physicians have an 
ownership or investment interest. The ownership or investment interest 
may be through equity, debt, or other means, and includes an interest 
in an entity that holds an ownership or investment interest in the 
hospital.
    20. Section 489.12 is amended by--
    a. Revising paragraph (a)(2).
    b. Redesignating paragraph (a)(3) as paragraph (a)(4).
    c. Adding a new paragraph (a)(3).
    The revision and addition read as follows:


Sec.  489.12  Decision to deny an agreement.

    (a) * * *
    (2) The prospective provider has failed to disclose ownership and 
control interests in accordance with Sec.  420.206 of this chapter;
    (3) The prospective provider is a physician-owned hospital as 
defined in Sec.  489.3 and does not have procedures in place for making 
physician ownership disclosures to patients in accordance with Sec.  
489.20(u) of this chapter; or
* * * * *
    21. Section 489.20 is amended by adding new paragraphs (u) and (v) 
to read as follows:


Sec.  489.20  Basic commitments.

* * * * *
    (u) In the case of a physician-owned hospital as defined in Sec.  
489.3--
    (1) To furnish all patients notice, in accordance with Sec.  
482.13(b)(2), at the beginning of their hospital stay or outpatient 
visit that the hospital is a physician-owned hospital. The notice 
should disclose, in a manner reasonably designed to be understood by 
all patients, the fact that the hospital meets the Federal definition 
of a physician-owned hospital specified in Sec.  489.3 and that the 
list of the hospital's physician owners or investors is available upon 
request. For the purposes of this paragraph, the hospital stay or 
outpatient visit begins with the provision of a package of information 
regarding scheduled preadmission testing and registration for a planned 
hospital admission for inpatient care or outpatient service.
    (2) To require all physician owners who also are members of the 
hospital's medical staff to agree, as a condition of continued medical 
staff membership, to disclose in writing their ownership interest in 
the hospital to all patients they refer to the hospital. Disclosure 
shall be required at the time the referral is made.
    (v) In the case of a hospital as defined in Sec.  489.24(b), to 
furnish all patients written notice, in accordance with Sec.  
482.13(b)(2), at the beginning of their hospital stay or outpatient 
visit if a doctor of medicine or a doctor of osteopathy is not present 
in the hospital 24 hours per day, seven days per week. The notice must 
indicate how the hospital will meet the medical needs of any inpatient 
who develops an emergency medical condition, as defined in Sec.  
489.24(b), at a time when there is no physician present in the 
hospital. For purposes of this paragraph, the hospital stay or 
outpatient visit begins with the provision of a package of information 
regarding scheduled preadmission testing and registration for a planned 
hospital admission for inpatient care or the provision of a package of 
information regarding an outpatient service.
    22. Section 489.24 is amended by revising paragraph (a)(2) to read 
as follows:


Sec.  489.24  Special responsibilities of Medicare hospitals in 
emergency cases.

    (a) * * *
    (2) Nonapplicability of provisions of this section. Sanctions under 
this section for an inappropriate transfer during a national emergency 
or for the direction or relocation of an individual to receive medical 
screening at an alternate location do not apply to a hospital with a 
dedicated emergency department located in an emergency area, as 
specified in section 1135(g)(1) of

[[Page 24834]]

the Act. A waiver of these sanctions is limited to a 72-hour period 
beginning upon the implementation of a hospital disaster protocol, 
except that, if a public health emergency involves a pandemic 
infectious disease (such as pandemic influenza), the waiver will 
continue in effect until the termination of the applicable declaration 
of a public health emergency, as provided for by section 1135(e)(1)(B) 
of the Act.
* * * * *
    23. Section 489.53 is amended by--
    a. Redesignating paragraph (c) and (d) as paragraphs (d) as (e), 
respectively.
    b. Adding a new paragraph (c).
    c. In newly redesignated paragraph (d) introductory text, removing 
the cross-reference ``paragraph (c)(2) of this section'' and adding the 
reference ``paragraph (d)(2) of this section'' in its place.
    The revisions and additions read as follows:


Sec.  489.53  Termination by CMS.

* * * * *
    (c) Termination of agreements with physician-owned hospitals. In 
the case of a physician-owned hospital, as defined at Sec.  489.3, CMS 
may terminate the provider agreement if the hospital failed to comply 
with the requirements of Sec.  489.20(u).
* * * * *

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

    Dated: April 13, 2007.
Leslie Norwalk,
Acting Administrator, Centers for Medicare & Medicaid Services.
    Dated: April 13, 2007.
Michael O. Leavitt,
Secretary.


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

Addendum--Proposed Schedule of Standardized Amounts, Update Factors, 
and Rate-of-Increase Percentages Effective With Cost Reporting Periods 
Beginning On or After October 1, 2007

I. Summary and Background

    In this Addendum, we are setting forth the proposed methods and 
data we are using to determine the proposed prospective payment 
rates for Medicare hospital inpatient operating costs and Medicare 
hospital inpatient capital-related costs. We are also setting forth 
the proposed rate-of-increase percentages for updating the target 
amounts for certain hospitals and hospital units excluded from the 
IPPS. In general, except for SCHs, MDHs, and hospitals located in 
Puerto Rico, each hospital's payment per discharge under the IPPS is 
based on 100 percent of the Federal national rate, also known as the 
national adjusted standardized amount. This amount reflects the 
national average hospital cost 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 historically have 
been 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 did not have the option to use their FY 1996 hospital-specific 
rate.) Section 5003(a)(1) of Pub. L. 109-171 extended and modified 
the MDH special payment provision which was previously set to expire 
on October 1, 2006, to discharges occurring on or after October 1, 
2006, but before October 1, 2011. Under section 5003(b) of Pub. L. 
109-171, if the change results in an increase to its target amount, 
an MDH must rebase its hospital-specific rates to its FY 2002 cost 
report. In addition, under section 5003(c) of Pub. L. 109-171, MDHs 
are now paid based on the Federal national rate or, if higher, the 
Federal national rate plus 75 percent of the difference between the 
Federal national rate and the updated hospital-specific rate. 
Further, based upon section 5003(d) of Pub. L. 109-171, MDHs are no 
longer subject to the 12-percent cap on their DSH payment adjustment 
factor.
    For hospitals in Puerto Rico, the payment per discharge is based 
on the sum of 25 percent of a Puerto Rico rate that reflects base 
year average costs per case of Puerto Rico hospitals and 75 percent 
of the Federal national rate. (See section II.D.3. of this Addendum 
for a complete description.)
    As discussed below in section II. of this Addendum, we are 
proposing to make changes in the determination of the prospective 
payment rates for Medicare inpatient operating costs for FY 2008. In 
section III. of this Addendum, we discuss our proposed changes for 
determining the prospective payment rates for Medicare inpatient 
capital-related costs for FY 2008. Section IV. of this Addendum sets 
forth our proposed changes for determining the rate-of-increase 
limits for certain hospitals excluded from the IPPS for FY 2008. The 
tables to which we refer in the preamble of this proposed rule are 
presented in section VI. of this Addendum of this proposed rule.

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

    The basic methodology for determining prospective payment rates 
for hospital inpatient operating costs for FY 2005 and subsequent 
fiscal years is set forth at Sec.  412.64. The basic methodology for 
determining the prospective payment rates for hospital inpatient 
operating costs for hospitals located in Puerto Rico for FY 2005 and 
subsequent fiscal years is set forth at Sec. Sec.  412.211 and 
412.212. Below we discuss the factors used for determining the 
prospective payment rates.
    In summary, the proposed standardized amounts set forth in 
Tables 1A, 1B, 1C, and 1D of section VI. of this Addendum reflect--
     Equalization of the standardized amounts for urban and 
other areas at the level computed for large urban hospitals during 
FY 2004 and onward, as provided for under section 1886(d)(3)(A)(iv) 
of the Act, updated by the applicable percentage increase required 
under sections 1886(b)(3)(B)(i)(XX) and 1886(b)(3)(B)(viii) of the 
Act.
     The labor-related share that is applied to the 
standardized amounts and Puerto Rico-specific standardized amounts 
to give the hospital the highest payment, as provided for under 
sections 1886(d)(3)(E), and 1886(d)(9)(C)(iv) of the Act.
     Proposed updates of 3.3 percent for all areas (that is, 
the estimated full market basket percentage increase of 3.3 
percent), as required by section 1886(b)(3)(B)(i)(XX) of the Act, as 
amended by section 5001(a)(1) of Pub. L. 109-171, and reflecting the 
requirements of section 1886(b)(3)(B)(viii) of the Act, as added by 
section 5001(a)(3) of Pub. L. 109-171, to reduce the applicable 
percentage increase by 2.0 percentage points for a hospital that 
fails 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 the standardized amount to ensure 
budget neutrality for DRG recalibration and reclassification, as 
provided for under section 1886(d)(4)(C)(iii) of the Act.
     An adjustment to ensure the wage index update and 
changes are budget neutral, as provided for under section 
1886(d)(3)(E) of the Act.
     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 2007 budget neutrality 
factor and applying a revised factor.
     An adjustment to remove the FY 2007 outlier offset and 
apply an offset for FY 2008.
     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.
     An adjustment to eliminate the effect of coding or 
classification changes that do not reflect real changes in case-mix 
using the Secretary's authority under section 1886(d)(3)(A)(vi) of 
the Act (as discussed in section II.D.6. of the preamble to this 
proposed rule).
    We note that two budget neutrality provisions will no longer be 
applied to the standardized amounts beginning with FY 2008. First, 
in the FY 2005 IPPS final rule (69 FR 49032 through 49034), we 
allowed urban hospitals that became rural under the new labor market 
area definitions to maintain their assignment to the MSA where they 
were previously located for the 3-year period of FY 2005, FY 2006, 
and FY 2007. In these years, we provided for a budget neutrality

[[Page 24835]]

adjustment to the standardized amount to ensure that this policy did 
not increase Medicare expenditures for hospital inpatient services. 
For FY 2008, this budget neutrality adjustment to the IPPS 
standardized amounts will no longer be necessary because the 
provision has expired. Second, in this proposed rule, we are 
proposing a prospective change to how budget neutrality is applied 
to implement the rural floor for FY 2008 and subsequent years. As 
discussed in section III.G.4. of the preamble of this proposed rule, 
we are proposing to apply the budget neutrality adjustment to 
hospital wage indices rather than the standardized amount.

A. Calculation of the Proposed Adjusted Standardized Amount

1. Standardization of Base-Year Costs or Target Amounts

    In general, 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.
    In accordance with 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. In 
general, 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 1886(d)(3)(E) 
of the Act 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 
1886(d)(9)(C)(iv)(II) of the Act extends this provision to the 
labor-related share for hospitals located in Puerto Rico.)
    For FY 2008, we are not proposing to change the national and 
Puerto Rico-specific labor-related and nonlabor-related shares from 
the percentages established for FY 2007. Therefore, the labor-
related share would continue to be 69.7 percent for the national 
standardized amounts and 58.7 percent for the Puerto Rico specific 
standardized amount. Consistent with section 1886(d)(3)(E) of the 
Act, we will apply the wage index to a labor-related share of 62 
percent for all non-Puerto Rico hospitals whose wage indexes are 
less than or equal to 1.0000. For all non-Puerto Rico hospitals 
whose wage indices are greater than 1.0000, we will apply the wage 
index to a labor share of 69.7 percent of the national standardized 
amount. For a Puerto Rico hospital, we will apply a labor share of 
58.7 percent if its Puerto Rico-specific wage index is less than or 
equal to 1.0000. For Puerto Rico hospitals whose Puerto Rico-
specific wage index values are greater than 1.0000, we will apply a 
labor share of 62 percent.
    The standardized amounts for operating costs appear in Table 1A, 
1B, and 1C of the Addendum to this proposed rule.

2. Computing the Average Standardized Amount

    Section 1886(d)(3)(A)(iv) of the Act requires 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. Section 1886(d)(9)(A) of the Act equalizes the Puerto Rico-
specific urban and rural area rates. Accordingly, we are calculating 
FY 2008 national and Puerto Rico standardized amounts, irrespective 
of whether a hospital is located in an urban or rural location.

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 2008 by the 
full estimated market basket percentage increase for hospitals in 
all areas, as specified in section 1886(b)(3)(B)(i)(XX) of the Act, 
as amended by section 5001(a)(1) of Pub. L. 109-171. 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 2008 is 3.3 percent. Thus, for FY 2008, the proposed 
update to the average standardized amount is 3.3 percent for 
hospitals in all areas. The estimated market basket increase of 3.3 
percent is based on the 2007 first quarter forecast of the hospital 
market basket increase by the Office of the Actuary (as discussed in 
Appendix B of this proposed rule).
    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)(viii) of the Act, as added by 
section 5001(a)(3) of Pub. L. 109-171, provides for a reduction of 
2.0 percentage points to the update percentage increase (also known 
as the market basket update) for FY 2007 and each subsequent fiscal 
year for any ``subsection (d) hospital'' that does not submit 
quality data as discussed in section IV.A. of the preamble of this 
proposed rule. The standardized amounts in Tables 1A through 1C of 
section VI. of the Addendum to this proposed rule reflect these 
differential amounts.
    Although the update factors for FY 2008 are set by law, we are 
required by section 1886(e)(4) of the Act to recommend, taking into 
account MedPAC's recommendations, appropriate update factors for FY 
2008 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 in Appendix B of this proposed rule.

4. Other Adjustments to the Average Standardized Amount

    As in the past, we are adjusting the FY 2008 standardized amount 
to remove the effects of the FY 2007 geographic reclassifications 
and outlier payments before applying the FY 2008 updates. We then 
apply budget neutrality offsets for outliers and geographic 
reclassifications to the standardized amount based on FY 2008 
payment policies.
    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 sections 
1886(d)(4)(C)(iii) and 1886(d)(3)(E) 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 these conditions.
    Budget neutrality is determined by comparing aggregate IPPS 
payments before and after making the changes that are required to be 
budget neutral (for example, changes to DRG classifications, 
recalibration of the DRG relative weights, updates to the wage 
index, and different geographic reclassifications). We include 
outlier payments in the simulations because they may be affected by 
changes in these parameters.
    We are also proposing to adjust the standardized amount this 
year by an estimated amount 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. For FY 2008 and FY 2009, we are also proposing an 
adjustment to eliminate the effect of coding or classification 
changes that do not reflect real changes in case-mix using the 
Secretary's authority under section 1886(d)(3)(A)(vi) of the Act.

a. Proposed 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 of this proposed rule, 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

[[Page 24836]]

recalibration. However, equating the average case weight after 
recalibration to the average case weight before recalibration does 
not necessarily achieve budget neutrality with respect to aggregate 
payments to hospitals because payments to hospitals are affected by 
factors other than average case weight. Therefore, as we have done 
in past years, we are proposing to make a budget neutrality 
adjustment to ensure that the requirement of section 
1886(d)(4)(C)(iii) of the Act is met.
    Section 1886(d)(3)(E) of the Act requires us to update the 
hospital wage index on an annual basis beginning October 1, 1993. 
This provision also requires us to make any updates or adjustments 
to the wage index in a manner that ensures that aggregate payments 
to hospitals are not affected by the change in the wage index. 
Consistent with current policy, for FY 2008, we are adjusting 100 
percent of the wage index factor for occupational mix. We describe 
the occupational mix adjustment in section III.C. of the preamble to 
this proposed rule.
    To comply with the requirement that DRG reclassification and 
recalibration of the relative weights and the updated wage index be 
budget neutral, we are using FY 2006 discharge data to simulate 
payments and compare aggregate payments using the FY 2007 relative 
weights and wage indexes to aggregate payments using the proposed FY 
2008 relative weights and wage indexes. The same methodology was 
used for the FY 2007 budget neutrality adjustment. Based on this 
comparison, we computed a budget neutrality adjustment factor equal 
to 0.999317 to be applied to the national standardized amount. 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 of 0.998557 to be applied to the 
Puerto Rico-specific standardized amount. These budget neutrality 
adjustment factors are applied to the standardized amounts for FY 
2007 without removing prior year budget neutrality adjustments. In 
addition, as discussed in section IV. of this addendum, we are 
applying the same DRG reclassification and recalibration budget 
neutrality factor of 0.998557 to the hospital-specific rates that 
are to be effective for cost reporting periods beginning on or after 
October 1, 2007.

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 the wage index adjustments 
provided under section 1886(d)(13) of the Act are not budget 
neutral. Section 1886(d)(13)(H) of the Act provides that any 
increase in a wage index under section 1886(d)(13) 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 the budget neutrality factor, we used FY 2006 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 calculated an 
adjustment factor of 0.991938 to ensure that the effects of this 
reclassification are budget neutral, consistent with the statute.
    The proposed adjustment factor is applied to the standardized 
amount after removing the effects of the FY 2007 budget neutrality 
adjustment factor. We note that the FY 2008 adjustment reflects FY 
2008 wage index reclassifications approved by the MGCRB or the 
Administrator. (Section 1886(d)(10)(D)(v) of the Act makes wage 
index reclassifications effective for 3 years. Therefore, the FY 
2008 geographic reclassification could either be the continuation of 
a 3-year reclassification that began in FY 2006 or FY 2007 or a new 
one beginning in FY 2008.)

c. Case-Mix Budget Neutrality Adjustment

    The proposed MS-DRGs will increase the total number of DRGs from 
538 to 745. Such a significant expansion in the number of DRGs could 
lead hospitals to improve coding and documentation in order to have 
a case assigned to a DRG with a higher payment. As explained above, 
we make an adjustment to ensure that the DRG relative weights remain 
budget neutral assuming constant utilization. However, without an 
adjustment to the IPPS rates to account for expected case mix growth 
due to improved coding rather than to underlying changes in patient 
status, the change to severity DRGs will not be budget neutral. 
Section 1886(d)(3)(A)(vi) of the Act provides the Secretary with 
explicit authority to adjust the standardized amounts to account for 
case mix growth due to improved documentation and coding. Further, 
the Secretary may subsequently revisit this adjustment if actual 
data is different than the projection.
    Based on the Actuary's analysis, using the Secretary's authority 
under section 1886(d)(3)(A)(vi) of the Act to adjust the 
standardized amount to eliminate the effect of changes in coding or 
classification of discharges that do not reflect real changes in 
case-mix, we are proposing to reduce the IPPS standardized amounts 
by 2.4 percent each year for FY 2008 and FY 2009. Section 
1886(d)(3)(A)(vi) further gives the Secretary authority to revisit 
adjustments to the standardized amounts for changes in coding or 
classification of discharges that were based on estimates in a 
future year. Consistent with the statute, we will compare the actual 
increase in case-mix due to documentation and coding to our 
projection once we have actual data for FY 2008 and FY 2009 for the 
FY 2010 and FY 2011 IPPS rules. As that time, if necessary, we may 
make a further adjustment to the standardized amounts to account for 
the difference between our projection and actual data.

d. 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 an 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 CCR is applied to the total covered charges 
for the case to convert the charges to estimated costs. Payments for 
eligible cases are then made based on a marginal cost factor, which 
is a percentage of the estimated costs above the fixed-loss cost 
threshold. The marginal cost factor for FY 2008 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/AcuteInpatientPPS/04_outlier.asp#TopOfPage.

(1) Proposed FY 2008 Outlier Fixed-Loss Cost Threshold

    For FY 2008, we are proposing to use the same methodology used 
for FY 2007 (71 FR 48148 through 484151) to calculate the outlier 
threshold. Similar to the methodology used in the FY 2007 final 
rule, for FY 2008, we are applying an adjustment factor to the CCRs 
to account for cost and charge inflation (as explained below). As we 
have done in the past, to calculate the proposed FY 2008 outlier 
threshold, we simulated payments by applying FY 2008 rates and 
policies using cases from the FY 2006 MedPAR files. Therefore, in 
order to determine the proposed FY 2008 outlier threshold, we 
inflate the charges on the MedPAR claims by 2 years, from FY 2006 to 
FY 2008.
    We are proposing to continue using a refined methodology that 
takes into account the lower inflation in hospital charges that is 
occurring as a result of the outlier final rule (68 FR 34494), which 
changed our methodology for determining outlier

[[Page 24837]]

payments by implementing the use of more current CCRs. Our refined 
methodology uses more recent data that reflect the rate-of-change in 
hospital charges under the new outlier policy.
    Using the most recent data available, we calculated the 1-year 
average annualized rate-of-change in charges-per-case from the last 
quarter of FY 2005 in combination with the first quarter of FY 2006 
(July 1, 2005 through December 31, 2005) to the last quarter of FY 
2006 in combination with the first quarter of FY 2007 (July 1, 2006 
through December 31, 2006). This rate of change was 7.26 percent 
(1.0726) or 15.04 percent (1.1504) over 2 years.
    As we have done in the past, we are proposing to establish the 
proposed FY 2008 outlier threshold using hospital CCRs from the 
December 2006 update to the Provider-Specific File--the most recent 
available at the time of this proposed rule. This file includes CCRs 
that reflect implementation of the changes to the policy for 
determining the applicable CCRs that became effective August 8, 2003 
(68 FR 34494).
    As discussed in the FY 2007 final rule (71 FR 48150), we worked 
with the Actuary to derive the methodology described below to 
develop the CCR adjustment factor. For FY 2008, we are proposing to 
use the same methodology by using the operating cost per discharge 
increase in combination with the final updated market basket 
increase determined by Global Insight, Inc., as well as the charge 
inflation factor described above to estimate the adjustment to the 
CCRs. By using the market basket rate-of-increase and the increase 
in the average cost per discharge from hospital cost reports, we are 
using two different measures of cost inflation. For FY 2008, we 
determined the adjustment by taking the percentage increase in the 
operating costs per discharge from FY 2004 to FY 2005 (1.0529) from 
the cost report and dividing it by the final market basket increase 
from FY 2005 (1.043) We repeated this calculation for 2 prior years 
to determine the 3-year average of the rate of adjusted change in 
costs between the market basket rate-of-increase and the increase in 
cost per case from the cost report (FY 2002 to FY 2003 percentage 
increase of operating costs per discharge of 1.0721 divided by FY 
2003 final market basket increase of 1.041, FY 2003 to FY 2004 
percentage increase of operating costs per discharge of 1.0624 
divided by FY 2004 final market basket increase of 1.04). For FY 
2008, we averaged the differentials calculated for FY 2003, FY 2004, 
and FY 2005 which resulted in a mean ratio of 1.0203. We multiplied 
the 3-year average of 1.0203 by the 2006 market basket percentage 
increase of 1.0420, which resulted in an operating cost inflation 
factor of 6.32 percent or 1.0632. We then divided the operating cost 
inflation factor by the 1-year average change in charges (1.0726) 
and applied an adjustment factor of 0.9912 to the operating CCRs 
from the Provider-Specific File.
    As stated in the FY 2007 final rule, we continue to believe it 
is appropriate to apply only a one year adjustment factor to the 
CCRs. On average, it takes approximately 9 months for fiscal 
intermediaries (or, if applicable, the MAC) to tentatively settle a 
cost report from the fiscal year end of a hospital's cost reporting 
period. The average ``age'' of hospitals'' CCRs from the time the 
fiscal intermediary or the MAC inserts the CCR in the PSF until the 
beginning of FY 2007 is approximately 1 year. Therefore, as stated 
above, we believe a one year adjustment to the CCRs is appropriate.
    We used the same methodology for the capital CCRs and applied an 
adjustment factor of 0.964 (cost inflation factor of 1.0340 divided 
by a charge inflation factor of 1.0726) to the capital CCRs. We are 
using the same charge inflation factor for the capital CCRs that was 
used for the operating CCRs. The charge inflation factor is based on 
the overall billed charges. Therefore, we believe it is appropriate 
to apply the charge factor to both the operating and capital CCRs.
    Using this methodology, we are proposing an outlier fixed-loss 
cost threshold for FY 2008 equal to the prospective payment rate for 
the DRG, plus any IME and DSH payments, and any add-on payments for 
new technology, plus $23,015. With this threshold, we are projecting 
that outlier payments will equal 5.1 percent of total IPPS payments.
    As we did in establishing the FY 2007 outlier threshold (71 FR 
48149), in our projection of FY 2008 outlier payments, we are not 
making any adjustments for the possibility that hospitals' CCRs and 
outlier payments may be reconciled upon cost report settlement. We 
continue to believe that, due to the policy implemented in the 
outlier final rule (68 FR 34494, June 9, 2003), CCRs will no longer 
fluctuate significantly and, therefore, few hospitals will actually 
have these ratios reconciled upon cost report settlement. In 
addition, it is difficult to predict the specific hospitals that 
will have CCRs and outlier payments reconciled in any given year. We 
also noted that reconciliation occurs because hospitals' actual CCRs 
for the cost reporting period are different than the interim CCRs 
used to calculate outlier payments when a bill is processed. Our 
simulations assume that CCRs accurately measure hospital costs based 
on information available to us at the time we set the outlier 
threshold. For these reasons, we are not making any assumptions 
about the effects of reconciliation on the outlier threshold 
calculation.
    We also note that there are several factors that contributed to 
a lower fixed loss outlier threshold for FY 2008 compared to FY 
2007. First, the case-weighted national average operating CCR 
declined by approximately an additional 1.3 percentage points from 
the March 2006 (used to calculate the FY 2007 outlier threshold) to 
the December 2006 update of the Provider-Specific File. Second, we 
further reduced the CCRs by applying an adjustment to reflect the 
differential increase between costs and charges. As noted above, 
using lower CCRs from the December 2006 Provider-Specific File, in 
combination with the FY 2006 MedPAR claims and inflated charges, 
contributes to a lower outlier threshold for FY 2008 in this 
proposed rule compared to an outlier threshold of $24,485 in FY 
2007. Finally, as discussed in section II.D. of the preamble of this 
proposed rule, we are proposing to adopt the use of MS-DRGs under 
the IPPS for FY 2008. The proposed MS-DRG system would increase the 
number of DRGs from 538 to 745 and better recognize severity of 
illness than the CMS DRGs. Better recognition of severity of illness 
with the MS-DRGs means that nonoutlier payments will compensate 
hospitals for the higher costs of some cases that previously 
received outlier payments. As cases are paid more accurately, in 
order to meet the 5.1 percent target, we would need to decrease the 
fixed-loss outlier threshold so that more cases qualify for outlier 
payments. Therefore, we believe that all of the above factors 
cumulatively contributed to a lower proposed fixed-loss outlier 
threshold in FY 2008 compared to FY 2007.

(2) Other Proposed Changes Concerning Outliers

    As stated in the FY 1994 IPPS 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 are project that 
the proposed thresholds for FY 2008 would result in outlier payments 
equal to 5.1 percent of operating DRG payments and 4.87 percent of 
capital payments based on the Federal rate.
    In accordance with section 1886(d)(3)(B) of the Act, we are 
reducing the FY 2008 standardized amount by the same percentage to 
account for the projected proportion of payments paid to outliers.
    The outlier adjustment factors that would be applied to the 
standardized amount for the proposed FY 2008 outlier threshold are 
as follows:

------------------------------------------------------------------------
                                             Operating
                                           standardized       Capital
                                              amounts      federal  rate
------------------------------------------------------------------------
National................................        0.948989        0.948377
Puerto Rico.............................        0.965244        0.954922
------------------------------------------------------------------------

    Consistent with current policy, we are applying the outlier 
adjustment factors to FY 2008 rates after removing the effects of 
the FY 2007 outlier adjustment factors on the standardized amount.
    To determine whether a case qualifies for outlier payments, we 
apply hospital-specific CCRs to the total covered charges for the 
case. Estimated operating and capital costs for the case are 
calculated separately by applying separate operating and capital 
CCRs. These costs are then combined and compared with the outlier 
fixed-loss cost threshold.
    The outlier final rule (68 FR 34494) eliminated the application 
of the statewide average CCRs for hospitals with CCRs that fall 
below 3 standard deviations from the national mean CCR. However, for 
those hospitals for which the fiscal intermediary or MAC computes 
operating CCRs greater than 1.221 or capital CCRs greater than 
0.150, or hospitals for whom the fiscal intermediary or MAC is 
unable to calculate a CCR (as described at Sec.  412.84(i)(3) of our 
regulations),

[[Page 24838]]

we are still using statewide average CCRs to determine whether a 
hospital qualifies for outlier payments.\18\ Table 8A in section VI. 
of this Addendum contains the statewide average operating CCRs for 
urban hospitals and for rural hospitals for which the fiscal 
intermediary or MAC is unable to compute a hospital-specific CCR 
within the above range. Effective for discharges occurring on or 
after October 1, 2007, these statewide average ratios would replace 
the ratios published in the IPPS final rule for FY 2007 (71 FR 
48303). Table 8B in section VI. of this Addendum contains the 
comparable statewide average capital CCRs. Again, the CCRs in Tables 
8A and 8B would be used during FY 2008 when hospital-specific CCRs 
based on the latest settled cost report are either not available or 
are outside the range noted above. For an explanation of Table 8C, 
please see section VI. of this Addendum.
---------------------------------------------------------------------------

    \18\ These figures represent 3.0 standard deviations from the 
mean of the log distribution of CCRs for all hospitals.
---------------------------------------------------------------------------

    We finally note that we published a manual update (Change 
Request 3966) to outliers on October 12, 2005 which updated Chapter 
3, Section 20.1.2 of the Medicare Claims Processing Manual. The 
manual update covered an array of topics, including CCRs, 
reconciliation, and the time value of money. We encourage hospitals 
that are assigned the statewide average operating and/or capital 
CCRs to work with their fiscal intermediaries or MAC on a possible 
alternative operating and/or capital CCR as explained in Change 
Request 3966. Use of an alternative CCR developed by the hospital in 
conjunction with the fiscal intermediary or MAC can avoid possible 
overpayments or underpayments at cost report settlement thus 
ensuring better accuracy when making outlier payments and negating 
the need for outlier reconciliation. We also note a hospital may 
request an alternative operating or capital CCR ratio at any time as 
long as the guidelines of Change Request 3966 are followed. To 
download and view the manual instructions on outlier and cost-to-
charge ratios, please visit the Web site: http://www.cms.hhs.gov/manuals/downloads/clm104c03.pdf.

(3) FY 2006 and FY 2007 Outlier Payments

    In the FY 2007 IPPS final rule (70 FR 47496), we stated that, 
based on available data, we estimated that actual FY 2006 outlier 
payments would be approximately 4.62 percent of actual total DRG 
payments. This estimate was computed based on simulations using the 
FY 2005 MedPAR file (discharge data for FY 2005 bills). That is, the 
estimate of actual outlier payments did not reflect actual FY 2006 
bills, but instead reflected the application of FY 2006 rates and 
policies to available FY 2005 bills.
    Our current estimate, using available FY 2006 bills, is that 
actual outlier payments for FY 2006 were approximately 4.50 percent 
of actual total DRG payments. Thus, the data indicate that, for FY 
2006, the percentage of actual outlier payments relative to actual 
total payments is lower than we projected before FY 2006. 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 2006 are equal to 5.1 percent of total DRG payments.
    We currently estimate that actual outlier payments for FY 2007 
will be approximately 4.9 percent of actual total DRG payments, 0.2 
percentage points lower than the 5.1 percent we projected in setting 
the outlier policies for FY 2007. This estimate is based on 
simulations using the FY 2006 MedPAR file (discharge data for FY 
2006 bills). We used these data to calculate an estimate of the 
actual outlier percentage for FY 2007 by applying FY 2007 rates and 
policies, including an outlier threshold of $24,485 to available FY 
2006 bills. We believe the 0.2 percentage point difference between 
the projected estimate of outlier payments for FY 2007 and our 
current estimate of actual outlier payments in this proposed rule 
provides preliminary evidence that incorporating an adjustment 
factor to the CCRs for FY 2007 in response to public comments has 
improved our estimating methodology.

e. Proposed 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 IV.G. of the preamble to this proposed rule, we have 
satisfied 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 $1,075,765. 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 9 participating hospitals, 
the total annual impact of the demonstration program is estimated to 
be $9,681,893. The required adjustment to the Federal rate used in 
calculating Medicare inpatient prospective payments as a result of 
the demonstration is 0.999899.
    In order to achieve budget neutrality, we are adjusting the 
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, consistent with past 
practice. We believe that the language of the statutory budget 
neutrality requirement permits the agency to implement the budget 
neutrality provision in this manner. The statutory language requires 
that ``aggregate payments made by the Secretary do not exceed the 
amount which the Secretary would have paid if the demonstration * * 
* was not implemented,'' but does not identify the range across 
which aggregate payments must be held equal.

5. Proposed FY 2008 Standardized Amount

    The proposed adjusted standardized amount is divided into labor-
related and nonlabor-related portions. Tables 1A and 1B in section 
VI. of this Addendum contain the national standardized amount that 
we are proposing to apply to all hospitals, except hospitals in 
Puerto Rico. The proposed Puerto Rico-specific amounts are shown in 
Table 1C. The proposed amounts shown in Tables 1A and 1B differ only 
in that the labor-related share applied to the standardized amounts 
in Table 1A is 69.7 percent, and 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 a 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. In effect, the statutory 
provision means that we will apply a labor-related share of 62 
percent for all hospitals (other than those in Puerto Rico) whose 
wage indexes are less than or equal to 1.0000.
    In addition, Tables 1A and 1B include proposed standardized 
amounts reflecting the proposed full 3.3 percent update for FY 2008, 
and proposed standardized amounts reflecting the 2.0 percentage 
point reduction to the update (a 1.3 percent update) applicable for 
hospitals that fail to submit quality data consistent with section 
1886(b)(3)(B)(viii) of the Act.
    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 (this 
proposed amount is set forth in Table 1A). The proposed labor-
related and nonlabor-related portions of the national average 
standardized amounts for Puerto Rico hospitals for FY 2008 are set 
forth in Table 1C of section VI. of this Addendum. This table also 
includes the proposed Puerto Rico standardized amounts. The labor-
related share applied to the proposed Puerto Rico specific 
standardized amount is 58.7 percent, or 62 percent, depending on 
which provides higher payments 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.)
    The following table illustrates the proposed changes from the FY 
2007 national average standardized amount. The second column shows 
the proposed changes from the FY 2007 standardized amounts for 
hospitals that satisfy the quality data submission requirement for 
receiving the full update (3.3 percent). The third column shows the 
proposed changes for hospitals receiving the reduced update (1.3 
percent). The first row of the table shows the proposed updated 
(through FY 2007) average standardized amount after restoring the FY 
2007 offsets for outlier payments, demonstration budget neutrality, 
the wage index transition budget neutrality, and the

[[Page 24839]]

geographic reclassification budget neutrality. The DRG 
reclassification and recalibration and wage index budget neutrality 
factor is cumulative. Therefore, the FY 2007 factor is not removed 
from this table. We have added two additional rows: One for the 
documentation and coding adjustment and the other for the rural 
floor adjustment. (For a complete discussion on the documentation 
and coding adjustment and the rural floor adjustment, see sections 
II.D.1.c and III.G.4 of the Addendum to this proposed rule). We have 
also added separate rows to this table to reflect the different 
labor related shares that apply to hospitals.

 Comparison of FY 2007 Standardized Amounts to Proposed FY 2008 Single Standardized Amount With Full Update and
                                                 Reduced Update
----------------------------------------------------------------------------------------------------------------
                                        Full update  (3.3 percent)             Reduced update  (1.3 percent)
----------------------------------------------------------------------------------------------------------------
FY 2007 Base Rate, after         Labor: $3,609.23.......................  Labor: $3,609.23
 removing reclassification       Nonlabor: $1,569.01....................  Nonlabor: $1,569.01
 budget neutrality,
 demonstration budget
 neutrality, wage index
 transition budget neutrality
 factors and outlier offset
 (based on the labor and market
 share percentage for FY 2008).
FY 2008 Update Factor..........  1.033..................................  1.013
FY 2008 DRG Recalibrations and   0.999317...............................  0.999317
 Wage Index Budget Neutrality
 Factor.
FY 2008 Reclassification Budget  0.991938...............................  0.991938
 Neutrality Factor.
Adjusted for Blend of FY 2007    Labor: $3,695.75.......................  Labor: $3,624.20
 DRG Recalibration and Wage      Nonlabor: $1,606.62....................  Nonlabor: $1,575.51
 Index Budget Neutrality
 Factors.
FY 2008 Outlier Factor.........  0.948989...............................  0.948989
Rural Demonstration Budget       0.999899...............................  0.999899
 Neutrality Factor.
Proposed FY 2008 Documentation   0.976..................................  0.976
 and Coding Adjustment.
Rural Floor Adjustment.........  1.002214...............................  1.002214
Proposed Rate for FY 2008        Labor: $3,051.33.......................  Labor: $2,992.26
 (after multiplying FY 2007      Nonlabor: $1,870.17....................  Nonlabor: $1,833.96
 base rate by above factors)
 where the wage index is less
 than or equal to 1.0000.
Proposed Rate for FY 2008        Labor: $3,430.29.......................  Labor: $3,363.88
 (after multiplying FY 2007      Nonlabor: $1,491.21....................  Nonlabor: $1,462.34
 base rate by above 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 standardized amount 
is 58.7 percent, or 62 percent, depending on which results in higher 
payments 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. Proposed Adjustments for Area Wage Levels and Cost-of-Living

    Tables 1A through 1C, as set forth in section VI. of this 
Addendum, contain the proposed labor-related and nonlabor-related 
shares that we are using to calculate the proposed prospective 
payment rates for hospitals located in the 50 States, the District 
of Columbia, and Puerto Rico for FY 2008. This section addresses two 
types of adjustments to the standardized amounts that are made in 
determining the proposed prospective payment rates as described in 
this Addendum.

1. Proposed Adjustment for Area Wage Levels

    Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require 
that we make an adjustment to the labor-related portion of the 
national and Puerto Rico prospective payment rates, respectively, to 
account for area differences in hospital wage levels. This 
adjustment is made by multiplying the labor-related portion of the 
adjusted standardized amounts by the appropriate wage index for the 
area in which the hospital is located. In section III. of the 
preamble to this proposed rule, we discuss the data and methodology 
for the proposed FY 2008 wage index.

2. Proposed 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 2008, we are proposing to adjust the payments for hospitals 
in Alaska and Hawaii by multiplying the nonlabor-related portion of 
the standardized amount by the applicable 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:
    City of Anchorage and 80-kilometer (50-mile)                  1.24
     radius by road.................................
    City of Fairbanks and 80-kilometer (50-mile)                  1.24
     radius by road.................................
    City of Juneau and 80-kilometer (50-mile) radius              1.24
     by road........................................
    Alaska-All areas................................              1.25
Hawaii:
    City and County of Honolulu.....................              1.25
    County of Hawaii................................              1.17
    County of Kauai.................................              1.25
    County of Maui and County of Kalawao............             1.25
------------------------------------------------------------------------
(The above factors are based on data obtained from the U.S. Office of
  Personnel Management.)


[[Page 24840]]

C. Proposed DRG Relative Weights

    As discussed in section II. of the preamble of this proposed 
rule, we are proposing to adopt a revised classification system for 
all hospital discharges, assigning them into proposed MS-DRGs, and 
have developed proposed relative weights for each MS-DRG that 
reflect the resource utilization of cases in each proposed MS-DRG 
relative to Medicare cases in other proposed MS-DRGs. Table 5 of 
section VI. of this Addendum contains the proposed relative weights 
that we would use for discharges occurring in FY 2008. These factors 
have been recalibrated as explained in section II. of the preamble 
of this proposed rule.

D. Calculation of the Proposed Prospective Payment Rates

    General Formula for Calculation of the Proposed Prospective 
Payment Rates for FY 2008
    In general, the operating prospective payment rate for all 
hospitals paid under the IPPS located outside of Puerto Rico, except 
SCHs and MDHs, for FY 2008 equals the Federal rate.
    The prospective payment rate for SCHs for FY 2008 equals the 
higher of the applicable Federal rate or the hospital-specific rate 
as described below. The prospective payment rate for MDHs for FY 
2008 equals the higher of the Federal rate, or the Federal rate plus 
75 percent of the difference between the Federal rate and the 
hospital-specific rate as described below. The prospective payment 
rate for Puerto Rico for FY 2008 equals 25 percent of the Puerto 
Rico rate plus 75 percent of the applicable national rate.

1. Federal Rate

    The Federal rate is determined as follows:
    Step 1--Select the applicable average standardized amount 
depending on whether the hospital has submitted qualifying quality 
data (full update for qualifying hospitals, update minus 2.0 
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.
    Step 3--For hospitals in Alaska and Hawaii, multiply the non-
labor-related portion of the standardized amount by the applicable 
cost-of-living adjustment factor.
    Step 4--Add the amount from Step 2 and the non-labor-related 
portion of the standardized amount (adjusted, if applicable, under 
Step 3).
    Step 5--Multiply the final amount from Step 4 by the relative 
weight corresponding to the applicable MS-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. In addition, for hospitals that qualify for a low-volume 
payment adjustment under section 1886(d)(12) of the Act, the payment 
in Step 5 would be increased by 25 percent.

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.
    As discussed previously, MDHs are required to rebase their 
hospital-specific rates to their FY 2002 cost reports if doing so 
results in higher payments. In addition, effective for discharges 
occurring on or after October 1, 2006, MDHs are to be paid based on 
the Federal national rate or, if higher, the Federal national rate 
plus 75 percent (changed from 50 percent) of the difference between 
the Federal national rate and the greater of the updated hospital-
specific rates based on either FY 1982, FY 1987 or FY 2002 costs per 
discharge. Further, MDHs will no longer be subject to the 12-percent 
cap on their DSH payment adjustment factor.
    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 
and for MDHs, the FY 2002 cost 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 (48 FR 
39772); the April 20, 1990 final rule with comment (55 FR 15150); 
the FY 1991 IPPS final rule (55 FR 35994); and the FY 2001 IPPS 
final rule (65 FR 47082). In addition, for both SCHs and MDHs, the 
hospital-specific rate is adjusted by the budget neutrality 
adjustment factor as discussed in section IV.C. of the preamble to 
this proposed rule. The resulting rate will be used in determining 
the payment rate an SCH or MDH will receive for its discharges 
beginning on or after October 1, 2007.

b. Updating the FY 1982, FY 1987, FY 1996, and FY 2002 Hospital-
Specific Rates for FY 2008

    We are proposing to increase the hospital-specific rates by 3.3 
percent (the proposed estimated hospital market basket percentage 
increase) for SCHs and MDHs for FY 2008. 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 2007, 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 2007, is the market basket rate-of-increase.

3. General Formula for Calculation of Proposed Prospective Payment 
Rates for Hospitals Located in Puerto Rico Beginning On or After 
October 1, 2007, and Before October 1, 2008

    Section 1886(d)(9)(E)(iv) of the Act provides that, 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 applicable average standardized amount 
considering the applicable wage index (see Table 1C).
    Step 2--Multiply the labor-related portion of the standardized 
amount by the applicable Puerto Rico-specific wage index.
    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 applicable MS-DRG 
relative weight (see Table 5 of section IV. of the Addendum).
    Step 5--Multiply the result in Step 4 by 25 percent.

b. National Rate

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

III. Proposed Changes to Payment Rates for Acute Care Hospital 
Inpatient Capital-Related Costs for FY 2008

    (If you choose to comment on issues in this section, please 
include the caption ``Capital Payment Rate'' at the beginning of 
your comment.)
    The PPS for acute care hospital inpatient capital-related costs 
was implemented for cost reporting periods beginning on or after 
October 1, 1991. Effective with that cost reporting period, 
hospitals were paid during a 10-year transition period (which 
extended through FY 2001) to change the payment methodology for 
Medicare acute care hospital inpatient capital-related costs from a 
reasonable cost-based methodology to a prospective methodology 
(based fully on the Federal rate).
    The basic methodology for determining Federal capital 
prospective rates is set forth in regulations at Sec. Sec.  412.308 
through 412.352. Below we discuss the factors that we are proposing 
to use to determine the capital Federal rate for FY 2008, which will 
be effective for discharges occurring on or after October 1, 2007.

[[Page 24841]]

    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, the budget 
neutrality adjustment factor in effect on September 30, 1995, be 
applied to the unadjusted capital standard Federal rate and the 
unadjusted hospital-specific rate. That factor was 0.8432, which was 
equivalent to a 15.68 percent reduction to the unadjusted capital 
payment rates. An additional 2.1 percent reduction to the rates was 
effective from October 1, 1997 through September 30, 2002, making 
the total reduction 17.78 percent. As we discussed in the FY 2003 
IPPS final rule (67 FR 50102) and implemented in Sec.  
412.308(b)(6), the 2.1 percent 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 payments are no 
longer being made under the regular exception policy effective with 
cost reporting periods beginning in FY 2002, 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 IPPS 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 Proposed Federal Hospital Inpatient Capital-
Related Prospective Payment Rate Update

    In the FY 2007 IPPS final rule (71 FR 48161), we established a 
tentative capital Federal rate of $427.38 for FY 2007. In the 
Federal Register notice establishing the occupational mix adjusted 
payment rates for FY 2007 (71 FR 59891), we established the final FY 
2007 Federal rate of $427.03 for FY 2007. In the discussion that 
follows, we explain the factors that we are proposing to use to 
determine the proposed FY 2008 capital Federal rate. However, as 
discussed in section V. of the preamble of this proposed rule, we 
are proposing two separate capital Federal rates for FY 2008: a 
capital Federal rate for rural hospitals and a capital Federal rate 
for urban hospitals. In particular, we explain why the proposed FY 
2008 capital Federal rate for rural hospitals would decrease 
approximately 2.3 percent, compared to the FY 2007 capital Federal 
rate, and why the proposed FY 2008 capital Federal rate for urban 
hospitals would decrease approximately 3.1 percent, compared to the 
FY 2007 capital Federal rate. Consequently, despite an estimated 
increase in Medicare fee-for-service discharges in FY 2008 as 
compared to FY 2007, we estimate aggregate capital payments would 
decrease by 0.13 percent during this same period. 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. As noted above, aggregate payments under the 
capital IPPS are estimated to decrease in FY 2008 compared to FY 
2007.

1. Projected Capital Standard Federal Rate Update

a. Description of the Update Framework

    Under Sec.  412.308(c)(1), the capital standard Federal rate is 
updated on the basis of an analytical framework that takes into 
account changes in a capital input price index (CIPI) and several 
other policy adjustment factors. Specifically, we have adjusted the 
projected CIPI rate-of-increase as appropriate each year for case-
mix index-related changes, for intensity, and for errors in previous 
CIPI forecasts. The proposed update factor for FY 2008 under that 
framework is 0.8 percent based on the best data available at this 
time. The proposed update factor under that framework is based on a 
projected 1.2 percent increase in the CIPI, a 0.0 percent adjustment 
for intensity, a 0.0 percent adjustment for case-mix, a -0.4 percent 
adjustment for the FY 2006 DRG

[[Page 24842]]

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 2008 CIPI 
projection in that same section of this Addendum. (However, as 
discussed in greater detail in section V. of the preamble of this 
proposed rule, we are proposing a zero percent update factor for 
urban hospitals instead of the 0.8 percent proposed update factor 
that we are proposing for rural hospitals. In addition, as also note 
below, the proposed capital rates would be further adjusted to 
account for upcoding under the proposed MS-DRGs discussed in section 
II.D. of the preamble of this proposed rule.) Below we describe the 
policy adjustments that have been applied in the update framework 
for FY 2008.
    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, 2004 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 II. of Appendix B in the FY 2006 IPPS final rule (70 FR 
47707).)
    Absent the proposed change to the MS-DRGs, for FY 2008, 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 2008. The net adjustment for change in case-mix is the 
difference between the projected real increase in case-mix and the 
projected total increase in case-mix. Therefore, the net adjustment 
for case-mix change in FY 2008 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 2006 DRG reclassification and recalibration as part of our 
proposed update for FY 2008. We estimate that FY 2006 DRG 
reclassification and recalibration resulted in a 0.4 percent change 
in the case-mix when compared with the case-mix index that would 
have resulted if we had not made the reclassification and 
recalibration changes to the DRGs. Therefore, we are proposing to 
make a -0.4 percent adjustment for DRG reclassification in the 
proposed update for FY 2008 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 0.10 percentage point was 
calculated for the FY 2006 update. That is, current historical data 
indicate that the forecasted FY 2006 CIPI (0.80 percent) used in 
calculating the FY 2006 update factor slightly understated the 
actual realized price increases (0.90 percent) by 0.10 percentage 
point. This slight underprediction was mostly due to the 
incorporation of newly available source data for fixed asset prices 
into the market basket. However, because this estimation of the 
change in the CIPI is less than 0.25 percentage points, it is not 
reflected in the update recommended under this framework. Therefore, 
we are proposing to make a 0.0 percent adjustment for forecast error 
in the update for FY 2008.
    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 past under 
the framework for 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 1.5 percent per year. However, 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.
    As noted above, our intensity measure is based on a 5-year 
average, and therefore, the intensity adjustment for FY 2008 is 
based on data from the 5-year period FY 2002 through FY 2006. We 
found a dramatic increase in hospital charges for each of those 5 
years 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, FY 2005 and FY 2006 update 
recommendations as discussed in the FY 2004 IPPS final rule (68 FR 
45482), the FY 2005 IPPS final rule (69 FR 49285) the FY 2006 IPPS 
final rule (70 FR 47500), and the

[[Page 24843]]

FY 2007 IPPS final rule (72 FR 47500), 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 2006 IPPS final rule (70 FR 47500) and 
the FY 2007 IPPS final rule (71 FR 48157), 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 2006 and FY 2007, 
respectively.
    On June 9, 2003, we published revisions to our outlier policy 
for determining the additional payment for extraordinarily high-cost 
cases (68 FR 34494 through 34515). These revised policies were 
effective on August 8, 2003, and October 1, 2003. While it does 
appear that a response to these policy changes is beginning to 
occur, that is, the change in charges for FYs 2004 and 2005 are 
somewhat less than the previous 4 years, and the change in charges 
for FY 2006 is slightly less than FY 2005, they still show a 
significant annual increase in charges without a corresponding 
increase in hospital case-mix. The increase in charges in FY 2004, 
for example, is approximately 12 percent, which, while less than the 
increase in the previous 3 years, is still much higher than 
increases in years prior to FY 2001. In addition, this approximate 
12-percent increase in charges for FY 2004 significantly exceeds the 
case-mix increase for the same period. Based on the approximate 12-
percent increase in charges for FY 2004, we believe residual effects 
of hospitals' charge practices prior to the implementation of the 
outlier policy revisions established in the June 9, 2003 final rule 
continue to appear in the data because hospitals may not have had 
enough time to adopt changes in their behavior in response to the 
new outlier policy. Thus, we believe that the FY 2004, FY 2005, and 
FY 2006 charge data may still be skewed. Because the intensity 
adjustment is based on a 5-year average, and although the new 
outlier policy was generally effective in FY 2004, we believe the 
effects of hospitals attempting to maximize outlier payments, while 
lessening, continue to skew the charge data.
    Therefore, we are proposing to make a 0.0 percent adjustment for 
intensity for FY 2008. 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 2008 until any increase in charges can be tied to intensity 
rather than to attempts to maximize outlier payments.
    Above, we described the basis of the components used to develop 
the proposed 0.8 percent capital update factor under the capital 
update framework for FY 2008 as shown in the table below. However, 
as discussed in section V. of the preamble of this proposed rule, we 
are proposing that the proposed 0.8 percent capital update be 
applied to rural hospitals only. We are proposing a 0.0 percent 
update for urban hospitals for reasons also discussed in section V. 
of the preamble of this proposed rule.

CMS Proposed FY 2008 Update Factor to the Capital Federal Rate for Rural
                                Hospitals
------------------------------------------------------------------------
 
------------------------------------------------------------------------
Capital Input Price Index.......................................     1.2
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 2005 Reclassification and Recalibration............    -0.4
Forecast Error Correction.......................................     0.0
                                                                 -------
  Total Update for Rural Hospitals..............................     0.8
------------------------------------------------------------------------

b. Comparison of CMS and MedPAC Update Recommendation

    In the past, MedPAC has included update recommendations for 
capital PPS in a Report to Congress. In its March 2007 Report to 
Congress, MedPAC did not make an update recommendation for capital 
IPPS payments for FY 2008. However, in that same report, MedPAC made 
an update recommendation for hospital inpatient and outpatient 
services (page 67). MedPAC reviews inpatient and outpatient services 
together because they are so closely interrelated. For FY 2008, 
MedPAC recommended an increase in the payment rate for the operating 
IPPS by the projected increase in the hospital market basket index 
concurrent with implementation of a quality incentive payment 
policy. (MedPAC's Report to the Congress: Medicare Payment Policy, 
March 2007, Section 2A.)

2. Proposed Outlier Payment Adjustment Factor

    Section 412.312(c) establishes a unified outlier methodology for 
inpatient operating and inpatient capital-related costs. A single 
set of thresholds is used to identify outlier cases for both 
inpatient operating and inpatient capital-related payments. Section 
412.308(c)(2) provides that the standard Federal rate for inpatient 
capital-related costs be reduced by an adjustment factor equal to 
the estimated proportion of capital-related outlier payments to 
total inpatient capital-related PPS payments. The outlier thresholds 
are set so that operating outlier payments are projected to be 5.1 
percent of total operating DRG payments.
    In the Federal Register notice establishing the final 
occupational mix adjusted payment rates for FY 2007 (71 FR 59890), 
we estimated that outlier payments for capital would equal 4.32 
percent of inpatient capital-related payments based on the capital 
Federal rate in FY 2007. Based on the proposed thresholds as set 
forth in section II.A.4.c. of this Addendum, we estimate that 
proposed outlier payments for capital-related costs would equal 5.16 
percent for inpatient capital-related payments based on the proposed 
Federal rate in FY 2008. Therefore, we are proposing to apply an 
outlier adjustment factor of 0.9484 to the capital Federal rate. 
Thus, we estimate that the percentage of capital outlier payments to 
total capital standard payments for FY 2008 will be slightly higher 
than the percentages for FY 2007.
    The outlier reduction factors are not built permanently into the 
capital rates; that is, they are not applied cumulatively in 
determining the capital Federal rate. The proposed FY 2008 outlier 
adjustment of 0.9484 is a -0.88 percent change from the FY 2007 
outlier adjustment of 0.9568. Therefore, the net change in the 
proposed outlier adjustment to the proposed capital Federal rate for 
FY 2008 is 0.9912 (0.9484/0.9568). Thus, the proposed outlier 
adjustment decreases the proposed FY 2008 capital Federal rate by 
0.88 percent compared with the FY 2007 outlier adjustment.

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

    Section 412.308(c)(4)(ii) requires that the capital Federal rate 
be adjusted so that aggregate payments for the fiscal year based on 
the capital Federal rate after any changes resulting from the annual 
DRG reclassification and recalibration and changes in the GAF are 
projected to equal aggregate payments that would have been made on 
the basis of the capital Federal rate without such changes. Because 
we implemented a separate GAF for Puerto Rico, we apply separate 
budget neutrality adjustments for the national GAF and the Puerto 
Rico GAF. We apply the same budget neutrality factor for DRG 
reclassifications and recalibration nationally and for Puerto Rico. 
Separate adjustments were unnecessary for FY 1998 and earlier 
because the GAF for Puerto Rico was implemented in FY 1998.
    In the past, we used the actuarial capital cost model (described 
in Appendix B of the FY 2002 IPPS final rule (66 FR 40099)) to 
estimate the aggregate payments that would have been made on the 
basis of the capital Federal rate with and without changes in the 
DRG classifications and weights and in the GAF to compute the 
adjustment required to maintain budget neutrality for changes in DRG 
weights and in the GAF. During the transition period, the capital 
cost model was also used to estimate the regular exception payment 
adjustment factor. As we explain in section III.A.4. of this 
Addendum, beginning in FY 2002, an adjustment for regular exception 
payments is no longer necessary. Therefore, we are no longer using 
the capital cost model. Instead, we are using historical data based 
on hospitals' actual cost experiences to determine the exceptions 
payment adjustment factor for special exceptions payments.
    To determine the proposed factors for FY 2008, we compared 
(separately for the national capital rate and the Puerto Rico 
capital rate) estimated aggregate capital Federal rate payments 
based on the FY 2007 DRG relative weights and the FY 2007 GAF to 
estimated aggregate capital Federal rate payments based on the 
proposed FY 2008 relative weights and the proposed FY 2008 GAF. As 
we established in the final FY 2007 occupational mix adjusted 
payment rates notice (71 FR 59890), the budget neutrality factors 
were 0.9906 for the national capital

[[Page 24844]]

rate and 0.9968 for the Puerto Rico capital rate. In making the 
comparison, we set the exceptions reduction factor to 1.00. To 
achieve budget neutrality for the changes in the national GAF, based 
on calculations using updated data, we propose to apply an 
incremental budget neutrality adjustment of 1.0026 for FY 2008 to 
the previous cumulative FY 2007 adjustments of 0.9906, yielding a 
proposed adjustment of 0.9932, through FY 2008 (calculations done on 
unrounded numbers). For the Puerto Rico GAF, we are proposing to 
apply a proposed incremental budget neutrality adjustment of 1.0009 
for FY 2008 to the previous cumulative FY 2007 adjustment of 0.9968, 
yielding a proposed cumulative adjustment of 0.9978 through FY 2008 
(calculations done on unrounded numbers).
    We then compared estimated aggregate capital Federal rate 
payments based on the FY 2007 DRG relative weights and the FY 2007 
GAF to estimated aggregate capital Federal rate payments based on 
the proposed FY 2008 DRG relative weights and the proposed FY 2008 
GAF. The proposed incremental adjustment for DRG classifications and 
changes in relative weights is 0.9992 both nationally and for Puerto 
Rico. The proposed cumulative adjustments for DRG classifications 
and changes in relative weights and for changes in the GAF through 
FY 2008 are 0.9924 nationally and 0.9970 for Puerto Rico. The 
following table summarizes the adjustment factors for each fiscal 
year:

[[Page 24845]]



                                         Budget Neutrality Adjustment for DRG Reclassifications and Recalibration and the Geographic Adjustment Factors
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                         National                                                          Puerto Rico
                                                           -------------------------------------------------------------------------------------------------------------------------------------
                                                                          Incremental adjustment                                             Incremental adjustment
                        Fiscal year                        ---------------------------------------------------                ---------------------------------------------------
                                                              Geographic           DRG                           Cumulative      Geographic           DRG                           Cumulative
                                                              adjustment    reclassifications     Combined                       adjustment    reclassifications     Combined
                                                                factor      and recalibration                                      factor      and recalibration
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1992......................................................  ..............  .................  ..............         1.00000  ..............  .................  ..............  ..............
1993......................................................  ..............  .................         0.99800         0.99800  ..............  .................  ..............  ..............
1994......................................................  ..............  .................         1.00531         1.00330  ..............  .................  ..............  ..............
1995......................................................  ..............  .................         0.99980         1.00310  ..............  .................  ..............  ..............
1996......................................................  ..............  .................         0.99940         1.00250  ..............  .................  ..............  ..............
1997......................................................  ..............  .................         0.99873         1.00123  ..............  .................  ..............  ..............
1998......................................................  ..............  .................         0.99892         1.00015  ..............  .................  ..............         1.00000
1999......................................................         0.99944           1.00335          1.00279         1.00294         0.99898           1.00335          1.00233         1.00233
2000......................................................         0.99857           0.99991          0.99848         1.00142         0.99910           0.99991          0.99901         1.00134
2001 \1\..................................................         0.99782           1.00009          0.99791         0.99933         1.00365           1.00009          1.00374         1.00508
2001 \2\..................................................     \3\ 0.99771       \3\ 1.00009      \3\ 0.99780         0.99922     \3\ 1.00365       \3\ 1.00009      \3\ 1.00374         1.00508
2002......................................................     \4\ 0.99666       \4\ 0.99668      \4\ 0.99335         0.99268     \4\ 0.98991       \4\ 0.99668      \4\ 0.99662         0.99164
2003 \5\..................................................         0.99915           0.99662          0.99577         0.98848         1.00809           0.99662          1.00468         0.99628
2003 \6\..................................................     \7\ 0.99896       \7\ 0.99662      \7\ 0.99558         0.98830         1.00809           0.99662          1.00468         0.99628
2004 \8\..................................................     \9\ 1.00175       \9\ 1.00081      \9\ 1.00256         0.99083         1.00028           1.00081          1.00109         0.99736
2004 \10\.................................................     \9\ 1.00164       \9\ 1.00081      \9\ 1.00245         0.99072         1.00028           1.00081          1.00109         0.99736
2005 \11\.................................................    \12\ 0.99967           1.00094     \12\ 1.00061         0.99137         0.99115           1.00094          0.99208         0.98946
2005 \13\.................................................    \12\ 0.99946           1.00094     \12\ 1.00040         0.99117         0.99115           1.00094          0.99208         0.98946
2006......................................................    \14\ 1.00185           0.99892     \14\ 1.00076         0.99198         1.00762           0.99892          1.00653         0.99592
2007......................................................         1.00000           0.99858          0.99858         0.99057         1.00234           0.99858          1.00092         0.99683
2008......................................................    \15\ 1.00261           0.99921     \15\ 1.00182    \15\ 0.99237    \15\ 1.00093           0.99921     \15\ 1.00014   \15\ 0.99697
------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Factors effective for the first half of FY 2001 (October 2000 through March 2001).
\2\ Factors effective for the second half of FY 2001 (April 2001 through September 2001).
\3\ Incremental factors are applied to FY 2000 cumulative factors.
\4\ Incremental factors are applied to the cumulative factors for the first half of FY 2001.
\5\ Factors effective for the first half of FY 2003 (October 2002 through March 2003).
\6\ Factors effective for the second half of FY 2003 (April 2003 through September 2003).
\7\ Incremental factors are applied to FY 2002 cumulative factors.
\8\ Factors effective for the first half of FY 2004 (October 2003 through March 2004).
\9\ Incremental factors are applied to the cumulative factors for the second half of FY 2003.
\10\ Factors effective for the second half of FY 2004 (April 2004 through September 2004).
\11\ Factors effective for the first quarter of FY 2005 (September 2004 through December 2004).
\12\ Incremental factors are applied to average of the cumulative factors for the first half (October 1, 2003 through March 31, 2004) and second half (April 1, 2004 through September 30, 2004)
  of FY 2004.
\13\ Factors effective for the last three quarters of FY 2005 (January 2005 through September 2005).
\14\ Incremental factors are applied to average of the cumulative factors for 2005.
\15\ Proposed factors for FY 2008, as discussed above in section III. of this Addendum.


[[Page 24846]]

    The methodology used to determine the recalibration and 
geographic (DRG/GAF) budget neutrality adjustment factor 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 Federal Register notice establishing the final FY 2007 
occupational mix adjusted payment rates (71 FR 59890), we calculated 
a GAF/DRG budget neutrality factor of 0.9986 for FY 2007. For FY 
2008, we are proposing to establish a proposed GAF/DRG budget 
neutrality factor of 1.0018. 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 proposed adjustment from FY 2007 
to FY 2008 is 1.0018. The cumulative change in the proposed capital 
Federal rate due to this proposed adjustment is 0.9924 (the product 
of the incremental factors for FYs 1994 through 2007 and the 
proposed incremental factor of 1.0018 for FY 2008). (We note that 
averages of the incremental factors that were in effect during FYs 
2004 and 2005, respectively, were used in the calculation of the 
proposed cumulative adjustment of 0.9924 for FY 2008.)
    This proposed factor accounts for DRG reclassifications and 
recalibration and for changes in the GAF. It also incorporates the 
effects on the proposed GAF of FY 2008 geographic reclassification 
decisions made by the MGCRB compared to FY 2007 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 2008 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 exceptions adjustment used in calculating the FY 
2007 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). Because we have cost reports ending in FY 2006 for 
all of these hospitals, we calculated the adjustment based on actual 
cost experience. Using data from cost reports ending in FY 2006 from 
the December 2006 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 2006, this ratio is 
rounded to 0.0003. Because we have not received all cost reports 
ending in FY 2006, we also divided the FY 2005 special exceptions 
payments by the total capital PPS payment amounts for all hospitals 
with cost reports ending in FY 2005. This ratio also rounds to 
0.0003. Because special exceptions are budget neutral, we are 
offsetting the proposed capital Federal rate by 0.03 percent for 
special exceptions payments for FY 2008. Therefore, the exceptions 
adjustment factor is equal to 0.9997 (1 - 0.0003) to account for 
special exceptions payments in FY 2008.
    In the FY 2007 IPPS final rule (71 FR 48161) we estimated that 
total (special) exceptions payments for FY 2007 would equal 0.03 
percent of aggregate payments based on the capital Federal rate. 
Therefore, we applied an exceptions adjustment factor of 0.9997 (1 - 
0.0003) in determining the FY 2007 capital Federal rate. As we 
stated above, we estimate that exceptions payments in FY 2008 will 
equal 0.03 percent of aggregate payments based on the proposed FY 
2008 capital Federal rate. Therefore, we are proposing to apply an 
exceptions payment adjustment factor of 0.9997 to the capital 
Federal rate for FY 2008. The proposed exceptions adjustment factor 
for FY 2008 is the same as the factor used in determining the FY 
2007 capital Federal rate in the FY 2007 IPPS final rule (71 FR 
48161) and is the same factor used for the occupational mix adjusted 
payment rates since the adjustments made to the wage index had no 
effect on capital exceptions payments (71 FR 59890). 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 proposed 
exceptions adjustment factor used in determining the proposed FY 
2008 capital Federal rate is 1.0000(0.9997/0.9997).

5. Proposed Capital Standard Federal Rate for FY 2008

    In the Federal Register notice that established the occupational 
mix adjusted payment rates for FY 2007 (71 FR 59891), we established 
a capital Federal rate of $427.03 for FY 2007. As discussed above 
and in section V. of the preamble of this proposed rule, we are 
proposing two separate capital Federal rates for FY 2008: a rural 
capital Federal rate based on an update of 0.8 percent and an urban 
capital Federal rate based on a 0.0 percent update. However, under 
the statutory authority at section 1886(d)(3)(A)(vi) of the Act, we 
are proposing an additional 2.4 percent reduction to the proposed 
standardized amounts for both capital and operating Federal payment 
rates. The proposed 2.4 percent reduction is based on our actuary's 
analysis to eliminate the effect of changes in coding or 
classification of discharges that do not reflect real changes in 
case-mix in light of the proposed MS-DRGs. Although the proposed 2.4 
percent reduction is outside the established process for developing 
the proposed capital Federal payment rate, it nevertheless is a 
factor in the final prospective payment rate to hospitals for 
capital-related costs. For that reason, the capital Federal payment 
rates proposed in this proposed rule were determined by applying the 
proposed 2.4 percent reduction. As a result of the proposed 0.8 
percent update for rural hospitals, the proposed 0.0 percent update 
for urban hospitals, the proposed 2.4 percent reduction to account 
for upcoding (for all hospitals), and the other factors as discussed 
above, we are proposing to establish a capital Federal rate for 
rural hospitals of $417.26 for FY 2008, and we are proposing to 
establish a capital Federal rate for urban hospitals of $413.87 for 
FY 2008. The proposed capital Federal rates for FY 2008 were 
calculated as follows:
     The proposed FY 2008 update factor for rural hospitals 
is 1.0080, that is, the update is 0.8 percent; and the proposed FY 
2008 update factor for urban hospitals is 1.0000, that is, the 
update is 0.0 percent.
     The proposed FY 2008 budget neutrality adjustment 
factor that is applied to the capital standard Federal payment rate 
for

[[Page 24847]]

changes in the DRG relative weights and in the GAF (for all 
hospitals) is 1.0018.
     The proposed FY 2008 outlier adjustment factor is 
0.9484.
     The proposed FY 2008 (special) exceptions payment 
adjustment factor is 0.9997.
     The proposed FY 2008 reduction for upcoding under the 
proposed MS-DRGs is -2.40 percent.
    Because the proposed capital Federal rate has already been 
adjusted for differences in case-mix, wages, cost-of-living, 
indirect medical education costs, and payments to hospitals serving 
a disproportionate share of low-income patients, we are not making 
additional adjustments in the capital standard Federal rate for 
these factors, other than the proposed budget neutrality factor for 
changes in the DRG relative weights and the GAF.
    We are providing the following charts that show how each of the 
proposed factors and adjustments for FY 2008 affected the 
computation of the proposed FY 2008 capital Federal rate for urban 
hospitals and the proposed FY 2008 capital Federal rate for rural 
hospitals in comparison to the FY 2007 capital Federal rate. The 
proposed FY 2008 update factor for urban hospitals of zero percent 
would have a 0.0 percent net effect on the proposed FY 2008 capital 
Federal compared to the FY 2007 capital Federal rate. The proposed 
FY 2008 update factor for rural hospitals has the effect of 
increasing the proposed capital Federal rate by 0.80 percent 
compared to the FY 2007 capital Federal rate. The proposed GAF/DRG 
budget neutrality factor has the effect of increasing the proposed 
capital Federal rate by 0.18 percent for both urban and rural 
hospitals. The proposed FY 2008 outlier adjustment factor has the 
effect of decreasing the proposed capital Federal rate by 0.89 
percent compared to the FY 2007 capital Federal rate for both urban 
and rural hospitals. The proposed FY 2008 exceptions payment 
adjustment factor remains unchanged from the FY 2007 exceptions 
payment adjustment factor, and therefore, has a 0.0 percent net 
effect on the proposed FY 2008 capital Federal rate for both urban 
and rural hospitals. In addition to the factors historically used to 
determine the capital Federal rate, for FY 2008, we are proposing an 
adjustment factor to account for upcoding expected to result if the 
proposed MS-DRGs are adopted, as discussed above in section III. of 
this Addendum, in determining the capital Federal rate for FY 2008. 
The combined effect of all the changes is to decrease the proposed 
capital Federal rate by 3.09 percent compared to the FY 2007 capital 
Federal rate for urban hospitals and to decrease the proposed 
capital Federal rate by 2.29 percent compared to the FY 2007 capital 
Federal rate for rural hospitals.

  Comparison of Factors and Adjustments: FY 2007 Capital Federal Rate and Proposed FY 2008 Capital Federal Rate
                                               for Urban Hospitals
----------------------------------------------------------------------------------------------------------------
                                                                    Proposed FY                       Percent
                                                      FY 2007         2008\4\         Change         change\5\
----------------------------------------------------------------------------------------------------------------
Update Factor\1\................................          1.0110          1.0000          0.0000            0.00
GAF/DRG Adjustment Factor\1\....................          0.9986          1.0018          1.0018            0.18
Outlier Adjustment Factor \2\...................          0.9568          0.9484          0.9912           -0.88
Exceptions Adjustment Factor \2\................          0.9997          0.9997          1.0000            0.00
MS-DRG Upcoding Adjustment Factor \3\...........  ..............          0.9760          0.9760           -2.40
Capital Federal Rate............................         $427.03         $413.87          0.9692          -3.10
----------------------------------------------------------------------------------------------------------------
\1\ The proposed update factor for rural hospitals and the proposed GAF/DRG budget neutrality factors are built
  permanently into the capital rates. Thus, for example, the incremental change from FY 2007 to FY 2008
  resulting from the application of the proposed 1.0018 GAF/DRG budget neutrality factor for FY 2008 is 1.0018.
\2\ The proposed outlier reduction factor and the proposed 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 proposed FY 2008
  outlier adjustment factor would be 0.9484/0.9568, or 0.9912.
\3\ Proposed adjustment to FY 2008 IPPS rates to account for upcoding expected to result if the proposed MS-DRGs
  are adopted, as discussed above in section III. of this Addendum.
\4\ Proposed factors for FY 2008, as discussed above in section III. of this Addendum.
\5\ Percent change of individual proposed factors may not sum due to rounding.


  Comparison of Factors and Adjustments: FY 2007 Capital Federal Rate and Proposed FY 2008 Capital Federal Rate
                                               for Rural Hospitals
----------------------------------------------------------------------------------------------------------------
                                                                    Proposed FY                       Percent
                                                      FY 2007         2008\4\         Change         change\5\
----------------------------------------------------------------------------------------------------------------
Update Factor \1\...............................          1.0110          1.0080          1.0080            0.80
GAF/DRG Adjustment Factor \1\...................          0.9986          1.0018          1.0018            0.18
Outlier Adjustment Factor \2\...................          0.9568          0.9484          0.9912           -0.88
Exceptions Adjustment Factor \2\................          0.9997          0.9997          1.0000            0.00
MS-DRG Upcoding Adjustment Factor \3\...........  ..............          0.9760          0.9760           -2.40
Capital Federal Rate............................         $427.03         $417.26          0.9771          -2.29
----------------------------------------------------------------------------------------------------------------
\1\ The proposed update factor for rural hospitals and the proposed GAF/DRG budget neutrality factors are built
  permanently into the capital rates. Thus, for example, the incremental change from FY 2007 to FY 2008
  resulting from the application of the proposed 1.0018 GAF/DRG budget neutrality factor for FY 2008 is 1.0018.
\2\ The proposed outlier reduction factor and the proposed 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 proposed FY 2008
  outlier adjustment factor would be 0.9484/0.9568, or 0.9912.
\3\ Proposed adjustment to FY 2008 IPPS rates to account for upcoding expected to result if the proposed MS-DRGs
  are adopted, as discussed above in section III. of this Addendum.
\4\ Proposed factors for FY 2008, as discussed above in section III. of this Addendum.
\5\ Percent change of individual proposed factors may not sum due to rounding.

6. Proposed Special Capital Rate for Puerto Rico Hospitals

    Section 412.374 provides for the use of a blended payment system 
for payments to Puerto Rico hospitals under the PPS for acute care 
hospital inpatient capital-related costs. Accordingly, under the 
capital PPS, we compute a separate payment rate specific to Puerto 
Rico hospitals using the same methodology used to compute the 
national Federal rate for capital-related costs. Under the broad 
authority of section 1886(g) of the Act, as discussed in section V. 
of the preamble of this proposed rule, beginning with discharges 
occurring on or after October

[[Page 24848]]

1, 2004, capital payments to hospitals in Puerto Rico are based on a 
blend of 25 percent of the Puerto Rico capital rate and 75 percent 
of the capital Federal rate. The Puerto Rico capital rate is derived 
from the costs of Puerto Rico hospitals only, while the capital 
Federal rate is derived from the costs of all acute care hospitals 
participating in the IPPS (including Puerto Rico).
    To adjust hospitals' capital payments for geographic variations 
in capital costs, we apply a GAF to both portions of the blended 
capital rate. The GAF is calculated using the operating IPPS wage 
index and varies, depending on the labor market area or rural area 
in which the hospital is located. We use the Puerto Rico wage index 
to determine the GAF for the Puerto Rico part of the capital-blended 
rate and the national wage index to determine the GAF for the 
national part of the blended capital rate.
    Because we implemented a separate GAF for Puerto Rico in FY 
1998, we also apply separate budget neutrality adjustments for the 
national GAF and for the Puerto Rico GAF. However, we apply the same 
budget neutrality factor for DRG reclassifications and recalibration 
nationally and for Puerto Rico. As we stated above in section 
III.A.4. of this Addendum, for Puerto Rico, the proposed GAF budget 
neutrality factor is 1.0009, while the DRG adjustment is 0.9992, for 
a combined proposed cumulative adjustment of 1.0001.
    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 2007, before application of the GAF, the special capital 
rate for Puerto Rico hospitals was $203.06 for discharges occurring 
on or after October 1, 2006 through September 30, 2007. With the 
changes we are making to the factors used to determine the capital 
rate, in addition to the proposed zero percent update for urban 
hospitals, the proposed FY 2008 special capital rate for rural 
hospitals in Puerto Rico is $197.21 For urban hospitals in Puerto 
Rico, the proposed FY 2008 special capital rate is $195.60.

B. Calculation of the Proposed Inpatient Capital-Related 
Prospective Payments for FY 2008

    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 2007. 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 2008, the capital standard Federal rate would be adjusted as 
follows: (Standard Federal Rate) x (DRG weight) x (GAF) x (COLA 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. (As discussed above and 
in section V. of the preamble of this proposed rule, we are 
proposing to eliminate the large urban add-on adjustment in existing 
regulations at Sec.  412.316, beginning in FY 2008.)
    Hospitals also may receive outlier payments for those cases that 
qualify under the thresholds established for each fiscal year. 
Section 412.312(c) provides for a single set of thresholds to 
identify outlier cases for both inpatient operating and inpatient 
capital-related payments. The proposed outlier thresholds for FY 
2008 are in section II.A.4.c. of this Addendum. For FY 2008, 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 the proposed fixed-loss amount of $23,015.
    An eligible hospital may also qualify for a special exceptions 
payment under Sec.  412.348(g) for up through the 10th year beyond 
the end of the capital transition period if it meets: (1) a project 
need requirement described at Sec.  412.348(g)(2), which in the case 
of certain urban hospitals includes an excess capacity test as 
described at Sec.  412.348(g)(4); and (2) a project size requirement 
as described at Sec.  412.348(g)(5). Eligible hospitals include 
SCHs, urban hospitals with at least 100 beds that have a DSH patient 
percentage of at least 20.2 percent or qualify for DSH payments 
under Sec.  412.106(c)(2), and hospitals that have a combined 
Medicare and Medicaid inpatient utilization of at least 70 percent. 
Under Sec.  412.348(g)(8), the amount of a special exceptions 
payment is determined by comparing the cumulative payments made to 
the hospital under the capital PPS to the cumulative minimum payment 
level. This amount is offset by: (1) any amount by which a 
hospital's cumulative capital payments exceed its cumulative minimum 
payment levels applicable under the regular exceptions process for 
cost reporting periods 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 IPPS 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 
2002 in the FY 2006 IPPS final rule (70 FR 47387).

2. Forecast of the CIPI for FY 2008

    Based on the latest forecast by Global Insight, Inc. (first 
quarter of 2007), we are forecasting the CIPI to increase 1.20 
percent in FY 2008. This reflects a projected 1.9 percent increase 
in vintage-weighted depreciation prices (building and fixed 
equipment, and movable equipment) and a 3.0 percent increase in 
other capital expense prices in FY 2008, partially offset by a 2.5 
percent decline in vintage-weighted interest expenses in FY 2008. 
The weighted average of these three factors produces the 1.2 percent 
increase for the CIPI as a whole in FY 2008.

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

    (If you choose to comment on issues in this section, please 
include the caption ``Excluded Hospitals Rate of Increase'' at the 
beginning of your comments.)
    Historically, hospitals and hospital units excluded from the 
prospective payment system 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

[[Page 24849]]

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 
(now referred to as IRFs), psychiatric hospitals and units (now 
referred to as IPFs), LTCHs, children's hospitals, and cancer 
hospitals).
    Payment for children's hospitals and cancer hospitals that are 
excluded from the IPPS continues to be subject to the rate-of-
increase ceiling based on the hospital's own historical cost 
experience. (We note that, in accordance with Sec.  403.752(a), 
RNHCIs are also subject to the rate-of-increase limits established 
under Sec.  413.40. IRFs, IPFs, and LTCHs were paid previously under 
the reasonable cost methodology. However, the statute was amended to 
provide for the implementation of prospective payment systems for 
IRFs, IPFs, and LTCHs. In general, the prospective payment systems 
for IRFs, IPFs, and LTCHs provide(d) transition periods of varying 
lengths during which time a portion of the prospective payment is 
(was) based on cost-based reimbursement rules under Part 413 
(certain providers do not receive a transition period or may elect 
to bypass the transition as applicable under Subparts N, O, and P.) 
We note that the various transition periods provided for under the 
IRF PPS, IPF PPS, and LTCH PPS have ended or will soon end.
    For cost reporting periods beginning on or after October 1, 
2002, all IRFs are paid 100 percent of the adjusted Federal rate 
under the IRF PPS. Therefore, for cost reporting periods beginning 
on or after October 1, 2002, no portion of an IRF PPS payment is 
subject to Part 413. Similarly, for cost reporting periods beginning 
on or after October 1, 2006, all LTCHs are paid 100 percent of the 
adjusted Federal rate under the LTCH PPS. Therefore, for cost 
reporting periods beginning on or after October 1, 2006, no portion 
of the LTCH PPS payment is subject to Part 413. However, except as 
provided in Sec.  412.426(c), IPFs remain under a blend methodology 
for cost reporting periods beginning on or after January 1, 2005, 
and before January 1, 2008.
    For IPFs paid under the blend methodology, the portion of the 
IPF PPS payment that is based on reasonable cost principles is 
subject to the rules of Part 413. In order to calculate the portion 
of the PPS payment that is based on reasonable cost principles, it 
is necessary to determine whether the IPF would be considered 
``existing'' for purposes of section 1886(b)(3)(H) of the Act or 
``new'' for purposes of section 1886(b)(7) of the Act. We note that 
readers should not confuse an IPF that is considered ``new'' for 
purposes of section 1886(b)(7) of the Act and Sec.  413.40(f)(2)(ii) 
with an IPF that is considered ``new'' under Sec.  412.426(c). Any 
IPF that, under present or previous ownership or both, has its first 
cost reporting period as an IPF beginning on or after January 1, 
2005, is considered ``new'' for purposes of Sec.  412.426(c). An IPF 
that is considered ``new'' under Sec.  412.426(c) is paid based on 
100 percent of the Federal per diem payment amount. Consequently, 
only those IPFs considered ``new'' under section 1886(b)(7) of the 
Act, but not ``new'' under Sec.  412.426(c) will be paid under a PPS 
blended payment methodology. An IPF considered ``new'' for purposes 
of Sec.  413.40(f)(2)(ii) would have its ``reasonable-cost based'' 
portion of its prospective payment subject to Sec.  413.40(f)(2)(ii) 
and Sec.  413.40(c)(4)(v), as applicable. An IPF considered ``new'' 
for purposes of section 1886(b)(7) of the Act has the target amount 
for its third cost reporting period determined in accordance with 
sections 1886(b)(7)(A)(ii) and 1886(b)(3)(A)(ii) of the Act. For the 
fourth and subsequent cost reporting periods, the target amount is 
calculated in accordance with section 1886(b)(3)(A)(ii) of the Act. 
An IPF that would be considered ``existing'' for purposes of section 
1886(b)(3)(H) of the Act has the target amount for the ``reasonable-
cost based'' portion of its prospective payment determined in 
accordance with section 1886(b)(3)(A)(ii) of the Act and Sec.  
413.40(c)(4)(ii).
    We are proposing that the applicable percentage increase to 
update the target amount for the reasonable cost-based portion of 
the PPS payment of an IPF that is considered existing under section 
1886(b)(3)(H) of the Act or new under section 1886(b)(7) of the Act, 
but not new under Sec.  412.426(c), is 3.4 percent using the first 
quarter of the 2007 forecast made by Global Insight, Inc.

V. Tables

    This section contains the tables referred to throughout the 
preamble to this proposed rule and in this Addendum. Tables 1A, 1B, 
1C, 1D, 2, 3A, 3B, 4A, 4B, 4C, 4D, 4F, 4G, 4H, 4J, 5, 6A, 6B, 6C, 
6D, 6E, 6F, 6J, 6K, 7A, 7B, 8A, 8B, 8C, 9A, 9C, 10, and 11 are 
presented below. As explained in sections II.D. 2. and II.G.8. of 
the preamble of this final rule, Table 6G--Additions to the CC 
Exclusions List, Table 6H, Deletions from the CC Exclusions List, 
and Table 6I--Complete List of Complication and Comorbidity (CC) 
Exclusions are available only through the Internet on the CMS Web 
site at: http://www.cms.hhs.gov/AcuteInpatientPPS/. The tables 
presented below are as follows:

Table 1A--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share If 
Wage Index Is Greater Than 1)
Table 1B--National Adjusted Operating Standardized Amounts, Labor/
Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share If Wage 
Index Is Less Than or Equal To 1)
Table 1C--Adjusted Operating Standardized Amounts for Puerto Rico, 
Labor/Nonlabor
Table 1D--Capital Standard Federal Payment Rate
Table 2--Hospital Case-Mix Indexes for Discharges Occurring in 
Federal Fiscal Year 2006; Hospital Wage Indexes for Federal Fiscal 
Year 2008; Hospital Average Hourly Wages for Federal Fiscal Years 
2006 (2002 Wage Data), 2007 (2003 Wage Data), and 2008 (2004 Wage 
Data); and 3-Year Average of Hospital Average Hourly Wages
Table 3A--FY 2008 and 3-Year Average Hourly Wage for Urban Areas by 
CBSA
Table 3B--FY 2008 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--FY 2008
Table 4B--Wage Index and Capital Geographic Adjustment Factor (GAF) 
for Rural Areas by CBSA--FY 2008
Table 4C--Wage Index and Capital Geographic Adjustment Factor (GAF) 
for Hospitals That Are Reclassified by CBSA--FY 2008
Table 4F--Puerto Rico Wage Index and Capital Geographic Adjustment 
Factor (GAF) by CBSA--FY 2008
Table 4J--Out-Migration Adjustment--FY 2008
Table 5--List of Proposed Medicare Severity Diagnosis-Related Groups 
(MS-DRGs), Relative Weighting Factors, and Geometric and Arithmetic 
Mean Length of Stay
Table 6A--New Diagnosis Codes
Table 6B--New Procedure Codes
Table 6C--Invalid Diagnosis Codes
Table 6D--Invalid Procedure Codes
Table 6E--Revised Diagnosis Code Titles
Table 6F--Revised Procedure Code Titles
Table 6J--Major Complication and Comorbidity (MCC) List
Table 6K--Complications and Comorbidity (CC) List
Table 7A--Medicare Prospective Payment System Selected Percentile 
Lengths of Stay: FY 2006 MedPAR Update--December 2006 GROUPER V24.0 
CMS DRGs
Table 7B--Medicare Prospective Payment System Selected Percentile 
Lengths of Stay: FY 2006 MedPAR Update--December 2006 GROUPER V25.0 
MS-DRGs
Table 8A--Proposed Statewide Average Operating Cost-to-Charge 
Ratios--March 2007
Table 8B--Proposed Statewide Average Capital Cost-to-Charge Ratios--
March 2007
Table 8C--Proposed Statewide Average Total Cost-to-Charge Ratios for 
LTCHs--March 2007
Table 9A--Revised Hospital Reclassifications and Redesignations--FY 
2008
Table 9C--Hospitals Redesignated as Rural under Section 
1886(d)(8)(E) of the Act--FY 2008
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 Proposed Medicare Severity Diagnosis-
Related Group (MS-DRG)--April 2007
Table 11--Proposed FY 2008 MS-LTC-DRGs, Relative Weights, Geometric 
Average Length of Stay, and 5/6ths of the Geometric Average Length 
of Stay

[[Page 24850]]



   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 (3.3 percent)                              Reduced update (1.3 percent)
----------------------------------------------------------------------------------------------------------------
                  Labor-related                      Nonlabor-related      Labor-related       Nonlabor-related
----------------------------------------------------------------------------------------------------------------
$3,430.29........................................           $1,491.21            $3,363.88            $1,462.34
----------------------------------------------------------------------------------------------------------------


 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 (3.3 percent)                              Reduced update (1.3 percent)
----------------------------------------------------------------------------------------------------------------
                  Labor-related                      Nonlabor-related      Labor-related       Nonlabor-related
----------------------------------------------------------------------------------------------------------------
$3,051.33........................................           $1,870.17            $2,992.26            $1,833.96
----------------------------------------------------------------------------------------------------------------


            Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico Labor, Labor/Nonlabor
----------------------------------------------------------------------------------------------------------------
                                                    Rates if wage index greater    Rates if wage index less than
                                                              than 1                       or equal to 1
                                                 ---------------------------------------------------------------
                                                       Labor         Nonlabor          Labor         Nonlabor
----------------------------------------------------------------------------------------------------------------
National........................................       $3,430.29       $1,491.21       $3,051.33       $1,870.17
----------------------------------------------------------------------------------------------------------------
Puerto Rico.....................................        1,442.56          884.15        1,365.78          960.93
----------------------------------------------------------------------------------------------------------------


            Table 1D.--Capital Standard Federal Payment Rate
------------------------------------------------------------------------
                                                      Urban      Rural
                                                       rate       rate
------------------------------------------------------------------------
National..........................................    $413.87    $417.26
Puerto Rico.......................................     195.60     197.21
------------------------------------------------------------------------


[[Page 24851]]







    --------------------
\1\ Based on salaries adjusted occupational mix, according to the 
calculation in section II.D.6. of the preamble to this final rule.

\2\ The transfer-adjusted case-mix index is based on the billed DRG on 
the FY 2006 MedPAR.

* Denotes wage data not available for the provider for that year.

** Based on the sum of the salaries and hours computed for Federal FYs 
2006, 2007, and 2008.

*** Denotes MedPAR data not available for the provider for FY 2006.

[[Page 24851]]



 TABLE 2.--Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2006; Hospital Wage Indexes
for Federal Fiscal Year 2008; Hospital Average Hourly Wages for Federal Fiscal Years 2006 (2002 Wage Data), 2007
         (2003 Wage Data, and 2008 (2004 Wage Data); and 3-Year Average of Hospital Average Hourly Wages
----------------------------------------------------------------------------------------------------------------
                                                                                          Average      Average
                                      Case-mix     FY 2008      Average      Average    hourly wage     hourly
           Provider No.              index \2\    wage index  hourly wage  hourly wage     FY 2008    wage**  (3
                                                                 FY 2006      FY 2007       \1\         years)
----------------------------------------------------------------------------------------------------------------
010001............................       1.5195       0.7598      21.6546      22.1989      23.2171      22.3607
010005............................       1.1370       0.8760      22.4906      23.6022      23.0192      23.0412
010006............................       1.5127       0.7971      23.4823      23.4975      25.1891      23.9924
010007............................       1.0231       0.7598      18.2429      19.9329      21.2159      19.8249
010008............................       1.0409       0.7843      20.4591      17.9533      22.0766      19.9260
010009............................       0.9710       0.8760      23.2228      23.5626      25.8995      24.2263
010010............................       1.1050       0.8737      21.4974      27.0385      22.8588      23.5938
010011............................       1.6744       0.8873      27.4850      27.6658      27.4650      27.5387
010012............................       1.2346       0.9391      22.7020      24.4059      25.5764      24.1955
010015............................       1.0427       0.7641      21.5111      22.3383      27.0786      23.3434
010016............................       1.5763       0.8873      25.1502      24.6488      26.8613      25.5445
010018............................       1.7123       0.8873      22.2990      23.7048      24.6173      23.5172
010019............................       1.2720       0.7971      22.0906      22.8766      23.3445      22.7780
010021............................       1.1864       0.7598      18.6785      19.7367      21.0596      19.7966
010022............................       0.9503       0.9845      24.5671      25.8404      27.4306      25.9296
010023............................       1.8483       0.8366      27.6174      25.4272      27.5972      26.8926
010024............................       1.6036       0.8366      20.7265      22.0819      25.0694      22.5299
010025............................       1.3014       0.8594      21.2674      22.7635      23.6162      22.5532
010027............................       0.7631       0.7598      15.3705      16.4682      17.0501      16.2714
010029............................       1.5702       0.8594      22.6976      23.9007      25.0667      23.9196
010032............................       0.9327       0.7918      19.1555      19.3311      20.5944      19.8444
010033............................       2.0856       0.8873      26.3784      27.4181      28.9456      27.5755
010034............................       1.0461       0.8366      16.9686      17.7457      19.1508      17.9500
010035............................       1.3138       0.8737      22.2870      24.2425      24.2739      23.6060
010036............................       1.1607       0.7598      22.9747      21.5796      24.2867      22.9472
010038............................       1.2692       0.8081      21.4509      23.7039      27.0732      24.1203
010039............................       1.6579       0.9175      25.8820      26.9919      29.2918      27.3990
010040............................       1.6552       0.8129      22.8851      24.3207      24.7653      23.9965
010043............................       1.0833       0.8873      22.5944      21.9774      23.9116      22.8203
010044............................       1.0847       0.8737      21.4036      22.5009      24.4278      22.7205
010045............................       1.2226       0.8737      19.8803      20.4927      23.1687      21.0753
010046............................       1.5338       0.8129      21.6965      23.4219      25.7750      23.5002
010047............................       0.8958       0.7777      21.0605      26.4851      19.7500      21.9482
010049............................       1.1433       0.7598      20.2413      21.7888      22.4234      21.5067
010050............................       1.0407       0.8873      22.1584      22.9620      24.4046      23.1653
010051............................       0.8299       0.8534      15.2207      18.7701      18.0235      17.3856
010052............................       0.8742       0.7722      16.4958      25.9233      36.3510      26.9113
010053............................          ***            *      19.0108            *            *      19.0108
010054............................       1.0737       0.8760      22.5554      23.3624      24.4797      23.4775
010055............................       1.6104       0.7598      22.3800      22.5396      22.4131      22.4446
010056............................       1.6382       0.8873      23.7144      23.7398      25.3239      24.2816
010058............................       1.0119       0.8873      18.5538      19.5092      17.0128      18.2407
010059............................       1.0247       0.8760      21.3237      23.0012      24.8195      23.0576
010061............................       0.9828       0.8164      21.9370      24.1185      25.2415      23.7777
010062............................       1.0229       0.7598      18.3435      21.4805      21.6281      20.4629
010064............................       1.6966       0.8873      26.1110      24.8155      27.6143      26.1440
010065............................       1.5287       0.8737      21.3785      23.0477      24.3340      22.9445
010066............................       0.8370       0.7598      17.6152      19.8692      25.1251      20.8278
010068............................          ***            *      19.0789      22.7156      24.4131      22.0065
010069............................       1.0243       0.7598      21.3609      23.1243      23.6305      22.6678
010072............................          ***            *      21.8169      24.4989      25.9729      24.0804
010073............................       0.9794       0.7598      16.4168      18.3963      19.0009      17.9403
010078............................       1.6186       0.8081      21.6857      23.5279      24.3805      23.2222
010079............................       1.2223       0.9175      21.8199      22.7337      22.1795      22.2414
010083............................       1.1876       0.7950      22.3040      22.4279      24.0017      22.9546
010084............................       1.3254       0.8873      24.7127      26.3238      26.5072      25.8381
010085............................       1.3296       0.8760      24.4710      24.2609      24.1142      24.2806
010086............................       1.1007       0.7598      18.6081      22.2096      21.5581      20.7408
010087............................       1.9814       0.7950      22.5225      22.4318      24.8042      23.2180
010089............................       1.2937       0.8873      22.8448      25.0811      26.2624      24.6787
010090............................       1.7447       0.8544      23.6948      26.0494      26.3950      25.3394
010091............................       0.9554       0.7641      18.6912      23.1310      22.5237      21.3015

[[Page 24852]]

 
010092............................       1.5528       0.8534      24.4592      26.6796      26.9923      26.0268
010095............................       0.8469       0.8534      13.9326      16.5250      16.9952      15.8664
010097............................       0.7113       0.8366      16.7549      19.4511      19.2462      18.4993
010098............................       0.9805            *      14.3076            *            *      14.3076
010099............................       0.9668       0.7598      18.7910      20.8383      20.6723      20.0887
010100............................       1.6853       0.8127      21.2915      23.8919      25.1439      23.5423
010101............................       1.1065       0.8737      21.6593      24.2575      25.0963      23.6319
010102............................       0.9355       0.7598      21.0902      25.6158      26.9801      24.5958
010103............................       1.8826       0.8873      26.1163      27.8272      28.9628      27.5988
010104............................       1.8819       0.8873      24.7394      27.6471      28.3109      26.8460
010108............................       1.0930       0.8366      28.4624      24.6740      27.0236      26.7335
010109............................       0.9845       0.7967      21.6194      17.6733      21.0403      20.0217
010110............................       0.7589       0.7901      17.5957      26.0038      19.8672      20.8809
010112............................       0.9638       0.7598      16.8902      17.1833      20.4001      18.1174
010113............................       1.6643       0.7950      21.4121      22.3282      24.7059      22.7828
010114............................       1.3627       0.8873      22.3752      25.6152      25.7061      24.6261
010115............................       0.6881            *      21.7477            *            *      21.7477
010118............................       1.2168       0.8166      19.7673      21.4630      22.7172      21.2736
010120............................       0.9648       0.7598      20.9450      20.9019      22.1859      21.3550
010121............................          ***            *      24.0867            *            *      24.0867
010125............................       1.0630       0.8069      18.4113      21.5123      22.8897      20.8635
010126............................       1.1765       0.8366      23.1381      23.9327      24.4934      23.8544
010128............................       0.8769       0.7641      21.4200      23.6647      24.9854      23.3827
010129............................       1.0370       0.7723      21.3555      22.1574      21.8496      21.7886
010130............................       1.0247       0.8873      23.2488      23.7528      24.5639      23.8766
010131............................       1.3971       0.9175      25.7837      26.4297      27.2704      26.5326
010137............................       1.2222       0.8873      24.7366      27.5782      28.5798      26.9175
010138............................       0.6028       0.7711      13.8476      16.7602      14.5508      15.1016
010139............................       1.5889       0.8873      25.3014      26.8726      28.1771      26.8342
010143............................       1.2118       0.8737      22.0215      26.2762      24.0663      24.0857
010144............................       1.6386       0.7950      20.8209      22.5133      22.3897      21.9331
010145............................       1.4710       0.8534      24.9531      24.5092      25.8279      25.1079
010146............................       1.0814       0.8081      20.8917      22.6586      22.6870      22.1060
010148............................       0.8685       0.7598      20.5589      23.9246      23.5683      22.6789
010149............................       1.2881       0.8366      26.5854      24.4805      26.7486      25.9662
010150............................       1.0284       0.8366      21.6377      23.6080      24.4087      23.2036
010152............................       1.2950       0.7950      22.6202      22.4075      23.7803      22.9411
010157............................       1.1360       0.7971      24.3559      23.3828      25.4582      24.3716
010158............................       1.1924       0.7927      24.3531      23.5533      25.5902      24.4669
010162............................          ***            *            *      33.8777            *      33.8777
010163............................          ***            *            *            *      34.0293      34.0293
010164............................       1.1750       0.8043            *            *            *            *
010165............................          ***            *            *            *      28.8030      28.8030
010166............................          ***            *            *            *      29.7218      29.7218
010167............................       1.4977       0.8873            *            *            *            *
010168............................       1.1410       0.9023            *            *            *            *
020001............................       1.7970       1.1840      32.8120      35.4232      36.5276      34.9502
020004............................       1.1210       1.1817      32.0966      31.8004      33.5991      32.4852
020006............................       1.3200       1.1840      36.0540      34.3752      37.0215      35.7759
020008............................       1.2398       1.1840      35.9236      36.1250      39.3416      37.1498
020012............................       1.3779       1.1817      31.8995      32.5975      33.9363      32.8387
020014............................       1.1267       1.1817      32.0894      29.4472      30.9718      30.8220
020017............................       1.9205       1.1840      33.5852      35.4119      35.8810      34.9151
020018............................       0.9351       1.9287            *            *            *            *
020019............................       0.8687       1.9287            *            *            *            *
020024............................       1.1749       1.1817      33.0644      29.5195      38.6904      33.4491
020026............................       1.4939       1.9287            *            *            *            *
020027............................       0.9384       1.9287            *            *            *            *
030001............................       1.5465       1.0115      29.9840      32.4791      33.4166      31.9038
030002............................       2.0925       1.0115      29.0519      30.2200      31.0794      30.0867
030006............................       1.6966       0.9484      25.8872      27.0599      27.8624      26.9763

[[Page 24853]]

 
030007............................       1.4533       0.9386      29.6174      31.1928      33.7190      31.5810
030009............................          ***            *      22.3993      26.5408            *      23.8204
030010............................       1.4068       0.9484      24.8275      28.5684      31.1684      28.1880
030011............................       1.4906       0.9484      25.1361      28.1423      29.3385      27.6326
030012............................       1.3882       0.9913      26.3859      27.3895      28.8355      27.5891
030013............................       1.4760       0.9468      25.7050      27.0111      29.3504      27.3749
030014............................       1.5924       1.0115      25.6259      29.6582      29.8251      28.4291
030016............................       1.2381       1.0115      26.7003      29.1980      31.9830      29.4207
030017............................       2.0661       1.0115      26.2452      30.6007      34.7863      30.8882
030018............................       1.3196       1.0115      28.9476      29.4566      31.8047      30.0509
030019............................       1.3553       1.0115      27.3156      29.5921      30.1929      29.0813
030022............................       1.5745       1.0115      26.4404      30.5710      30.3718      29.2058
030023............................       1.7864       1.1558      33.8333      34.2142      35.8265      34.6818
030024............................       2.0620       1.0115      31.6658      31.9247      33.1810      32.2887
030027............................       0.9709            *      20.4032            *            *      20.4032
030030............................       1.5755       1.0115      30.2712      32.0994      34.4162      32.2545
030033............................       1.2964       1.1310      26.6531      28.7508      29.9363      28.4678
030036............................       1.4582       1.0115      30.3521      30.9834      33.0517      31.6114
030037............................       2.1468       1.0115      28.6453      31.2877      34.1070      31.4095
030038............................       1.6738       1.0115      29.5509      29.9314      31.6720      30.2088
030040............................       0.9098       0.9398      24.8145      27.5322      29.5727      27.3145
030043............................       1.2683       0.9386      24.7932      26.5834      27.3802      26.2787
030055............................       1.4609       0.9534      24.5202      27.1473      27.0569      26.3168
030060............................       1.0905       0.9386      24.3523      24.8373      29.6494      26.3133
030061............................       1.6820       1.0115      25.5529      28.0696      27.7958      27.1919
030062............................       1.2021       0.9386      23.8068      26.6880      28.9557      26.5828
030064............................       1.9609       0.9484      25.4922      28.3853      29.7464      27.9854
030065............................       1.5921       1.0115      27.1646      29.5883      31.0784      29.3868
030067............................       1.0573       0.9616      20.4376      20.7591      27.4426      22.9577
030068............................       1.1143       0.9386      20.8846      23.1394      24.0540      22.7233
030069............................       1.4255       0.9386      26.3518      30.2224      29.7783      28.7287
030071............................       0.8871       1.4406            *            *            *            *
030073............................       0.8952       1.4406            *            *            *            *
030074............................       0.8727       1.4406            *            *            *            *
030077............................       0.7676       1.4406            *            *            *            *
030078............................       0.9879       1.4406            *            *            *            *
030080............................       1.5499       0.9484      25.2077      27.1360      28.7349      27.0418
030083............................       1.4209       1.0115      27.5353      27.4983      33.5289      29.3975
030084............................       0.9014       1.4406            *            *            *            *
030085............................       1.5899       0.9484      24.5792      26.8364      28.1362      26.6157
030087............................       1.6946       1.0115      26.6594      29.5962      31.2063      29.3936
030088............................       1.3692       1.0115      26.6796      27.8604      29.9743      28.2304
030089............................       1.6385       1.0115      27.1835      28.9068      30.1558      28.8088
030092............................       1.4976       1.0115      27.3203      31.7512      30.6298      30.0149
030093............................       1.2964       1.0115      25.8955      26.4430      27.4271      26.6702
030094............................       1.4055       1.0115      29.5948      31.5422      33.4045      31.6118
030099............................       0.8736       0.9386      26.3236      27.1402      26.7474      26.7410
030100............................       2.0536       0.9484      29.0691      31.5628      35.1381      31.9181
030101............................       1.4386       1.1205      26.1927      27.8302      30.6747      28.3387
030102............................       2.3668       1.0115      29.0942      31.6285      34.2046      31.6905
030103............................       1.7576       1.0115      30.1994      31.7322      32.2839      31.3999
030105............................       2.2412       1.0115      31.3094      31.2970      32.7440      31.8776
030106............................       1.7570       1.0115      34.7221      32.9840      36.4650      34.9441
030107............................       1.9168       1.0115            *      35.6197      35.5345      35.5697
030108............................       2.0343       1.0115            *            *      31.3337      31.3337
030109............................          ***            *            *      16.5906      32.6823      26.5780
030110............................       1.6153       1.0115            *      31.4852      29.7956      30.5019
030111............................       1.0328       0.9484            *            *      34.7976      34.7976
030112............................       1.9764       1.0115            *            *      37.4931      37.4931
030113............................       0.8965       1.4406            *            *            *            *
030114............................       1.3891       0.9484            *            *            *            *

[[Page 24854]]

 
030115............................       1.3513       1.0115            *            *            *            *
030117............................       1.1172       0.9386            *            *            *            *
030118............................       1.0947       0.9913            *            *            *            *
030119............................       1.1646       1.0115            *            *            *            *
040001............................       1.0784       0.8876      23.7718      22.9327      22.9909      23.2119
040002............................       1.2054       0.7519      20.1384      21.2020      24.9965      22.0316
040004............................       1.7231       0.8876      25.0286      27.1741      28.1077      26.7777
040007............................       1.7566       0.8965      25.7142      40.1291      29.1919      31.6848
040010............................       1.4680       0.8876      23.0274      24.2315      26.5274      24.6221
040011............................       1.0468       0.7519      20.3970      21.0967      22.2391      21.2815
040014............................       1.3549       0.8721      25.3451      26.4777      29.0061      26.8567
040015............................       0.9946       0.7519      19.2831      20.4279      20.1045      19.9373
040016............................       1.7637       0.8965      22.1228      25.8056      26.5895      24.8381
040017............................       1.0958       0.8719      21.9875      21.9147      23.8741      22.5732
040018............................       1.0813       0.8056      23.6044      24.0026      25.6731      24.3846
040019............................       1.1103       0.8951      23.7328      23.8706      24.9108      24.1693
040020............................       1.5840       0.8951      21.6603      22.6497      23.9443      22.7533
040021............................       1.5369       0.8965      25.6917      25.4046      26.1832      25.7531
040022............................       1.5691       0.8876      25.4052      29.5000      27.9883      27.5941
040026............................       1.5094       0.9110      25.4072      27.7931      29.5278      27.6084
040027............................       1.4822       0.8943      21.1412      21.4252      23.8205      22.1269
040029............................       1.4949       0.8965      24.0704      24.8409      25.1455      24.6984
040036............................       1.6116       0.8965      26.3226      27.6234      29.7111      27.9661
040039............................       1.2751       0.8145      19.5998      21.2712      21.4793      20.7967
040041............................       1.1737       0.8721      22.1531      23.7787      26.4923      24.1425
040042............................       1.3814       0.9291      19.9627      21.1716      19.8670      20.3330
040045............................       1.0416            *      17.2281            *            *      17.2281
040047............................       1.1246       0.7636      21.9163      22.4249      22.9939      22.4384
040050............................       1.2272       0.7519      16.3930      17.6906      18.5104      17.5655
040051............................       0.9636       0.7519      19.1400      21.3342      22.0350      20.8371
040053............................          ***            *      20.7823            *            *      20.7823
040054............................          ***            *      18.2685      18.0509      19.5333      18.6002
040055............................       1.5255       0.8056      23.3156      23.0448      24.9139      23.7090
040062............................       1.6634       0.8056      23.3082      23.8994      25.2283      24.1348
040067............................       1.1389       0.7527      16.8800      19.0471      18.9849      18.2674
040069............................       1.0195       0.8951      24.4662      24.8060      24.9975      24.7596
040071............................       1.4618       0.8721      24.3824      25.4680      25.2804      25.0562
040072............................       1.1155       0.7519      19.9009      22.4741      22.1027      21.4210
040074............................       1.1976       0.8965      25.2423      25.2699      26.2628      25.5873
040075............................          ***            *      18.3253            *            *      18.3253
040076............................       1.0003       0.8721      20.6272      23.5742      23.0930      22.4189
040077............................       0.9991            *      18.2082            *            *      18.2082
040078............................       1.5953       0.8721      24.5377      23.5915      26.1923      24.6731
040080............................       1.0440       0.8507      22.3392      24.1921      24.8730      23.8545
040081............................       0.8586       0.7877      15.1081      16.8437      17.2484      16.4107
040084............................       1.1954       0.8965      24.7225      27.7626      26.6430      26.4194
040085............................       0.9761       0.8951      29.8444      22.9916      25.7190      25.8628
040088............................       1.4629       0.7766      22.6183      22.4860      23.5774      22.9018
040091............................       1.1778       0.8131      23.1320      24.2398      23.1902      23.5097
040100............................       1.3421       0.8721      20.0460      21.3051      22.6107      21.3761
040105............................       1.0556            *      18.2182            *            *      18.2182
040109............................       1.1066            *      22.8801            *            *      22.8801
040114............................       1.8067       0.8965      24.8992      26.7581      27.7902      26.5373
040118............................       1.4739       0.8507      24.7363      26.0388      26.8888      25.8805
040119............................       1.4199       0.8721      21.0103      24.3680      24.2386      23.2176
040126............................          ***            *      14.0700      15.6985      17.3697      15.6131
040132............................          ***            *      28.1393            *      22.0041      24.3526
040134............................       2.3675       0.8965      27.3412      31.9325      32.2786      30.5646
040137............................       1.3088       0.8965      25.2907      25.9979      27.7350      26.2747
040138............................       1.4228       0.8876      25.7513      27.8584      28.3338      27.5135
040141............................       0.8436       0.8876      24.0901      26.1041      30.3458      26.8841

[[Page 24855]]

 
040142............................       1.4686       0.9110      27.9696      21.4222      23.8619      24.1239
040143............................          ***            *            *      37.1976            *      37.1976
040144............................          ***            *            *      21.4008            *      21.4008
040145............................       1.7857       0.8507            *            *      24.4378      24.4378
040146............................          ***            *            *            *      33.7847      33.7847
040147............................       1.7126       0.8965            *            *            *            *
050002............................       1.3851       1.5308      34.1948      35.5184      41.7235      37.3172
050006............................       1.6409       1.2666      30.5373      33.5751      37.1649      33.5394
050007............................       1.4954       1.4906      38.7033      43.4440      44.3636      42.1957
050008............................       1.2737       1.4766      39.1539      49.3167      46.6961      45.1213
050009............................       1.8128       1.4201      39.6393      43.0584      46.2195      43.0446
050013............................       1.9755       1.4201      31.9837      35.7591      42.0547      36.4664
050014............................       1.2470       1.2853      33.0373      36.0305      36.6124      35.2529
050015............................       1.3326            *      30.7940      32.2188            *      31.5274
050016............................       1.3291       1.1912      26.2161      24.5768      30.7245      27.1606
050017............................       1.9798       1.2999      36.6593      39.6653      41.8986      39.4161
050018............................       1.1984       1.1633      22.3472      23.3204      32.0787      25.3874
050022............................       1.5660       1.1607      29.8632      31.6467      33.0584      31.4880
050024............................       1.1369       1.1607      27.5587      29.4062      33.4319      30.1998
050025............................       1.8832       1.1607      36.1622      33.5466      32.7463      34.1066
050026............................       1.5092       1.1607      28.3027      31.5250      33.1265      31.0369
050028............................       1.2326       1.1607      26.6160      27.3826      28.5775      27.5352
050030............................       1.2224       1.1607      24.9707      27.2945      30.8991      27.6427
050036............................       1.5126       1.1607      32.7929      33.8000      36.1357      34.2635
050038............................       1.6564       1.5378      38.7527      44.2265      47.1554      43.4736
050039............................       1.6086       1.1607      31.6734      35.2630      36.6920      34.5165
050040............................       1.2745       1.1633      34.3279      35.8322      35.7021      35.3245
050042............................       1.5024       1.2666      33.9415      37.3760      40.3545      37.2138
050043............................       1.6351       1.5308      43.1589      45.4887      46.5540      45.1118
050045............................       1.3005       1.1607      23.8408      25.0150      27.0633      25.4065
050046............................       1.1311       1.1607      25.6875      26.1926      29.1122      26.9714
050047............................       1.7663       1.4766      40.9874      55.9367      45.1678      47.4628
050054............................       1.1907       1.1607      24.1262      21.3650      24.3196      23.2719
050055............................       1.3282       1.4766      37.5879      42.9516      44.2917      41.4280
050056............................       1.3806       1.1633      27.9330      30.6126      32.7669      30.4544
050057............................       1.6643       1.1607      29.4351      30.0236      31.7448      30.4500
050058............................       1.6025       1.1633      33.8215      33.1409      36.7723      34.5428
050060............................       1.4468       1.1607      27.3282      29.9762      32.0159      29.7243
050061............................          ***            *      32.2172            *            *      32.2172
050063............................       1.3855       1.1633      33.3039      34.0906      36.3153      34.5052
050065............................          ***            *      34.0280      34.9110      38.2458      35.7018
050067............................       1.1904       1.1989      31.9597      38.8070      40.1284      37.4041
050069............................       1.7481       1.1607      31.2172      34.6353      35.3837      33.8181
050070............................       1.2855       1.4906      45.3382      47.4099      46.4023      46.4528
050071............................       1.2901       1.5299      44.9464      50.7602      49.6475      48.7318
050072............................       1.3299       1.5299      44.2651      49.4344      50.0340      48.1854
050073............................       1.2899       1.5299      45.9765      49.9730      49.0059      48.5022
050075............................       1.3067       1.5308      47.2356      54.4089      49.8285      50.5647
050076............................       1.9114       1.5299      46.4991      52.3788      50.2028      49.9368
050077............................       1.6174       1.1607      32.0245      34.8660      36.5360      34.5322
050078............................       1.2621       1.1633      31.1425      32.0133      30.4267      31.1476
050079............................       1.5036       1.5299      47.8597      47.3449      48.9005      47.9787
050082............................       1.6860       1.1607      37.7783      38.2878      37.6622      37.9070
050084............................       1.5634       1.1870      33.0179      35.5196      39.3825      35.9583
050088............................          ***            *      25.7385            *            *      25.7385
050089............................       1.3526       1.1607      33.5324      33.9593      36.6955      34.6956
050090............................       1.2774       1.4766      32.9584      33.8953      37.7343      34.8362
050091............................       1.0225       1.1633      30.8560      32.1301      37.1046      33.3130
050093............................       1.5010       1.1607      33.4118      36.9481      36.8258      35.7320
050096............................       1.2246       1.1633      24.6679      34.9237      35.3586      31.7202
050099............................       1.4900       1.1607      31.0437      33.4174      30.2843      31.6087

[[Page 24856]]

 
050100............................       1.8340       1.1607      29.6949      31.4404      33.3955      32.0304
050101............................       1.2896       1.5299      40.3195      42.4589      47.1051      43.3558
050102............................       1.2784       1.1607      29.1364      32.0617      33.1773      31.7561
050103............................       1.5384       1.1633      34.2529      34.0935      35.6753      34.7042
050104............................       1.4343       1.1633      29.7326      32.3043      33.6194      31.9097
050107............................       1.5161       1.1607      33.1358      32.5846      33.3632      33.0279
050108............................       1.9249       1.2999      35.5711      38.8672      41.2472      38.6817
050110............................       1.2782       1.1607      26.1453      26.8408      28.0669      27.0290
050111............................       1.2607       1.1633      28.1588      28.7875      31.8716      29.6669
050112............................       1.5328       1.1633      36.8026      37.7281      38.9441      37.8605
050113............................       1.2281       1.4906      33.8064      39.4882      42.8855      38.6355
050114............................       1.4308       1.1633      31.1295      34.0309      35.7244      33.6736
050115............................       1.4652       1.1607      30.9288      28.8051      31.3553      30.3610
050116............................       1.7182       1.1633      34.5109      36.8825      37.7999      36.4915
050117............................          ***            *      32.4413      34.2020      35.0365      33.2948
050118............................       1.2267       1.1989      35.4044      39.9683      41.6676      39.0057
050121............................       1.2979       1.1607      27.9537      30.6105      34.6208      31.1203
050122............................       1.5166       1.1870      34.2416      33.9812      33.4644      33.8813
050124............................       1.2868       1.1633      28.0288      30.2522      29.9912      29.4686
050125............................       1.4991       1.5378      41.7020      44.9523      47.5179      44.7128
050126............................       1.4832       1.1633      29.3360      31.7619      32.6678      31.2865
050127............................       1.3323       1.2999      26.1222      32.0355      40.6863      31.7609
050128............................       1.4725       1.1607      31.0662      31.1308      33.4220      31.8925
050129............................       1.8434       1.1607      32.2680      34.7359      36.8660      34.5472
050131............................       1.3349       1.4766      40.5321      45.3152      46.4089      44.1170
050132............................       1.4284       1.1633      35.1544      35.9199      39.7742      36.9321
050133............................       1.5409       1.2853      31.3530      31.9527      33.1808      32.2800
050135............................       1.0356       1.1633      24.3927      25.1813      25.3138      25.0595
050136............................       1.3586       1.4766      37.4560      43.3747      46.6589      42.5331
050137............................       1.4390       1.1633      38.4827      39.1496      40.2454      39.4249
050138............................       1.8383       1.1633      46.9557      45.3727      40.6348      43.8131
050139............................       1.1867       1.1633      37.6217      37.8986      38.7381      38.1891
050140............................       1.3250       1.1607      39.6269      40.9725      39.4950      39.9745
050144............................          ***            *      33.5109      33.6662      38.2322      35.1744
050145............................       1.4358       1.4408      42.3134      42.2921      47.7276      44.2033
050146............................       1.7437            *            *            *            *            *
050148............................       1.0844            *      27.3005      28.2305            *      27.7734
050149............................       1.5003       1.1633      33.2270      35.8821      37.5338      35.8255
050150............................       1.2112       1.2853      31.7560      33.6583      37.9935      34.4495
050152............................       1.4654       1.4766      43.6487      46.1553      51.6554      47.1764
050153............................       1.4478       1.5378      43.3190      42.8955      47.6370      44.7561
050155............................          ***            *      21.8550      16.9516      16.7744      18.0647
050158............................       1.3562       1.1633      35.1326      35.7805      39.9584      36.9833
050159............................       1.4342       1.1607      31.3199      32.5704      34.6887      32.9759
050167............................       1.3285       1.1870      28.5179      31.4798      34.0379      31.2291
050168............................       1.6239       1.1607      33.2506      37.9784      40.5914      37.3803
050169............................       1.4414       1.1633      27.4644      29.4693      31.4104      29.5643
050172............................          ***            *      28.5604            *            *      28.5604
050173............................       1.3511       1.1607      30.3582      29.0576      31.6677      30.3441
050174............................       1.5304       1.4766      40.1747      44.4199      46.5960      43.8522
050175............................          ***            *      30.5733      33.3061      35.0178      32.9399
050177............................          ***            *      25.1442      24.0717            *      24.6196
050179............................       1.2436       1.1989      27.1155      30.4973      31.6619      30.0118
050180............................       1.5479       1.5299      40.2504      42.0358      45.8035      42.8295
050188............................       1.4249       1.5378      39.5110      41.0943      43.7368      41.3969
050189............................       1.0036       1.4408      29.1279      30.1155      28.7585      29.3260
050191............................       1.5059       1.1633      34.2091      37.7805      38.1482      36.6461
050192............................       0.9796       1.1607      27.0424      27.1400      27.8369      27.3395
050193............................       1.2019       1.1607      29.6421      33.9520      29.3437      30.8548
050194............................       1.3917       1.5378      40.9096      44.7107      49.0012      44.8981
050195............................       1.5361       1.5308      48.4358      48.8595      53.5569      50.3390

[[Page 24857]]

 
050196............................       1.0257       1.1607      32.1933      34.0956      32.8081      33.0293
050197............................       2.1096       1.5299      48.9053      50.0728      53.0188      50.6957
050204............................       1.4245       1.1633      28.6423      32.0121      35.3934      32.0132
050205............................       1.4343       1.1633      27.8611      29.3334      30.6295      29.3017
050207............................          ***            *      29.5214      30.0062      31.3426      30.2627
050211............................       1.2807       1.5308      41.2166      35.0515      35.0280      36.9044
050214............................          ***            *      23.9972      25.4647            *      24.7211
050215............................          ***            *      43.7985      48.8112      50.7559      47.7254
050219............................       1.2468       1.1633      22.4065      26.4143      25.8363      24.8922
050222............................       1.7017       1.1607      29.1094      32.3882      33.7497      31.8383
050224............................       1.7128       1.1607      29.3143      32.5010      35.6597      32.5126
050225............................       1.4566       1.1607      29.9656      34.0836      35.1213      33.2219
050226............................       1.6579       1.1607      30.5867      32.4411      35.4589      32.8047
050228............................       1.2788       1.4766      42.4226      43.7939      47.1404      44.4641
050230............................       1.5673       1.1607      32.9555      34.0600      35.8511      34.3224
050231............................       1.6215       1.1633      30.9607      32.1813      33.7123      32.3028
050232............................       1.7615       1.1912      27.4099      26.3004      33.8542      29.2047
050234............................       1.1631       1.1607      29.6561      32.3726      34.8300      32.2029
050235............................       1.5179       1.1633      29.2979      30.5405      37.0848      32.3685
050236............................       1.4101       1.1607      32.1647      33.0686      32.6449      32.6397
050238............................       1.5170       1.1633      31.1764      33.3346      33.6829      32.8238
050239............................       1.6079       1.1633      31.0963      33.1148      35.9031      33.4237
050240............................          ***            *      35.5735      36.1154      40.8103      37.5129
050242............................       1.3921       1.5378      44.3130      46.4844      51.0202      47.3613
050243............................       1.6372       1.1607      31.4883      32.9385      36.1250      33.6127
050245............................       1.3931       1.1607      28.6527      27.3866      30.1898      28.7713
050248............................       1.0716       1.4408      35.3864            *      37.5312      36.3536
050251............................          ***            *      27.2675      27.8452      31.2316      28.9392
050253............................          ***            *      24.0044      23.5381            *      23.7879
050254............................       1.2481       1.2999      27.0041      31.2386      33.0846      30.5672
050256............................          ***            *      29.8194      29.6793      32.7134      30.6554
050257............................       0.9659       1.1607      21.3216      20.1829      24.0681      21.8475
050261............................       1.3127       1.1607      27.3234      29.2150      30.8667      29.2674
050262............................       2.1485       1.1633      44.0256      39.9946      41.4804      41.8523
050264............................       1.3229       1.5308      41.1211      47.7024      42.5208      43.7371
050270............................          ***            *      32.4812      33.6855      36.0101      34.0808
050272............................       1.3845       1.1607      27.1989      29.4671      29.7379      28.8393
050276............................       1.1469       1.5299      39.3778      41.1406      43.7919      41.5068
050277............................       1.0179       1.1633      32.5213      35.4443      35.0053      34.2959
050278............................       1.5501       1.1633      29.9244      31.8712      34.3775      32.1732
050279............................       1.1687       1.1607      27.6573      29.7118      31.6720      29.7046
050280............................       1.6972       1.2827      35.2030      38.8341      41.4106      38.4388
050281............................       1.3952       1.1633      27.3824      29.4882      31.6589      29.5764
050283............................       1.4814       1.5308      43.0638      44.3122      43.6531      43.6816
050289............................       1.6758       1.4906      41.1774      44.2814      50.1743      45.4605
050290............................       1.7004       1.1633      34.5482      37.3563      40.6183      37.4594
050291............................       1.9448       1.4766      35.3653      38.4365      40.5938      38.0951
050292............................       1.0728       1.1607      26.8879      26.9786      27.3320      27.0736
050295............................       1.4731       1.1607      36.1950      34.7382      38.4514      36.5567
050296............................       1.1731       1.5378      39.0060      39.9842      42.4133      40.4982
050298............................       1.1705       1.1607      27.7416      30.2022      33.7827      30.5459
050299............................          ***            *      31.5435      35.1249      32.3683      32.9738
050300............................       1.4374       1.1607      30.7148      30.2874      33.6814      31.6607
050301............................       1.2925       1.3959      31.9995      35.9491      37.1092      35.1038
050305............................       1.4791       1.5308      44.8630      44.9681      48.5337      46.1773
050308............................       1.5108       1.5378      43.0691      43.7413      46.4167      44.3891
050309............................       1.4575       1.2999      34.4145      38.2659      39.4649      37.4701
050312............................          ***            *      33.9022      36.8498            *      35.1423
050313............................       1.2017       1.1870      31.8003      35.0478      36.4099      34.5831
050315............................       1.2450       1.1607      28.5933      33.2038      32.7454      31.6158
050320............................       1.3087       1.5308      40.2352      45.7686      46.2016      44.0250

[[Page 24858]]

 
050324............................       1.7816       1.1607      32.9792      34.5503      36.3466      34.6946
050325............................       1.2711       1.1653      30.6116      31.3730      34.1213      32.1145
050327............................       1.7344       1.1607      33.0087      33.9507      35.9352      34.3186
050329............................       1.2920       1.1607      26.2121      23.2927      33.0376      27.5535
050331............................       1.1678            *      20.2692            *            *      20.2692
050333............................       1.0014       1.1607      23.4009      19.6352      18.6523      20.3799
050334............................       1.6310       1.4408      40.7467      43.9656      47.2949      44.0643
050335............................       1.3975       1.1653      28.9403      30.9928      34.7177      31.6175
050336............................       1.2358       1.1870      28.5659      30.4664      31.5467      30.2591
050342............................       1.2392       1.1607      26.8507      29.2244      30.4210      28.9056
050348............................       1.7661       1.1607      37.7898      31.5156      32.7100      33.8507
050349............................       0.9614       1.1607      17.4791      24.4863      25.4172      22.6502
050350............................       1.3638       1.1633      31.1833      31.0136      31.7899      31.3395
050351............................       1.5080       1.1633      30.8661      30.6599      33.3053      31.6202
050352............................       1.3698       1.2999      33.9362      36.7673      37.0787      35.9203
050353............................       1.4800       1.1633      31.8291      29.4215      30.4196      30.5532
050357............................       1.4453       1.1607      32.3095      32.6763      36.2079      33.9112
050359............................       1.1700       1.1607      25.7739      29.8345      31.3346      29.0474
050360............................       1.4970       1.4766      37.0769      47.4497      52.3803      45.4207
050366............................       1.1799       1.1632      31.1854      33.6714      37.2628      33.8566
050367............................       1.4038       1.5299      38.7727      38.6330      40.1880      39.2564
050369............................       1.4156       1.1633      29.5697      30.6439      32.2454      30.8342
050373............................       1.5222       1.1633      31.9271      35.1380      34.3691      33.8391
050376............................       1.5665       1.1633      32.9393      34.3539      35.2799      34.2228
050378............................       0.9465       1.1633      34.2417      37.9904      40.1809      37.5492
050379............................          ***            *      32.9576            *            *      32.9576
050380............................       1.6825       1.5378      42.0781      46.0276      49.5391      45.8231
050382............................       1.3846       1.1633      29.4323      30.4014      32.6664      30.8161
050385............................       1.3037       1.4766      34.5183      36.8107      36.4189      35.9493
050390............................       1.1270       1.1607      26.0066      27.3183      27.9319      27.0754
050391............................          ***            *      18.1005      17.2141            *      17.6460
050393............................       1.4106       1.1633      30.0661      34.1743      35.6327      33.2864
050394............................       1.6045       1.1607      27.5061      27.4861      32.1896      29.1045
050396............................       1.6169       1.1607      33.5699      32.4918      37.3957      34.4570
050397............................       0.7585       1.1607      28.1639      28.3671      29.6760      28.7665
050407............................       1.1110       1.4766      37.9066      42.2748      44.6803      41.6942
050410............................          ***            *      21.3814            *            *      21.3814
050411............................       1.2156       1.1633      37.8064      38.8294      38.6322      38.4661
050414............................       1.3232       1.2999      34.6672      38.7585      41.8000      38.4949
050417............................       1.2775       1.1607      29.5031      32.9341      35.4935      32.6699
050419............................       0.8450            *      33.3124            *            *      33.3124
050420............................          ***            *      24.9401      35.2869      39.9207      32.7471
050423............................       1.0736       1.1607      30.6416      28.3768      31.9703      30.4039
050424............................       1.9922       1.1607      31.0730      34.5680      36.6083      34.1649
050425............................       1.3129       1.2999      42.4177      49.2245      46.6607      46.3205
050426............................       1.4945       1.1607      30.6899      33.2031      34.9839      32.9980
050430............................       0.9735       1.1607      25.0604      23.9045      24.5322      24.4190
050432............................          ***            *      30.8030      33.1876      35.2390      33.0678
050433............................       1.6238       1.1607      23.0807      21.3573      21.1315      21.8793
050434............................       1.0477       1.1607      26.1622      32.6255      33.7752      31.2596
050435............................       1.2739       1.1607      28.0305      30.6530      33.0355      30.6062
050438............................       1.5355       1.1633      27.2662      36.3026      35.3864      33.0894
050441............................       1.9488       1.5378      42.9765      44.5694      46.5348      44.7312
050444............................       1.3278       1.2190      30.5504      34.6313      37.6608      34.7182
050447............................       0.9388       1.1607      25.2573      26.7960      29.0758      27.0881
050448............................       1.3448       1.1607      27.9759      30.6201      32.7714      30.3926
050454............................       1.9034       1.4766      43.5311      38.5833      40.2800      40.7576
050455............................       1.6170       1.1607      22.7235      30.4606      34.6359      29.0896
050456............................       1.2382       1.1633      22.5630      21.6261      27.7648      24.0206
050457............................       1.6418       1.4766      45.5828      47.8947      50.0192      47.8408
050464............................       1.6913       1.1989      37.3692      38.3058      41.6239      39.0263

[[Page 24859]]

 
050468............................       1.5319       1.1633      29.5448      31.1111      35.7762      32.2134
050469............................       1.0269            *      28.9080      30.6502            *      29.7684
050470............................       1.1011       1.1607      24.6755      27.8678      31.0441      28.1043
050471............................       1.7564       1.1633      34.5211      35.4768      36.9130      35.6374
050476............................       1.4491       1.3959      34.6585      38.7856      40.0425      37.8312
050477............................          ***            *      34.6995      37.7668      40.1536      37.8017
050478............................       0.9888       1.1607      33.3999      40.2558      41.1616      38.4325
050481............................       1.4433       1.1633      33.7445      36.1394      38.8656      36.2142
050485............................       1.6549       1.1633      31.4233      36.1488      34.6206      34.0200
050488............................       1.3383       1.5308      42.9904      42.6854      44.0641      43.2687
050491............................          ***            *      32.1379      34.3598            *      33.1420
050492............................       1.2507       1.1607      27.1540      28.0826      30.7637      28.6534
050494............................       1.3609       1.2853      35.9910      38.1177      40.6396      38.1898
050496............................       1.7129       1.5299      42.2672      48.2468      51.6358      47.5808
050498............................       1.3359       1.2999      33.0298      37.1667      40.8114      36.9608
050502............................       1.7107       1.1633      29.5616      28.7046      31.8871      30.0325
050503............................       1.5082       1.1607      31.6418      34.0994      36.4360      34.1126
050506............................       1.6141       1.1912      36.0164      37.7420      39.8585      37.9166
050510............................       1.1758       1.5299      47.5510      52.5376      49.4515      49.9476
050512............................       1.3824       1.5308      46.9233      50.9264      48.8054      49.0410
050515............................       1.3440       1.1607      38.9978      38.9542      40.2968      39.4969
050516............................       1.4933       1.2999      36.2772      39.8161      42.9590      39.7253
050517............................       1.2446       1.1607      23.9007      20.0213      17.0548      19.9099
050523............................       1.2609       1.5299      35.5452      40.6535      42.4719      39.5900
050526............................       1.3227       1.1607      31.3744      28.1997      33.3951      30.8787
050528............................       1.1384       1.1607      29.6838      31.4941      36.0123      32.5346
050531............................       1.0428       1.1633      26.9420      27.1974      28.3319      27.4850
050534............................       1.4831       1.1607      29.8603      33.1666      36.6525      33.1997
050535............................          ***            *      32.3723      34.6143      37.8210      35.0693
050537............................       1.4155       1.2999      31.3844      34.9931      37.4208      34.7283
050539............................          ***            *      29.8242            *            *      29.8242
050541............................       1.5613       1.5299      46.1121      52.5908      48.0854      48.9361
050543............................       0.7511       1.1607      26.1103      29.4443      24.4854      26.5566
050545............................       0.8423       1.1633      30.5554      31.3080      35.3180      32.3823
050546............................       0.6608       1.1607      30.2329      33.2245      36.5097      33.2376
050547............................       0.9307       1.4766      33.2204      34.8401      33.8021      33.9238
050548............................       0.8110       1.1607      30.3775      39.2234      41.0903      36.6511
050549............................       1.5395       1.1607      34.9818      35.2792      38.3717      36.2083
050550............................          ***            *      30.2301      30.9612      34.9589      31.9521
050551............................       1.3357       1.1607      31.6165      34.0467      37.2494      34.3696
050552............................       1.0550       1.1633      27.1744      33.0711      33.9787      31.2577
050557............................       1.6018       1.1989      31.8048      33.3654      35.3341      33.5504
050561............................       1.6005       1.1633      38.8652      38.0196      38.2536      38.3442
050567............................       1.6021       1.1607      32.9829      35.7063      37.6375      35.4787
050568............................       1.1551       1.1607      24.4061      25.2337      26.0875      25.2903
050569............................       1.3174            *      33.0259      31.6785            *      32.3431
050570............................       1.5427       1.1607      34.0171      34.5161      38.5202      35.7251
050571............................          ***            *      33.6156      34.7627      39.0735      35.8473
050573............................       1.6272       1.1607      34.1991      34.7279      35.2835      34.7592
050575............................       1.2410       1.1633      25.2513      25.1457      23.7972      24.6719
050577............................          ***            *      30.8841      32.3744            *      31.6437
050578............................       1.4930       1.1633      33.8825      35.2390      31.3598      33.5038
050579............................          ***            *      39.4976      42.5081            *      40.8657
050580............................       1.2328       1.1607      31.6256      31.5806      34.1537      32.4723
050581............................       1.4907       1.1633      32.1801      34.0136      37.7567      34.6700
050583............................       1.6465       1.1607      33.3697      34.5747      37.4560      35.0083
050584............................       1.3234       1.1607      24.8180      30.3434      30.7795      28.6016
050585............................          ***            *      22.7121      22.2521      29.4264      24.4704
050586............................       1.2846       1.1607      27.4173      26.4782      31.3482      28.3860
050588............................       1.3412       1.1633      32.8212      32.7556      37.7367      34.4128
050589............................       1.1523       1.1607      30.9546      34.5100      37.6873      34.3938

[[Page 24860]]

 
050590............................       1.2935       1.2999      32.2142      38.4971      41.6861      37.3399
050591............................          ***            *      28.8549      30.6106      34.7108      31.3299
050592............................          ***            *      24.4542      27.3606      31.8084      27.4577
050594............................          ***            *      34.7946      36.5256      42.0829      37.6368
050597............................       1.2589       1.1633      27.5691      28.8294      31.5618      29.3957
050599............................       1.8935       1.2999      38.1975      32.7835      34.7192      35.1753
050601............................       1.5556       1.1633      34.7409      36.0572      39.7718      36.8583
050603............................       1.4451       1.1607      30.2464      34.0275      35.0261      33.2299
050604............................       1.3991       1.5378      49.9428      55.0821      49.4433      51.2946
050608............................       1.2668       1.1607      23.3630      30.4169      36.3844      29.5731
050609............................       1.2823       1.1607      41.1797      41.7208      39.7400      40.7274
050613............................          ***            *            *      42.8108      42.9921      42.8888
050615............................          ***            *      33.2909      35.9547      39.0455      36.0526
050616............................       1.5105       1.1607      36.9017      37.7284      36.7844      37.1319
050618............................       0.9805       1.1607      27.4539      31.3182      33.1445      30.7673
050623............................          ***            *      32.0627            *            *      32.0627
050624............................       1.2791       1.1633      32.2907      33.9594      35.9335      34.1562
050625............................       1.7399       1.1633      36.3631      38.6591      40.4646      38.5119
050630............................          ***            *      30.9410            *            *      30.9410
050633............................       1.2279       1.1912      35.3734      36.8302      38.4914      36.8992
050636............................       1.2912       1.1607      30.5156      32.5576      32.7924      31.9970
050641............................       1.2917       1.1633      21.4612      39.6921      32.3562      29.3375
050644............................       0.9882       1.1633      27.6547      28.8237      30.7956      29.0870
050660............................       1.7424            *            *            *            *            *
050662............................       0.8701       1.5378      32.6362      33.2446      38.2978      34.3623
050663............................       1.2772       1.1633      25.7747      27.7334      17.7021      22.5197
050667............................       0.8494       1.4201      26.3937      24.2771      25.9164      25.5328
050668............................       1.2080       1.4766      31.8065      56.6555      51.6039      44.4443
050674............................       1.1203       1.2999      42.6866      48.0893      47.0699      46.1683
050677............................       1.4565       1.1633      38.7984      38.5770      39.2158      38.8993
050678............................       1.3172       1.1607      30.7219      32.4473      33.7604      32.3831
050680............................       1.2341       1.5299      38.3946      38.2871      37.9841      38.2002
050682............................       0.8469       1.1607      21.7792      17.9077      22.2175      20.5426
050684............................       1.1147       1.1607      26.4234      27.5256      28.8345      27.6181
050686............................       1.2077       1.1607      40.9486      41.0188      39.7765      40.4756
050688............................       1.2025       1.5378      41.9325      44.1510      49.4057      45.3228
050689............................       1.5246       1.5299      42.2018      45.0951      48.8526      45.3622
050690............................       0.9979       1.4766      47.2769      50.9094      49.0219      49.1860
050693............................       1.3853       1.1607      35.0621      34.5797      39.7191      36.4072
050694............................       1.0504       1.1607      28.9544      30.7858      32.1040      30.6710
050695............................          ***            *      35.6548      39.6004      49.0312      41.9280
050696............................       2.2819       1.1633      35.9220      37.3837      39.9251      37.7376
050697............................       1.1042       1.2827      25.1984      16.6605      22.1435      20.8109
050699............................          ***            *      26.8211      28.9083      21.5729      25.9116
050701............................       1.3266       1.1607      29.6253      31.9529      34.9885      32.5135
050704............................       1.0008       1.1633      25.3488      29.7740      31.6053      29.0130
050707............................       1.2478       1.4906      34.0550      35.7311      43.5546      37.4835
050708............................       1.5869       1.1607      22.5034      30.5860      31.8452      27.9330
050709............................       1.4175       1.1607      25.6119      26.8549      24.5600      25.5795
050710............................       1.4517       1.1607      39.9858      45.8022      44.2474      43.5806
050713............................          ***            *      20.2803      21.1273      21.4809      20.8075
050714............................       1.3837       1.5378      33.6676      31.9527      33.6833      33.1222
050717............................       1.4243       1.1633      38.0796      39.3227      38.8757      38.7310
050718............................          ***            *      21.4996      25.5140      31.9633      26.0532
050720............................       0.9023       1.1607      30.0811      29.4726      30.3598      29.9464
050722............................       0.9960       1.1607            *      31.4867      33.8005      32.6977
050723............................       1.3624       1.1633      35.0119      38.5446      38.7138      37.6299
050724............................       1.9836       1.1607      34.4267      31.6910      38.4705      34.9427
050725............................       0.8893       1.1633      21.7816      24.3100      30.0558      25.0162
050726............................       1.4929       1.1989      27.8433      30.6479      29.2940      29.3768
050727............................       1.1939       1.1633      24.3026      33.9118      32.7726      30.6197

[[Page 24861]]

 
050728............................          ***            *      36.0820      39.3581      41.8244      38.7029
050729............................          ***            *      34.2580      36.5432      38.1758      36.3888
050730............................          ***            *      51.5425      37.0629      39.2017      42.2681
050732............................       2.3945       1.1607            *            *      33.6903      33.6903
050733............................       1.6526       1.2827            *            *      40.1993      40.1993
050734............................          ***            *            *            *      31.2860      31.2860
050735............................       1.3420       1.1633            *            *            *            *
050736............................       1.2208       1.1633            *            *            *            *
050737............................       1.4932       1.1633            *            *            *            *
050738............................       1.3746       1.1633            *            *            *            *
050739............................       1.6730       1.1633            *            *            *            *
050740............................       1.3849       1.1633            *            *            *            *
050741............................       1.4970       1.1633            *            *            *            *
050742............................       1.3975       1.1633            *            *            *            *
050744............................       1.9678       1.1613            *            *            *            *
050745............................       1.3654       1.1613            *            *            *            *
050746............................       1.7819       1.1613            *            *            *            *
050747............................       1.3997       1.1613            *            *            *            *
050748............................       1.0732       1.1870            *            *            *            *
050749............................       1.2517       1.1607            *            *            *            *
050750............................       1.4161       1.1989            *            *            *            *
050751............................       3.2977       1.1633            *            *            *            *
050752............................       1.4164       1.1633            *            *            *            *
050753............................       1.7096       1.1633            *            *            *            *
050754............................       1.3352       1.4906            *            *            *            *
050755............................       1.4093       1.1633            *            *            *            *
050756............................       1.9522       1.1612            *            *            *            *
060001............................       1.5646       1.0490      26.8470      29.6191      30.9980      29.1621
060003............................       1.3969       1.0490      24.2224      29.4809      31.3617      28.3333
060004............................       1.2516       1.0490      29.9649      32.4609      32.0087      31.4835
060006............................       1.3325       0.9451      24.5704      25.2139      27.2049      25.6626
060008............................       1.2017       0.9451      23.3859      23.0947      26.5156      24.3263
060009............................       1.4938       1.0490      28.7645      31.5210      32.4188      30.9671
060010............................       1.6914       0.9664      28.9850      27.1916      29.5311      28.5346
060011............................       1.6393       1.0490      27.2833      35.1573      32.0985      31.3626
060012............................       1.4822       0.9451      26.2469      27.3885      28.7720      27.4499
060013............................       1.5070       0.9451      24.5994      26.8675      27.9147      26.4239
060014............................       1.8624       1.0490      31.2588      31.0542      31.9644      31.4172
060015............................       1.7856       1.0490      30.4533      32.5285      32.2927      31.6808
060016............................       1.2375       0.9451      25.6527      26.5427      27.2625      26.4975
060018............................       1.2860       0.9451      25.7628      24.1086      25.3951      25.0897
060020............................       1.6180       0.9451      22.6748      24.5992      25.9131      24.3728
060022............................       1.6508       0.9471      26.5238      28.2944      29.3376      28.0338
060023............................       1.6737       1.0490      27.7644      29.5760      31.1545      29.4765
060024............................       1.8352       1.0490      29.0130      30.0279      32.1201      30.4150
060027............................       1.6708       1.0490      28.0909      29.6121      30.9359      29.6320
060028............................       1.5172       1.0490      30.0448      31.6900      32.1646      31.3043
060030............................       1.4469       0.9664      26.6251      27.8642      29.9492      28.1539
060031............................       1.5587       0.9471      26.3650      27.8345      29.3903      27.8461
060032............................       1.4866       1.0490      30.4247      31.0686      32.7381      31.4187
060034............................       1.6603       1.0490      29.8445      30.9359      32.1087      30.9310
060036............................       1.1013       0.9451      20.7131      20.3226      22.8253      21.2501
060041............................       0.8769       0.9451      23.4978      24.6142      25.9681      24.7293
060043............................       1.1879       0.9451      18.7897      18.2143      21.9824      19.6548
060044............................       1.2127       0.9451      25.0360      26.5611      24.8343      25.4577
060049............................       1.2785       0.9577      29.0598      29.3724      29.9878      29.4858
060054............................       1.4507       1.0141      22.3490      24.3389      25.0987      23.9190
060064............................       1.7291       1.0490      31.3105      32.3681      33.2430      32.1358
060065............................       1.3997       1.0490      31.1987      32.4735      33.8541      32.5474
060071............................       1.1696       0.9451      25.7248      27.6657      28.1744      27.2773
060075............................       1.3332       1.0141      32.7563      32.2545      37.6040      34.1974

[[Page 24862]]

 
060076............................       1.2672       0.9451      26.8236      26.5631      30.7794      28.0379
060096............................       1.5553       1.0490      30.0602      32.1310      37.8250      33.2700
060100............................       1.6877       1.0490      32.1537      32.6104      33.2259      32.6698
060103............................       1.3574       1.0490      30.3003      31.6314      32.9699      31.6641
060104............................       1.3822       1.0490      32.0889      32.4232      35.4406      33.2463
060107............................       1.4409       1.0490      26.1883      26.8388      28.0661      27.0406
060112............................       1.6546       1.0490            *      34.9272      34.6910      34.8011
060113............................       1.4263       1.0490            *            *      32.6081      32.6081
060114............................       1.3802       1.0490            *            *      34.8551      34.8551
060115............................       0.8095       0.9451            *            *            *            *
060116............................       1.4116       1.0490            *            *            *            *
060117............................       1.5193       0.9451            *            *            *            *
060118............................       1.1985       0.9451            *            *            *            *
070001............................       1.6168       1.2565      34.0302      35.8958      37.0362      35.6784
070002............................       1.7626       1.2439      31.1530      33.4398      34.7608      33.1047
070003............................       1.1121       1.2439      32.4197      34.1352      34.1274      33.5632
070004............................       1.1692       1.2439      29.2544      29.4448      29.9492      29.5629
070005............................       1.3946       1.2565      32.1668      33.7813      34.9377      33.6339
070006............................       1.3747       1.2993      36.8469      37.9148      39.3915      38.0389
070007............................       1.3254       1.2439      31.7125      35.9617      36.6407      34.7798
070008............................       1.1970       1.2439      26.4806      28.5506      29.6687      28.2382
070009............................       1.1839       1.2439      30.2706      32.9299      35.2475      32.8064
070010............................       1.7654       1.2993      32.5798      35.3730      36.6948      34.9639
070011............................       1.4451       1.2439      29.9105      31.8987      31.2283      31.0248
070012............................       1.2709       1.2439      44.1424      29.4216      31.9349      33.9311
070015............................       1.3970       1.2993      33.4595      35.3385      36.6708      35.2092
070016............................       1.4996       1.2565      31.0904      31.4930      33.2371      31.9049
070017............................       1.3568       1.2565      31.7223      34.0490      35.6418      33.8503
070018............................       1.4233       1.2993      37.6081      39.7515      41.9173      39.8452
070019............................       1.3270       1.2565      31.8148      34.5125      33.7229      33.3664
070020............................       1.3297       1.2439      31.0935      33.6453      33.6696      32.8254
070021............................       1.1568       1.2439      33.2357      36.9241      38.5585      36.2050
070022............................       1.6749       1.2565      35.4120      39.0462      40.2702      38.3013
070024............................       1.3613       1.2439      32.0430      35.2323      34.7400      34.0483
070025............................       1.8064       1.2439      30.9938      32.4085      34.5858      32.6659
070027............................       1.4451       1.2439      31.8018      29.8513      30.4430      30.7111
070028............................       1.5984       1.2993      31.5035      35.1966      38.0833      34.9177
070029............................       1.3083       1.2439      27.7213      30.9299      31.0636      29.9122
070031............................       1.2711       1.2565      28.9189      30.1915      30.4044      29.8550
070033............................       1.4708       1.2993      37.1929      40.1594      43.7004      40.4535
070034............................       1.3980       1.2993      36.3899      38.3965      39.3798      38.0564
070035............................       1.2872       1.2439      27.5585      30.7440      31.1401      29.7921
070036............................       1.6067       1.2439      36.1610      38.3413      42.3416      39.0119
070038............................       1.3936       1.2565      25.7516      25.7914      35.8029      27.8679
070039............................       0.9377       1.2565      31.2269      36.1369      34.7131      33.8173
070040............................       0.9996       1.2439            *            *            *            *
080001............................       1.6239       1.0778      30.0242      32.0105      33.5308      31.8695
080002............................          ***            *      27.7932      29.6800      30.4575      29.3051
080003............................       1.5693       1.0778      29.2266      30.7697      34.2596      31.4914
080004............................       1.5151       1.0752      27.4921      30.1094      32.2239      29.9990
080006............................       1.3057       1.0023      25.6160      27.4749      28.8828      27.4029
080007............................       1.3920       1.0358      27.0074      30.1100      31.1628      29.4879
090001............................       1.7712       1.0679      35.0413      36.6577      38.1321      36.5957
090003............................       1.2511       1.0679      29.2660      31.0419      32.1944      30.9271
090004............................       1.9599       1.0679      32.2021      35.6964      37.3772      35.0391
090005............................       1.3874       1.0679      30.7728      33.0178      33.7415      32.5062
090006............................       1.4067       1.0679      29.5590      29.4912      31.3551      30.1261
090008............................       1.3393       1.0679      29.1059      32.0745      33.7464      31.3882
090011............................       2.0566       1.0990      34.0693      36.7579      37.7551      36.1901
100001............................       1.5278       0.9129      24.4060      26.4631      27.2801      26.0725
100002............................       1.4353       1.0245      25.3389      27.2350      28.7046      27.1080

[[Page 24863]]

 
100004............................       0.9210            *      16.5974            *            *      16.5974
100006............................       1.6439       0.9383      26.3789      29.1505      29.0886      28.2008
100007............................       1.6370       0.9383      26.5378      28.5702      29.1608      28.1327
100008............................       1.7232       1.0023      27.4314      29.1705      30.3372      29.0485
100009............................       1.4531       1.0023      25.9381      27.4424      27.8595      27.0413
100012............................       1.6158       0.9490      26.3788      28.4600      29.8330      28.2805
100014............................       1.4087       0.9245      24.5862      25.1524      27.4005      25.7596
100015............................       1.3031       0.9174      24.6038      26.0916      27.2172      25.9252
100017............................       1.6269       0.9245      26.1580      27.9654      28.2380      27.5012
100018............................       1.6499       0.9756      28.1481      30.2423      30.6513      29.7097
100019............................       1.6615       0.9385      27.6179      28.6630      30.2983      28.8662
100020............................          ***            *      23.9414      27.1257            *      25.5458
100022............................       1.7406       1.0245      29.9345      32.8088      36.7902      33.2230
100023............................       1.5155       0.9245      23.0074      25.2652      25.4238      24.5727
100024............................       1.1735       1.0023      30.2395      29.1894      29.5413      29.6467
100025............................       1.6820       0.8749      22.1580      23.3843      26.7005      24.0623
100026............................       1.5785       0.8749      21.4703      23.4730      25.3313      23.5015
100027............................          ***            *      16.1223      18.9432            *      17.4007
100028............................       1.3559       0.9385      26.8661      27.7497      27.5647      27.4069
100029............................       1.2842       1.0023      27.5844      28.8842      30.5354      29.0520
100030............................       1.2822       0.9383      24.0943      24.6314      25.3501      24.7166
100032............................       1.8033       0.9174      25.2450      26.8162      26.9247      26.3589
100034............................       1.8267       1.0023      25.9415      28.1280      27.2895      27.0668
100035............................       1.5643       0.9758      26.9407      29.4803      29.9645      28.7904
100038............................       1.8187       1.0245      29.8583      31.3403      31.6634      30.9762
100039............................       1.5150       1.0245      28.4627      28.2531      29.3708      28.6925
100040............................       1.7018       0.9129      23.6443      26.2429      27.2813      25.7448
100043............................       1.3790       0.9174      25.2273      26.4221      27.0030      26.2279
100044............................       1.4158       0.9990      28.3596      30.3659      33.1112      30.6144
100045............................       1.3355       0.9245      26.9641      29.7375      26.5408      27.7585
100046............................       1.3033       0.9174      26.3673      26.9469      26.7694      26.6960
100047............................       1.8638       0.9758      25.0404      26.7674      29.9682      27.2642
100048............................       0.9252       0.8749      18.8770      19.3226      20.2658      19.5008
100049............................       1.1600       0.8839      22.9809      24.0385      24.5536      23.8777
100050............................       1.1288       1.0023      19.8713      21.5101      25.3238      22.2723
100051............................       1.3534       0.9383      23.1940      28.0946      28.7737      26.7720
100052............................       1.4455       0.8839      22.3920      23.6796      23.4019      23.1671
100053............................       1.2920       1.0023      27.3224      28.5118      31.7384      29.1111
100054............................       1.3034       0.8749      28.0512      28.7646      30.5206      29.0875
100055............................       1.4156       0.9174      23.5332      25.6243      27.3802      25.3794
100057............................       1.4516       0.9383      25.3897      24.8010      26.3122      25.5302
100061............................       1.5414       1.0023      29.2565      31.4413      30.4499      30.3963
100062............................       1.6808       0.8749      25.2340      25.1280      25.9585      25.4595
100063............................       1.3036       0.9174      24.7026      25.5097      26.4124      25.5740
100067............................       1.4074       0.9174      26.1213      26.8628      27.4739      26.8557
100068............................       1.6613       0.9245      25.9202      26.1341      27.6575      26.5514
100069............................       1.4508       0.9174      24.7442      25.7450      27.2096      25.8883
100070............................       1.7116       0.9758      24.8883      26.8461      29.1991      26.9663
100071............................       1.2756       0.9174      24.9682      26.3768      25.3651      25.5845
100072............................       1.3879       0.9245      26.0459      25.7962      27.1887      26.3539
100073............................       1.7697       1.0245      30.3358      30.5845      28.7281      29.8848
100075............................       1.4457       0.9174      25.1691      25.7612      27.6513      26.2369
100076............................       1.1677       1.0023      21.9483      23.4551      24.0435      23.1100
100077............................       1.3560       0.9758      26.0347      30.6925      30.7522      29.1481
100079............................       1.4994            *            *            *            *            *
100080............................       1.7074       1.0245      27.0126      28.2188      29.5332      28.2762
100081............................       0.9413       0.8749      15.6661      16.9756      19.5662      17.4288
100084............................       1.7880       0.9383      26.3393      27.4947      32.7477      28.7729
100086............................       1.2961       1.0245      28.2641      28.5971      29.9082      28.9237
100087............................       1.8973       0.9758      27.1531      29.5823      30.5733      29.1231
100088............................       1.5785       0.9129      25.9182      26.7574      28.0793      26.9516

[[Page 24864]]

 
100090............................       1.4902       0.9129      24.2422      26.5703      27.6128      26.1872
100092............................       1.5151       0.9385      28.4789      27.8341      26.6301      27.6308
100093............................       1.7136       0.8749      21.3524      21.6438      22.5555      21.8792
100099............................       1.0877       0.8839      21.3035      25.8454      26.2362      24.4514
100102............................       1.0972       0.8749      23.8596      26.1015      27.9371      25.9898
100105............................       1.4481       0.9990      26.8091      29.9745      30.9880      29.1998
100106............................       1.0557       0.8749      24.0389      24.7650      24.8062      24.5422
100107............................       1.2356       0.9490      26.1337      27.4760      30.5712      28.1061
100108............................       0.8045       0.8749      22.0750      21.3540      22.6250      21.9874
100109............................       1.2501       0.9245      24.9951      25.5669      26.2294      25.6245
100110............................       1.6562       0.9383      29.1494      29.4788      29.5964      29.4181
100113............................       2.0208       0.9306      26.3806      28.0440      29.2410      27.9265
100114............................       1.3823       1.0023      29.2195      29.2862      30.2549      29.5960
100117............................       1.2128       0.9129      26.4536      27.7198      28.5709      27.6304
100118............................       1.3599       0.9129      28.0569      27.6438      27.0971      27.5184
100121............................       1.1040       0.8839      24.8579      26.2990      27.9335      26.4257
100122............................       1.2270       0.8749      23.4751      24.6285      26.7143      24.9527
100124............................       1.1549       0.8749      22.7023      24.0333      24.8875      23.9085
100125............................       1.1784       1.0023      26.7452      29.7750      31.7723      29.5535
100126............................       1.3316       0.9174      24.4515      29.6247      28.3189      27.4135
100127............................       1.5660       0.9174      24.4485      26.0923      27.4608      26.0307
100128............................       2.2062       0.9174      29.4979      29.2566      30.0299      29.6024
100130............................       1.1799       1.0245      24.2046      26.0268      28.3616      26.1493
100131............................       1.4156       1.0023      29.2462      27.8164      29.7632      28.9648
100132............................       1.2458       0.9174      24.3293      26.0526      27.2007      25.9267
100134............................       0.8562       0.9129      20.9243      20.7367      21.6532      21.1182
100135............................       1.6098       0.9032      24.0024      26.7030      29.1837      26.5344
100137............................       1.2884       0.8839      25.1974      24.8519      26.8344      25.6687
100139............................       0.8318       0.9306      17.5489      18.2197      21.1258      18.9546
100140............................       1.0846       0.9129      26.4720      26.1352      27.8649      26.8242
100142............................       1.2099       0.8749      22.9577      24.8853      25.5354      24.4855
100150............................       1.2678       1.0023      26.1990      26.8492      27.7741      26.9186
100151............................       1.7467       0.9129      28.1322      30.6447      30.6281      29.7879
100154............................       1.5748       1.0023      27.6127      28.2506      29.7317      28.5810
100156............................       1.1336       0.9306      26.7092      27.5706      28.3909      27.6104
100157............................       1.5752       0.9174      27.3851      29.7455      30.3052      29.2294
100160............................       1.1392       0.8749      26.9851      30.7454      30.6896      29.5443
100161............................       1.5169       0.9383      28.8077      28.0545      29.5663      28.8152
100166............................       1.4668       0.9758      27.9618      28.8685      30.1807      28.9923
100167............................       1.3035       1.0245      30.3694      30.2166      31.7804      30.8185
100168............................       1.4079       1.0245      27.1292      27.6739      27.0923      27.2992
100172............................       1.2812       1.0023      18.2735      20.7857      22.2204      20.2640
100173............................       1.6813       0.9174      24.8721      26.5436      28.6368      26.6618
100175............................       0.9372       0.8749      23.5455      23.9665      25.0985      24.2176
100176............................       1.9303       1.0245      31.2694      30.7087      33.3165      31.7296
100177............................       1.3039       0.9385      26.6781      28.0089      29.6265      28.1065
100179............................       1.8024       0.9129      29.5619      29.1111      29.0431      29.2333
100180............................       1.3657       0.9174      27.1804      29.9238      31.0064      29.4502
100181............................       1.0909       1.0023      21.8540      24.3708      23.9591      23.5687
100183............................       1.2321       1.0023      27.4951      29.0270      30.5104      28.9871
100187............................       1.2376       1.0023      27.3653      27.8144      30.7495      28.5855
100189............................       1.3212       1.0245      28.4136      28.8320      29.9369      29.0845
100191............................       1.3259       0.9174      26.6341      28.3710      29.4499      28.2023
100200............................       1.3580       1.0245      29.8963      28.7694      29.6406      29.4299
100204............................       1.5566       0.9306      25.7537      27.4763      27.2798      26.8486
100206............................       1.3050       0.9174      25.2196      27.0295      27.7525      26.6834
100209............................       1.4522       1.0023      26.6245      26.8473      28.5311      27.3559
100210............................       1.6430       1.0245      28.9486      29.8515      32.0804      30.2950
100211............................       1.2007       0.9174      24.7095      24.7533      26.2817      25.2452
100212............................       1.5281       0.8749      24.7566      26.1846      27.7936      26.2582
100213............................       1.5668       0.9758      27.1936      27.9283      29.5190      28.1989

[[Page 24865]]

 
100217............................       1.2132       0.9990      25.2907      27.3989      27.7642      26.8865
100220............................       1.7260       0.9490      26.0905      28.3868      29.3570      28.0175
100223............................       1.5835       0.8749      24.7015      25.0332      26.1109      25.3046
100224............................       1.2839       1.0245      24.8077      26.6446      28.0429      26.4939
100225............................       1.2937       1.0245      28.4316      28.5259      30.8876      29.2153
100226............................       1.2744       0.9129      29.3317      28.8165      29.7725      29.3198
100228............................       1.3709       1.0245      29.8952      28.1396      30.1621      29.3737
100230............................       1.3733       1.0245      28.1703      29.8493      31.9424      29.9630
100231............................       1.7080       0.8749      25.5175      25.7037      26.6772      25.9675
100232............................       1.2524       0.9306      24.9322      28.5537      28.3856      27.3012
100234............................       1.2976       1.0245      26.3601      27.4456      28.8835      27.5798
100236............................       1.4832       0.9758      26.6585      28.9955      28.2984      27.9868
100237............................       1.9057       1.0245      31.3543      31.7848      33.1739      32.0770
100238............................       1.6522       0.9174      28.4302      30.1094      31.4171      30.0491
100239............................       1.2460       0.9758      27.7592      28.6893      29.7638      28.7444
100240............................       1.0076       1.0023      25.3265      27.3523      29.6971      27.5087
100242............................       1.4479       0.8749      24.0990      25.6083      26.1976      25.3020
100243............................       1.5946       0.9174      26.1131      27.4534      28.3866      27.3439
100244............................       1.4203       0.9490      25.2584      26.6876      28.2865      26.8118
100246............................       1.5758       0.9990      28.9894      29.3310      30.1050      29.4942
100248............................       1.5253       0.9174      27.7798      28.8082      30.2111      28.9505
100249............................       1.2737       0.9174      23.2084      24.9876      26.4639      24.9121
100252............................       1.1792       0.9482      25.8540      27.8256      27.1607      26.9474
100253............................       1.3715       1.0245      25.7121      27.4927      28.7770      27.3720
100254............................       1.5090       0.9032      25.7338      26.1406      27.4880      26.4891
100255............................       1.2936       0.9174      24.4808      26.5571      27.3842      26.1577
100256............................       1.8521       0.9174      28.8856      30.3081      30.2061      29.8124
100258............................       1.5130       1.0245      31.2482      31.2203      33.8699      32.1188
100259............................       1.2828       0.9174      26.0175      27.4809      29.0586      27.5346
100260............................       1.3245       0.9990      27.5188      26.7129      27.5087      27.2404
100264............................       1.3422       0.9174      25.5489      26.8216      28.0330      26.7861
100265............................       1.2694       0.9174      24.1454      25.7432      26.3305      25.4668
100266............................       1.4188       0.8749      23.2340      23.0208      24.2518      23.5319
100267............................       1.3150       0.9758      27.3769      28.7259      28.9660      28.3534
100268............................       1.1556       1.0245      29.2898      29.0668      30.5747      29.6377
100269............................       1.3559       1.0245      26.7450      26.6047      27.8403      27.0868
100271............................       2.3619            *            *            *            *            *
100275............................       1.2874       1.0245      26.0361      26.8943      28.6334      27.2552
100276............................       1.2400       1.0245      30.0576      29.7606      30.5728      30.1330
100277............................       1.4125       1.0023      16.5427      20.4791      30.6239      22.8795
100279............................       1.3368       0.9490      26.8606      28.6383      29.2235      28.2854
100281............................       1.3697       1.0245      28.6660      29.6698      30.9112      29.8011
100284............................       1.0112       1.0023      23.8170      22.3134      25.2610      23.6819
100285............................       1.2699       1.0245            *            *      41.9448      41.9448
100286............................       1.6117       0.9756      29.4284      28.3645      27.9816      28.5432
100287............................       1.3865       1.0245      28.3427      28.1051      29.7774      28.7085
100288............................       1.5054       1.0245      33.8141      28.7902      31.2667      31.1545
100289............................       1.6862       1.0245      29.2915      29.6376      31.8991      30.3057
100290............................       1.1911       0.9139      23.5080      27.1011      29.0093      26.4993
100291............................       1.2462       0.9385            *      28.4722      28.1498      28.2965
100292............................       1.3546       0.8749            *      26.7063      27.7643      27.2417
100293............................          ***            *            *      32.7963            *      32.7963
100294............................          ***            *            *      30.7557            *      30.7557
100295............................          ***            *            *      26.1983            *      26.1983
100296............................       1.3420       1.0023            *            *      29.3841      29.3841
100297............................          ***            *            *            *      32.1504      32.1504
100298............................       0.8097       0.9032            *            *      19.0284      19.0284
100299............................       1.2650       0.9758            *            *      34.3125      34.3125
100300............................       1.5491       0.9758            *            *            *            *
100301............................       2.4311       0.8749            *            *            *            *
100302............................       1.1202       0.9383            *            *            *            *

[[Page 24866]]

 
110001............................       1.3403       0.8587      25.3102      26.4338      26.5634      26.1061
110002............................       1.3617       0.9845      25.3897      26.4715      26.2215      26.0373
110003............................       1.2936       0.7864      21.4002      22.7066      24.2076      22.7653
110004............................       1.3585       0.8967      23.9911      24.9978      25.1820      24.7375
110005............................       1.2330       0.9845      22.8999      28.1209      27.2810      26.2179
110006............................       1.5291       1.0543      28.6090      28.3839            *      28.4953
110007............................       1.5859       0.8671      23.8729      26.6396      26.3115      25.6309
110008............................       1.3085       0.9845      27.1711      29.2947      30.9741      29.1802
110010............................       2.2306       0.9845      29.7142      31.7185      33.2379      31.5593
110011............................       1.2246       0.9845      26.0899      28.0598      28.5710      27.5776
110015............................       1.0603       0.9845      26.6610      28.1274      28.8247      27.9582
110016............................       1.2635       0.8594      21.7610      22.7263      24.3540      22.9370
110018............................       1.1624       0.9845      28.2431      26.8016      30.1831      28.3506
110020............................       1.3217       0.9845      26.8501      28.3822      27.5540      27.6137
110023............................       1.2996       0.9845      27.3029      29.8061      29.4091      28.8898
110024............................       1.4914       0.8987      25.7205      27.0225      27.9321      26.8777
110025............................       1.4742       0.9768      26.1311      31.0703      30.2808      29.1365
110026............................       1.1095       0.7864      21.2827      21.8018      22.8797      21.9817
110027............................       1.0927       0.7864      20.2175      22.6058      25.5227      22.6306
110028............................       1.7897       0.9600      28.1619      30.4641      31.4549      30.0483
110029............................       1.8272       0.9845      24.8893      27.3618      29.2101      27.2811
110030............................       1.3175       0.9845      26.4770      29.6841      29.9483      28.7919
110031............................       1.2896       0.9845      24.7874      27.1989      29.5494      27.2201
110032............................       1.1833       0.7864      21.9407      23.2586      25.1864      23.4269
110033............................       1.4729       0.9845      28.3210      30.3415      32.4147      30.4690
110034............................       1.7212       0.9600      26.9986      27.2338      28.7910      27.6793
110035............................       1.7465       0.9845      27.4583      28.9408      30.1817      28.9116
110036............................       1.8415       0.8987      26.8789      26.6664      27.4572      27.0225
110038............................       1.5058       0.8458      21.2138      22.2720      22.9667      22.1527
110039............................       1.3686       0.9600      24.7248      26.3503      26.2463      25.8073
110040............................       1.0915       0.9845      19.7509      20.9487      23.9465      21.5965
110041............................       1.2635       0.9845      23.4073      24.8864      26.1928      24.8269
110042............................       1.0549       0.9845      28.6873      34.9954      33.4345      32.3594
110043............................       1.7583       0.8987      26.6323      27.8477      28.8534      27.7746
110044............................       1.1546       0.7864      20.9654      23.3039      24.3743      22.8665
110045............................       1.0610       0.9845      24.9821      24.4275      27.7578      25.7221
110046............................       1.1568       0.9845      23.8292      26.7464            *      25.2689
110050............................       1.0878       0.8587      26.1319      27.5985      27.0646      26.9504
110051............................       1.1326       0.7864      19.4276      20.1756      21.4871      20.4304
110054............................       1.3876       0.9845      25.7085      28.9254      29.4622      28.1271
110059............................       1.1627       0.7864      20.5565      23.2137      24.7765      22.7757
110064............................       1.5562       0.9023      24.2739      24.1219      26.9345      25.1478
110069............................       1.3180       0.9571      24.1669      26.2085      29.9100      26.8648
110071............................       1.1303       0.7864      18.0224      21.3963      21.1989      20.2203
110073............................       1.0754       0.7864      18.6336      18.5753      22.2470      19.7421
110074............................       1.5617       1.0543      27.1207      27.9190      32.6801      29.0878
110075............................       1.2369       0.8987      22.0935      23.7585      24.8206      23.5710
110076............................       1.4782       0.9845      26.3506      28.7871      29.4324      28.2022
110078............................       2.0225       0.9845      29.5779      29.9625      30.5184      30.0314
110079............................       1.4284       0.9845      23.1024      26.8412      28.0337      25.8338
110080............................          ***            *      22.3213      18.4714            *      20.3904
110082............................       1.9490       0.9845      29.8366      30.8320      30.1059      30.2637
110083............................       1.8986       0.9845      27.8245      30.4287      34.0590      30.7532
110086............................       1.2924       0.7864      21.1508      21.6898      22.9935      21.9527
110087............................       1.4777       0.9845      28.0471      28.1633      31.0389      29.1236
110089............................       1.1256       0.7864      21.9509      23.9026      24.3270      23.4297
110091............................       1.2981       0.9845      26.5523      29.5337      27.0969      27.7297
110092............................       1.0712       0.7864      18.5527      20.8911      21.4146      20.2698
110095............................       1.4672       0.8671      23.4846      26.3075      28.0497      25.9749
110100............................       0.9766       0.8653      16.5600      16.2575      20.8152      17.8654
110101............................       1.0211       0.7931      16.4269      19.4257      23.2580      19.5226

[[Page 24867]]

 
110104............................       1.0874       0.7864      18.7951      20.3777      21.8924      20.4307
110105............................       1.3393       0.7864      21.1077      23.1405      23.3989      22.5523
110107............................       1.9642       0.9753      26.2526      28.9352      30.0994      28.5415
110109............................       1.0213       0.7864      21.4279      23.0376      21.5988      22.0288
110111............................       1.1558       0.9600      29.2189      25.1270      25.6830      26.4544
110112............................       0.9103       0.7864      24.2464      22.7672      26.4049      24.5402
110113............................       0.9648       0.9600      19.1752      21.3417      21.9483      20.8449
110115............................       1.6873       0.9845      32.0198      31.5074      32.7917      32.1142
110121............................       1.0432       0.8458      21.6637      26.2336      23.4538      23.8292
110122............................       1.5380       0.8458      23.7589      25.1934      25.4416      24.7892
110124............................       1.0505       0.7864      22.7058      22.9212      22.9564      22.8635
110125............................       1.2986       0.9571      22.4238      23.7834      24.7325      23.6383
110128............................       1.2616       0.8987      24.4596      25.7839      25.4173      25.2192
110129............................       1.5741       0.9023      23.3631      25.9625      30.0382      26.3966
110130............................       0.9401       0.7864      18.7549      19.1284      20.4320      19.4659
110132............................       0.9896       0.7864      19.2307      20.2502      21.2623      20.2550
110135............................       1.2755       0.7864      20.4412      22.5346      23.7098      22.3469
110136............................          ***            *      15.8573      18.8212            *      17.2827
110142............................       0.9496       0.8066      18.1980      21.3935      21.6229      20.4888
110143............................       1.4028       0.9845      27.7055      28.6583      29.9107      28.7952
110146............................       1.0440       0.9129      23.9067      27.0987      29.0166      26.6342
110149............................          ***            *      27.1477      28.4040            *      27.8380
110150............................       1.3057       0.9845      22.6624      25.3742      26.9867      24.9549
110153............................       1.1345       0.9571      24.5368      25.7467      29.3255      26.5464
110161............................       1.5056       0.9845      29.3201      30.4885      31.4996      30.4387
110163............................       1.4445       0.8671      26.0764      28.2169      27.7657      27.3535
110164............................       1.6473       0.9753      27.0600      28.8946      29.9927      28.6570
110165............................       1.3818       0.9845      26.8378      27.0977      28.7885      27.5696
110166............................          ***            *      26.8070            *            *      26.8070
110168............................       1.8211       0.9845      27.0022      28.5700      29.7626      28.4639
110172............................       1.3224       0.9845      29.1703      31.1234      31.3978      30.5995
110177............................       1.7871       0.9600      26.7504      28.8356      29.7970      28.4770
110179............................          ***            *      26.0759            *            *      26.0759
110183............................       1.2702       0.9845      29.6132      28.6208      28.3576      28.8287
110184............................       1.2372       0.9845      26.5240      28.3545      28.9228      28.0035
110186............................       1.3737       0.9023      25.0298      27.4925      28.2840      26.9603
110187............................       1.2184       0.9845      24.2933      25.2139      26.9609      25.5777
110189............................       1.1273       0.9845      26.7654      26.1418      26.2773      26.3807
110190............................       1.0375       0.8106      14.2518      23.3204      24.5194      20.0516
110191............................       1.3326       0.9845      26.8277      27.7760      30.8738      28.4664
110192............................       1.3983       0.9845      26.7852      28.8267      30.0811      28.6170
110193............................          ***            *      27.3341      27.9161            *      27.6234
110194............................       0.9362       0.7864      18.4776      19.1920      21.0803      19.6202
110198............................       1.3960       0.9845      31.7748      31.0557      32.8394      31.8698
110200............................       1.9208       0.9023      22.3249      24.9236      27.2957      24.7898
110201............................       1.4602       0.9753      28.2232      31.0841      32.0685      30.4669
110203............................       0.9675       0.9845      26.8768      29.7888      32.3439      29.6045
110205............................       1.1514       0.8378      19.7408      22.0207      23.9713      21.9556
110209............................       0.5322       0.7864      19.0450      21.1534      21.2405      20.5449
110212............................       1.1996       0.8208      40.5120            *            *      40.5120
110214............................          ***            *            *      37.1450            *      37.1450
110215............................       1.2923       0.9845      25.7886      27.5566      29.5222      27.7244
110219............................       1.4243       0.9845      27.0362      28.8814      32.1875      29.3856
110220............................          ***            *            *      37.5741            *      37.5741
110221............................          ***            *            *      28.0500            *      28.0500
110222............................          ***            *            *      35.6189            *      35.6189
110223............................          ***            *            *            *      25.3054      25.3054
110224............................          ***            *            *            *      33.6431      33.6431
110225............................       1.1643       0.9845            *            *      29.5367      29.5367
110226............................       1.1727       0.9845            *            *            *            *
120001............................       1.7822       1.1289      34.7715      34.1385      39.6365      36.0758

[[Page 24868]]

 
120002............................       1.2099       1.0751      29.9913      32.3784      34.2093      32.2039
120004............................       1.3321       1.1289      28.6527      30.0668      31.3533      30.0073
120005............................       1.3153       1.0751      29.3405      31.1985      33.6910      31.4352
120006............................       1.2715       1.1289      31.2285      31.6785      34.2215      32.3967
120007............................       1.7204       1.1289      30.4247      30.2473      30.8768      30.5121
120010............................       1.8846       1.1289      30.1659      29.5714      30.8509      30.1898
120011............................       1.5402       1.1289      34.1643      37.1792      39.1930      36.8947
120014............................       1.2834       1.0751      28.6416      30.3463      30.9833      30.0254
120016............................          ***            *      19.6039            *            *      19.6039
120019............................       1.1324       1.0751      30.3809      30.4257      33.0105      31.2828
120022............................       1.9143       1.1289      26.6100      29.9527      32.5281      29.5900
120025............................          ***            *      30.2367            *            *      30.2367
120026............................       1.4053       1.1289      30.3293      32.4566      33.3760      32.1741
120027............................       1.3450       1.1289      28.6717      28.7905      29.5804      29.0480
120028............................       1.2954       1.1289      30.3794      32.4847      34.0426      32.3412
120029............................          ***            *            *            *      44.6372      44.6372
130002............................       1.4431       0.8780      23.6078      24.7871      25.0585      24.5110
130003............................       1.3979       0.9620      27.6345      28.6158      28.6132      28.2893
130005............................          ***            *      25.7523            *            *      25.7523
130006............................       1.7739       0.9501      25.3221      27.2158      28.0040      26.8672
130007............................       1.8211       0.9501      24.9562      28.7246      30.4947      27.9564
130013............................       1.3826       0.9501      27.9209      30.9609      36.1511      31.7450
130014............................       1.2242       0.9501      24.3885      27.2543      27.5904      26.3556
130018............................       1.6969       0.9158      26.4125      27.3439      28.3984      27.3763
130021............................          ***            *      16.1658            *            *      16.1658
130024............................       1.1828       0.8301      23.3347      23.6212      24.8040      23.9295
130025............................       1.2433       0.7879      20.1452      21.1998      22.7959      21.4284
130028............................       1.4838       0.9158      26.3443      27.2195      28.3768      27.4425
130049............................       1.6070       1.0220      26.9749      27.3597      29.0154      27.8217
130062............................          ***            *      20.6642      25.6467      29.1889      24.9258
130063............................       1.3933       0.9501      22.5904      26.0955      27.7566      25.3649
130065............................       1.9742       0.9352            *      21.9792      30.4515      26.6732
130066............................       2.0918       0.9679            *            *      28.9875      28.9875
130067............................       0.5728       0.9352            *            *      21.3846      21.3846
130068............................       2.6786       0.9679            *            *            *            *
140001............................       1.1037       0.8717      22.3170      22.3001      22.2001      22.2725
140002............................       1.3394       0.8885      24.6954      27.0165      27.4774      26.4099
140007............................       1.3528       1.0455      28.3482      30.7378      31.4003      30.1858
140008............................       1.4476       1.0455      28.5297      29.1767      31.7996      29.7868
140010............................       1.5346       1.0455      35.1024      31.8806      38.1652      34.8498
140011............................       1.1266       0.8355      22.4091      23.8575      25.8844      24.1276
140012............................       1.1597       1.0455      28.6564      29.0336      31.8902      29.7936
140013............................       1.4751       0.9374      23.3065      23.9269      25.0217      24.0534
140015............................       1.4264       0.8885      23.0600      24.4687      24.6395      24.0656
140016............................       1.0141            *      18.1242            *            *      18.1242
140018............................       1.4726       1.0455      27.7548      26.3533      30.4549      28.1330
140019............................       0.9079       0.8355      18.9228      21.3438      22.3154      20.8677
140024............................          ***            *      17.5249            *            *      17.5249
140026............................       1.1365       0.8643      23.0470      25.9669      26.0469      25.0148
140029............................       1.5607       1.0455      28.6565      30.2688      34.0184      30.9961
140030............................       1.5584       1.0455      29.7771      30.2776      31.6814      30.5817
140032............................       1.2249       0.8885      24.0573      26.7310      27.5346      26.1088
140033............................       0.7961       1.0455      25.6068      27.9993      29.5213      27.5598
140034............................       1.1477       0.8885      23.0033      24.0470      24.4638      23.8456
140040............................       1.2142       0.9217      22.2969      23.2293      24.5572      23.3448
140043............................       1.2818       0.8898      26.7996      27.3469      29.8613      28.0415
140045............................          ***            *      20.6548            *            *      20.6548
140046............................       1.5062       0.8885      23.2127      24.7334      25.6221      24.5832
140048............................       1.2927       1.0455      28.2222      29.3877      31.1842      29.5804
140049............................       1.4736       1.0455      27.4009      29.0976      26.9354      27.8062
140051............................       1.5046       1.0455      27.7901      30.9696      31.8207      30.1641

[[Page 24869]]

 
140052............................       1.2921       0.8885      23.5662      25.9617      26.9889      25.4996
140053............................       1.8971       0.8947      24.8455      27.4518      28.4493      26.9022
140054............................       1.4490       1.0455      31.8564      33.1406      33.1984      32.7274
140058............................       1.2533       0.8885      22.8423      24.6058      25.2553      24.2520
140059............................       1.0745       0.8885      22.4652      22.6743      21.6222      22.2387
140061............................          ***            *      20.8063            *            *      20.8063
140062............................       1.3499       1.0455      34.7704      34.1230      35.0300      34.6455
140063............................       1.4129       1.0455      27.8306      28.6559      30.3699      28.9237
140064............................       1.1958       0.9217      22.0407      23.8639      25.7536      23.9574
140065............................       1.4079       1.0455      29.4678      30.1856      31.2501      30.2861
140066............................       1.0941       0.8885      21.9771      22.1524      22.0209      22.0493
140067............................       1.8444       0.9374      25.3986      28.3506      29.8952      27.9255
140068............................       1.2095       1.0455      27.3956      28.3938      26.2136      27.3581
140075............................       1.3302       1.0455      27.9325      26.2626      35.9501      29.4586
140077............................       1.0119       0.8885      19.1363      20.3999      21.6458      20.4041
140080............................       1.4034       1.0455      23.2575      28.8791      29.8040      27.0165
140082............................       1.5858       1.0455      25.6645      28.3429      30.4657      28.1091
140083............................       0.9164       1.0455      26.2972      26.8919      28.2249      27.1579
140084............................       1.3044       1.0455      29.2515      30.5036      30.7227      30.1514
140088............................       1.9222       1.0455      32.4978      30.5450      32.1232      31.7009
140089............................       1.2577       0.8355      23.3401      24.1066      24.9116      24.1079
140091............................       1.7612       0.9320      26.8518      27.8536      28.2076      27.6623
140093............................       1.2233       0.9250      25.3127      28.3298      28.6735      27.3134
140094............................       1.0630       1.0455      27.9273      27.3841      27.1458      27.4606
140095............................       1.1848       1.0455      27.6799      28.7617      30.7468      28.9831
140100............................       1.4123       1.0455      37.0820      41.3374      37.4204      38.7591
140101............................       1.2093       1.0455      28.5365      29.4081      28.9681      28.9900
140103............................       1.1489       1.0455      23.3258      23.6406      24.0915      23.6943
140105............................       2.4503       1.0455      27.4531      29.5274      29.6559      28.8375
140109............................       1.2813            *      19.5675            *            *      19.5675
140110............................       1.1015       1.0455      27.9844      28.6364      30.2949      28.9917
140113............................       1.6269       0.9320      26.7969      29.5452      30.2650      28.8697
140114............................       1.4992       1.0455      28.3014      28.2151      29.2174      28.5888
140115............................       1.1220       1.0455      25.1498      26.0383      26.1931      25.7916
140116............................       1.2809       1.0455      31.9902      34.5537      34.3854      33.6663
140117............................       1.5470       1.0455      26.8802      27.7201      28.9000      27.8446
140118............................       1.5344       1.0455      29.7570      32.5518      32.3262      31.5081
140119............................       1.8434       1.0455      36.1419      34.2118      32.2183      34.0198
140120............................       1.2653       0.9374      22.7375      23.9724      25.9262      24.2579
140122............................       1.4641       1.0455      28.4188      30.5653      30.3888      29.7745
140124............................       1.2574       1.0455      36.1327      35.7563      36.8811      36.2568
140125............................       1.1737       0.8885      20.4014      22.7571      26.5780      23.2030
140127............................       1.5914       0.9488      24.1658      25.6668      27.8334      25.8831
140130............................       1.2375       1.0455      29.5247      32.6209      32.3345      31.5415
140133............................       1.2957       1.0455      28.0339      31.0269      30.3222      29.7591
140135............................       1.4311       0.8355      22.3264      23.3196      24.6627      23.4674
140137............................       1.0306       0.8885      21.4699      23.4174      31.4330      24.5875
140141............................          ***            *      21.7872            *            *      21.7872
140143............................       1.1599       1.0455      26.2954      27.4499      26.1598      26.6232
140145............................       1.0894       0.8885      23.4608      26.0875      25.2020      24.9373
140147............................       1.1116       0.8355      19.8541      21.0686      21.1816      20.6906
140148............................       1.7302       0.8947      24.7031      25.5677      27.0025      25.7602
140150............................       1.7104       1.0455      35.2711      52.0970      35.5387      41.0090
140151............................       0.8042       1.0455      23.4879      27.0312      26.0771      25.5353
140152............................       1.1878       1.0455      27.6086      30.2209      29.8651      29.2052
140155............................       1.3645       1.0455      28.9724      29.5734      32.7948      30.4667
140158............................       1.3840       1.0455      27.0986      27.3721      30.9913      28.4461
140160............................       1.2239       0.9659      24.5373      25.8684      28.2651      26.1623
140161............................       1.0974       1.0455      23.1647      25.2898      28.8243      25.7885
140162............................       1.5875       0.9488      27.4471      29.4121      32.1785      29.6154
140164............................       1.8228       0.8885      23.7457      24.6009      25.9708      24.8069

[[Page 24870]]

 
140165............................          ***            *      16.6304            *            *      16.6304
140166............................       1.1618       0.8355      23.1005      26.4800      26.2861      25.2805
140167............................       1.1617       0.8355      22.8911      22.8703      24.9899      23.5834
140172............................       1.3657       1.0455      29.8568      32.1220      33.3088      31.7850
140174............................       1.5727       1.0455      27.8131      30.5905      30.2862      29.6018
140176............................       1.2302       1.0455      31.3490      32.9794      32.6124      32.3400
140177............................       0.9043       1.0455      22.5610      26.4340      25.5687      24.9308
140179............................       1.2690       1.0455      27.6376      29.3657      30.0402      29.0241
140180............................       1.1754       1.0455      28.3629      27.8887      29.4333      28.5589
140181............................       1.1327       1.0455      25.0101      25.0226      28.8391      26.2494
140182............................       1.5032       1.0455      28.2211      30.1755      31.5975      29.8792
140184............................       1.2950       0.8355      21.1802      25.2327      26.6072      24.4269
140185............................       1.4647       0.8885      23.8531      25.2423      26.5377      25.2109
140186............................       1.5405       1.0455      30.6951      29.8022      38.6436      32.7202
140187............................       1.5457       0.8885      23.2892      24.8332      25.5863      24.5665
140189............................       1.1672       0.8355      23.7198      22.5965      24.6993      23.6830
140190............................          ***            *      19.8296            *            *      19.8296
140191............................       1.3320       1.0455      25.8678      28.5836      31.2506      28.4103
140197............................       1.2420       1.0455      23.0684      24.0463      24.9086      23.9560
140199............................       1.0545            *      22.0315            *            *      22.0315
140200............................       1.4398       1.0455      26.3379      28.8435      30.7340      28.6128
140202............................       1.5519       1.0455      29.7870      32.7915      32.9414      31.9574
140206............................       1.2672       1.0455      30.6561      29.7953      29.0219      29.8266
140207............................       1.2156       1.0455      24.1048      26.0535      28.2239      26.0077
140208............................       1.6599       1.0455      29.4708      29.5380      30.9464      29.9911
140209............................       1.5590       0.9374      24.5376      26.3230      29.5947      26.7186
140210............................       1.0674       0.8355      19.2640      20.6954      19.2050      19.6893
140211............................       1.3080       1.0455      29.7054      30.3286      31.2117      30.4786
140213............................       1.2474       1.0455      30.2945      31.6926      32.1006      31.3680
140217............................       1.5469       1.0455      31.5324      32.1277      37.4373      33.6828
140223............................       1.4766       1.0455      30.4923      31.7267      33.4712      31.9196
140224............................       1.3766       1.0455      28.2177      29.6181      30.0109      29.2702
140228............................       1.5676       0.9659      25.6419      27.9456      28.2837      27.2857
140231............................       1.4308       1.0455      30.6410      30.0236      34.5759      31.7645
140233............................       1.6659       1.0455      28.6305      29.7093      31.5127      29.9816
140234............................       1.0449       0.8643      23.6928      24.5476      25.7284      24.6519
140239............................       1.5972       0.9659      29.0092      31.1879      29.9224      30.0310
140240............................       1.4146       1.0455      28.7310      31.5637      29.6215      29.9537
140242............................       1.5035       1.0455      32.0522      34.6120      35.2330      33.9219
140250............................       1.2383       1.0455      28.5971      29.6305      30.9236      29.7408
140251............................       1.3945       1.0455      27.1687      28.0622      28.5295      27.9306
140252............................       1.4015       1.0455      33.3351      34.4268      35.9410      34.5696
140258............................       1.5168       1.0455      30.2639      34.2333      33.0067      32.5344
140275............................       1.3109       0.8898      26.1473      27.8186      28.5054      27.4336
140276............................       1.8663       1.0455      29.8325      31.6359      31.5673      31.0394
140280............................       1.4652       0.8898      23.4447      24.9401      26.6521      24.9136
140281............................       1.7579       1.0455      30.4838      33.3903      35.4009      33.0950
140285............................          ***            *      20.7576            *            *      20.7576
140286............................       1.1525       1.0455      29.1543      30.3237      30.9916      30.1576
140288............................       1.5216       1.0455      29.3988      31.5197      31.5935      30.8906
140289............................       1.3073       0.8885      22.6211      23.8452      25.6053      24.0376
140290............................       1.3588       1.0455      31.7341      31.8135      32.5219      32.0520
140291............................       1.6125       1.0455      29.8958      31.9052      33.4588      31.8392
140292............................       1.1018       1.0455      27.6285      28.5094      31.4636      29.0642
140294............................       1.1266       0.8355      23.4503      24.0750      26.1581      24.6191
140300............................       1.1893       1.0455      34.8568      35.1494      41.7895      37.1471
140301............................       1.1592       1.0455      31.7073      49.9507      36.3852      36.8862
140303............................       2.2098       1.0455            *      29.6470            *      29.6470
150001............................       1.1317       0.9723      29.6844      28.9075      31.8065      30.1183
150002............................       1.4425       1.0455      25.0063      26.6222      27.6466      26.6689
150003............................       1.7495       0.8682      25.3458      26.7585      26.9767      26.3732

[[Page 24871]]

 
150004............................       1.4758       1.0455      26.8458      28.7336      30.9613      28.8233
150005............................       1.2795       0.9723      27.2369      29.5371      30.5354      29.1851
150006............................       1.3972       0.9488      26.4062      25.6265      27.1359      26.4178
150007............................       1.3722       0.9468      26.6073      29.4971      30.0493      28.8173
150008............................       1.3877       1.0455      26.6928      27.5703      27.0507      27.1181
150009............................       1.4332       0.9045      22.2147      25.4496      25.7590      24.5202
150010............................       1.4964       0.9468      26.8523      27.2272      28.4110      27.4598
150011............................       1.2442       0.9723      24.3490      25.3178      26.7670      25.4609
150012............................       1.5635       0.9649      27.3029      30.0348      31.2245      29.5420
150013............................          ***            *      21.8465            *            *      21.8465
150015............................       1.3255       0.8876      26.2434      28.0931      27.3806      27.2242
150017............................       1.8579       0.9046      25.2342      26.3973      26.3375      26.0050
150018............................       1.7216       0.9488      26.3289      27.3689      28.6052      27.4720
150021............................       1.8099       0.9046      29.6967      28.9196      30.0025      29.5365
150022............................       1.0830       0.8750      22.6773      23.1041      23.8966      23.1998
150023............................       1.5634       0.8828      23.7159      26.9095      27.7498      25.8885
150024............................       1.4799       0.9723      27.1589      28.1655      28.4136      27.8886
150026............................       1.3156       0.9488      28.1127      28.6517      30.4957      29.1720
150027............................       1.0482            *      17.4862            *            *      17.4862
150029............................       1.4693       0.9649      26.9680      28.7187      29.9297      28.4268
150030............................       1.1962       0.9723      26.9534      29.1493      29.3548      28.5129
150033............................       1.5588       0.9723      27.9995      28.6838      29.7732      28.8056
150034............................       1.4551       1.0455      26.0465      28.6429      28.0423      27.6123
150035............................       1.5978       0.9246      26.6620      26.9700      27.8888      27.1974
150037............................       1.3215       0.9723      28.5451      31.0935      29.0142      29.5229
150038............................       1.1335       0.9723      28.8054      29.3156      33.0091      30.3929
150042............................       1.3921       0.8828      23.0102      22.8786      25.1381      23.6707
150044............................       1.3933       0.9045      23.7066      25.2137      25.2653      24.7681
150045............................       1.0745       0.9046      25.2225      26.9818      27.5333      26.5864
150046............................       1.4897       0.8828      21.9369      24.5593      26.5855      24.4151
150047............................       1.7148       0.9046      25.8348      25.5194      25.8493      25.7349
150048............................       1.3885       0.9654      27.1817      27.1233      28.1517      27.5020
150049............................       1.3621            *      22.3370            *            *      22.3370
150051............................       1.6351       0.9723      23.7061      26.5655      28.9114      26.4833
150052............................       1.0751            *      20.6339            *            *      20.6339
150056............................       1.9411       0.9723      28.2842      28.8727      29.3498      28.8452
150057............................       2.0977       0.9723      24.8605      28.9529      30.3290      27.8808
150058............................       1.5682       0.9649      27.5341      29.1444      29.1247      28.6422
150059............................       1.5558       0.9723      28.5715      31.4987      31.3363      30.4971
150060............................          ***            *      24.8544            *            *      24.8544
150061............................       1.1276       0.8599      22.2822      21.3711      22.6744      22.1017
150062............................       1.1339            *      24.6088            *            *      24.6088
150064............................       1.2004       0.8599      23.7707      25.4987      28.7959      26.0974
150065............................       1.2639       0.9723      25.9461      27.9283      30.2038      27.9980
150069............................       1.1735       0.9654      25.2656      26.2028      26.0888      25.8557
150072............................       1.1652       0.8700      20.5111      21.2120      21.7638      21.1631
150074............................       1.4434       0.9723      25.2586      25.9321      28.5642      26.5896
150075............................       1.0984       0.9046      24.0745      25.1568      25.7242      24.9786
150076............................       1.2878       0.9488      28.1874      29.3249      30.1109      29.2163
150079............................       1.1099            *      21.4067            *            *      21.4067
150082............................       1.6791       0.8599      25.5860      28.3494      26.4526      26.8041
150084............................       1.8404       0.9723      29.3905      31.1720      33.1783      31.1870
150086............................       1.1730       0.9654      23.9404      25.1992      26.6732      25.3038
150088............................       1.2755       0.9723      23.6253      27.2103      29.1480      26.6296
150089............................       1.6030       0.8599      25.0449      24.7233      24.8038      24.8594
150090............................       1.6395       1.0455      26.2899      30.4835      30.6398      29.1396
150091............................       1.1639       0.9046      30.6209      30.4234      32.1616      31.1002
150097............................       1.1292       0.9723      25.0367      27.7468      29.1332      27.3211
150100............................       1.6890       0.8599      24.3530      25.7997      26.9731      25.6241
150101............................       1.0674       0.9046      29.1657      29.0301      30.5475      29.5655
150102............................       1.0330       0.9246      24.5923      25.7424      25.8716      25.4594

[[Page 24872]]

 
150104............................       1.0855       0.9723      25.5872      28.2552      28.7782      27.5175
150106............................       1.0158            *      20.9387            *            *      20.9387
150109............................       1.4646       0.8682      23.5865      25.3367      26.8460      25.2374
150112............................       1.4973       0.9723      26.5643      28.0068      29.8515      28.1779
150113............................       1.2888       0.9723      24.8760      24.7960      25.9794      25.2152
150115............................       1.4221       0.8599      19.3411      22.0747      22.5784      21.2668
150122............................       1.3185       0.9723      26.0173            *      29.1651      27.6449
150124............................          ***            *      21.3933            *            *      21.3933
150125............................       1.5108       1.0455      26.7666      27.6535      29.3573      27.9334
150126............................       1.4163       1.0455      26.9887      28.9454      29.4277      28.4460
150128............................       1.4408       0.9723      26.4976      28.7810      29.4982      28.2798
150129............................       1.1548       0.9723      29.9099      29.7398      31.4309      30.3982
150130............................       1.6136            *      21.7400            *            *      21.7400
150132............................          ***            *      25.6257      27.6560            *      26.6249
150133............................       1.2465       0.9046      22.7292      25.1322      24.2528      24.0310
150134............................       1.0184       0.9045      23.8525      26.3249      21.6507      23.7520
150136............................          ***            *      26.2704            *            *      26.2704
150146............................       1.1375       0.9046      29.3383      29.5256      30.3340      29.7675
150147............................       1.5119       1.0455      22.8456      27.2339      26.1631      25.6991
150149............................       1.0014       0.8599      23.6360      23.7026      24.9628      24.1402
150150............................       1.3168       0.9046      25.5331      27.0542      26.7708      26.4923
150151............................          ***            *      38.1445            *            *      38.1445
150152............................          ***            *      44.7145            *            *      44.7145
150153............................       2.4179       0.9723            *      32.1022      35.0601      33.7419
150154............................       2.5731       0.9723            *      29.8514      29.8867      29.8697
150155............................          ***            *            *      45.0121            *      45.0121
150156............................          ***            *            *      25.9681            *      25.9681
150157............................       1.6752       0.9723            *            *      32.3095      32.3095
150158............................       1.2386       0.9723            *            *            *            *
150160............................       2.0084       0.9723            *            *            *            *
150161............................       1.4704       0.9723            *            *            *            *
150162............................       1.7757       0.9723            *            *            *            *
150163............................       1.1085       0.9045            *            *            *            *
160001............................       1.2040       0.9227      25.1220      24.5108      25.7253      25.1337
160005............................       1.2097       0.8480      21.8949      23.1034      24.7751      23.2876
160008............................       1.0520       0.8480      20.7200      22.1402      22.4752      21.7844
160013............................       1.2954       0.8659      23.7163      24.0956      24.4092      24.0732
160014............................          ***            *      20.5882            *            *      20.5882
160016............................       1.5631       0.9227      23.3619      24.5338      27.1450      24.9572
160020............................       1.1531            *      19.5554            *            *      19.5554
160024............................       1.5664       0.9162      26.2392      27.4158      29.3740      27.6163
160026............................          ***            *      24.7424            *            *      24.7424
160028............................       1.3103       0.9419      26.2948      27.8535      30.0834      28.2015
160029............................       1.6376       0.9428      27.9277      28.7324      30.6688      29.0932
160030............................       1.3828       0.9982      26.7068      28.7786      30.9401      28.8516
160031............................       0.7988            *      19.7368            *            *      19.7368
160032............................       1.0670       0.8715      23.4727      25.4662      26.2923      25.1089
160033............................       1.7494       0.8898      24.6768      26.5315      27.2044      26.1333
160034............................       1.0217            *      19.3503            *            *      19.3503
160039............................       0.9129            *      22.1180            *            *      22.1180
160040............................       1.2918       0.8891      23.9053      25.9032      26.8096      25.5667
160045............................       1.6888       0.8689      25.4153      26.6463      27.5279      26.5336
160047............................       1.3942       0.9419      25.2072      26.0227      28.1257      26.4461
160048............................          ***            *      19.5831            *            *      19.5831
160050............................       1.0566            *      24.5402            *            *      24.5402
160057............................       1.2586       0.9142      23.0937      25.1272      25.6262      24.6658
160058............................       1.9687       0.9428      27.1646      28.4167      28.9914      28.2022
160064............................       1.6018       0.8891      28.6139      28.7668      28.4201      28.5965
160066............................       0.9354            *      22.7709            *            *      22.7709
160067............................       1.3642       0.8891      23.4060      24.8137      26.0201      24.7707
160069............................       1.5288       0.8874      25.3402      27.4473      27.6151      26.8148

[[Page 24873]]

 
160079............................       1.4776       0.8689      23.7234      24.7372      26.1612      24.8785
160080............................       1.2820       0.8898      23.1837      25.8252      27.2360      25.4030
160081............................          ***            *      23.1930            *            *      23.1930
160082............................       1.7712       0.9162      26.4398      27.4718      28.7814      27.5576
160083............................       1.6609       0.9162      28.2193      27.3004      28.3914      27.9723
160089............................       1.2895       0.9142      22.6551      23.2149      23.2885      23.0561
160091............................          ***            *      17.9862            *            *      17.9862
160101............................       1.0822       0.9162      25.1000      25.0503      25.4729      25.2118
160104............................       1.6559       0.8898      24.9134      28.1891      29.8108      27.8792
160110............................       1.5339       0.8891      24.9434      26.6633      28.8124      26.8746
160112............................       1.2909       0.8480      23.0672      24.7957      25.2879      24.4324
160117............................       1.3812       0.8874      25.0278      25.4659      27.3401      25.9559
160118............................          ***            *      19.7764            *            *      19.7764
160122............................       1.0949       0.8480      22.5872      23.9177      24.4983      23.6840
160124............................       1.1525       0.8480      23.1690      22.5482      24.2654      23.3247
160126............................       1.0265            *      19.8323            *            *      19.8323
160146............................       1.3905       0.9220      22.9897      22.6949      25.9575      23.8222
160147............................       1.2917       0.9227      26.6438      28.6303      29.8976      28.4670
160153............................       1.7355       0.9220      28.9881      29.9378      30.6170      29.8519
160154............................       0.9478            *            *            *            *            *
170001............................       1.1452       0.7989      21.9131      23.1260      23.8847      22.9700
170006............................       1.3255       0.9040      21.9019      24.2068      27.1291      24.4623
170009............................       1.0521       0.9321      29.2588      30.9025      29.6048      29.9146
170010............................       1.2446       0.7989      24.0008      23.9707      25.5578      24.5520
170012............................       1.6138       0.8761      24.7392      26.1367      27.1174      25.9599
170013............................       1.6219       0.8761      25.0419      25.2476      26.7123      25.6576
170014............................       1.0198       0.9321      23.5960      23.8135      24.1592      23.8605
170015............................          ***            *      20.2368            *            *      20.2368
170016............................       1.6404       0.8561      25.9482      25.8061      26.7533      26.1670
170017............................       1.0741       0.9009      24.7771      26.9657      25.7301      25.8416
170019............................       1.1990            *      22.0251            *            *      22.0251
170020............................       1.5979       0.8761      23.1800      23.2757      24.1120      23.5234
170022............................       1.1485            *      22.2878            *            *      22.2878
170023............................       1.4202       0.8761      23.9808      24.0561      23.9805      24.0052
170027............................       1.3965       0.7989      22.5103      23.1766      23.4023      23.0164
170033............................       1.3534       0.8761      20.7864      21.9709      24.1874      22.2849
170039............................       0.9441       0.9009      21.5203      26.9852      26.0906      24.6284
170040............................       1.9811       0.9321      28.2856      28.4458      30.2460      29.0254
170049............................       1.5233       0.9321      24.7895      25.2070      26.4091      25.4878
170052............................          ***            *      18.5291            *            *      18.5291
170058............................       1.1011       0.9321      23.3398      22.9210      26.5943      24.2597
170068............................       1.2238       0.9141      22.6087      23.0635      23.8790      23.1876
170070............................          ***            *      16.0162            *            *      16.0162
170074............................       1.2234       0.7989      21.0565      23.7829      23.1854      22.7215
170075............................       0.8299       0.7989      16.5444      19.7760      19.9316      18.7462
170085............................       0.6104            *            *            *            *            *
170086............................       1.5817       0.8561      24.0812      26.1362      26.3581      25.5514
170093............................          ***            *      16.5553            *            *      16.5553
170094............................       0.9370       0.7989      21.3887      21.5295      16.5371      19.6987
170098............................          ***            *      20.1242            *            *      20.1242
170103............................       1.2881       0.9009      22.8707      23.8042      24.1990      23.6448
170104............................       1.4659       0.9321      26.9671      26.2990      27.5482      26.9346
170105............................       1.0954       0.7989      21.4422      21.9606      22.7400      22.0339
170109............................       1.0332       0.9321      23.2626      23.1088      23.8520      23.4043
170110............................       0.8843       0.7989      22.9195      23.3260      23.9496      23.4209
170114............................       0.9064            *      18.9158            *            *      18.9158
170120............................       1.3879       0.9040      21.0499      22.0253      22.2797      21.7557
170122............................       1.6841       0.9009      25.3982      26.6605      28.3325      26.7103
170123............................       1.6957       0.9009      27.2239      27.6653      28.4687      27.7816
170133............................       1.0455       0.9321      22.9309      23.1226      25.2821      23.8233
170137............................       1.2780       0.7989      23.8862      24.7096      25.4425      24.7034

[[Page 24874]]

 
170142............................       1.4027       0.8455      22.5778      23.9527      24.5814      23.7373
170143............................          ***            *      20.4459            *            *      20.4459
170144............................          ***            *      24.6259            *            *      24.6259
170145............................       1.0836       0.7989      21.5756      23.2162      23.3953      22.7060
170146............................       1.5040       0.9321      29.1358      29.8858      29.0538      29.3514
170147............................          ***            *      21.4753      22.4973      24.3378      22.5659
170150............................       1.1592       0.8165      18.5744      20.9448      19.5537      19.7042
170166............................       0.9974       0.7989      19.2842      21.0762      22.6927      21.0426
170175............................       1.4188       0.8761      23.9304      25.6281      26.7215      25.4230
170176............................       1.5962       0.9321      26.2366      27.2332      29.0423      27.5653
170180............................          ***            *      25.1368      32.5010      17.4887      26.4266
170182............................       1.4423       0.9321      25.7443      27.3503      29.0642      27.4067
170183............................       1.9419       0.9009      24.5539      25.8340      26.1875      25.5204
170185............................       1.2362       0.9321      26.7797      27.8139      28.1777      27.6777
170186............................       2.6637       0.9009      31.7896      32.8392      30.2636      31.6204
170187............................       1.4879       0.7989      23.3702      22.8493      24.1467      23.4567
170188............................       1.9751       0.9321      29.9751      30.6844      32.2575      31.0138
170190............................       1.0179       0.8455      22.8729      22.9540      26.2542      24.0445
170191............................       1.7210       0.7989      21.3069      22.1197      24.3772      22.6585
170192............................       1.9138       0.9009      27.9704      26.2724      27.8171      27.3379
170193............................       1.4210       0.8761      24.7429      20.6821      24.8461      23.2169
170194............................       1.0788       0.9321      27.9903      29.9014      27.6979      28.5234
170195............................       2.2822       0.9321            *      30.1001      29.5948      29.8108
170196............................       2.3751       0.9009            *            *      33.9653      33.9653
180001............................       1.2529       0.9654      25.4217      27.6917      29.7401      27.6436
180002............................       1.0605       0.8095      22.9727      25.7862      26.5375      25.1104
180004............................       1.0975       0.7812      19.5437      22.0797      20.8790      20.8280
180005............................       1.1216       0.8706      24.5561      24.9779      25.6139      25.0800
180006............................          ***            *      14.8011            *            *      14.8011
180007............................       1.5270       0.9027      22.7606      25.7042      27.1922      25.2358
180009............................       1.7023       0.8845      25.3837      26.4101      27.3217      26.4312
180010............................       1.8869       0.9027      24.7256      25.6153      27.5042      25.9590
180011............................       1.5431       0.8815      22.7364      25.5463      24.9907      24.4167
180012............................       1.4916       0.9045      24.6642      25.6000      26.7267      25.6686
180013............................       1.5075       0.9408      22.9512      23.7075      24.8114      23.8153
180016............................       1.3308       0.9045      23.1832      24.8408      24.7149      24.2505
180017............................       1.3241       0.7983      20.8630      21.8885      21.9702      21.5929
180018............................       1.3149       0.7812      19.0992      20.9857      23.3022      21.1380
180019............................       1.0936       0.9654      24.1342      24.0283      24.6269      24.2636
180020............................       1.0484       0.7812      21.9494      24.6953      25.9626      24.2590
180021............................       0.9695       0.7812      18.5966      20.7950      22.0692      20.5351
180024............................       1.1161       0.9045      32.1824      31.1159      26.3521      29.7116
180025............................       1.1404       0.9045      19.1543      22.6897      28.5920      23.5032
180026............................       1.0693            *      18.2120            *            *      18.2120
180027............................       1.2463       0.8116      23.8763      20.8303      21.7638      22.0496
180028............................       0.9145            *      24.7967            *            *      24.7967
180029............................       1.3855       0.8815      23.0536      25.6479      26.1493      24.9987
180035............................       1.6206       0.9654      29.8438      31.0794      32.3484      31.1163
180036............................       1.2432       0.8845      25.1154      25.2972      25.6952      25.3661
180037............................       1.3242       0.9045      25.7361      26.3132      27.8489      26.6113
180038............................       1.5454       0.8801      24.6348      26.0440      27.2813      25.9999
180040............................       1.9659       0.9045      26.2125      27.9979      28.5206      27.6117
180043............................       1.1551       0.7812      19.0617      20.9326      20.6423      20.2174
180044............................       1.7151       0.8706      23.0971      24.4569      25.8053      24.4867
180045............................       1.3294       0.9654      25.8349      27.4732      29.4298      27.6399
180046............................       0.9468       0.9027      27.2244      27.1034      27.0962      27.1405
180047............................          ***            *      21.8036            *            *      21.8036
180048............................       1.2958       0.9045      21.6571      23.9230      24.3681      23.3115
180049............................       1.4452       0.8815      23.3407      22.4769      24.3690      23.3958
180050............................       1.1562       0.7840      22.6473      26.3604      25.9528      24.9966
180051............................       1.2881       0.8223      21.3312      23.5299      24.3892      23.1284

[[Page 24875]]

 
180053............................       0.9917       0.7812      19.1578      21.3044      22.1656      20.9703
180055............................       1.1922            *      20.7237            *            *      20.7237
180056............................       1.1792       0.8469      22.8910      24.3074      24.5323      23.9076
180063............................       1.1034            *      17.9741            *            *      17.9741
180064............................       1.1673       0.8132      16.2638      17.1009      20.1789      17.8235
180066............................       1.0846       0.9408      24.9543      22.2713      23.7855      23.6483
180067............................       2.0226       0.9027      25.4080      26.0238      27.9851      26.5261
180069............................       1.0877       0.8706      22.3673      26.3701      26.5123      25.1423
180070............................       1.1704       0.8052      20.1308      20.6741      20.2176      20.3429
180078............................       1.1538       0.8706      26.2636      27.6806      28.2744      27.4277
180079............................       1.1904       0.8076      19.7791      20.2100      23.5989      21.2535
180080............................       1.2800       0.8043      21.7380      21.5818      23.7258      22.3548
180087............................       1.2583       0.7812      18.4331      20.8841      22.0260      20.4628
180088............................       1.6703       0.9045      27.5767      28.0916      28.6098      28.1048
180092............................       1.1856       0.9027      22.5679      23.7909      23.7858      23.3986
180093............................       1.6485       0.8127      20.5422      20.5807      21.4392      20.8528
180095............................       1.0480       0.7812      17.9677      17.9146      21.5629      18.9607
180101............................       1.1642       0.9027      25.4796      27.4506      28.1621      27.0742
180102............................       1.5957       0.8116      18.4388      21.0896      25.2335      21.3174
180103............................       2.1735       0.9027      26.9407      28.4583      28.7043      28.0357
180104............................       1.5681       0.8116      24.9441      25.6157      25.9724      25.5137
180105............................       0.8867       0.7812      19.7615      21.6002      23.1861      21.5257
180106............................       0.8975       0.7812      17.8020      20.2884      20.7179      19.6699
180115............................       0.9142       0.7812      20.9831      20.5539      20.3082      20.6168
180116............................       1.2136       0.8116      22.7353      23.5354      25.8909      24.0619
180117............................       0.9574       0.7812      21.1854      22.8469      24.7355      22.8804
180124............................       1.3107       0.9408      23.1917      24.8292      25.4651      24.5479
180127............................       1.3506       0.9045      23.4765      24.6774      26.3498      24.8205
180128............................       0.9287       0.7812      20.8406      22.6056      23.8117      22.4352
180130............................       1.6785       0.9045      26.0278      27.8900      29.1689      27.7419
180132............................       1.4706       0.8815      23.7652      24.5105      25.3772      24.5770
180134............................       0.9988            *      18.6779            *            *      18.6779
180138............................       1.2338       0.9045      27.3400      28.1901      29.3488      28.3067
180139............................       0.9711       0.7812      23.5363      23.3569      24.7565      23.8893
180141............................       1.7986       0.9045      25.3042      25.3357      27.7799      26.1558
180143............................       1.6391       0.9027      25.1613      28.1924      30.8722      28.2377
180144............................          ***            *            *      29.5052            *      29.5052
180146............................          ***            *            *            *      39.8522      39.8522
180147............................          ***            *            *            *      31.1601      31.1601
180148............................          ***            *            *            *      30.1239      30.1239
180149............................       0.9790       0.7812            *            *            *            *
190001............................       1.1333       0.7591      19.7516      22.1394      22.1542      21.3054
190002............................       1.6405       0.8323      22.0056      23.3368      24.6968      23.3287
190003............................       1.4815       0.8323      23.4977      25.8294      26.7813      25.3494
190004............................       1.5567       0.7980      23.3290      25.3473      25.0771      24.6162
190005............................       4.8105       0.8732      22.3208      22.6029      24.2903      23.0170
190006............................       1.4353       0.8323      22.2467      22.7979      24.8816      23.2624
190007............................       1.1757       0.7591      19.7528      21.8205      23.1401      21.5662
190008............................       1.7630       0.7980      24.0111      24.6074      26.3623      24.9673
190009............................       1.2905       0.7982      19.8404      21.1005      24.0685      21.5282
190010............................          ***            *      21.6889            *            *      21.6889
190011............................       0.9928       0.7872      19.7319      21.4052      21.6962      20.9421
190013............................       1.4551       0.7787      20.8626      21.4573      23.7328      22.0203
190014............................       1.1835       0.7591      22.4596      22.7151      22.6381      22.6119
190015............................       1.3255       0.8732      22.8875      23.7789      25.1756      23.9762
190017............................       1.3888       0.7775      21.5033      24.5390      24.7505      23.6069
190019............................       1.7979       0.7982      23.7168      24.0468      25.4650      24.4147
190020............................       1.2332       0.8014      21.6136      22.1967      23.4576      22.4009
190025............................       1.3044       0.7591      20.8950      23.5007      24.6432      22.9599
190026............................       1.6216       0.7982      22.5087      23.7702      24.1540      23.4852
190027............................       1.6703       0.7787      21.2526      24.3006      26.7106      24.0302

[[Page 24876]]

 
190034............................       1.2388       0.7779      19.6943      20.7334      21.2104      20.5402
190036............................       1.7113       0.8732      24.8152      25.4164      25.6548      25.3040
190037............................       0.6483       0.7787      18.6393      19.4071      20.7258      19.5618
190039............................       1.6431       0.8732      25.6665      24.4386      26.1249      25.3976
190040............................       1.3443       0.8732      26.7428      28.6297      28.0162      27.7945
190041............................       1.4784       0.8615      24.6734      28.5376      28.9554      27.3327
190043............................          ***            *      17.3477            *            *      17.3477
190044............................       1.3215       0.7850      19.5567      20.9993      21.2561      20.6002
190045............................       1.6092       0.8732      25.3854      25.8238      27.1982      26.1752
190046............................       1.4988       0.8732      24.2128      23.8552      24.7362      24.2695
190048............................       1.0173            *      19.6288            *            *      19.6288
190050............................       1.0982       0.7635      19.1076      21.0259      20.9111      20.3638
190053............................       1.1453       0.7691      16.4968      17.9788      18.5781      17.7244
190054............................       1.3652       0.7676      20.1108      23.1471      22.7018      22.0096
190060............................       1.4952       0.7787      23.6278      23.7393      22.6278      23.3255
190064............................       1.6402       0.8014      23.3617      23.1358      23.7283      23.4081
190065............................       1.6040       0.8014      23.7450      22.1880      23.1207      23.0049
190077............................       0.9332            *      18.8409            *            *      18.8409
190078............................       1.0564       0.7775      21.3786      22.2431      22.2313      21.9581
190079............................       1.2248       0.8732      21.2546      24.0985      23.8184      23.0907
190081............................       0.8766       0.7591      15.6146      20.0121      21.4422      18.9706
190086............................       1.3003       0.7766      19.8823      22.0610      22.2872      21.4347
190088............................       1.0986       0.8615      22.3480      23.8562      23.1624      23.1091
190090............................       1.0652       0.7591      20.2045      23.1241      24.3261      22.5629
190095............................          ***            *      18.0174            *            *      18.0174
190098............................       1.7622       0.8615      24.6353      25.6854      25.7430      25.3592
190099............................       1.0523       0.8014      20.4597      22.0610      23.2316      21.9191
190102............................       1.5318       0.8323      25.2267      27.3126      26.9670      26.4739
190106............................       1.1180       0.7982      21.7228      23.5376      26.6201      23.8308
190109............................       1.2707            *      18.6524            *            *      18.6524
190111............................       1.6579       0.8615      24.4998      25.5729      26.5701      25.5474
190114............................       1.0545       0.7591      15.8031      17.2678      19.1533      17.4110
190115............................       1.2581       0.8615      26.6295      28.2066      26.0782      26.9661
190116............................       1.1767       0.7675      20.3845      22.3710      23.3978      22.0626
190118............................       0.9130       0.8615      19.7024      22.8809      21.2519      21.3058
190122............................       1.3212       0.8014      23.7082      22.0072      22.2352      22.6295
190124............................          ***            *      24.6675      26.0032      27.7799      26.1591
190125............................       1.6008       0.7872      23.9649      25.5463      24.8247      24.7613
190128............................       1.1165       0.8014      27.9136      28.3257      29.6644      28.6603
190131............................       1.2880       0.8014      25.1917      27.8465      28.6764      27.2755
190133............................       0.9001       0.7692      13.6266      18.2045      22.4265      19.4499
190135............................          ***            *      26.8238      27.7540      30.5687      28.1641
190140............................       0.9712       0.7625      17.6936      18.9652      23.0383      19.9091
190144............................       1.1643       0.8615      21.7547      22.9181      23.7865      22.8277
190145............................       0.9240       0.7681      18.9678      19.9265      20.8537      19.9351
190146............................       1.5652       0.8732      26.1792      27.4824      28.7186      27.4154
190149............................       1.0427            *      18.8819            *            *      18.8819
190151............................       0.9491       0.7591      18.6293      18.7467      18.8350      18.7414
190152............................       1.5642       0.8732      27.6099      28.1334      30.8510      28.8848
190158............................          ***            *      26.3042      26.4787      30.6477      27.6762
190160............................       1.6099       0.7872      21.6740      22.9325      24.7806      22.9867
190161............................       1.2439       0.7787      19.1022      22.6187      22.9017      21.4139
190162............................          ***            *      25.0328      25.2953            *      25.1543
190164............................       1.1710       0.8204      22.8599      25.2560      26.6165      24.9924
190167............................       1.2685       0.8323      24.3185      26.4669      25.3251      25.3437
190175............................       1.3812       0.8732      27.1531      26.0547      27.4234      26.8723
190176............................       1.7573       0.8732      25.6997      25.8826      26.2601      25.9478
190177............................       1.7189       0.8732      27.4621      27.7792      28.2738      27.8343
190182............................          ***            *      28.4799      27.1682      29.8646      28.5185
190183............................       1.1704       0.7980      19.8084      22.6928      22.0098      21.4396
190184............................       1.0119       0.7766      23.9608      24.9476      24.1551      24.3727

[[Page 24877]]

 
190185............................          ***            *      24.7912      25.6394      28.9749      26.4361
190190............................       0.9347       0.7666      16.1195      24.3327      26.6988      22.8823
190191............................       1.3282       0.8323      23.5734      24.1923      26.1592      24.6307
190196............................       0.9301       0.8323      24.7135      24.0385      25.8459      24.8783
190197............................       1.3888       0.7872      24.3735      25.8071      26.4794      25.5487
190199............................       0.9962       0.8014      14.1409      27.3304      31.9843      22.9932
190200............................          ***            *      27.5681      28.8173      27.4772      27.9970
190201............................       1.2434       0.7787      24.5877      25.1010      24.4557      24.7118
190202............................       1.4035       0.8014      24.7944      27.6084      29.6583      27.4867
190203............................          ***            *      26.8795      28.1832      29.9743      28.2126
190204............................       1.5156       0.8732      28.3684      28.1033      30.5137      28.9471
190205............................       1.6777       0.8323      24.4540      26.6832      28.2453      26.4792
190206............................       1.5774       0.8732      26.0139      26.7401      29.2352      27.2855
190208............................       0.8622       0.7591      24.2588      28.7308      27.9789      27.1350
190218............................       1.1036       0.8615      25.0356      26.7262      28.1014      26.6009
190236............................       1.4949       0.8615      23.6824      24.7142      26.4588      24.9853
190241............................       1.2210       0.7980      23.9700      25.2123      25.7878      25.0872
190242............................       1.1667       0.8014      23.0072      24.8461      25.0011      24.3286
190245............................       1.7065       0.7872      27.1786      25.5751      26.7636      26.5208
190246............................       1.6693       0.7666            *            *      22.7824      22.7824
190247............................          ***            *            *      32.7499            *      32.7499
190248............................          ***            *            *      23.2220            *      23.2220
190249............................       1.8972       0.8014            *      20.0468      25.2505      22.1285
190250............................       2.1200       0.8732            *      31.5101      33.3274      32.3417
190251............................       1.2888       0.8014            *      21.4464      23.8397      22.5827
190252............................          ***            *            *      23.6924            *      23.6924
190253............................          ***            *            *      22.8060      23.8029      23.3045
190254............................          ***            *            *      32.9290            *      32.9290
190255............................       0.7428       0.8323            *      22.2412      16.1597      18.3000
190256............................       0.7572       0.8732            *            *      25.9565      25.9565
190257............................       1.6034       0.7641            *            *      26.5480      26.5480
190258............................       1.0329       0.8615            *      31.3715      26.1129      28.3727
190259............................       1.8027       0.8323            *            *      26.5073      26.5073
190260............................          ***            *            *            *      29.3937      29.3937
190261............................       1.6302       0.7872            *            *      27.0423      27.0423
190262............................          ***            *            *            *      30.3709      30.3709
190263............................       2.4724       0.8323            *            *      26.1353      26.1353
190264............................          ***            *            *            *      26.5809      26.5809
190265............................       0.7095       0.7872            *            *      22.6214      22.6214
190266............................       1.9489       0.8014            *            *            *            *
190267............................       1.1620       0.8732            *            *            *            *
190268............................       1.3593       0.8323            *            *            *            *
190270............................       1.7989       0.8732            *            *            *            *
190272............................       1.5539       0.8323            *            *            *            *
190273............................       1.6476       0.8014            *            *            *            *
200001............................       1.3871       0.9860      25.1144      25.2542      25.8813      25.4247
200002............................       1.0767       0.8412      25.7478      25.7212      27.1134      26.1897
200008............................       1.3366       1.0008      27.4412      27.7137      29.1729      28.1437
200009............................       1.9757       1.0008      31.1056      30.7510      32.5792      31.4767
200012............................       1.3501            *      25.7623            *            *      25.7623
200013............................          ***            *      24.4131            *            *      24.4131
200018............................       1.2572       0.8412      23.6337      23.5632      22.5017      23.1550
200019............................       1.2471       1.0008      25.1367      25.6649      27.7886      26.2301
200020............................       1.2349       1.0179      31.7083      32.6436      34.0918      32.8280
200021............................       1.2518       1.0008      24.5519      27.1381      29.2049      27.0894
200024............................       1.5842       0.9601      26.0080      27.5410      29.7792      27.8456
200025............................       1.1474       1.0008      26.0573      26.3124      28.5747      27.0014
200027............................          ***            *      26.3118            *            *      26.3118
200028............................          ***            *      24.3271            *            *      24.3271
200031............................       1.2585       0.8412      21.9489      21.2370      22.2140      21.8009
200032............................       1.1124       0.8728      25.5227      26.3322      26.8986      26.2491

[[Page 24878]]

 
200033............................       1.8739       0.9860      28.6479      29.3108      31.6996      29.9418
200034............................       1.3348       0.9601      26.2926      27.0582      27.0093      26.8000
200037............................       1.2314       0.8412      23.2333      24.1732      24.9410      24.1296
200039............................       1.3026       0.9601      25.1196      25.1179      26.6405      25.6397
200040............................       1.2321       1.0008      25.5405      25.9893      28.5564      26.8006
200041............................       1.1532       0.8412      24.5532      24.9670      26.6764      25.4292
200050............................       1.2564       0.9860      26.4992      27.6825      29.5020      27.9403
200052............................       1.0964       0.8412      21.8726      22.5159      24.3571      22.9652
200063............................       1.1435       0.9601      25.0167      25.8623      27.9736      26.3217
210001............................       1.3542       0.9443      27.7561      28.2858      29.3435      28.4858
210002............................       1.9660       1.0108      26.4992      32.3005      36.0667      31.3519
210003............................       1.6629       1.0679      29.8684      34.1109      30.7342      31.5420
210004............................       1.4235       1.0990      34.2392      33.6056      31.7115      33.1029
210005............................       1.2775       1.0990      28.7557      28.9554      29.5819      29.1061
210006............................       1.0872       1.0108      25.4081      25.9005      27.3618      26.2241
210007............................       1.8897       1.0108      30.2548      31.8767      30.7107      30.9321
210008............................       1.3824       1.0108      25.2833      24.3341      28.8840      26.1400
210009............................       1.6952       1.0108      26.2360      27.7900      30.2658      28.0854
210010............................          ***            *      25.7775            *            *      25.7775
210011............................       1.3763       1.0108      27.5031      30.8575      31.5191      30.0101
210012............................       1.6038       1.0108      27.4103      30.3078      31.1748      29.7268
210013............................       1.2768       1.0108      25.1348      28.5328      28.9896      27.5055
210015............................       1.2773       1.0108      28.2029      29.9261      32.2753      30.1829
210016............................       1.7524       1.0990      32.2081      32.3506      33.5480      32.6959
210017............................       1.1893       0.8917      23.2167      25.1890      26.8569      25.0995
210018............................       1.1888       1.0990      29.1870      29.5533      29.6505      29.4657
210019............................       1.7923       0.8917      26.1824      27.3731      28.7828      27.4738
210022............................       1.3936       1.0990      33.8015      35.4727      37.3067      35.4764
210023............................       1.4340       1.0178      30.4656      32.1812      32.9572      31.9405
210024............................       1.7289       1.0108      29.5579      30.6359      32.9413      31.0661
210025............................       1.2738       0.8917      26.0771      23.8552      24.8558      24.7696
210027............................       1.5328       0.8917      26.0111      24.6343      24.4810      25.0054
210028............................       1.0549       0.9273      25.9221      26.3469      26.7453      26.3458
210029............................       1.2581       1.0108      27.9741      31.0266      31.8522      30.2804
210030............................       1.2162       0.8917      29.5635      26.9763      32.2035      29.6025
210032............................       1.1541       1.0752      26.1829      27.0727      27.9355      27.1027
210033............................       1.1657       1.0108      29.0420      28.5534      29.2497      28.9509
210034............................       1.3012       1.0108      28.4308      30.2908      32.3804      30.4301
210035............................       1.2771       1.0679      26.1083      28.6484      27.3876      27.3991
210037............................       1.1898       0.8917      27.0973      27.3287      27.8387      27.4523
210038............................       1.2283       1.0108      29.5980      29.8121      32.3190      30.5512
210039............................       1.1414       1.0679      27.6940      30.4991      32.4126      30.2663
210040............................       1.2135       1.0108      29.3514      28.3559      29.2360      28.9742
210043............................       1.2986       1.0178      27.5657      26.6524      32.6967      28.8479
210044............................       1.3219       1.0108      28.8700      29.7339      30.3340      29.6364
210045............................       0.9653       0.8917      15.6380      14.2223      16.3687      15.4676
210048............................       1.2738       1.0108      28.4638      27.5043      26.0631      27.2649
210049............................       1.2021       1.0108      26.9656      26.0900      27.0156      26.6995
210051............................       1.3641       1.0679      29.2998      29.8892      30.4320      29.8760
210054............................       1.2925       1.0679      26.2295      27.4328      27.7592      27.1401
210055............................       1.1649       1.0679      29.9708      30.6941      31.4895      30.7115
210056............................       1.2979       1.0108      28.6091      30.0810      32.3482      30.4741
210057............................       1.3579       1.0990      32.2883      31.6787      32.8280      32.2611
210058............................       1.0861       1.0108      29.7841      31.0873      31.6688      30.9534
210060............................       1.1807       1.0679      28.5087      27.1764      29.9635      28.5560
210061............................       1.2431       0.8917      23.6662      23.1645      25.0234      23.9963
220001............................       1.2013       1.1256      29.0014      30.6070      31.2364      30.2908
220002............................       1.3849       1.1256      30.3598      32.4356      33.6641      32.2134
220003............................       1.1827            *      22.0549            *            *      22.0549
220006............................          ***            *      30.8599      30.7673      33.6421      31.7227
220008............................       1.2815       1.1256      30.1043      31.3385      34.5830      32.0429

[[Page 24879]]

 
220010............................       1.2469       1.1256      29.7998      30.7804      31.9799      30.8557
220011............................       1.1289       1.1256      34.4064      34.7655      36.5621      35.2403
220012............................       1.5401       1.2617      35.7872      37.8763      39.7533      37.8795
220015............................       1.1911       1.0236      28.3397      29.6315      32.4890      30.2084
220016............................       1.1228       1.0236      28.0608      30.4813      31.3113      29.9507
220017............................       1.2759       1.1710      29.7108      31.6170      33.2998      31.5458
220019............................       1.0827       1.1256      23.2544      24.4009      25.7854      24.4946
220020............................       1.2031       1.1256      26.5305      28.5288      31.0989      28.7645
220024............................       1.2986       1.0236      27.3488      28.7342      31.9477      29.2908
220025............................       1.0403       1.1256      23.0637      25.6478      30.4365      26.1068
220028............................          ***            *      32.0980      31.7122      39.3268      34.1946
220029............................       1.1325       1.1256      28.6970      30.6935      31.6352      30.3488
220030............................       1.1318       1.0236      24.4289      26.8849      28.1322      26.5391
220031............................       1.6575       1.1710      34.8183      36.8477      38.9417      36.9168
220033............................       1.2129       1.1256      28.2539      31.8249      32.3475      30.8015
220035............................       1.4185       1.1256      28.6238      31.4470      29.7381      29.8711
220036............................       1.5118       1.1710      31.5184      33.1436      35.9106      33.5792
220046............................       1.4766       1.0071      28.1396      30.4460      31.4997      30.0722
220049............................       1.2129       1.1256      27.7518      30.4740      32.4636      30.2579
220050............................       1.0822       1.0236      26.3768      28.3434      29.0272      27.9399
220051............................       1.3072       0.9739      29.8380      30.2552      30.1012      30.0680
220052............................       1.1348       1.1710      29.8577      32.4130      31.6356      31.2805
220058............................       0.9616       1.1256      24.9642      25.7247      27.8893      26.1882
220060............................       1.1736       1.1710      32.3362      32.5477      34.7327      33.2257
220062............................       0.5719       1.1256      24.2779      25.0766      25.4179      24.9410
220063............................       1.2562       1.1256      27.3968      30.2866      32.9101      30.2203
220065............................       1.2427       1.0236      26.5513      27.6009      30.0468      28.0391
220066............................       1.3446       1.0236      27.1317      27.8073      28.9742      27.9354
220067............................       1.1851       1.1710      29.8911      30.2222      32.4000      30.8641
220070............................       1.1334       1.1256      31.9283      33.1299      34.2574      33.1431
220071............................       1.8646       1.1710      32.2936      36.5065      37.4053      35.4736
220073............................       1.1771       1.1256      31.3566      34.2989      36.0252      33.8940
220074............................       1.3059       1.1710      28.4930      30.5607      31.4701      30.1999
220075............................       1.5111       1.1710      29.1588      30.9175      31.3628      30.4689
220076............................          ***            *      29.7507      27.5148            *      28.6235
220077............................       1.6760       1.0955      30.2684      31.7325      33.0291      31.6979
220080............................       1.2069       1.1256      28.9835      29.9595      31.1248      30.0444
220082............................       1.2848       1.1256      26.9841      30.0611      30.8211      29.3136
220083............................       1.0840       1.1710      32.9143      34.5118      34.5698      33.9822
220084............................       1.2047       1.1256      32.5711      30.9527      31.6948      31.7155
220086............................       1.8174       1.1710      34.3667      34.2388      34.5669      34.3947
220088............................       1.8786       1.1710      28.5462      35.8255      37.4460      33.3973
220089............................          ***            *      31.1708      32.6305      34.7959      32.8331
220090............................       1.1952       1.1256      30.8685      32.9011      33.8958      32.6221
220095............................       1.1079       1.1256      27.4273      28.0673      30.1157      28.5485
220098............................       1.1442       1.1256      28.8314      30.5869      31.5393      30.3882
220100............................       1.3485       1.1710      29.6912      31.9859      34.6575      32.1939
220101............................       1.2852       1.1256      33.1690      35.3464      37.5665      35.4542
220105............................       1.2082       1.1256      31.9421      33.2625      32.8161      32.6900
220108............................       1.1274       1.1710      30.6252      32.6131      33.8841      32.3642
220110............................       2.0174       1.1710      36.6084      39.2167      41.0472      39.0591
220111............................       1.2048       1.1710      31.1850      33.6167      34.8506      33.2566
220116............................       1.9490       1.1710      32.9988      36.4149      38.8221      35.9865
220119............................       1.0935       1.1710      30.1056      30.9965      32.0844      31.1223
220126............................       1.1449       1.1710      28.7805      31.4882      32.5432      30.9197
220133............................          ***            *      33.6003      29.4855      34.8935      32.6268
220135............................       1.3229       1.2617      33.9866      36.0203      37.5164      35.8937
220153............................          ***            *            *            *      19.8073      19.8073
220154............................       0.9781       1.1710      28.6461            *      28.7843      28.7087
220162............................       1.6507            *            *            *            *            *
220163............................       1.5700       1.1256      33.6484      34.4874      37.4931      35.2930

[[Page 24880]]

 
220171............................       1.7192       1.1256      30.4036      32.7414      35.9925      33.0852
220174............................       1.2036       1.1256      31.7572      30.0406      30.9354      30.8546
220175............................       1.2654            *            *            *            *            *
220176............................       1.6837       1.1341            *            *            *            *
230002............................       1.2951       1.0138      29.1410      32.9010      34.0440      32.0073
230003............................       1.2255       0.9472      26.1278      27.5824      28.4694      27.4073
230004............................       1.7409       0.9935      26.7206      29.3934      31.2926      29.2276
230005............................       1.2575       0.9372      24.1902      25.8768      27.7463      25.8963
230006............................       1.0740            *      23.8835            *            *      23.8835
230013............................       1.3227       1.0272      23.7822      24.6511      27.2066      25.1217
230015............................       1.1463       0.9196      24.6571      26.2782      27.2542      26.0748
230017............................       1.7002       1.0505      29.5178      31.8821      32.5376      31.3890
230019............................       1.6505       1.0272      28.4575      32.3401      34.3193      31.6359
230020............................       1.7492       1.0138      29.2869      28.5646      29.4792      29.1157
230021............................       1.5950       1.0151      24.9551      26.5659      28.6153      26.7251
230022............................       1.3120       0.9933      23.3000      25.6683      30.1226      26.2395
230024............................       1.6703       1.0138      30.0813      32.1483      32.5866      31.6095
230027............................       1.0649            *      23.5511            *            *      23.5511
230029............................       1.6011       1.0272      29.0935      32.3538      32.3835      31.2335
230030............................       1.2717       0.8979      22.3174      23.8082      25.1077      23.7832
230031............................       1.3725       1.0040      25.4679      29.7232      30.0088      28.2704
230034............................       1.3787       0.8899      26.7967      24.4845      24.4133      25.2367
230035............................       1.2605       0.9380      21.2317      24.8822      24.9648      23.8027
230036............................       1.4572       0.9399      28.3622      29.3754      29.9622      29.2264
230037............................       1.3454       1.0138      26.2000      28.9244      28.5469      27.9089
230038............................       1.7903       0.9472      26.3480      28.2012      29.1247      27.9594
230040............................       1.2075       0.9380      24.2349      25.5154      26.3754      25.4050
230041............................       1.6026       0.9399      26.1760      27.8853      27.9569      27.3833
230042............................          ***            *      26.2037            *            *      26.2037
230046............................       1.9037       1.0504      30.3591      31.6235      32.2914      31.4688
230047............................       1.4047       1.0092      28.1351      31.1771      31.7053      30.3603
230053............................       1.6336       1.0138      29.8703      32.5711      32.1537      31.5469
230054............................       1.8873       0.9339      24.9905      25.7591      26.0031      25.5906
230055............................       1.2628       0.8899      25.4143      27.4349      28.4779      27.1071
230058............................       1.1265       0.8899      24.0657      25.9291      27.1214      25.7327
230059............................       1.5531       0.9472      25.5350      27.9091      28.5859      27.3987
230060............................       1.2198       0.8899      25.5015      28.2874      27.0286      26.9332
230065............................          ***            *      28.4631      32.6255            *      29.9929
230066............................       1.3087       0.9935      27.4928      30.6184      30.2070      29.5125
230069............................       1.1594       1.0138      29.5556      30.2663      31.3407      30.4158
230070............................       1.6381       0.9127      24.2342      25.6778      26.8296      25.5681
230071............................       0.8679       1.0272      26.3907      28.3064      29.6710      28.1425
230072............................       1.3914       0.9472      24.4933      26.2838      27.4723      26.0939
230075............................       1.3793       1.0090      27.6193      28.2540      30.8862      28.9422
230077............................       1.9012       1.0272      27.6157      29.8538      30.5516      29.3453
230078............................       1.0892       0.8899      23.9902      25.6809      25.7228      25.1288
230080............................       1.3068       0.9399      21.2314      24.1573      24.5418      23.3433
230081............................       1.1913       0.8899      23.0788      24.7374      26.4321      24.7713
230082............................       1.6774            *      22.2165            *            *      22.2165
230085............................       1.1930       1.0505      22.7313      23.4959      25.4277      23.9142
230087............................          ***            *      16.9168            *            *      16.9168
230089............................       1.3349       1.0138      28.7015      31.0522      32.8429      30.6482
230092............................       1.3637       1.0138      26.3584      28.6829      29.3419      28.2028
230093............................       1.2101       0.8959      26.4967      25.5804      27.4458      26.5307
230095............................       1.3066       0.8899      21.3916      22.8681      25.1829      23.1772
230096............................       1.1221       1.0151      28.7681      30.6024      31.7385      30.4262
230097............................       1.7992       0.9380      26.5773      28.2526      29.8946      28.2263
230099............................       1.2069       1.0138      26.4882      29.0221      29.3700      28.3176
230100............................       1.1878       0.8899      21.8895      24.1881      25.2112      23.7860
230101............................       1.2004       0.8899      24.3772      25.4839      28.4355      26.1552
230103............................          ***            *      21.6609            *            *      21.6609

[[Page 24881]]

 
230104............................       1.5972       1.0138      30.5570      32.4634      32.4102      31.7987
230105............................       1.8553       0.9399      27.2705      32.4583      30.5507      30.1271
230106............................       1.1795       0.9472      24.3980      25.3243      27.8566      25.9485
230108............................       1.1243       0.8899      18.4064      20.2539      24.4337      20.8956
230110............................       1.2976       0.8899      28.7704      27.0040      25.7173      27.1019
230117............................       1.8708       1.0505      29.4775      32.7994      33.0575      31.7174
230118............................       1.0456       0.8899      22.3636      23.6110      24.8873      23.5918
230119............................       1.3915       1.0138      30.2441      30.7488      31.9681      31.0533
230120............................       1.1881            *      24.1485            *            *      24.1485
230121............................       1.2797       0.9933      24.5220      26.4940      26.8351      25.9742
230130............................       1.7334       1.0272      26.6076      30.1608      31.2720      29.4071
230132............................       1.4190       1.1078      30.5318      32.3939      35.5753      32.8039
230133............................       1.3873       0.8899      24.3174      23.9442      25.0634      24.4534
230135............................       1.4715       1.0138      25.8407      25.9583      23.6004      25.1117
230141............................       1.6569       1.1078      28.6326      31.6152      33.8730      31.3710
230142............................       1.2441       1.0138      26.9433      27.8377      29.7407      28.1855
230143............................          ***            *      21.4083            *            *      21.4083
230144............................       2.3494       1.0504            *            *            *            *
230146............................       1.3935       1.0138      26.3432      26.8156      27.2610      26.8176
230151............................       1.3152       1.0272      28.2243      27.4546      29.8352      28.4827
230153............................          ***            *      22.8644            *            *      22.8644
230156............................       1.6276       1.0504      31.1909      32.3755      33.9016      32.4963
230165............................       1.6917       1.0138      28.9636      29.6376      31.4221      30.0161
230167............................       1.6184       1.0053      27.4562      29.8071      31.0585      29.4605
230169............................          ***            *      31.8442            *            *      31.8442
230172............................       1.1867            *      25.7402            *            *      25.7402
230174............................       1.2752       0.9472      27.6920      30.0563      29.7361      29.1540
230176............................       1.2857       1.0138      27.3605      28.1498      25.8188      27.0655
230180............................       1.1332       0.8899      24.7358      26.0707      24.9693      25.2513
230184............................          ***            *      23.6706      34.6295            *      25.2502
230186............................          ***            *      26.2282            *            *      26.2282
230189............................          ***            *      23.0100            *            *      23.0100
230190............................       0.8738       1.0505      29.9603      30.7875      33.8238      31.5782
230193............................       1.2840       1.0040      23.3565      25.1626      26.4717      25.0021
230195............................       1.4440       1.0092      28.2892      29.5656      30.9245      29.6342
230197............................       1.5802       1.1078      30.0367      32.0063      33.6990      31.9260
230204............................       1.3301       1.0092      29.1466      31.5615      32.2850      31.0158
230207............................       1.3447       1.0272      24.5201      25.4268      25.2547      25.0743
230208............................       1.1990       0.9380      21.9651      23.7523      24.3741      23.3710
230212............................       0.9926       1.0504      29.7981      31.9818      32.8564      31.5064
230216............................       1.5508       1.0040      27.5230      29.0147      29.2047      28.5834
230217............................       1.3812       0.9933      28.6074      30.1136      31.9706      30.2655
230222............................       1.3799       0.9399      26.9724      29.9341      30.6473      29.2057
230223............................       1.2979       1.0272      29.2854      28.6745      29.8419      29.2657
230227............................       1.4986       1.0092      29.5798      30.8218      33.6697      31.2203
230230............................       1.5219       1.0053      27.9607      29.8763      31.1701      29.6591
230235............................       1.0691            *      21.8777            *            *      21.8777
230236............................       1.5046       0.9472      28.4754      31.3110      30.8531      30.2122
230239............................       1.2710       0.8899      22.1040      21.0814      22.1569      21.7756
230241............................       1.2149       1.0040      27.4890      27.6106      28.5505      27.9009
230244............................       1.4355       1.0138      26.4326      29.6283      30.0355      28.6450
230254............................       1.5080       1.0272      28.1216      29.2653      29.5865      28.9731
230257............................       0.9510       1.0092      27.8198      29.6712      30.6373      29.3897
230259............................       1.2666       1.0504      26.8677      27.4217      27.5982      27.2972
230264............................       1.8606       1.0092      19.2398      22.7768      28.5389      23.0403
230269............................       1.5016       1.0272      28.8187      31.3226      31.3773      30.6050
230270............................       1.2640       1.0138      27.8488      28.5372      28.8505      28.4218
230273............................       1.5123       1.0138      29.9307      31.9862      31.5372      31.1375
230275............................       0.4718       0.9127      23.1095      23.8104      25.2117      24.0696
230277............................       1.4037       1.0272      29.1973      29.8372      31.4001      30.1455
230279............................       0.4947       1.0138      24.7673      27.2816      27.9709      26.6920

[[Page 24882]]

 
230283............................          ***            *      26.2622      33.5531            *      27.8105
230289............................          ***            *      29.7721            *            *      29.7721
230291............................          ***            *      30.9656            *            *      30.9656
230292............................          ***            *      31.8943            *            *      31.8943
230294............................          ***            *            *      31.6195            *      31.6195
230295............................          ***            *            *      27.1298            *      27.1298
230296............................          ***            *            *            *      34.2091      34.2091
230297............................       1.6725       1.0092            *            *            *            *
230299............................       0.7569       1.0092            *            *            *            *
230300............................       2.9372       1.0092            *            *            *            *
240001............................       1.5321       1.0961      31.5753      33.1499      34.9488      33.2343
240002............................       1.8802       1.0151      28.9860      31.6000      33.5414      31.3640
240004............................       1.5917       1.0961      30.8072      32.7010      32.0885      31.8534
240006............................       1.0930       1.0761      30.1949      31.0777      34.0824      31.7954
240010............................       2.0488       1.0761      31.3733      33.4668      33.9391      32.9198
240013............................          ***            *      28.3860            *            *      28.3860
240014............................       1.0233       1.0961      29.8623      29.8905      31.5902      30.4899
240016............................       1.2758            *      26.7814            *            *      26.7814
240017............................       1.1862            *      24.4417      24.3596            *      24.4015
240018............................       1.2795       1.0085      25.6236      28.1432      29.6619      27.8174
240019............................       1.0510       1.0151      28.6723      33.7546      32.9757      31.6807
240020............................       1.0696       1.0961      31.2443      31.3874      33.4700      32.0413
240021............................       1.0320            *      27.1236            *            *      27.1236
240022............................       1.0296       0.9212      25.2066      26.1920      27.4384      26.3075
240027............................       0.9334            *      18.2482            *            *      18.2482
240029............................       0.9036            *      25.3568            *            *      25.3568
240030............................       1.3356       1.0390      24.7154      26.5508      27.1291      26.1210
240031............................          ***            *      26.7778            *            *      26.7778
240036............................       1.6917       1.0961      28.0812      32.7028      34.2927      31.6446
240038............................       1.5420       1.0961      31.0779      31.9891      33.2977      32.1250
240040............................       1.0727       1.0151      27.4895      27.5074      29.2269      28.0678
240043............................       1.2145       0.9212      21.8684      23.3489      24.2153      23.1696
240044............................       1.0574       0.9883      22.0973      25.0988      26.8667      24.6227
240047............................       1.5016       1.0151      28.8289      28.6406      29.7813      29.0973
240050............................       1.1126       1.0961      26.4854      27.5553      31.2060      28.4938
240052............................       1.2197       0.9212      26.4256      28.7206      29.4594      28.2281
240053............................       1.4802       1.0961      29.5315      31.4324      33.1815      31.4253
240056............................       1.2486       1.0961      31.6623      33.1728      33.9981      32.9754
240057............................       1.8365       1.0961      30.6258      30.7703      33.6438      31.6657
240059............................       1.1404       1.0961      29.7916      31.0911      33.3840      31.4927
240061............................       1.8183       1.0761      30.6383      33.1799      32.1083      31.9962
240063............................       1.6444       1.0961      32.3487      33.7895      35.3585      33.8590
240064............................       1.1841       1.0020      29.9662      34.3757      27.2367      30.4831
240066............................       1.5085       1.0961      33.4532      35.3441      36.1920      35.0530
240069............................       1.2060       1.0761      28.9496      29.3718      31.1575      29.8505
240071............................       1.1294       1.0761      28.0586      28.6950      31.7403      29.4814
240075............................       1.1560       1.0390      26.1956      27.5039      29.1165      27.5981
240076............................       1.0348       1.0961      29.8561      30.6936      33.0908      31.3206
240078............................       1.7539       1.0961      32.3235      32.5785      35.5096      33.5022
240080............................       1.9135       1.0961      31.6828      32.5725      34.9990      33.0567
240083............................       1.2282            *      26.6582            *            *      26.6582
240084............................       1.1715       1.0151      26.8141      26.5975      26.6137      26.6743
240088............................       1.2868       1.0390      28.0825      28.0603      30.7452      28.9706
240093............................       1.4141       1.0961      25.5805      27.2928      29.1386      27.3669
240100............................       1.3062       0.9212      27.6299      30.8391      31.5746      30.0094
240101............................       1.1577       0.9212      25.5355      25.6963      26.8837      26.0839
240103............................          ***            *      22.7077            *            *      22.7077
240104............................       1.1355       1.0961      31.4306      31.6511      34.8590      32.7610
240106............................       1.6068       1.0961      29.3455      30.5927      33.3656      31.1028
240109............................       0.8676            *      16.5051            *            *      16.5051
240115............................       1.5324       1.0961      31.3869      32.0107      33.7716      32.4047

[[Page 24883]]

 
240117............................       1.1786       0.9805      23.6230      24.5750      27.6916      25.3192
240123............................          ***            *      21.7500            *            *      21.7500
240128............................          ***            *      21.5791      23.3334            *      22.4504
240132............................       1.2801       1.0961      31.7139      32.1233      34.6782      32.8020
240141............................       1.1202       1.0961      26.4016      31.4468      32.3861      30.2635
240143............................       0.8966            *      21.7416            *            *      21.7416
240152............................          ***            *      29.6196            *            *      29.6196
240162............................          ***            *      22.2722            *            *      22.2722
240166............................       1.1548       0.9212      25.7509      27.6987      29.6615      27.8068
240187............................       1.3295       1.0961      27.8811      27.8844      29.6502      28.5206
240196............................       0.8200       1.0961      30.7720      31.5965      34.1199      32.1844
240206............................       0.8831       1.4406            *            *            *            *
240207............................       1.1958       1.0961      31.7665      32.5589      34.9881      33.1636
240210............................       1.2897       1.0961      32.1564      32.7123      34.4858      33.1223
240211............................       0.9769       0.9598      18.8503      22.5430      29.3644      22.2558
240213............................       1.3950       1.0961      32.7532      33.8680      35.9799      34.2403
250001............................       1.9054       0.8273      22.7827      23.5222      24.5227      23.6272
250002............................       0.9546       0.7971      23.3844      23.4063      25.4201      24.0840
250004............................       1.9123       0.8951      24.1065      24.7907      25.8710      24.9580
250006............................       1.1113       0.8951      24.0191      24.4282      25.9197      24.8139
250007............................       1.2347       0.8618      25.8710      24.8929      27.7647      26.1856
250009............................       1.2422       0.8432      22.2323      23.0352      23.4128      22.8968
250010............................       0.9918       0.7915      19.4402      21.4322      21.8643      20.9156
250012............................       0.9475       0.9291      20.2922      21.5540      23.3688      21.7206
250015............................       1.1234       0.7915      20.7555      22.0067      22.2776      21.6577
250017............................       1.0264       0.7915      21.3950      22.7660      33.6797      25.4557
250018............................       0.8932       0.7915      16.6292      17.1276      17.9011      17.2147
250019............................       1.5216       0.8618      23.9741      25.7376      26.2315      25.3074
250020............................       0.9941       0.7915      21.4019      22.1851      23.7217      22.4960
250021............................          ***            *      20.3564            *            *      20.3564
250023............................       0.8676       0.8223      16.2418      18.0108      18.4674      17.5916
250025............................       1.0998       0.7915      20.5258      22.5621      23.1721      22.1086
250027............................       0.9597       0.7915      17.3481      24.4937      26.9874      22.7342
250031............................       1.3175       0.8273      21.4326      24.8139      55.6623      27.5006
250034............................       1.5394       0.8951      24.3189      26.1887      27.0455      25.8383
250035............................       0.8591       0.7915      17.2046      20.1622      19.6892      19.0949
250036............................       1.0384       0.8544      19.1975      20.3625      19.7915      19.8090
250037............................       0.9020            *      17.4012            *            *      17.4012
250038............................       0.9401       0.8273      18.9050      22.2571      26.9582      22.1495
250039............................       0.9692            *      17.3155            *            *      17.3155
250040............................       1.4830       0.8223      23.2285      24.5962      27.3356      25.0598
250042............................       1.2092       0.8951      23.4135      25.6807      26.1154      25.0557
250043............................       1.0145       0.7915      19.8097      18.8979      20.8820      19.8715
250044............................       1.0512       0.7971      23.3862      24.0508      24.9245      24.1146
250045............................       0.8706            *      26.3831            *            *      26.3831
250048............................       1.6243       0.8273      22.9765      25.2092      24.7651      24.3109
250049............................       0.8732       0.7915      17.7005      19.1044      20.4694      19.2002
250050............................       1.1890       0.7915      19.1467      20.8084      21.1669      20.4034
250051............................       0.8083       0.7915      10.6095      14.3741      13.9457      12.9300
250057............................       1.1224       0.7915      20.1900      22.7601      24.3633      22.3987
250058............................       1.2423       0.7915      18.1704      19.2502      18.9952      18.8123
250059............................       0.9230       0.7915      19.2976      23.8997      26.7379      23.0872
250060............................       0.7986       0.7915      16.8247      28.1431      25.4705      22.9625
250061............................       0.9038       0.7915      12.8174      17.8267      18.7359      16.2197
250067............................       1.0777       0.7915      21.6911      23.1193      25.2181      23.3708
250069............................       1.4806       0.8166      22.8162      22.6353      22.4221      22.6169
250072............................       1.6976       0.8273      24.6587      25.8399      25.5321      25.3433
250077............................       0.9345       0.7915      14.7632      18.3735      19.0379      17.4294
250078............................       1.6953       0.8223      20.9354      22.1243      22.8399      21.9357
250079............................       0.8536       0.8273      38.0032      45.5166      43.0813      42.6359
250081............................       1.3342       0.8166      24.7031      23.9995      25.6789      24.7909

[[Page 24884]]

 
250082............................       1.4651       0.7959      19.6966      23.0287      23.5384      22.0708
250084............................       1.2101       0.7915      18.5775      19.6492      19.1096      19.1057
250085............................       1.0005       0.7915      19.7008      22.5513      24.2875      22.2560
250093............................       1.1880       0.7915      21.3237      23.0984      23.9098      22.7648
250094............................       1.7339       0.8223      22.7312      24.1422      24.7709      23.8832
250095............................       1.0360       0.7915      21.3511      21.7488      23.6079      22.2424
250096............................       1.1761       0.8273      22.6298      24.9187      26.3717      24.6250
250097............................       1.6174       0.8014      20.1687      21.8139      22.0204      21.3427
250099............................       1.2805       0.8273      19.5797      21.1269      21.9028      20.8103
250100............................       1.4738       0.8166      24.2209      25.6846      27.0283      25.6565
250101............................          ***            *      19.3543            *            *      19.3543
250102............................       1.5948       0.8273      24.2868      24.6652      25.4029      24.7878
250104............................       1.4895       0.8166      22.6591      23.4303      24.4287      23.5414
250105............................       0.9250            *      18.1195            *            *      18.1195
250107............................       0.5882            *      17.8999            *            *      17.8999
250112............................       0.9900       0.7915      21.2824      24.3069      26.3311      23.9682
250117............................       1.1064       0.8223      23.3673      22.2450      23.7325      23.1044
250120............................          ***            *      23.4277      24.6370      26.6502      24.9393
250122............................       1.1114       0.7915      24.5854      27.2795      27.4403      26.3821
250123............................       1.3317       0.8618      24.5115      26.6221      27.9144      26.3804
250124............................       0.8188       0.8273      17.2181      20.4394      20.5596      19.3903
250125............................       1.2236       0.8618      27.7077      27.5158      26.8377      27.3634
250126............................       0.9502       0.7915      21.7112      24.4126      25.6980      23.8290
250127............................       0.8851       1.4406            *            *            *            *
250128............................       0.9292       0.8308      17.6269      17.7624      21.7827      19.2616
250134............................       0.8844       0.8273      25.8369      22.2167      21.0199      22.9407
250136............................       1.0311       0.8273      23.0637      22.9468      25.2250      23.7174
250138............................       1.3295       0.8273      23.8861      24.3018      25.2632      24.4952
250141............................       1.5450       0.9291      27.6158      28.5922      30.5462      28.9990
250146............................       0.7934            *      18.6486            *            *      18.6486
250149............................       0.8346       0.7915      15.0641      16.8796      17.2245      16.4086
250151............................       0.4710       0.7915      17.2205      18.8846      22.8221      18.4859
250152............................       0.8555       0.8273      25.7837      26.9334      26.4561      26.3576
250153............................          ***            *      29.0461            *            *      29.0461
250155............................          ***            *            *      22.5728            *      22.5728
250156............................          ***            *            *            *      16.8646      16.8646
250157............................          ***            *            *            *      29.6366      29.6366
250160............................       1.4401       0.8308            *            *            *            *
250161............................       2.1565       0.8273            *            *            *            *
260001............................       1.6521       0.9318      25.9250      27.9230      29.5231      27.7476
260002............................          ***            *      26.4879            *            *      26.4879
260004............................       0.9694       0.8145      16.9422      20.3217      21.3539      19.5722
260005............................       1.5541       0.8885      26.5773      27.7855      27.9465      27.4311
260006............................       1.4864       0.8145      26.7587      30.3440      27.3734      28.2406
260008............................          ***            *      18.9522            *            *      18.9522
260009............................       1.1616       0.9321      22.1816      24.2360      25.7517      24.0687
260011............................       1.5006       0.8706      22.7062      25.6387      27.5729      25.2802
260012............................          ***            *      20.3061            *            *      20.3061
260013............................          ***            *      20.5007            *            *      20.5007
260015............................       1.0081       0.8507      22.5409      24.6139      25.0595      24.0549
260017............................       1.3305       0.8706      22.7022      23.5713      24.9740      23.7836
260018............................       1.0396            *      17.0434            *            *      17.0434
260020............................       1.7371       0.8885      26.0407      27.4730      29.3071      27.6646
260021............................       1.3993       0.8885      27.6329      29.3646      31.7013      29.4504
260022............................       1.4087       0.8480      22.8085      23.3393      24.8696      23.6522
260023............................       1.3563       0.8885      21.2077      24.3192      25.4291      23.5894
260024............................       1.1337       0.8145      18.4829      19.4952      19.2179      19.0576
260025............................       1.3611       0.8885      22.4645      22.2451      24.0348      22.9414
260027............................       1.6424       0.9321      25.3348      26.3590      29.3205      26.9768
260032............................       1.8499       0.8885      23.9478      25.6763      25.8890      25.1792
260034............................       0.9779       0.9321      24.1143      25.0573      27.1644      25.5181

[[Page 24885]]

 
260035............................          ***            *      17.8741            *            *      17.8741
260036............................          ***            *      22.1913            *            *      22.1913
260040............................       1.6639       0.9196      23.3566      24.3938      28.5815      25.2261
260047............................       1.4482       0.8706      24.4185      25.4978      26.6318      25.5311
260048............................       1.1759       0.9321      24.3906      27.6117      28.2868      26.7437
260050............................       1.1594       0.8831      23.6849      25.0506      26.2320      25.0309
260052............................       1.3110       0.8885      24.5165      26.0052      27.6348      26.0327
260053............................       1.0761            *      21.6607            *            *      21.6607
260057............................       1.0699       0.9321      19.3335      20.9639      21.5895      20.6144
260059............................       1.1568       0.8272      19.7243      22.6922      22.3875      21.6445
260061............................       1.1351       0.8145      21.5264      22.4766      22.8581      22.2790
260062............................       1.2507       0.9321      26.4539      28.1661      28.4951      27.7044
260064............................       1.3834       0.8545      19.0543      22.2395      23.5352      21.5798
260065............................       1.7778       0.9196      23.0015      27.1014      29.3548      26.5318
260067............................       0.9311            *      17.6256            *            *      17.6256
260068............................       1.7969       0.8545      24.9504      26.0295      27.3717      26.1290
260070............................       0.9563       0.8145      18.4779      24.6331      21.9646      21.9639
260073............................          ***            *      21.6214            *            *      21.6214
260074............................       1.2375       0.8545      24.8655      25.6218      28.0454      26.1516
260077............................       1.6221       0.8885      25.5782      26.7466      27.7359      26.6839
260078............................       1.2835       0.8145      19.0802      20.1983      21.1532      20.1475
260080............................       0.9195       0.8145      14.7774      17.9107      18.6028      17.0061
260081............................       1.5691       0.8885      26.3969      28.1182      29.1725      27.9063
260085............................       1.5670       0.9321      25.6302      26.6718      28.0298      26.7543
260086............................       0.9570            *      19.1702            *            *      19.1702
260091............................       1.5269       0.8885      27.2407      28.0537      28.5213      27.9452
260094............................       1.7017       0.8943      23.2544      24.1473      23.8642      23.7598
260095............................       1.3903       0.9321      25.5668      24.2698      27.3917      25.6438
260096............................       1.4990       0.9321      27.5592      29.7312      30.7246      29.3745
260097............................       1.2006       0.8440      21.3957      25.0624      25.5604      24.1093
260102............................       0.9518       0.9321      24.2368      27.2145      26.7618      26.1063
260104............................       1.5655       0.8885      26.2867      28.6247      28.0218      27.6808
260105............................       1.8539       0.8885      28.8849      29.8848      29.4761      29.4215
260107............................       1.2949       0.9321      26.7781      25.8177      27.8030      26.7722
260108............................       1.8342       0.8885      24.9880      26.6374      27.0748      26.2654
260110............................       1.6392       0.8885      23.7978      24.7656            *      24.2985
260113............................       1.1068       0.8355      20.9644      21.2072      21.8850      21.3616
260115............................       1.1392       0.8885      21.9858      23.1396      24.6379      23.3009
260116............................       1.0986       0.8145      18.5076      21.3503      20.7451      20.1801
260119............................       1.3299       0.8507      24.9937      27.9769      31.5417      28.0654
260122............................          ***            *      20.8015            *            *      20.8015
260127............................       0.9486            *      21.8533            *            *      21.8533
260137............................       1.7247       0.9318      22.7431      24.3273      28.2386      25.0868
260138............................       1.9895       0.9321      28.5610      30.4410      30.7179      29.9246
260141............................       1.8510       0.8545      22.4886      24.1555      25.5660      24.0282
260142............................       1.0871       0.8145      20.3993      21.5923      21.7584      21.2691
260147............................       0.9229       0.8145      18.5153      21.4235      22.1878      20.7802
260159............................          ***            *      23.7427      22.6276      23.9520      23.4461
260160............................       1.0728       0.8145      21.0544      23.8257      25.5072      23.4620
260162............................       1.3823       0.8885      25.1423      27.0236      28.4645      26.9318
260163............................       1.1437       0.8145      20.1949      21.6408      21.5551      21.0992
260164............................       1.3771            *      19.7068            *            *      19.7068
260166............................       1.2260       0.9321      27.0237      29.1225      28.4735      28.1987
260175............................       1.0782       0.9321      22.6171      25.1817      24.6035      24.1897
260176............................       1.7016       0.8885      27.4244      29.3034      31.1025      29.3195
260177............................       1.2061       0.9321      26.1178      27.0185      28.7735      27.3063
260178............................       1.8406       0.8545      22.2251      25.4782      27.1192      25.2033
260179............................       1.5483       0.8885      26.1419      26.6069      28.1578      26.9703
260180............................       1.5417       0.8885      26.7461      28.2931      29.3792      28.1552
260183............................       1.6671       0.8885      26.0418      27.5577      29.2666      27.6346
260186............................       1.5449       0.8706      25.3148      26.9797      28.8584      27.0989

[[Page 24886]]

 
260190............................       1.1940       0.9321      26.4505      27.9137      30.5095      28.3280
260191............................       1.3655       0.8885      23.3856      24.6973      26.3196      24.8420
260193............................       1.1900       0.9321      26.2979      26.8922      28.1060      27.0944
260195............................       1.2147       0.8145      22.3959      22.6870      24.0387      23.0815
260198............................       0.9613       0.8885      27.5996      28.0021      27.2554      27.6065
260200............................       1.2655       0.8885      24.8624      28.2453      27.4813      26.8911
260207............................       1.1543       0.9196      19.7294      22.6109      22.9594      22.0277
260209............................       1.1051       0.8706      23.2430      25.0098      25.0733      24.4643
260210............................       1.2690       0.8885      25.3781      26.8745      30.6046      27.6608
260211............................       1.5777       0.9321      33.9109      40.9821      35.9066      37.0319
260213............................          ***            *            *            *      34.8944      34.8944
260214............................       1.2355       0.9321            *            *            *            *
260215............................       0.8925            *            *            *            *            *
260216............................       1.1874       0.9321            *            *            *            *
260217............................       1.9096       0.8145            *            *            *            *
270002............................       1.1595       0.8337      22.7322      24.0534      25.2902      24.0315
270003............................       1.3079       0.8765      26.4843      28.8700      29.2082      28.2134
270004............................       1.6792       0.8877      23.5454      26.1319      26.7037      25.4969
270011............................       1.0335       0.8337      22.1394      22.7061      24.4678      23.0847
270012............................       1.5539       0.8765      25.2873      25.2914      26.5782      25.7174
270014............................       1.9641       0.8737      26.2025      25.8231      27.4790      26.5061
270017............................       1.3145       0.8737      27.5483      26.5404      27.4092      27.1700
270021............................          ***            *      21.7056            *            *      21.7056
270023............................       1.5491       0.8737      26.7576      25.5682      26.2592      26.1753
270032............................       1.0285       0.8337      19.6212      20.3469      20.4332      20.1360
270036............................          ***            *      20.4241            *            *      20.4241
270049............................       1.7523       0.8877      26.3996      27.1634      28.6651      27.4207
270051............................       1.5590       0.8337      26.6619      26.5621      24.8924      25.9335
270057............................       1.2521       0.8337      24.2980      25.5811      27.1840      25.7302
270060............................          ***            *      17.7564            *            *      17.7564
270074............................       0.9141       1.4406            *            *            *            *
270081............................       0.9750       0.8573      17.4862      19.5612      20.0422      18.9880
270086............................       1.0637       0.8765            *      21.0808      20.7990      20.9439
270087............................       1.2165       0.8337            *      25.9772      24.8182      25.3750
280003............................       1.7455       0.9836      29.3921      30.6124      29.8995      29.9681
280009............................       1.8639       0.9603      26.7678      27.0705      29.3561      27.7370
280013............................       1.7316       0.9419      26.1908      27.0250      27.9514      27.0724
280020............................       1.7365       0.9836      26.5068      27.3284      32.3886      28.7653
280021............................       1.1556            *      22.0489            *            *      22.0489
280023............................       1.3658       0.9603      22.3230      26.7980      29.5116      26.0300
280030............................       1.8923       0.9419      30.7481      29.5102      30.6995      30.3315
280032............................       1.2987       0.9603      23.6462      24.3995      24.7535      24.2695
280040............................       1.6382       0.9419      26.9827      28.7207      29.5254      28.4311
280054............................       1.1439            *      23.5665            *            *      23.5665
280057............................       0.8567            *      20.4830            *            *      20.4830
280060............................       1.6740       0.9419      26.2139      27.7496      30.3288      28.0764
280061............................       1.3931       0.9049      24.9482      26.0208      26.4808      25.8452
280065............................       1.2398       0.9747      26.0135      28.0581      27.9710      27.3272
280077............................       1.3381       0.8905      25.5624      27.0860      28.2199      26.9868
280081............................       1.7001       0.9419      26.0541      28.7464      31.1636      28.6498
280105............................       1.2700       0.9419      26.7555      27.8599      24.0173      26.1446
280108............................       1.0629            *      23.2503            *            *      23.2503
280111............................       1.1871       0.8848      23.4770      24.5617      27.4621      25.3069
280117............................       1.1227            *      24.1521            *            *      24.1521
280119............................       0.8644       1.4406            *            *            *            *
280123............................       0.9968       0.8966            *      15.4047      22.2049      17.7468
280125............................       1.5933       0.8848      21.7657      22.1345      23.2889      22.4198
280127............................       1.7915       0.9836            *      29.3684      25.6815      27.2620
280128............................       2.9058       0.9836            *      28.5422      28.8725      28.7209
280129............................       1.9022       0.9419            *            *      27.8784      27.8784
280130............................       1.3728       0.9419            *            *      30.5784      30.5784

[[Page 24887]]

 
290001............................       1.8544       1.1062      31.1981      36.3129      35.5076      34.2980
290002............................       0.9059       0.9688      18.3469      17.3876      24.0115      19.4175
290003............................       1.8294       1.1431      28.1625      30.3373      32.8160      30.4044
290005............................       1.4257       1.1431      27.6697      28.3366      31.4494      28.9962
290006............................       1.1856       1.0851      27.9501      31.7301      31.9783      30.5921
290007............................       1.6373       1.1431      37.5559      38.1938      39.6409      38.4737
290008............................       1.2052       0.9688      27.9714      27.3019      30.8413      28.7097
290009............................       1.7177       1.1062      29.8019      36.2724      32.3330      32.7004
290010............................          ***            *      23.9655            *            *      23.9655
290012............................       1.3586       1.1431      31.0843      32.3966      35.7987      33.1284
290016............................          ***            *      26.1925            *            *      26.1925
290019............................       1.4100       1.0851      28.6158      29.3650      30.5954      29.5666
290020............................       0.9879       0.9688      21.6993      23.2103      27.7976      23.8850
290021............................       1.7397       1.1431      33.2116      32.7894      36.5004      34.2290
290022............................       1.6627       1.1431      29.4422      29.9717      33.3048      30.8956
290027............................       0.8977       0.9688      15.1448      23.9959      23.9599      21.2093
290032............................       1.4275       1.1062      31.7105      31.6711      34.3860      32.5896
290039............................       1.5604       1.1431      31.2941      32.1423      34.9629      32.8645
290041............................       1.3801       1.1431      33.9877      34.2436      37.4249      35.3803
290042............................          ***            *            *            *      22.4809      22.4809
290044............................          ***            *            *      37.1662            *      37.1662
290045............................       1.5925       1.1431      30.9612      33.1512      34.4159      32.9841
290046............................       1.3247       1.1431            *            *      38.6235      38.6235
290047............................       1.4996       1.1431            *            *      33.4701      33.4701
290049............................       1.3670       0.9688            *            *      26.1159      26.1159
290051............................       1.6067       0.9688            *            *            *            *
290052............................       0.8797       0.9688            *            *            *            *
300001............................       1.5438       1.1266      27.5032      29.2260      29.8127      28.8790
300003............................       2.1029       1.1266      33.3560      34.7900      37.0864      35.1213
300005............................       1.4046       1.1266      25.6699      27.8000      27.8412      27.1335
300006............................          ***            *      23.3200            *            *      23.3200
300010............................          ***            *      27.5028            *            *      27.5028
300011............................       1.2842       1.1266      28.4044      30.9403      31.8926      30.4452
300012............................       1.3771       1.1266      30.5198      30.4972      31.2638      30.7723
300014............................       1.1567       1.1266      27.5151      29.7667      29.1829      28.8585
300017............................       1.3103       1.1266      29.6957      29.9560      31.6688      30.4410
300018............................       1.4114       1.1266      29.7209      29.4270      31.7886      30.3782
300019............................       1.2727       1.1266      25.9656      27.5672      28.2267      27.2944
300020............................       1.1629       1.1266      28.6723      30.8491      31.0585      30.2190
300023............................       1.3399       1.1266      28.6309      31.0040      31.2712      30.3856
300029............................       1.7610       1.1266      29.0806      29.8117      31.4416      30.1530
300034............................       1.9071       1.1266      29.7484      30.7676      31.6879      30.7462
310001............................       1.7811       1.3215      35.3612      41.7460      39.3376      38.8070
310002............................       1.8123       1.2993      37.3461      37.9183      37.9222      37.7187
310003............................       1.1430       1.3215      32.8935      36.2346      39.0744      36.1389
310005............................       1.3201       1.1681      29.0084      32.1319      33.6294      31.6189
310006............................       1.2212       1.3215      27.4545      28.4771      28.7318      28.2233
310008............................       1.3025       1.3215      31.2579      32.6788      33.3151      32.4229
310009............................       1.3174       1.2993      32.7384      33.6940      33.6147      33.3544
310010............................       1.2786       1.0879      28.5852      33.9552      33.6979      32.1224
310011............................       1.2517       1.0749      30.8612      31.2907      33.3167      31.8219
310012............................       1.6584       1.3215      34.6882      38.3590      39.8553      37.6612
310013............................       1.3584       1.2993      30.6248      31.0447      35.6324      32.2990
310014............................       1.9437       1.0778      29.7204      30.0793      32.9002      30.9524
310015............................       1.9917       1.2993      36.4776      36.8818      39.2914      37.5855
310016............................       1.3455       1.3215      33.9862      35.6155      38.2693      36.0382
310017............................       1.3323       1.2993      30.9233      32.2434      35.7519      32.9534
310018............................       1.1951       1.2993      30.3381      30.3234      32.9700      31.1742
310019............................       1.5537       1.3215      29.6592      30.3518      30.6364      30.2332
310020............................       1.5411       1.3215      30.6722      33.5516      38.4379      35.7904
310021............................       1.6686       1.1578      31.3410      32.1929      31.6553      31.7275

[[Page 24888]]

 
310022............................       1.2932       1.0522      28.2024      30.4043      31.1924      29.9525
310024............................       1.2738       1.1681      30.9171      33.3415      33.8601      32.7346
310025............................       1.3587       1.3215      31.1274      34.3687      32.2621      32.6290
310026............................       1.1830       1.3215      27.5171      29.1588      30.1373      28.9603
310027............................       1.3922       1.1681      28.8314      29.7793      31.5949      30.0511
310028............................       1.1686       1.1681      31.3849      32.2977      33.9891      32.5798
310029............................       1.9312       1.0522      30.7707      32.9246      33.6690      32.4532
310031............................       3.0093       1.1131      33.9685      37.0668      38.5892      36.5339
310032............................       1.3412       1.0752      27.5232      30.7865      33.0210      30.4618
310034............................       1.3882       1.1131      29.9162      31.7012      32.7508      31.4426
310037............................       1.3836       1.3215      35.0329      38.5415      38.2849      37.2929
310038............................       1.9989       1.2993      33.4822      35.9190      36.3324      35.3010
310039............................       1.2659       1.2993      28.8292      31.4278      33.2087      31.1027
310040............................       1.3296       1.3215      34.1113      33.8535      37.7941      35.2736
310041............................       1.3039       1.1131      32.8085      32.8390      33.9785      33.1810
310042............................          ***            *      30.7357      34.4986            *      32.5359
310044............................       1.3429       1.0879      31.3205      31.9678      33.7598      32.3234
310045............................       1.6626       1.3215      34.1060      36.7862      38.4412      36.4048
310047............................       1.3101       1.2095      32.7880      34.1520      37.6016      34.9123
310048............................       1.3620       1.1578      30.2025      32.9681      33.9471      32.4207
310049............................          ***            *      27.8565            *            *      27.8565
310050............................       1.2631       1.2993      27.3033      29.1732      32.3677      29.5223
310051............................       1.4207       1.1681      33.7168      35.0121      38.1175      35.6230
310052............................       1.3148       1.1131      30.8036      32.5778      33.5833      32.3042
310054............................       1.3494       1.2993      34.1860      34.4431      36.9103      35.1809
310057............................       1.3560       1.0652      29.5221      31.1268      31.8882      30.8455
310058............................       1.1001       1.3215      28.0815      27.1555      30.4060      28.5493
310060............................       1.2254       1.0024      25.1575      27.3415      27.8235      26.8641
310061............................       1.2038       1.0652      28.2129      31.6648      39.0527      32.6386
310063............................       1.3573       1.1681      31.4884      31.9247      33.8500      32.3995
310064............................       1.5574       1.2095      33.4440      35.7607      38.6296      36.0384
310069............................       1.2293       1.0752      28.1681      31.7642      34.4614      31.6133
310070............................       1.4396       1.2993      33.2310      34.3225      36.3246      34.6566
310073............................       1.9339       1.1131      32.0328      32.6733      34.2852      33.0130
310074............................       1.4038       1.3215      29.4834      40.3494      39.6126      36.4273
310075............................       1.3460       1.1131      31.6869      31.5226      32.5325      31.9056
310076............................       1.6950       1.2993      36.4280      38.0643      37.5145      37.3322
310077............................          ***            *      32.6644      34.6085            *      33.6290
310078............................          ***            *      29.8014      30.5761            *      30.1919
310081............................       1.2439       1.0778      26.6136      30.1561      31.0670      29.3003
310083............................       1.2968       1.2993      28.2392      30.3580      31.9125      30.1899
310084............................       1.2502       1.1131      32.9001      33.5941      32.6073      33.0241
310086............................       1.2173       1.0522      29.3058      29.5566      29.8937      29.5898
310088............................       1.1945       1.2095      26.4966      29.9929      30.3513      28.9184
310090............................       1.2500       1.1681      30.8941      32.8191      33.4603      32.3294
310091............................       1.1866       1.0752      27.7204      29.3969      31.9736      29.6731
310092............................       1.4214       1.0879      29.4998      29.7958      32.7029      30.6404
310093............................       1.2379       1.2993      28.0401      29.1288      30.2858      29.1452
310096............................       2.0679       1.2993      34.4275      34.1524      35.0725      34.5578
310105............................       1.2685       1.3215      31.9769      30.1069      32.5642      31.5185
310108............................       1.3924       1.2993      30.1002      33.0172      34.2946      32.4532
310110............................       1.3064       1.0879      31.2164      33.2246      33.4787      32.6988
310111............................       1.2383       1.1131      30.7475      31.8393      34.8278      32.5301
310112............................       1.3378       1.1131      30.4192      31.2372      32.2812      31.3132
310113............................       1.2461       1.1131      29.6079      31.0436      33.6769      31.5139
310115............................       1.3278       1.0024      29.6020      29.5320      32.8144      30.7156
310116............................       1.2564       1.3215      25.6976      29.2748      29.8219      28.1707
310118............................       1.2957       1.3215      28.8797      31.1803      31.2285      30.4796
310119............................       1.9246       1.2993      37.7876      43.1238      41.5679      40.9083
310120............................       1.1067       1.1681      31.4111      29.2535      33.3847      31.2917
310122............................          ***            *            *            *      41.9008      41.9008

[[Page 24889]]

 
310123............................          ***            *            *            *      37.1088      37.1088
310124............................          ***            *            *            *      41.8807      41.8807
310125............................          ***            *            *            *      36.2250      36.2250
310126............................       1.5770       1.1681            *            *            *            *
310127............................       2.1663       1.0652            *            *            *            *
320001............................       1.6846       0.9740      26.9434      29.6182      30.0055      28.9118
320002............................       1.4659       1.0689      30.5158      32.0477      33.1322      31.9531
320003............................       1.1337       1.0376      28.1402      27.6222      31.4451      29.2080
320004............................       1.3346       0.8965      24.9481      24.7803      26.2118      25.3020
320005............................       1.3975       0.9740      23.8264      24.7543      28.7944      25.7110
320006............................       1.3191       0.9740      24.2812      26.9080      28.0944      26.5127
320009............................       1.5658       0.9740      22.8293      32.0116      27.1448      26.7952
320011............................       1.1525       0.9302      24.2279      25.6693      27.9505      25.9804
320013............................       1.1100       1.0376      28.9276      22.8283      30.3766      26.8594
320014............................       1.0803       0.8965      24.5310      27.2806      28.7043      26.9250
320016............................       1.1846       0.8965      23.5040      25.0835      27.1469      25.3042
320017............................       1.1945       0.9740      25.0286      31.6357      33.3482      30.1538
320018............................       1.4713       0.8990      23.2360      26.5109      25.9235      25.0329
320019............................       1.5781       0.9740      31.5192      27.8067      35.0213      30.9859
320021............................       1.6048       0.9740      27.2357      26.9918      28.8474      27.7575
320022............................       1.1613       0.8965      23.7160      23.9595      25.3696      24.3630
320030............................       1.0965       0.8965      22.1971      21.0378      24.4482      22.6073
320033............................       1.1954       1.0376      27.6393      31.7114      30.1473      29.8085
320037............................       1.2522       0.9740      23.3999      24.9657      25.2866      24.5732
320038............................       1.2773       0.8965      20.1533      21.7022      32.7170      25.2881
320046............................          ***            *      24.3534            *            *      24.3534
320057............................       0.8707       1.4406            *            *            *            *
320058............................       0.7716       1.4406            *            *            *            *
320059............................       0.8741       1.4406            *            *            *            *
320060............................       0.9480       1.4406            *            *            *            *
320061............................       0.8805       1.4406            *            *            *            *
320062............................       0.8907       1.4406            *            *            *            *
320063............................       1.3149       0.9527      24.4696      25.0031      26.0095      25.1843
320065............................       1.3098       0.9527      26.6603      27.3163      25.7921      26.5970
320067............................       0.8747       0.8965      23.7745      24.9865      24.6963      24.5130
320069............................       1.1001       0.8965      20.9167      22.4128      23.9847      22.4801
320070............................       0.9497       1.4406            *            *            *            *
320074............................       1.1777       0.9740      22.2175      31.1333      28.4393      27.5521
320079............................       1.0738       0.9740      25.2105      26.1188      27.6850      26.3851
320083............................       2.5853       0.9740      28.2114      26.6921      31.4628      28.8401
320084............................       0.9586       0.8965      17.2511      17.5788      22.7674      19.1162
320085............................       1.7001       0.8990      24.8752      27.9944      27.4093      26.8652
330001............................          ***            *      33.4718            *            *      33.4718
330002............................       1.4716       1.3215      31.1924      30.9600      32.1948      31.4363
330003............................       1.3901       0.8672      22.9945      24.4326      25.2199      24.2253
330004............................       1.2791       1.0644      26.0445      28.0594      29.9032      27.9539
330005............................       1.5858       0.9586      29.0124      30.3200      31.5013      30.2919
330006............................       1.2547       1.3215      31.5370      33.6284      34.1959      33.1177
330008............................       1.1969       0.9586      21.8198      23.4429      25.1985      23.4724
330009............................       1.2178       1.3215      35.4986      36.2820      34.8184      35.5246
330010............................       0.9609       0.8482      19.6920      20.7476      19.2838      19.8627
330011............................       1.3855       0.9072      21.8008      25.1308      27.4732      24.7762
330013............................       1.8823       0.8672      24.5162      26.4578      26.8359      25.9711
330014............................       1.3016       1.3215      38.8123      42.1759      45.7594      42.1079
330016............................          ***            *      28.4391      22.0493      23.0754      24.0041
330019............................       1.2360       1.3215      34.8266      38.5368      39.7366      37.6971
330023............................       1.5534       1.2380      31.6208      35.9428      35.4371      34.4826
330024............................       1.8516       1.3215      37.8398      42.7691      43.2449      41.1310
330025............................       1.0757       0.9586      20.2776      21.2565      23.2412      21.5971
330027............................       1.3299       1.2993      39.0717      42.8000      45.1871      42.3247
330028............................       1.4253       1.3215      34.2709      36.6498      36.2872      35.6905

[[Page 24890]]

 
330029............................       0.4640       0.9586      19.1589      23.2039      24.0652      21.4784
330030............................       1.2459       0.8899      22.9937      24.6175      24.7514      24.0792
330033............................       1.1944       0.8645      22.5680      24.5510      24.8008      23.9488
330036............................       1.1736       1.3215      28.9409      29.1884      30.3728      29.5020
330037............................       1.1939       0.8899      20.6904      22.3689      21.9242      21.6478
330041............................       1.3232       1.3215      36.0286      37.4883      36.9921      36.8224
330043............................       1.3836       1.2791      34.7480      39.1643      37.6666      37.1976
330044............................       1.3066       0.8440      24.1907      26.5669      28.2003      26.3311
330045............................       1.3331       1.2791      36.1893      38.1269      40.0305      38.1670
330046............................       1.3803       1.3215      44.8494      50.3152      47.4949      47.5038
330047............................       1.1860       0.8482      24.0678      24.3932      24.9779      24.4959
330049............................       1.5206       1.2380      29.2904      29.8350      34.8972      31.4643
330053............................       1.0498       0.8899      18.5289      20.6272      21.8755      20.3411
330055............................       1.5727       1.3215      38.4839      41.5934      42.1979      40.8295
330056............................       1.4393       1.3215      37.8444      36.0136      38.8876      37.5779
330057............................       1.7325       0.8672      24.4680      26.4989      27.7098      26.2555
330058............................       1.2589       0.8899      21.3727      22.2524      21.7018      21.7824
330059............................       1.5266       1.3215      39.7387      41.7343      44.9131      42.1510
330061............................       1.1887       1.3215      33.2848      36.0587      37.8810      35.7856
330062............................       2.5188            *      21.0464            *            *      21.0464
330064............................       1.1807       1.3215      36.4276      38.0437      38.2307      37.5268
330065............................       1.0348       0.9586      23.9128      25.3043      24.3986      24.5180
330066............................       1.2793       0.8672      24.7941      29.1780      25.8149      26.6311
330067............................       1.4313       1.2380      26.4243      27.8900      29.2544      27.8289
330072............................       1.3663       1.3215      36.4336      37.8505      39.6955      37.9159
330073............................       1.0847       0.8899      20.1490      22.5592      23.0765      21.9326
330074............................       1.2115       0.8899      21.4274      22.6629      23.5142      22.5510
330075............................       1.1310       0.9912      22.4188      23.1592      23.4332      23.0114
330078............................       1.4633       0.9586      23.3981      25.8073      27.2852      25.5265
330079............................       1.3908       0.9431      22.5237      24.6054      24.9934      24.0663
330080............................       1.1615       1.3215      39.1724      39.1417      38.9393      39.0845
330084............................       1.0885       0.8440      21.5455      22.5573      25.6859      23.2864
330085............................       1.1343       0.9577      23.9568      25.3285      26.6208      25.3039
330086............................       1.3317       1.3215      29.1784      32.7675      35.4708      32.6068
330088............................       1.0150       1.2791      31.3973      34.0789      35.3841      33.6057
330090............................       1.4726       0.8440      23.6174      25.5351      26.8715      25.3561
330091............................       1.3639       0.9586      23.8063      25.9378      27.0011      25.6211
330094............................       1.2532       0.9231      23.0001      25.7116      26.9119      25.1924
330095............................          ***            *      31.9873            *            *      31.9873
330096............................       1.2270       0.8440      22.0337      22.7189      23.4149      22.7206
330097............................       1.0476            *      20.3189            *            *      20.3189
330100............................       1.0853       1.3215      34.4621      38.3333      39.6209      37.5339
330101............................       1.9268       1.3215      38.7503      40.1929      43.7932      40.9960
330102............................       1.3805       0.9586      24.8184      25.3879      26.6873      25.6615
330103............................       1.1459       0.8440      21.1452      22.8242      24.5566      22.8013
330104............................       1.3468       1.3215      32.8818      33.7537      34.3166      33.6767
330106............................       1.7224       1.2993      41.4561      43.8210      45.9263      43.7752
330107............................       1.2622       1.2791      31.3888      34.9047      35.7373      34.0849
330108............................       1.1634       0.8440      22.2607      23.2919      23.9344      23.1799
330111............................       1.0675       0.9586      20.9387      20.3473      40.4318      24.2734
330115............................       1.1809       0.9912      23.3043      25.2373      23.0235      23.8663
330119............................       1.7982       1.3215      39.1114      39.0528      42.2871      40.1393
330125............................       1.7876       0.8899      26.7119      27.2920      28.0831      27.3803
330126............................       1.3169       1.2993      31.6370      35.2257      36.5676      35.2858
330127............................       1.3510       1.3215      44.6103      45.3680      45.2974      45.0865
330128............................       1.2215       1.3215      37.7166      39.5197      41.7780      39.6521
330132............................       1.1465       0.8561      17.4946      21.0479      21.7624      20.0513
330133............................       1.3487       1.3215      36.6962      39.3837      38.5211      38.1371
330135............................       1.1424       1.0853      29.0837      27.9132      32.0511      29.6957
330136............................       1.5153       0.9577      24.2010      25.8531      26.6667      25.5991
330140............................       1.8341       0.9912      25.7573      27.6183      29.3429      27.5920

[[Page 24891]]

 
330141............................       1.3225       1.2791      34.8902      39.4701      38.2473      37.6083
330144............................       1.0373       0.8440      20.9935      22.9561      23.3863      22.4512
330151............................       1.1211       0.8440      19.1841      21.7665      19.7949      20.1954
330152............................       1.2983       1.3215      36.5136      37.6721      38.2040      37.4693
330153............................       1.7286       0.8672      24.5219      26.4386      28.4427      26.4924
330154............................       1.7054            *            *            *            *            *
330157............................       1.3498       0.9577      25.2312      26.5686      27.1422      26.3135
330158............................       1.5257       1.3215      32.2990      38.2033      41.6972      37.3734
330159............................       1.3649       0.9912      28.9094      28.2774      31.7829      29.5878
330160............................       1.5299       1.3215      34.1960      36.6208      39.4136      36.7564
330162............................       1.2873       1.3215      32.1783      34.9460      37.6198      34.8798
330163............................       1.1299       0.9586      24.0200      27.1933      28.3889      26.5653
330164............................       1.4611       0.8899      28.8481      27.7217      27.4988      28.0125
330166............................       1.0839       0.8440      19.4360      20.4680      20.7114      20.1915
330167............................       1.7102       1.2993      34.4748      36.7653      39.1206      36.7231
330169............................       1.3871       1.3215      39.3361      45.3774      46.4890      43.5617
330171............................          ***            *      30.0122      30.4005      35.1552      31.6496
330175............................       1.1110       0.8681      22.2067      23.8509      23.3990      23.1608
330177............................       0.9871       0.8440      19.6100      20.6338      22.9802      21.0952
330180............................       1.2281       0.8672      22.1920      24.3761      25.4142      23.9988
330181............................       1.2689       1.2993      38.5351      41.4104      42.2619      40.7706
330182............................       2.3122       1.2993      39.6038      40.9014      40.8712      40.4724
330184............................       1.4040       1.3215      34.4044      35.8102      39.0405      36.4609
330185............................       1.2787       1.2791      32.3466      36.3155      37.9564      35.6879
330188............................       1.2378       0.9586      23.9210      25.1153      27.5982      25.5241
330189............................       1.3891       0.8672      21.6229      22.3484      22.4386      22.1392
330191............................       1.2684       0.8672      24.0232      25.5656      26.4297      25.3758
330193............................       1.3149       1.3215      37.1807      39.9327      38.9508      38.7084
330194............................       1.7330       1.3215      43.9910      45.5639      46.8833      45.5303
330195............................       1.7148       1.3215      40.0206      39.7802      41.7863      40.5425
330196............................       1.2484       1.3215      33.2171      36.7178      38.2483      36.0767
330197............................       1.0598       0.8440      23.4290      26.8921      25.9860      25.4379
330198............................       1.3670       1.2993      30.5485      33.4930      34.8948      33.0511
330199............................       1.1951       1.3215      35.0059      38.6407      40.3929      37.9482
330201............................       1.5880       1.3215      39.3682      37.2064      42.6689      39.7174
330202............................       1.2474       1.3215      38.0129      37.4150      37.4138      37.6069
330203............................       1.4679       0.9912      26.5882      32.1207      34.0475      30.8848
330204............................       1.3409       1.3215      37.6849      39.6393      41.9936      39.7972
330205............................       1.1766       1.0853      32.1618      31.9510      33.9404      32.7289
330208............................       1.1551       1.3215      29.6282      32.1256      33.5256      31.7765
330209............................          ***            *      29.7988      30.2038            *      30.0002
330211............................       1.1593       0.8440      22.9966      24.4470      25.8735      24.4782
330212............................          ***            *      27.2232            *            *      27.2232
330213............................       1.1110       0.8440      22.5191      24.4049      27.4887      24.8464
330214............................       1.9082       1.3215      37.8500      41.8719      41.2768      40.2400
330215............................       1.3064       0.8774      22.6744      23.7361      23.9564      23.4614
330218............................       1.0749       0.9912      24.1106      26.9638      26.9959      26.0466
330219............................       1.7271       0.9586      29.3644      29.8889      32.5646      30.5813
330221............................       1.3239       1.3215      36.5539      39.2080      40.0488      38.6287
330222............................       1.2884       0.8672      23.9746      25.8507      27.7182      25.9131
330223............................       1.0004       0.8440      19.4229      23.3669      26.1256      22.8479
330224............................       1.3202       1.0644      25.7850      27.9231      29.0864      27.6364
330225............................       1.2316       1.2993      29.2719      32.3585      35.7735      32.4753
330226............................       1.3388       0.8899      21.8977      24.5646      24.8456      23.8231
330229............................       1.1912       0.8440      20.6095      21.9356      23.0562      21.8540
330230............................       1.0097       1.3215      33.3175      37.1298      38.6523      36.3361
330231............................       1.0931       1.3215      36.9619      40.6697      44.9376      40.8957
330232............................       1.1619       0.8672      24.4531      26.3313      27.4623      26.1064
330233............................       1.4121       1.3215      45.5132      47.3497      52.7025      48.3771
330234............................       2.3848       1.3215      40.6314      48.2306      49.3194      45.8234
330235............................       1.1939       0.9577      23.3866      27.7031      29.4294      26.7553

[[Page 24892]]

 
330236............................       1.5608       1.3215      35.6347      40.2386      42.8923      39.6820
330238............................       1.2614       0.8899      20.8639      21.7435      21.7652      21.4610
330239............................       1.2560       0.8440      21.5397      22.3854      23.6653      22.5395
330240............................       1.2133       1.3215      39.9450      43.5753      40.4972      41.3029
330241............................       1.8038       0.9912      29.0882      30.2304      32.6139      30.7098
330242............................       1.3307       1.3215      33.6926      37.4870      36.8969      35.9769
330245............................       1.8750       0.8440      22.8003      26.1811      27.4329      25.5153
330246............................       1.3359       1.2791      34.6329      37.1611      35.7391      35.8256
330247............................       0.8986       1.3215      32.2300      35.4980      39.0193      35.4567
330249............................       1.3518       0.9912      22.9834      25.3246      23.8548      24.0420
330250............................       1.3308       0.9589      25.1664      27.1606      29.0058      27.1464
330259............................       1.4194       1.2993      31.9152      35.1514      36.5831      34.5776
330261............................       1.2665       1.3215      30.7942      33.7834      40.2554      34.7041
330263............................       1.0289       0.8440      22.4675      23.8738      24.1312      23.5399
330264............................       1.2912       1.0853      30.0139      30.4701      30.1809      30.2033
330265............................       1.1849       0.8899      20.4635      21.6477      23.9070      21.9772
330267............................       1.3602       1.3215      31.5478      32.8541      34.9869      33.1372
330268............................       0.9192       0.8440      20.9720      25.3567      23.8791      23.3606
330270............................       2.0325       1.3215      42.2111      57.3596      55.2076      51.3946
330273............................       1.3982       1.3215      30.4720      37.0157      34.5032      34.0363
330276............................       1.0979       0.8440      22.2353      24.3300      26.0917      24.2198
330277............................       1.1791       0.9715      25.3582      26.4535      30.9561      27.3784
330279............................       1.5215       0.9586      25.2130      27.4539      29.4540      27.4527
330285............................       1.9980       0.8899      27.9018      30.1928      31.1219      29.7572
330286............................       1.3653       1.2791      33.3552      35.5895      36.8535      35.2974
330290............................       1.7316       1.3215      36.9981      39.4690      40.3862      38.9177
330304............................       1.3060       1.3215      34.5761      36.2845      37.3516      36.1507
330306............................       1.4126       1.3215      35.6640      36.3552      38.7631      36.9884
330307............................       1.3336       0.9715      27.5699      29.2529      29.5522      28.8425
330314............................          ***            *      25.5597      26.2719      28.1362      26.6009
330316............................       1.2421       1.3215      34.8623      34.8567      37.1744      35.6156
330331............................       1.2559       1.2993      36.1630      39.8402      41.2652      39.1610
330332............................       1.2705       1.2993      33.3050      35.1646      37.0082      35.2111
330333............................          ***            *      26.1917            *            *      26.1917
330338............................          ***            *      31.3761      37.7497            *      34.6182
330339............................       0.7038       0.8672      22.6569      23.5786      24.3064      23.5064
330340............................       1.2556       1.2791      33.9358      37.9000      36.0162      35.9189
330350............................       1.4768       1.3215      36.6250      41.1339      43.9324      40.6020
330353............................       1.2410       1.3215      37.6549      45.9692      45.0917      43.0066
330354............................       2.1053            *            *            *            *            *
330357............................       1.2623       1.3215      35.5975      38.2286      40.3814      37.9050
330372............................       1.2696       1.2993      32.6721      36.1840      35.1250      34.7426
330385............................       1.1071       1.3215      46.3221      48.6175      49.0841      47.9726
330386............................       1.2194       1.1578      27.9943      29.9366      33.3181      30.4738
330389............................       1.7372       1.3215      34.7669      37.1862      38.6409      36.8607
330390............................       1.2371       1.3215      36.0573      36.3842      35.5521      35.9765
330393............................       1.7369       1.2791      34.8095      38.0619      39.2461      37.4154
330394............................       1.6366       0.9072      25.2229      27.3388      28.4575      27.0150
330395............................       1.4366       1.3215      37.3096      36.3921      37.5757      37.0853
330396............................       1.5239       1.3215      35.0297      37.4998      39.4882      37.3251
330397............................       1.4326       1.3215      38.4741      37.5682      41.4413      39.1429
330399............................       1.0763       1.3215      32.3688      34.7394      37.1175      34.7258
330401............................       1.3610       1.2791      40.6249      37.8559      40.4446      39.6483
330403............................       0.9812       0.8899      23.1886      25.5163      25.2928      24.6329
330404............................       0.8616       1.3215            *            *            *            *
330405............................       0.8688       1.3215            *            *            *            *
330406............................       0.8701       0.8672            *            *            *            *
340001............................       1.5147       0.9512      25.0041      28.3988      29.5669      27.7156
340002............................       1.8220       0.9209      27.3349      28.4860      29.6875      28.5183
340003............................       1.1852       0.8608      23.3066      24.1602      26.0869      24.5118
340004............................       1.4192       0.9083      25.4474      26.6404      27.5270      26.5361

[[Page 24893]]

 
340005............................       0.9877            *      22.3814            *            *      22.3814
340008............................       1.1889       0.9348      26.6314      26.7443      27.7190      27.0539
340010............................       1.3717       0.9373      24.5666      27.2105      28.7525      26.8565
340011............................       1.1370       0.8608      19.9484      19.7441      22.0042      20.5589
340012............................       1.2498       0.8608      22.7189      23.2288      24.7564      23.5968
340013............................       1.2487       0.9348      23.0261      23.9492      26.3599      24.4158
340014............................       1.5497       0.9083      25.1872      27.4888      27.8361      26.8911
340015............................       1.3640       0.9348      26.2276      28.0585      28.3916      27.5637
340016............................       1.2883       0.8608      23.0359      25.6454      27.3478      25.3411
340017............................       1.3186       0.9209      23.8229      25.7780      27.4678      25.6896
340018............................          ***            *      23.7243            *            *      23.7243
340020............................       1.2004       0.8751      23.7995      26.4465      27.5449      25.9051
340021............................       1.3001       0.9348      26.0995      29.4864      29.3819      28.3674
340023............................       1.3623       0.9386      24.4896      26.4225      26.3102      25.7592
340024............................       1.1037       0.8779      22.2522      23.6638      26.3988      24.1337
340025............................       1.3303       0.9209      21.2276      23.5881      24.0074      22.9989
340027............................       1.1601       0.9272      23.6326      25.5973      26.3812      25.2702
340028............................       1.5219       0.9926      26.3298      28.0323      30.7692      28.3795
340030............................       2.0869       0.9814      29.0122      29.6630      30.7705      29.8384
340032............................       1.4485       0.9512      26.7475      26.5958      28.7619      27.4144
340035............................       1.0891       0.8608      23.5476      23.9669      24.6257      24.0393
340036............................       1.3731       0.9373      25.2077      27.2691      27.3834      26.6507
340037............................       1.1089       0.8770      21.6411      25.6262      29.0640      25.6376
340038............................       1.2278       0.8861      14.0713      22.4829      24.2103      19.1095
340039............................       1.2800       0.9348      27.1275      27.4457      27.8213      27.4756
340040............................       1.9806       0.9272      26.3325      27.6626      28.7422      27.6117
340041............................       1.1961       0.8977      23.6600      24.3595      26.8306      25.0114
340042............................       1.2712       0.8608      23.0236      25.0110      25.6323      24.5577
340045............................          ***            *      23.1918            *            *      23.1918
340047............................       1.8383       0.9083      25.0605      27.4022      28.4974      27.0298
340049............................       1.8540       0.9814      30.4827      30.6791      29.6812      30.2355
340050............................       1.1120       0.9600      24.2533      26.0365      27.5249      25.9399
340051............................       1.2212       0.8819      23.4091      23.9612      24.4546      23.9484
340053............................       1.4963       0.9512      27.7261      27.8577      28.9350      28.1745
340055............................       1.2461       0.8977      24.1057      26.0647      26.5750      25.5722
340060............................       1.1427       0.9111      22.8657      22.9097      25.1769      23.6611
340061............................       1.8071       0.9814      27.5594      27.0089      29.8565      28.1789
340064............................       1.0727       0.8608      22.9143      23.4233      23.9696      23.4392
340068............................       1.2508       0.9172      21.8830      22.6814      23.6737      22.7405
340069............................       1.8779       0.9603      27.4473      29.3439      29.2259      28.6869
340070............................       1.2886       0.9111      24.9033      25.3226      26.6539      25.6456
340071............................       1.0909       0.9373      25.4537      26.3921      27.9724      26.6149
340072............................       1.2076       0.8608      23.1163      25.2493      24.1322      24.1635
340073............................       1.6001       0.9603      30.2061      30.9849      32.2694      31.1640
340075............................       1.2345       0.8977      26.0226      25.1551      25.1432      25.4400
340084............................       1.1990       0.9512      21.2580      21.1363      23.1513      21.8365
340085............................       1.1471       0.8858      23.9793      26.5164      27.9544      26.0796
340087............................       1.2862       0.8608      22.0070      22.4287      25.4716      23.2830
340090............................       1.3672       0.9373      23.4541      26.4031      26.7407      25.6220
340091............................       1.5781       0.9083      25.8266      27.1285      28.8018      27.2994
340096............................       1.2035       0.8858      25.2169      24.9036      26.5426      25.5725
340097............................       1.2771       0.8608      24.2127      26.2228      29.7729      26.6118
340098............................       1.4524       0.9512      27.3308      28.2493      29.6697      28.4313
340099............................       1.3064       0.8608      20.3683      21.8564      23.9712      22.0909
340104............................       0.9032       0.8770      15.7521      16.1204      17.6322      16.5484
340106............................       1.1107       0.8608      22.4894      26.0892      26.1296      24.8414
340107............................       1.2094       0.9017      22.9698      24.1762      26.6468      24.6193
340109............................       1.2629       0.8785      23.4419      25.4464      26.6306      25.1776
340113............................       1.9347       0.9512      28.2568      28.5587      30.3822      29.0843
340114............................       1.5707       0.9603      26.6813      28.3222      28.1306      27.7302
340115............................       1.6239       0.9603      25.0212      26.7592      27.2771      26.3716

[[Page 24894]]

 
340116............................       1.7637       0.8977      25.3213      27.5881      29.3675      27.4184
340119............................       1.3184       0.9512      24.2287      25.6226      29.4442      26.4327
340120............................       1.0120       0.8608      23.0915      25.9134      25.5502      24.8610
340121............................       1.1179       0.9338      21.7576      23.1343      23.8832      22.9461
340123............................       1.3434       0.9111      26.1083      26.0637      28.5642      26.9157
340124............................       1.0382       0.9373      20.8018      22.2988      23.5464      22.2123
340126............................       1.2877       0.9373      25.0189      26.9866      28.2229      26.7660
340127............................       1.1542       0.9603      25.7831      26.4746      28.2146      26.8344
340129............................       1.2616       0.9348      25.4902      25.7976      26.7596      26.0411
340130............................       1.3513       0.9512      25.2941      26.1717      28.1587      26.5937
340131............................       1.5011       0.9272      27.9358      27.4750      28.8528      28.1009
340132............................       1.1993       0.8608      21.3521      23.5856      24.3442      23.1134
340133............................       1.0170       0.8850      22.5558      23.4678      24.8551      23.5976
340137............................          ***            *      21.0642      22.1741      28.9661      23.0832
340138............................       0.8420       0.9603      21.3670            *            *      21.3670
340141............................       1.6591       0.9338      27.3355      29.3878      29.3158      28.6960
340142............................       1.1639       0.8608      22.9907      26.6886      27.7501      25.8989
340143............................       1.5072       0.8977      25.3633      28.0082      27.9782      27.1350
340144............................       1.2446       0.9348      27.2686      26.1865      27.0139      26.8084
340145............................       1.1838       0.9348      23.7131      25.8459      26.7457      25.4570
340147............................       1.3000       0.9373      25.4534      26.9162      28.2605      26.9066
340148............................       1.4008       0.9083      23.5880      25.3660      25.8316      24.9275
340151............................       1.1664       0.8661      22.0052      22.7736      23.2142      22.6702
340153............................       1.8779       0.9512      26.4896      27.6509      28.5972      27.6009
340155............................       1.4283       0.9814      30.4940      30.3443      31.6013      30.8281
340156............................       0.8549       1.4406            *            *            *            *
340158............................       1.1124       0.9338      26.4849      27.7816      27.9252      27.3725
340159............................       1.2301       0.9814      23.2991      24.2588      24.8366      24.1490
340160............................       1.3374       0.8608      20.7525      21.7923      23.4619      22.0119
340166............................       1.2904       0.9512      26.0558      27.1132      28.5388      27.2672
340168............................       0.3793       0.9338      17.3249            *            *      17.3249
340171............................       1.1735       0.9512      28.2734      27.8539      27.4705      27.8496
340173............................       1.2951       0.9603      27.5072      28.3502      30.2808      28.7935
340177............................       1.0970            *      24.7471      26.7155            *      25.7127
340178............................          ***            *      28.7218            *            *      28.7218
340179............................          ***            *            *      34.1895            *      34.1895
340182............................          ***            *            *      27.8071            *      27.8071
340183............................       1.0771       0.9512            *            *            *            *
350002............................       1.8102       0.7329      22.0283      22.4307      23.7161      22.7683
350003............................       1.1838       0.7329      21.8061      23.9639      24.9963      23.6034
350006............................       1.5606       0.7329      19.4985      21.2726      22.4602      21.0489
350009............................       1.1335       0.8189      23.0873      23.8681      24.5724      23.8525
350010............................       0.9681       0.7313      19.1964      20.1290      20.4189      19.9339
350011............................       1.9833       0.8189      23.1947      23.8400      24.1118      23.7255
350014............................       0.9073       0.7313      17.7565      19.1684      17.5803      18.1595
350015............................       1.6832       0.7329      20.1161      20.9046      21.3324      20.8688
350017............................       1.2724       0.7313      21.0243      22.4359      21.6164      21.6690
350019............................       1.6835       0.7729      22.1960      23.2018      23.9585      23.1800
350030............................       0.9605       0.7313      18.9978      20.2722      22.5960      20.6212
350061............................       1.4521            *      22.0515            *            *      22.0515
350063............................       0.8930       1.4406            *            *            *            *
350070............................       1.8146       0.8189      25.2836      25.2365      26.2446      25.5900
360001............................       1.4375       0.9654      23.9101      25.8669      28.8621      26.1633
360002............................       1.2626       0.8843      24.5789      24.5155      25.4859      24.8654
360003............................       1.7692       0.9654      27.5029      28.9672      30.7793      29.0933
360006............................       1.9028       1.0048      28.1698      30.1363      30.9800      29.7938
360008............................       1.3248       0.8706      24.5714      26.2632      27.5658      26.1301
360009............................       1.6042       0.9312      23.1012      25.0007      27.0599      25.0987
360010............................       1.2239       0.8810      23.1178      23.7825      24.7338      23.9116
360011............................       1.2624       0.9840      25.5340      27.6036      31.5555      28.1828
360012............................       1.3983       1.0048      27.5470      30.1416      31.0504      29.6648

[[Page 24895]]

 
360013............................       1.0938       0.9312      26.8130      27.0893      29.8398      27.9263
360014............................       1.1288       0.9840      25.3861      27.1017      27.0725      26.5476
360016............................       1.4363       0.9654      26.1283      27.8031      29.6279      27.8538
360017............................       1.7059       1.0048      27.2910      29.8525      31.7064      29.6400
360019............................       1.2999       0.9238      25.5926      26.9178      27.2984      26.6159
360020............................       1.6208       0.9238      24.4343      23.6400      25.6319      24.5731
360024............................          ***            *      23.5793            *            *      23.5793
360025............................       1.4533       0.9276      25.5633      27.4533      27.1537      26.7665
360026............................       1.3236       0.9283      23.5898      25.5379      25.2930      24.8033
360027............................       1.6124       0.9238      25.4894      27.4454      28.2908      27.0616
360029............................       1.0866       0.9276      22.7785      24.3216      26.4202      24.5304
360032............................       1.2094       0.8701      23.2638      25.0034      25.9909      24.7561
360035............................       1.7332       1.0048      27.5220      30.0172      31.3158      29.6736
360036............................       1.2090       0.9238      27.6094      27.8343      29.3509      28.2916
360037............................       1.4254       0.9365      24.3982      29.0046      30.0437      27.6733
360038............................       1.5417       0.9654      22.8009      25.4274      31.0557      26.2991
360039............................       1.4955       0.9840      24.0218      23.9783      24.7864      24.2787
360040............................       1.1428       0.9093      24.0942      24.8569      25.5333      24.8327
360041............................       1.4963       0.9365      24.1080      26.1522      26.6728      25.6861
360044............................       1.1371       0.8824      21.8411      21.5619      24.3827      22.5765
360046............................       1.2025       0.9654      25.0775      25.4673      26.2408      25.5991
360047............................       1.0860            *      21.7248            *            *      21.7248
360048............................       1.7551       0.9276      28.8107      29.3415      29.4798      29.2208
360049............................          ***            *      25.8367      26.2222            *      26.0185
360051............................       1.6982       0.9283      25.7556      26.8501      28.1154      26.9160
360052............................       1.6085       0.9283      24.5405      26.2066      26.8786      25.8857
360054............................       1.3922       0.8706      23.0376      22.9359      24.8241      23.5843
360055............................       1.4135       0.8996      26.3112      27.3941      30.0124      27.8965
360056............................       1.6196       0.9654      23.1024      26.5318      30.3674      26.6370
360058............................       1.0570       0.8701      23.4429      23.8119      24.5004      23.9275
360059............................       1.5019       0.9365      25.3516      29.3624      30.6157      28.4896
360062............................       1.4828       1.0048      28.6518      31.7422      33.1325      31.3394
360064............................       1.5894       0.8996      22.2393      25.2336      27.7775      24.9757
360065............................       1.2185       0.9276      26.3036      28.0405      29.7142      28.0320
360066............................       1.5174       0.9312      27.3362      27.1436      29.7605      28.0751
360068............................       1.8821       0.9276      25.8414      26.2065      26.6926      26.2580
360069............................       1.2464            *      24.2444            *            *      24.2444
360070............................       1.6601       0.8921      24.8863      27.2389      27.8858      26.6566
360071............................       1.1154       0.8736      22.0786      23.4619      26.4057      23.9592
360072............................       1.5235       1.0048      24.4332      25.9589      27.2266      25.9252
360074............................       1.3006       0.9276      24.9055      25.8959      27.5322      26.1110
360075............................       1.1470       0.9365      26.8453      26.8925      26.1643      26.5899
360076............................       1.4896       0.9654      25.9369      28.1013      29.0117      27.7066
360077............................       1.5217       0.9365      25.6505      28.4449      28.2382      27.4520
360078............................       1.2784       0.9238      26.1313      25.7885      27.4681      26.4451
360079............................       1.7865       0.9654      26.0935      27.2437      30.1207      27.8332
360080............................       1.1298       0.8701      20.8309      21.4526      22.7007      21.7293
360081............................       1.3482       0.9276      27.5695      29.8366      29.5312      28.9628
360082............................       1.3502       0.9365      27.1197      29.2561      28.7914      28.4294
360084............................       1.6070       0.8854      25.8415      27.3917      28.5391      27.2562
360085............................       2.0277       1.0048      29.0081      31.5800      33.1242      31.3481
360086............................       1.6599       0.9283      22.1859      25.4218      27.1112      24.8912
360087............................       1.3509       0.9365      25.4040      29.6579      28.4514      27.8631
360089............................       1.1462       0.8701      22.7951      25.3465      25.5599      24.5871
360090............................       1.5838       0.9276      26.7717      29.0199      30.7505      28.8607
360091............................       1.3280       0.9365      27.5067      25.8657      27.6802      27.0162
360092............................       1.2657       1.0048      25.6618      25.4954      25.4045      25.5161
360094............................          ***            *      26.6348            *            *      26.6348
360095............................       1.4017       0.9276      26.1275      26.4635      29.3772      27.2940
360096............................       1.0892       0.8775      24.6317      25.9275      26.8627      25.8201
360098............................       1.3635       0.9365      24.8447      25.5973      26.6025      25.7083

[[Page 24896]]

 
360100............................       1.2005       0.8921      23.0561      25.4523      23.6159      24.0347
360101............................       1.3623       0.9365      26.6209      27.6030      29.7806      28.0278
360106............................          ***            *      24.1588            *            *      24.1588
360107............................       1.1250       0.9276      25.9697      24.6095      26.0530      25.5447
360109............................       1.0690       0.8701      25.4184      26.3131      30.1363      27.2357
360112............................       1.9961       0.9276      28.6784      30.5715      31.1515      30.1229
360113............................       1.3136       0.9654      25.6493      26.6556      30.2863      27.4972
360115............................       1.2841       0.9365      24.0052      25.9841      26.1795      25.4590
360116............................       1.1939       0.9654      18.0655      25.1717      26.4955      23.3907
360118............................       1.5237       0.9214      27.7289      27.3884      28.5629      27.8928
360121............................       1.3620       0.9276      24.5593      27.4442      28.3823      26.7820
360123............................       1.4133       0.9365      22.6523      27.1920      28.0320      25.8332
360125............................       1.1982       0.8701      22.1096      24.1388      25.9042      23.9896
360128............................          ***            *      21.0067            *            *      21.0067
360130............................       1.4718       0.9365      22.9762      25.6570      26.3962      25.2266
360131............................       1.3051       0.8921      24.0496      25.3719      26.6628      25.3527
360132............................       1.3639       0.9654      25.9453      27.7724      29.4046      27.6748
360133............................       1.6035       0.9283      24.6208      29.8684      31.7499      28.7264
360134............................       1.7956       0.9654      29.2974      27.7339      28.5138      28.4864
360137............................       1.7463       0.9365      26.9522      26.1250      27.6882      26.9252
360141............................       1.6594       0.8996      27.7085      29.7937      31.1769      29.5398
360142............................       1.0704            *      22.1610            *            *      22.1610
360143............................       1.2891       0.9365      24.6306      28.3057      27.3743      26.8209
360144............................       1.3643       0.9365      25.7079      28.2473      28.9166      27.6777
360145............................       1.6714       0.9365      25.8268      27.1908      28.1802      27.1029
360147............................       1.2484       0.8701      24.1953      25.5854      27.5529      25.7869
360148............................       1.0883       0.8701      26.1947      26.0837      26.3390      26.2100
360150............................       1.2297       0.9238      24.7667      25.1217      31.2684      26.9639
360151............................       1.6221       0.8921      24.8629      25.3780      26.5001      25.5913
360152............................       1.5017       1.0048      27.9147      29.9425      31.5364      29.7871
360153............................       0.9767       0.8701      19.0226      19.8499      20.2124      19.7383
360155............................       1.4479       0.9365      25.3909      26.9127      28.9551      27.1136
360156............................       1.1512       0.8796      24.0509      24.3281      25.0839      24.5014
360159............................       1.2592       0.9840      33.1613      29.1529      28.6161      30.0443
360161............................       1.3686       0.8996      24.3792      25.4433      27.0861      25.6054
360163............................       1.9114       0.9654      26.9728      28.9742      30.0503      28.6581
360170............................       1.3066       1.0048      24.3620      28.5474      30.2417      27.8461
360172............................       1.3796       0.9365      26.3501      27.5669      28.8276      27.5898
360174............................       1.2817       0.9283      24.9990      26.8586      28.3284      26.7426
360175............................       1.2427       0.9840      26.5949      28.1531      28.3038      27.6954
360177............................       1.1565            *      24.4712            *            *      24.4712
360179............................       1.5926       0.9654      28.8645      30.0311      29.8291      29.5971
360180............................       2.2538       0.9365      26.1514      29.6633      31.4318      29.1118
360185............................       1.1979       0.8775      23.7173      25.6800      26.1053      25.1940
360187............................       1.5392       0.9283      24.8173      24.9353      25.7593      25.1880
360189............................       1.1090       1.0048      24.2136      26.3756      27.5194      26.0228
360192............................       1.2914       0.9365      26.7577      26.4616      27.5979      26.9455
360195............................       1.0872       0.9365      26.1281      25.0922      27.6148      26.2465
360197............................       1.1400       0.9840      27.0896      28.7580      28.9190      28.2666
360203............................       1.2433       0.8701      22.1414      24.4433      25.3724      24.0021
360210............................       1.1676       1.0048      27.8415      28.2976      29.1231      28.4261
360211............................       1.5603       0.8701      22.5449      25.7053      26.5443      24.7611
360212............................       1.3255       0.9365      25.2756      25.6080      27.2263      26.0408
360218............................       1.1995       1.0048      27.4288      29.8662      30.0072      29.0783
360230............................       1.5565       0.9365      27.0223      28.8018      30.0644      28.6832
360234............................       1.3350       0.9654      24.3625      25.9360      31.0655      27.0902
360236............................       1.2597       0.9654      35.8143      25.6728      29.5312      29.3312
360239............................       1.3159       0.9283      25.2474      27.2939      30.7698      27.7358
360241............................          ***            *      24.7001      23.0662      25.7293      24.4913
360242............................       1.8997            *            *            *            *            *
360245............................       0.5512       0.9238      19.1884      20.6504      20.3411      20.0849

[[Page 24897]]

 
360247............................       0.3793       1.0048      19.8891      19.3677            *      19.6148
360253............................       2.4484       0.9654      30.4276      33.2371      34.3298      32.7134
360259............................       1.3020       0.9276      25.1338      25.9878      27.2896      26.1978
360260............................          ***            *      27.3903            *            *      27.3903
360261............................       1.3730       0.8845      22.5431      22.3614      25.6328      23.5171
360262............................       1.3188       0.9276      27.1680      28.6995      30.1562      28.7641
360263............................       1.8192       0.9312      20.8884      25.1652      25.4813      23.9900
360264............................          ***            *            *      36.0754            *      36.0754
360265............................          ***            *            *      36.6265            *      36.6265
360266............................       2.1280       1.0048            *            *      31.7532      31.7532
360267............................          ***            *            *            *      34.0914      34.0914
360268............................          ***            *            *            *      34.0503      34.0503
360269............................       1.7180       0.9654            *            *      24.8569      24.8569
360270............................       1.1022       0.8701            *            *            *            *
360271............................       1.4810       0.9654            *            *            *            *
360273............................       1.6114       0.8701            *            *            *            *
370001............................       1.6364       0.8504      27.7245      26.0194      26.9066      26.8618
370002............................       1.2199       0.7702      20.1479      22.0476      23.6850      21.9862
370004............................       1.1269       0.9040      25.3919      26.7434      26.8511      26.3097
370006............................       1.2605       0.8504      20.1063      22.4802      23.9928      22.1048
370007............................       1.0754       0.7702      17.6547      19.4036      20.3673      19.1460
370008............................       1.4647       0.8764      24.2978      25.3352      26.6546      25.4718
370011............................       0.9837       0.8764      19.7821      21.9649      22.3379      21.3301
370013............................       1.5640       0.8764      24.9294      26.5364      27.2662      26.2290
370014............................       1.0060       0.8535      25.3576      25.9393      26.4459      25.9300
370015............................       1.0124       0.8504      23.6694      24.7547      25.5786      24.6931
370016............................       1.6367       0.8764      25.4062      26.7938      29.8253      27.2541
370018............................       1.5049       0.8504      23.5336      25.3573      24.6848      24.5166
370019............................       1.2516       0.7702      21.4474      22.0221      25.2799      22.9578
370020............................       1.3456       0.7702      18.5046      20.8723      22.7512      20.7432
370022............................       1.2128       0.8071      19.6495      24.6099      22.2254      22.0686
370023............................       1.3507       0.7792      21.5762      23.5170      23.9997      23.0468
370025............................       1.2923       0.8504      23.5659      23.9873      24.5531      24.0379
370026............................       1.4292       0.8764      23.0848      25.8428      25.3460      24.7668
370028............................       1.8835       0.8764      26.6153      27.8621      28.5594      27.6903
370029............................       1.1365       0.7702      23.9956      26.8508      28.5284      26.4589
370030............................       1.0204       0.7702      23.3037      24.1483      25.8183      24.4349
370032............................       1.4524       0.8764      23.4843      24.8626      26.3171      24.8715
370034............................       1.2252       0.7702      18.2341      19.5099      20.4074      19.4048
370036............................       1.1122       0.7702      17.7575      19.2318      19.8132      18.9467
370037............................       1.6252       0.8764      23.9685      24.9553      25.5152      24.8480
370039............................       1.0449       0.8504      21.8220      23.0254      23.5733      22.8098
370040............................       0.9665       0.8056      22.4048      22.8356      26.7367      23.9154
370041............................       0.8802       0.8504      22.3496      22.6731      22.9777      22.6684
370047............................       1.3864       0.8764      20.4657      24.1991      24.4738      23.0657
370048............................       1.0417       0.7702      19.2464      21.4543      22.0594      20.9179
370049............................       1.3124       0.8764      23.2171      23.8844      22.8742      23.3160
370051............................       1.0579       0.7702      17.2618      19.8329      19.3164      18.8224
370054............................       1.2325       0.7702      21.5044      22.4652      25.2122      22.9823
370056............................       1.8614       0.8406      22.0312      24.3986      25.5420      23.9740
370057............................       0.9753       0.8504      19.7284      19.8683      22.1308      20.5333
370060............................       0.9969       0.8504      18.7592      19.9025      23.3793      20.5008
370064............................       0.8912            *      14.2053            *            *      14.2053
370065............................       1.0064       0.7799      20.0227      21.2343      23.5785      21.6442
370072............................       0.8029       0.7962       9.9615      11.7942      13.0903      11.6655
370078............................       1.5669       0.8504      25.4068      27.8611      26.6945      26.6513
370080............................       0.8703       0.7702      18.0665      19.9595      22.3662      20.0726
370083............................       0.8972       0.7753      16.8836      19.2568      20.9831      18.9413
370084............................       0.9999       0.7702      16.6513      19.6230      20.7278      19.1519
370089............................       1.3096       0.7702      20.4699      20.6153      22.1503      21.0632
370091............................       1.5724       0.8504      23.3357      24.1438      25.8676      24.4372

[[Page 24898]]

 
370093............................       1.6188       0.8764      26.9774      26.0459      27.4328      26.8140
370094............................       1.4242       0.8764      23.1191      24.5555      26.5223      24.7218
370097............................       1.3209       0.8406      22.3267      26.3168      26.7940      25.2222
370099............................       1.0704       0.7702      20.5075      24.9971      26.7160      23.9172
370100............................       0.9275       0.7803      14.7711      17.9732      19.3931      17.4549
370103............................       1.0056       0.7702      17.8018      18.8933      19.4227      18.7231
370105............................       1.9411       0.8764      23.8978      26.7973      26.6370      25.8992
370106............................       1.4000       0.8764      26.5867      27.8979      28.5947      27.7396
370112............................       0.9491       0.8056      15.4471      16.0592      16.7860      16.1368
370113............................       1.1449       0.8719      25.3565      26.9720      26.4599      26.2279
370114............................       1.5828       0.8504      21.7880      23.0006      25.9816      23.5714
370123............................          ***            *      25.4733            *            *      25.4733
370125............................          ***            *      17.1361            *            *      17.1361
370138............................       1.0409       0.7702      18.3113      20.2528      22.1656      20.1240
370139............................       0.9462       0.7702      18.5226      19.4287      20.5120      19.5050
370148............................       1.5477       0.8764      25.2348      27.0904      28.1920      26.9001
370149............................       1.2424       0.8764      22.3537      23.3493      23.3403      23.0323
370153............................       1.1462       0.7702      19.8349      23.2778      24.1577      22.4430
370156............................       0.9979       0.7824      19.4743      25.2562      23.0030      22.5278
370158............................       0.9453       0.8764      18.5578      20.7641      21.5187      20.2564
370166............................       0.8427       0.8504      23.1682      25.1107      24.7202      24.3416
370169............................       0.8651       0.7866      15.8002      16.8252      16.6722      16.4248
370170............................       0.9077       1.4406            *            *            *            *
370171............................       0.8795       1.4406            *            *            *            *
370172............................       0.8593       1.4666            *            *            *            *
370173............................       0.9221       1.4406            *            *            *            *
370174............................       0.7942       1.4406            *            *            *            *
370176............................       1.2142       0.8504      25.0509      24.7655      24.9681      24.9283
370177............................          ***            *      14.7193            *            *      14.7193
370178............................       0.8842       0.7702      14.6070      16.0179      16.0702      15.5699
370179............................       0.8038            *      23.5794            *            *      23.5794
370180............................       1.0055       1.4406            *            *            *            *
370183............................       0.9349       0.8504      21.8147      24.7103      23.8398      23.4249
370190............................       1.4248       0.8504      33.1137      29.1568      34.8952      32.5860
370192............................       1.9859       0.8764      31.4930      27.6367      19.0636      24.5970
370196............................          ***            *      22.6824      22.3498      20.8286      21.9381
370199............................       0.7713       0.8764      26.0450      23.3989      23.7422      24.3360
370200............................       1.0426       0.7702      17.6317      20.5175      21.7857      19.8245
370201............................       1.6779       0.8764      23.3550      23.8090      24.2461      23.8017
370202............................       1.4321       0.8504      25.1181      26.1132      25.7745      25.6728
370203............................       2.0656       0.8764      23.5190      22.8869      25.7761      24.0066
370206............................       1.5795       0.8764      26.0912      26.0353      27.5742      26.5857
370210............................       2.1553       0.8504      21.2682      23.3786      27.2693      23.9762
370211............................       1.0823       0.8764      26.5345      27.8737      28.6515      27.7373
370212............................       1.7647       0.8764      21.0758      19.1720      20.3497      20.1566
370213............................          ***            *      29.3777            *            *      29.3777
370214............................       0.9301       0.7824            *      20.6217      21.0658      20.8579
370215............................       2.4404       0.8764      32.3589      31.5652      32.4081      32.1113
370216............................       2.0143       0.8504            *      27.2429      25.8238      26.4842
370217............................          ***            *            *      26.8677            *      26.8677
370218............................       2.3290       0.8504            *            *      30.3422      30.3422
370220............................       2.0085       0.8764            *            *            *            *
370222............................       1.8273       0.8764            *            *            *            *
370223............................       0.8874       0.8764            *            *            *            *
370224............................       1.0183       0.8764            *            *            *            *
380001............................       1.3085       1.1233      30.0103      29.5842      32.0772      30.5857
380002............................       1.2471       0.9950      27.1861      30.3385      31.5214      29.7041
380004............................       1.7236       1.1233      30.5172      32.6901      34.5430      32.6119
380005............................       1.4094       1.0304      30.2210      30.9087      33.2838      31.5051
380007............................       2.0573       1.1233      33.9969      33.9601      35.1698      34.3879
380008............................          ***            *      25.8356            *            *      25.8356

[[Page 24899]]

 
380009............................       2.0468       1.1233      31.7042      32.4016      34.5626      32.8910
380010............................          ***            *      30.2957      34.4208            *      32.1520
380014............................       1.9254       1.0708      29.9648      33.6078      33.1920      32.2199
380017............................       1.8307       1.1233      32.2447      34.2605      35.3727      33.9499
380018............................       1.9127       1.0304      28.0701      30.9923      31.8162      30.3574
380020............................       1.4175       1.1008      28.3563      29.6053      34.6178      30.5328
380021............................       1.4799       1.1233      29.3295      29.2164      32.6143      30.3295
380022............................       1.3427       1.0322      29.2642      30.1742      29.6225      29.6961
380023............................       1.1613            *      26.5439            *            *      26.5439
380025............................       1.2130       1.1233      33.2105      35.5084      36.4904      35.1203
380027............................       1.2891       1.0713      25.5161      26.4982      28.0232      26.6747
380029............................       1.2598       1.0404      26.9967      28.7994      29.4458      28.4963
380033............................       1.7477       1.1008      30.8767      33.4828      34.0066      32.8324
380037............................       1.3213       1.1233      30.5818      32.4033      32.7927      31.9695
380038............................       1.3172       1.1233      34.2303      34.5971      35.1114      34.6434
380039............................          ***            *      32.3959      38.0989            *      34.9720
380040............................       1.4149       0.9950      32.0103      31.2286      32.9082      32.0782
380047............................       1.8758       1.0592      29.8627      31.0584      32.8186      31.2890
380050............................       1.4603       1.0151      25.6190      27.1814      29.7312      27.5470
380051............................       1.6397       1.0404      29.7219      30.8891      32.8537      31.1839
380052............................       1.2960       0.9950      24.9476      25.6085      28.6112      26.2863
380056............................       1.1337       1.0404      25.1475      27.7253      29.1649      27.4834
380060............................       1.4638       1.1233      30.7041      32.0101      33.8855      32.2257
380061............................       1.6749       1.1233      29.8217      32.3699      34.5222      32.2741
380071............................       1.3167       1.1233      30.2304      31.7761      31.0905      31.0383
380075............................       1.3427       1.0304      29.0368      33.8962      31.6899      31.4887
380081............................       0.6765       0.9950      21.8850      26.8149      28.9626      25.5794
380082............................       1.2728       1.1233      32.3002      35.6708      35.7815      34.6173
380089............................       1.3127       1.1233      33.4214      34.6015      35.4845      34.5150
380090............................       1.3031       1.0713      34.4536      33.0990      35.5491      34.3699
380091............................       1.3581       1.1233      33.8950      39.9703      40.5058      38.1381
380100............................       1.6492       1.1233            *            *            *            *
390001............................       1.5910       0.8366      22.5309      23.6075      24.3387      23.5011
390002............................       1.2796       0.8388      22.4388      24.7867      25.0846      24.1306
390003............................       1.1972       0.8366      21.6477      23.3672      24.6385      23.2157
390004............................       1.5727       0.9240      24.3249      24.4068      25.3218      24.7131
390006............................       1.9184       0.9130      25.1216      26.8581      28.7849      27.0024
390008............................       1.1369       0.8421      22.2680      22.8042      22.6293      22.5687
390009............................       1.8139       0.8507      25.5482      26.7462      26.7227      26.3592
390010............................       1.1864       0.8388      23.5390      24.5785      24.8175      24.2866
390011............................          ***            *      21.9279      21.4856      20.2276      21.2239
390012............................       1.2254       1.0906      28.5076      30.7542      32.3118      30.5163
390013............................       1.3340       0.9130      24.0044      25.0037      26.2309      25.0972
390016............................       1.2391       0.8701      21.9549      23.2095      24.3473      23.2182
390019............................       1.1019       1.0024      23.4636      24.0538      25.7506      24.3568
390022............................          ***            *      29.0710      30.3565      29.6304      29.6954
390023............................       1.2530       1.0906      31.7149      35.4452      34.7747      34.0474
390024............................       1.0208       1.0906      35.3960      33.5186      39.7191      35.9814
390025............................       0.4785       1.0906      17.2977      19.1362      20.3840      18.9796
390026............................       1.2151       1.0906      29.5157      31.8512      31.8294      31.0655
390027............................       1.7286       1.0906      35.8381      35.5692      39.2148      36.9324
390028............................       1.6335       0.8388      25.7246      27.1869      27.1447      26.6793
390030............................       1.1566       1.0024      22.1581      23.6063      24.6318      23.4864
390031............................       1.2252       0.9419      22.6828      26.2654      27.2007      25.3401
390032............................       1.2843       0.8388      22.7205      23.9466      24.5233      23.7226
390035............................       1.1523       1.0906      26.2647      28.4564      29.5405      28.1286
390036............................       1.4372       0.8388      24.6032      21.6358      24.4924      23.5132
390037............................       1.4045       0.8388      24.7820      25.4290      25.2295      25.1463
390039............................       1.1412       0.8366      20.3787      22.0208      23.2288      21.8618
390041............................       1.2811       0.8388      21.5925      22.9814      24.2252      22.9571
390042............................       1.3531       0.8388      25.6328      28.3633      28.0982      27.3600

[[Page 24900]]

 
390043............................       1.2012       0.8366      22.2549      23.2378      24.2078      23.2254
390044............................       1.6708       1.0778      27.1505      28.7758      29.4037      28.4744
390045............................       1.5821       0.8366      23.0712      23.9343      24.6486      23.8977
390046............................       1.6479       0.9589      27.2630      29.6574      29.9620      28.9961
390048............................       1.0778       0.9130      24.9759      28.5342      28.3118      27.3366
390049............................       1.5920       1.0024      27.1366      29.6121      30.7411      29.2421
390050............................       2.0718       0.8388      26.6931      27.2599      27.3478      27.1027
390052............................       1.1793       0.8410      23.3474      24.9510      25.1446      24.4778
390054............................          ***            *      22.8087      24.4435      27.4795      24.7386
390055............................          ***            *      25.6945            *            *      25.6945
390056............................       1.0633       0.8366      19.5537      23.5077      23.5637      22.1096
390057............................       1.3240       1.0906      27.9583      29.7982      30.8283      29.5698
390058............................       1.3199       0.9240      27.4799      26.9546      27.7268      27.3837
390061............................       1.4182       0.9589      28.4538      29.1318      30.0565      29.1849
390062............................       1.1297       0.8366      21.4051      21.2999      21.0708      21.2582
390063............................       1.8004       0.8507      24.7614      26.4998      26.8353      26.0645
390065............................       1.2577       1.0108      25.2188      27.6249      29.5649      27.4343
390066............................       1.4268       0.9130      24.2087      25.9645      25.4393      25.2120
390067............................       1.8076       0.9240      26.3287      29.7234      30.6094      28.8535
390068............................       1.3351       0.9589      25.8291      26.7358      29.0944      27.1392
390070............................       1.4180       1.0906      30.9500      33.3185      34.4930      32.9334
390071............................       1.0299       0.8366      21.8367      24.6462      24.8460      23.7235
390072............................       1.0763       0.8366      24.9389      25.3029      26.2548      25.5020
390073............................       1.7429       0.8366      26.3698      25.7822      26.4077      26.2014
390074............................          ***            *      22.8545      23.6500      25.4092      23.9492
390075............................          ***            *      24.6359            *            *      24.6359
390076............................       1.4123       1.0906      27.9004      31.8500      32.7649      30.8669
390079............................       1.8385       0.8779      23.3053      22.5607      24.4435      23.4342
390080............................       1.3296       1.0906      27.2616      28.7063      29.2639      28.4487
390081............................       1.2598       1.0752      30.3840      31.7569      33.6236      31.9438
390084............................       1.0968       0.8366      19.8606      23.2039      24.3329      22.4562
390086............................       1.6536       0.8366      22.5317      23.5141      25.0983      23.7475
390090............................       1.9853       0.8388      25.2014      27.3528      27.0118      26.5228
390091............................       1.1455       0.8775      21.5586      21.7010      23.3559      22.1984
390093............................       1.1582       0.8388      21.4401      22.6082      22.6016      22.2273
390095............................       1.1970       0.8366      23.6240      22.6150      24.6271      23.6286
390096............................       1.5973       1.0778      27.0763      28.8258      28.6039      28.1713
390097............................       1.2470       1.0906      25.6660      26.1741      27.9853      26.5901
390100............................       1.7090       0.9589      27.7208      30.0132      30.0428      29.3272
390101............................       1.2975       0.9307      21.9418      23.1497      24.8352      23.3524
390102............................       1.4439       0.8388      24.8898      24.8369      24.4585      24.7139
390103............................       0.8439       0.8388      20.6775      20.5741      20.4440      20.5654
390104............................       1.0870       0.8366      19.6428      19.2326      19.6622      19.5081
390107............................       1.5261       0.8388      24.1386      24.1159      24.6567      24.3173
390108............................       1.2329       1.0906      27.2661      27.8171      28.5901      27.9019
390109............................       1.1589            *      19.9156            *            *      19.9156
390110............................       1.6020       0.8388      23.9808      27.7311      25.3386      25.6176
390111............................       2.1643       1.0906      32.6510      34.2990      34.8737      33.9658
390112............................       1.2290       0.8366      19.2126      20.2380      21.5428      20.3235
390113............................       1.2888       0.8775      22.2591      23.3686      24.2583      23.3082
390114............................       1.5631       0.8388      24.0473      26.9620      27.9174      26.3014
390115............................       1.4526       1.0906      27.7333      29.6905      30.8033      29.4301
390116............................       1.2416       1.0906      30.2722      32.2513      33.2549      31.9771
390117............................       1.1678       0.8366      20.3946      20.7821      21.5035      20.9015
390118............................       1.1725       0.8366      21.5001      20.5614      21.8906      21.3374
390119............................       1.3029       0.8366      22.2746      23.0928      24.3227      23.2316
390121............................          ***            *      23.1408      25.4826            *      24.2748
390122............................       1.0760       0.8415      22.5786      23.1866      23.3220      23.0325
390123............................       1.1933       1.0906      28.6269      32.4528      34.0037      31.6497
390125............................       1.2622       0.8366      20.9456      22.4033      22.8792      22.0898
390127............................       1.3278       1.0906      30.9374      31.9091      33.6955      32.1928

[[Page 24901]]

 
390128............................       1.2537       0.8388      23.1539      24.1628      24.1382      23.8227
390130............................       1.2868       0.8366      24.0685      23.0592      23.2426      23.4688
390131............................       1.3320       0.8388      22.6306      23.0577      23.5768      23.1072
390132............................       1.4492       1.0906      27.7250      29.6396      31.1131      29.5021
390133............................       1.7198       1.0778      28.7162      31.1083      32.9942      31.0177
390135............................          ***            *      24.4738            *            *      24.4738
390136............................          ***            *      22.1415      23.9813            *      23.0891
390137............................       1.4877       0.8366      23.4877      24.2878      26.1444      24.6484
390138............................       1.1925       0.9130      24.2769      25.3410      27.4226      25.7127
390139............................       1.3707       1.0906      30.4246      34.1447      34.0800      32.9175
390142............................       1.5236       1.0906      32.5786      33.8224      34.5755      33.7216
390145............................       1.5372       0.8388      23.8041      24.6672      25.6972      24.7296
390146............................       1.2178       0.8385      25.2460      22.6752      25.1795      24.3869
390147............................       1.3587       0.8388      25.0971      26.8522      28.6585      26.8141
390150............................       1.1283       0.8388      24.1855      22.8228      22.7669      23.2856
390151............................       1.3568       1.0990      27.1539      29.9254      31.4053      29.5922
390153............................       1.3449       1.0906      30.0585      32.8234      33.2401      32.1631
390154............................       1.2257       0.8366      20.6982      22.8391      23.3554      22.2878
390156............................       1.3797       1.0752      31.2571      32.2688      32.8981      32.1217
390157............................       1.2706       0.8388      22.7493      21.5923      22.1101      22.1488
390160............................       1.2523       0.8388      21.4877      24.0208      22.9688      22.8164
390162............................       1.4945       1.1578      30.0900      35.5057      34.5792      33.2581
390163............................       1.2309       0.8388      22.1741      23.2055      22.8331      22.7280
390164............................       2.1785       0.8388      26.4971      26.3087      27.1941      26.6933
390166............................       1.1701       0.8388      24.9810      20.9272      23.3249      23.1376
390168............................       1.5196       0.8388      24.5820      26.1365      26.9801      25.9244
390169............................       1.4291       0.8366      27.2242      26.5514      26.2631      26.6871
390173............................       1.1808       0.8366      22.8220      23.9927      25.6446      24.1667
390174............................       1.7023       1.0906      32.6265      34.2069      35.2897      34.0693
390176............................       1.0556       0.8388            *      23.9779      24.1240      24.0542
390178............................       1.3607       0.8996      20.7270      22.6006      23.1440      22.1434
390179............................       1.4433       1.0906      27.2222      28.0688      30.1208      28.5190
390180............................       1.4073       1.0752      32.4375      34.9832      35.5103      34.3001
390181............................       1.1003       0.8366      24.4573      25.9871      26.6009      25.6297
390183............................       1.1425       0.8366      25.6554      27.0122      27.8354      26.8138
390184............................       1.1043       0.8388      22.5519      22.7451      23.9729      23.0650
390185............................       1.2679       0.8366      23.0202      25.4256      27.1111      25.2264
390189............................       1.1536       0.8366      22.3722      22.6796      23.6210      22.9386
390191............................       1.1480            *      20.8761            *            *      20.8761
390192............................       0.9891       0.8366      21.2619      20.5459      23.6172      21.8230
390193............................          ***            *      20.1024            *            *      20.1024
390194............................       1.1200       1.0024      25.4235      27.5890      26.3138      26.4431
390195............................       1.6265       1.0906      31.0019      34.2980      34.5552      33.3460
390196............................       1.6615            *            *            *            *            *
390197............................       1.3824       1.0024      25.7739      26.8270      27.2431      26.6095
390198............................       1.0937       0.8507      18.7222      20.5979      20.4340      19.9083
390199............................       1.1706       0.8366      21.3157      22.3224      23.0031      22.2033
390200............................          ***            *      23.7471            *            *      23.7471
390201............................       1.3000       0.8366      26.3658      27.0054      27.3536      26.9243
390203............................       1.6186       1.0906      28.9054      29.4930      29.1367      29.1780
390204............................       1.2999       1.0906      28.6829      29.5251      30.3378      29.5558
390211............................       1.2565       0.8996      23.1450      25.1689      26.5027      24.9525
390215............................          ***            *      28.0403            *            *      28.0403
390217............................       1.2441       0.8388      24.3610      23.5879      24.1877      24.0510
390219............................       1.3184       0.8388      25.1705      25.4886      26.1182      25.5759
390220............................       1.1219       1.0906      41.6138      28.9128      30.7413      32.7167
390222............................       1.2934       1.0752      28.7488      30.9464      31.7312      30.5055
390223............................       2.0315       1.0906      27.6407      30.2523      34.3250      30.7316
390224............................          ***            *      18.7624            *            *      18.7624
390225............................       1.2235       0.9589      24.9391      27.5803      27.2537      26.6140
390226............................       1.7791       1.0906      28.5890      32.6658      32.6482      31.2951

[[Page 24902]]

 
390228............................       1.3964       0.8388      23.3078      23.9845      24.2239      23.8473
390231............................       1.4024       1.0906      29.2653      30.9339      32.8332      30.9979
390233............................       1.3811       0.9307      24.8690      25.6904      27.2575      25.9600
390236............................       0.9656       0.8366      21.9169      22.1144      23.1290      22.3772
390237............................       1.6150       0.8366      26.9533      27.4944      28.4317      27.5813
390246............................       1.1274       0.8366      20.1581      25.1956      26.0175      23.4881
390256............................       1.9049       0.9240      26.3619      28.0617      28.8967      27.8208
390258............................       1.5061       1.0906      29.4626      30.4142      31.7149      30.6070
390263............................       1.5329       1.0024      26.0170      28.5864      29.9800      28.2983
390265............................       1.5078       0.8388      23.4836      24.0675      24.5237      24.0290
390266............................       1.1594       0.8996      20.3918      20.8789      22.2224      21.1790
390267............................       1.2788       0.8388      23.1051      24.2428      24.8302      24.0574
390268............................       1.3895       0.8625      25.0021      25.6643      26.7336      25.8427
390270............................       1.6237       0.8366      24.1496      24.9510      26.5010      25.2638
390272............................       0.5351       1.0906            *            *            *            *
390278............................       0.5328       1.0906      23.6843      26.6664      28.6253      26.2989
390279............................          ***            *      17.0012            *            *      17.0012
390285............................       1.4982       1.0906      35.0426      36.7163      37.6664      36.3989
390286............................       1.1892       1.0906      28.1761      29.5281      31.3380      29.6274
390287............................          ***            *      37.6569      39.3176      42.2395      39.3145
390288............................          ***            *      29.7287      30.9701            *      30.3388
390289............................          ***            *      28.8826      30.7583            *      29.8023
390290............................       1.8483       1.0906      37.9040      38.3776      41.1403      39.1280
390301............................          ***            *      30.9836            *            *      30.9836
390302............................       2.0384       1.0906            *            *            *            *
390303............................          ***            *            *      27.5580            *      27.5580
390304............................       1.2294       1.0906            *      30.4832      32.1625      31.3744
390305............................          ***            *            *            *      29.3209      29.3209
390306............................          ***            *            *            *      40.3778      40.3778
390307............................       1.9734       0.8996            *            *      24.5413      24.5413
390308............................          ***            *            *            *      36.1732      36.1732
390309............................          ***            *            *            *      37.8919      37.8919
390310............................          ***            *            *            *      44.3970      44.3970
390311............................       2.0736       1.0906            *            *            *            *
390312............................       1.1713       1.0906            *            *            *            *
390313............................       1.1482       0.9419            *            *            *            *
400001............................       1.2869       0.4517      13.1847      13.9386      14.9133      14.0366
400002............................       1.8475       0.4161      16.7582      15.3833      12.9440      14.8789
400003............................       1.3852       0.4161      12.8329      13.9258      15.6771      14.1320
400004............................       1.2261       0.4517      14.3108      12.0923      12.5936      12.8944
400005............................       1.1254       0.4517      10.7207      10.3505      11.1153      10.7266
400006............................       1.1848       0.4517       9.2265       8.1841       8.4089       8.6005
400007............................       1.2016       0.4517       9.2463      11.8203      12.0726      11.0856
400009............................       1.0096       0.2946       9.3116       9.3834       9.5111       9.4052
400010............................       0.9284       0.3298      10.0962       9.8132      10.7991      10.2159
400011............................       1.0610       0.4517       8.5534       9.6641       8.5501       8.9390
400012............................       1.4671       0.4517       8.3802      12.3362      10.1144      10.1137
400013............................       1.2470       0.4517      10.3347      11.1414      11.4213      10.9909
400014............................       1.3721       0.3659      12.2169      10.5286       9.9385      10.8298
400015............................       1.3247       0.4517      15.6349      13.7043      22.1997      17.0460
400016............................       1.3936       0.4517      14.7607      16.6472      16.1412      15.8512
400017............................       0.9861       0.4517      10.2734      10.3123       9.9191      10.1746
400018............................       1.1698       0.4517      11.6165      11.9184      12.3935      11.9802
400019............................       1.4381       0.4517      12.8029      12.8380      14.7123      13.3471
400021............................       1.4346       0.4605      14.1534      14.4549      13.9215      14.1634
400022............................       1.4165       0.4161      15.9246      14.9089      15.2620      15.3447
400024............................       0.8885       0.3659      12.4648      10.8439      12.6216      11.9950
400026............................       1.0798       0.2946       5.8200       9.9262       7.1176       7.2041
400028............................       1.0991       0.4161      10.9808      11.3260      10.6709      10.9928
400032............................       1.1384       0.4517      10.2652      10.3736      10.7136      10.4544
400044............................       1.2888       0.4161      13.7509      14.6420      10.5388      12.6107

[[Page 24903]]

 
400048............................       1.1731       0.4517      10.4266       9.6416       9.6856       9.9021
400061............................       2.0008       0.4517      18.9123      18.1303      18.0103      18.3237
400079............................       1.2350       0.3298      12.7825       9.5296      10.2856      10.6551
400087............................       1.1993       0.4517      10.6849      11.0377      11.4156      11.0321
400098............................       1.3670       0.4517      12.8230      13.8034      13.7875      13.3736
400102............................       1.3166       0.4517      10.2677      10.5879      12.1755      10.9323
400103............................       1.7536       0.3659       9.3859      10.6971      11.7480      10.5154
400104............................       1.1995       0.4517       9.3854      11.4322      12.8402      11.2160
400105............................       1.1555       0.4517      14.0219      15.6626      16.9039      15.5355
400106............................       1.1079       0.4517      11.4507      13.4097      12.9264      12.5584
400109............................       1.4454       0.4517      14.2111      14.4386      14.8196      14.4933
400110............................       1.2255       0.3203      12.3449      11.1812       9.9275      11.1279
400111............................       1.1570       0.3298      14.5029      14.1718      10.0679      12.5939
400112............................       1.2217       0.4517      19.3945      10.1512      13.4904      13.2997
400113............................       1.2935       0.4161       9.6778      10.5305      10.9503      10.3752
400114............................       1.1422       0.4517      11.5478      10.1379      10.8905      10.8232
400115............................       1.0297       0.4517      13.7392      12.0713       9.6200      11.5296
400117............................       1.1097       0.4517      12.7600       9.5929      11.2873      10.9990
400118............................       1.2474       0.4517      12.5743      12.8692      12.2614      12.5587
400120............................       1.3545       0.4517      12.7955      13.4069      14.0810      13.4541
400121............................       1.0490       0.4517       8.2197       9.7427       9.1824       9.0004
400122............................       1.9135       0.4517      11.2324       8.9478       9.5819      10.3492
400123............................       1.2192       0.3659      12.3041      12.8317      12.5605      12.5624
400124............................       2.7654       0.4517      16.1812      17.2139      17.9135      17.1102
400125............................       1.2125       0.4121      11.6386      11.9787      12.7755      12.1173
400126............................       1.2050       0.4605       9.8008      14.1062      16.5721      12.5521
400127............................       1.7568       0.4517            *      17.8303      20.7788      19.5311
400128............................       1.0765       0.4517            *            *      12.3508      12.3508
410001............................       1.3006       1.1256      28.0816      29.0877      30.0107      29.0623
410004............................       1.2498       1.1256      27.4209      29.4953      33.5477      30.0869
410005............................       1.2488       1.1256      30.1606      28.1141      31.7260      29.9813
410006............................       1.3443       1.0654      29.4395      30.1855      32.8447      30.8317
410007............................       1.6516       1.1256      31.8548      33.2896      32.0716      32.4071
410008............................       1.2351       1.0654      29.6092      30.9505      32.5870      31.0405
410009............................       1.2438       1.0654      29.4094      31.7300      32.8406      31.3626
410010............................       1.1857       1.1256      32.8599      32.0704      32.7383      32.5468
410011............................       1.3917       1.1256      30.3787      33.8781      30.2382      31.4189
410012............................       1.6858       1.1256      32.6009      33.6072      37.0294      34.4552
410013............................       1.2112       1.1794      35.4624      35.8075      41.0799      37.4473
420002............................       1.5894       0.9512      28.2848      29.5592      30.5925      29.4848
420004............................       1.9971       0.9144      27.2620      28.1455      28.9237      28.1331
420005............................       1.1309       0.8791      23.1943      25.0420      26.3939      24.9179
420006............................          ***            *      24.0811      26.3293      27.7699      26.0549
420007............................       1.6214       0.9386      25.2650      26.8165      28.8268      26.9868
420009............................       1.3837       0.9386      25.5079      27.0147      29.9490      27.4958
420010............................       1.1456       0.8791      23.4562      25.1452      25.5677      24.7554
420011............................       1.1700       0.9664      21.4029      22.1787      24.5883      22.7258
420015............................       1.3589       0.9664      26.2154      24.1685      26.3714      25.5781
420016............................       0.9742       0.8791      17.1229      21.6266      22.2776      20.2191
420018............................       1.8381       0.8791      24.8024      25.6687      27.5522      26.0434
420019............................       1.0975       0.8933      22.5312      22.5489      25.4922      23.3958
420020............................       1.2772       0.9144      25.8883      28.4344      29.5695      27.8470
420023............................       1.6934       0.9664      26.7263      27.4589      29.9819      28.0277
420026............................       1.8820       0.8791      27.4814      27.8986      27.2418      27.5412
420027............................       1.5860       0.9386      25.1692      26.4472      28.1687      26.6066
420030............................       1.2464       0.9144      26.0079      27.8435      28.4401      27.4508
420033............................       1.1208       0.9664      31.8759      30.4162      31.6349      31.2973
420036............................       1.2394       0.9348      22.8294      23.8742      24.6494      23.7914
420037............................       1.3000       0.9664      29.4156      29.8321      30.8503      30.0400
420038............................       1.2507       0.9664      24.2259      24.6642      26.6292      25.1611
420039............................       1.1499       0.9334      25.1148      28.2220      28.9841      27.4319

[[Page 24904]]

 
420043............................       1.1016       0.8923      23.0555      24.0971      25.7926      24.3478
420048............................       1.2711       0.8791      24.1923      25.9610      26.8917      25.7298
420049............................       1.2515       0.8791      23.9722      26.0953      25.6953      25.2614
420051............................       1.6594       0.8791      24.8026      25.9056      26.6341      25.7969
420053............................       1.1285       0.8791      22.2825      23.2246      24.4642      23.3619
420054............................       1.1334       0.8791      24.8931      25.6779      25.6413      25.3982
420055............................       1.0786       0.8791      21.9764      24.0965      25.1550      23.7646
420056............................       1.3295       0.8791      21.6963      27.7250      25.5489      24.9908
420057............................       1.1850       0.8791      23.4312      24.9313      25.4571      24.6270
420062............................       1.0478       0.9348      25.9526      26.7467      25.9555      26.2258
420064............................       1.1882       0.8791      23.3610      24.3540      24.5219      24.0703
420065............................       1.4437       0.9144      24.5715      25.5483      26.8333      25.6653
420066............................       1.0105       0.8791      23.9049      25.1062      26.7458      25.3096
420067............................       1.3630       0.8987      25.0345      25.8561      26.5058      25.8193
420068............................       1.3719       0.9144      23.4248      25.6857      27.5799      25.6023
420069............................       1.1737       0.8791      20.5546      22.3445      23.7228      22.2320
420070............................       1.2994       0.8875      23.4355      24.7899      27.5115      25.3139
420071............................       1.4292       0.9386      24.9418      25.2862      27.6368      25.9945
420072............................       1.0662       0.8791      18.6742      17.8019      21.6507      19.2795
420073............................       1.3854       0.8791      24.5813      25.5204      26.1111      25.4567
420078............................       1.9217       0.9664      28.9112      29.5135      30.6777      29.7053
420079............................       1.4849       0.9144      25.4935      27.5439      28.6353      27.2411
420080............................       1.4418       0.8987      28.4735      28.6060      31.5679      29.4702
420082............................       1.5165       0.9600      29.8528      31.2671      33.6740      31.5607
420083............................       1.4762       0.9386      27.1322      26.4932      28.9023      27.5471
420085............................       1.5565       0.9172      26.8692      27.8386      29.2277      27.9683
420086............................       1.4540       0.8791      25.8869      28.0485      27.9384      27.3327
420087............................       1.8324       0.9144      24.3609      25.4697      27.3264      25.7075
420089............................       1.3997       0.9144      26.0074      28.1855      29.5860      27.9479
420091............................       1.4226       0.8791      26.9214      26.0592      26.8712      26.6184
420093............................          ***            *      27.4767      28.0765      32.8212      29.1829
420098............................       1.1883       0.8791            *      30.7532      29.4620      30.0328
420099............................          ***            *            *            *      30.2160      30.2160
420101............................       1.1332       0.8791            *            *            *            *
430005............................       1.3007       0.8343      22.3272      22.4111      23.8690      22.8727
430008............................       1.1443       0.8880      23.3790      24.4277      26.0865      24.5248
430012............................       1.3092       0.9395      24.0850      24.0326      25.2032      24.4263
430013............................       1.1862       0.9395      25.1378      25.9828      27.6885      26.2696
430014............................       1.4176       0.8343      26.4964      26.8752      27.9285      27.1026
430015............................       1.2647       0.8343      22.7947      23.6296      26.5781      24.3440
430016............................       1.6466       0.9558      27.8453      28.9376      32.8752      29.8586
430027............................       1.7919       0.9558      26.2139      26.6044      27.5745      26.8174
430031............................          ***            *      16.0346            *            *      16.0346
430047............................       1.0090            *      18.8982            *            *      18.8982
430048............................       1.2827       0.8343      23.0782      24.1969      25.1698      24.1626
430060............................       0.8255       0.8343            *      13.2618      13.5646      13.4165
430064............................       1.0259       0.8343      17.5376      18.3125      16.4884      17.3474
430077............................       1.8114       0.8690      25.1763      25.8572      27.2106      26.0775
430081............................       0.8795       1.4406            *            *            *            *
430082............................       0.8113       1.4406            *            *            *            *
430083............................       0.8773       1.4406            *            *            *            *
430084............................       0.9092       1.4406            *            *            *            *
430085............................       0.8887       1.4406            *            *            *            *
430089............................       1.8601       0.9220      22.5625      22.3335      23.2471      22.7179
430090............................       1.4726       0.9558      25.8460      26.4862      29.0203      27.2004
430091............................       2.1556       0.8690      24.3021      25.1105      24.7273      24.7229
430092............................       1.8602       0.8343      20.9486      21.6478      21.9206      21.5139
430093............................       0.8372       0.8690      29.5244      27.5326      26.0248      27.6517
430094............................       1.6473       0.8398      18.9099      22.9091      23.2862      21.6352
430095............................       2.4550       0.9558      28.1749      31.3409      32.2291      30.5974
430096............................       1.8925       0.8343      21.6997      21.6713      24.6038      22.6697

[[Page 24905]]

 
440001............................       1.1421       0.7916      19.3100      21.2398      21.5725      20.7286
440002............................       1.7517       0.8951      24.6664      25.7434      26.3607      25.6113
440003............................       1.3294       0.9675      25.9209      28.4862      28.3551      27.6394
440006............................       1.5106       0.9675      28.5951      29.7146      31.5513      29.9422
440007............................       1.0215       0.8142      25.8236      19.9754      18.8253      20.7863
440008............................       1.0651       0.8432      23.4301      23.2126      27.3717      24.8406
440009............................       1.2224       0.7916      21.5970      23.9279      23.8117      23.1545
440010............................       0.9454       0.7916      17.1803      19.3669      19.6194      18.7378
440011............................       1.3473       0.8043      22.5068      23.6154      23.6692      23.2732
440012............................       1.5819       0.7916      22.3029      24.0169      23.7854      23.3703
440015............................       1.8656       0.8043      23.7422      25.0430      26.0583      24.9717
440016............................       1.0064       0.8060      22.1645      23.0350      24.5792      23.2189
440017............................       1.8252       0.7916      22.9364      25.0588      24.6678      24.2288
440018............................       1.1288       0.7916      23.3445      23.2107      25.0764      23.9420
440019............................       1.7505       0.8043      25.2553      25.3592      26.0762      25.5315
440020............................       1.0946       0.8760      23.9475      24.0995      24.7759      24.2798
440024............................       1.2187       0.8967      23.2717      23.9745      24.7683      24.0292
440025............................       1.1305       0.8608      20.6798      22.5407      22.4856      21.9261
440026............................       0.6838       0.9675      26.8986      28.0349      26.8138      27.2465
440029............................       1.3902       0.9675      28.0779      30.1204      31.2276      29.8852
440030............................       1.3259       0.7931      22.1217      23.7670      22.1894      22.7002
440031............................       1.1820       0.7941      19.6684      20.8964      22.3877      20.9813
440032............................       1.2192       0.7916      18.5277      19.7150      21.0368      19.7420
440033............................       1.0331       0.7952      20.7917      21.1087      22.7949      21.5084
440034............................       1.6264       0.8043      23.5403      24.6994      25.5041      24.6078
440035............................       1.4158       0.9408      24.3752      25.9613      26.2444      25.5503
440039............................       2.1833       0.9675      28.4678      29.8611      30.1798      29.5492
440040............................       0.9032       0.7916      17.8509      20.8637      20.8737      19.8795
440041............................       0.9123            *      17.9409            *            *      17.9409
440046............................       1.2556       0.9675      26.1341      27.9539      29.7354      27.9631
440047............................       0.9027       0.8254      21.4280      21.7892      22.9125      22.0779
440048............................       1.8381       0.9291      27.7560      29.4789      29.3276      28.8736
440049............................       1.6379       0.9291      25.3043      26.4772      28.8751      26.9261
440050............................       1.3564       0.7916      23.1363      24.4616      24.9749      24.2258
440051............................       0.9547       0.7987      21.9108      23.9253      23.4849      23.1289
440052............................       0.9974       0.7916      21.1133      22.8016      22.6093      22.1794
440053............................       1.2683       0.9675      25.4345      27.1197      27.8161      26.7570
440054............................       1.1306       0.7916      21.4400      23.5137      23.7916      22.9255
440056............................       1.1615       0.8043      22.1067      22.7820      23.2296      22.7142
440057............................       1.0901       0.7944      16.4451      16.6346      17.2159      16.7756
440058............................       1.1778       0.7916      22.9263      24.3522      26.0692      24.4594
440059............................       1.4611       0.7916      26.3551      28.3565      27.9440      27.5537
440060............................       1.1303       0.8432      23.3014      24.1024      25.0943      24.2363
440061............................       1.1231       0.7916      21.8274      23.9678      23.7344      23.1104
440063............................       1.5848       0.7916      22.3256      24.2566      23.9625      23.5403
440064............................       1.0103       0.8967      22.0955      23.7176      26.1228      23.9663
440065............................       1.2648       0.9675      22.3247      24.6169      25.8517      24.2948
440067............................       1.1058       0.7916      23.1089      24.4772      24.6523      24.0976
440068............................       1.1547       0.8967      24.5972      24.8146      26.1066      25.1512
440070............................       0.9790       0.8025      19.4372      20.0938      21.9133      20.5428
440072............................       1.1053       0.8951      27.1442      23.9563      25.6126      25.4529
440073............................       1.4655       0.9408      23.9198      26.3570      27.6130      25.9554
440081............................       1.1997       0.7985      19.7878      20.7125      20.7679      20.4353
440082............................       2.1152       0.9675      27.9724      30.6115      32.5266      30.3207
440083............................       0.9664       0.7916      17.3329      25.6099      23.6295      22.2394
440084............................       1.1855       0.7950      16.3738      18.6043      18.8661      17.9487
440091............................       1.7522       0.8967      25.6797      26.5687      28.1980      26.8419
440102............................       1.1442       0.7916      17.5261      20.7363      21.6734      19.9750
440104............................       1.7686       0.8967      25.3739      26.5741      27.9739      26.6317
440105............................       0.8903       0.7916      22.3438      22.9372      27.5434      24.0199
440109............................       0.9695       0.7986      18.6720      20.8924      21.4586      20.4120

[[Page 24906]]

 
440110............................       1.1525       0.8043      21.3287      20.9179      22.5922      21.8673
440111............................       1.2969       0.9675      28.5705      29.0975      28.8328      28.8339
440114............................          ***            *      24.0146            *            *      24.0146
440115............................       1.0086       0.8254      21.7830      23.1409      23.7906      22.9173
440120............................       1.5948       0.8043      25.5961      25.7161      24.7561      25.3527
440125............................       1.6036       0.8043      22.4196      22.8097      23.6317      22.9327
440130............................       1.1054       0.7916      23.4517      23.9955      25.1259      24.1967
440131............................       1.2045       0.9291      24.9599      25.6666      26.9643      25.8558
440132............................       1.2396       0.7916      21.5085      23.9410      24.0684      23.2162
440133............................       1.7133       0.9675      26.2422      29.2829      30.7751      28.6805
440135............................       0.9959       0.7916      26.6615      28.1925      27.7163      27.5263
440137............................       1.0781       0.8679      20.6663      22.2538      22.9527      21.8983
440141............................       0.9681       0.7916      21.3314      24.2406      24.9849      23.5732
440144............................       1.3047       0.9408      23.3828      23.9241      25.2267      24.2122
440145............................       1.0761            *      20.7875            *            *      20.7875
440147............................          ***            *      31.4012      33.1756      35.3815      33.3203
440148............................       1.1126       0.9408      24.6412      23.9810      22.6179      23.6901
440149............................          ***            *      20.4563            *            *      20.4563
440150............................       1.3903       0.9675      26.8308      28.1012      29.4367      28.1239
440151............................       1.1741       0.9408      23.9808      27.1729      28.2182      26.4231
440152............................       1.9279       0.9291      26.5513      27.1877      27.6451      27.1413
440153............................       1.0815       0.7916      22.2846      23.6473      24.7378      23.4975
440156............................       1.6521       0.8967      26.9689      27.7309      28.5630      27.7803
440159............................       1.5137       0.9291      22.8645      26.9098      25.8246      25.2919
440161............................       1.8708       0.9675      28.6971      28.7074      29.9892      29.1536
440162............................          ***            *      21.1418      27.6837      24.8692      24.4630
440166............................          ***            *      31.0779      35.3064            *      32.7296
440168............................       0.9651       0.9291      22.8768      28.1215      29.4005      26.9610
440173............................       1.4388       0.8043      22.8846      23.1167      24.0604      23.3811
440174............................       0.8951       0.8226      22.0974      25.4829      26.2049      24.7272
440175............................       1.0345       0.9408      22.7299      24.4848      24.7857      23.9708
440176............................       1.2746       0.7916      23.6659      22.9631      24.1236      23.6112
440180............................       1.2911       0.7952      23.3808      24.9841      22.3062      23.4471
440181............................       0.9192       0.8277      22.7151      24.8857      26.0287      24.6007
440182............................       0.9950       0.8060      22.3612      24.3302      25.0070      23.9818
440183............................       1.5965       0.9291      27.1515      29.1982      30.6570      28.9837
440184............................       0.9643       0.7916      22.3475      24.5786      23.3803      23.4120
440185............................       1.1499       0.8967      23.9052      25.3817      26.7453      25.4013
440186............................       0.9668       0.9675      25.7445      27.3733      28.9113      27.3826
440187............................       1.0856       0.7916      21.3252      24.0723      25.8192      23.7538
440189............................       1.3576       0.8590      27.5435      28.2621      28.8947      28.1761
440192............................       1.0840       0.9408      25.7495      27.3917      29.6238      27.6362
440193............................       1.3501       0.9675      24.4299      24.3622      25.2113      24.6709
440194............................       1.3057       0.9675      26.6527      29.4706      30.8500      29.0988
440197............................       1.3661       0.9675      27.1534      29.4275      30.3318      28.9141
440200............................       0.9726       0.9675      17.7491      21.1860      23.8598      20.9517
440203............................          ***            *      19.3864      23.7451      17.9024      20.1678
440217............................       1.3238       0.9291      28.5968      28.8641      29.9206      29.1168
440218............................       2.1944       0.9675      24.6465      23.7257      18.7271      22.2602
440222............................       1.0509       0.9291      29.7292      28.4664      29.0064      29.0426
440224............................       0.8974       0.9675            *            *            *            *
440225............................       0.7984       0.8043            *      24.8328      27.8866      26.2413
440226............................       1.5497       0.8043            *      26.5831      28.3236      27.4254
440227............................       1.3258       0.9675            *            *      30.7783      30.7783
440228............................       1.4433       0.9291            *            *      28.3673      28.3673
450002............................       1.4197       0.9144      25.7171      28.0936      28.8502      27.4825
450005............................       1.0714       0.8587      23.5576      24.4933      24.5392      24.1596
450007............................       1.3062       0.8916      20.7321      23.0026      23.9736      22.5788
450008............................       1.2938       0.8308      22.9669      24.4701      24.5969      24.0254
450010............................       1.6531       0.8488      23.7529      25.5503      26.5222      25.2850
450011............................       1.6897       0.9177      24.8831      26.7418      28.5316      26.6971

[[Page 24907]]

 
450015............................       1.5327       0.9795      27.4012      29.9193      29.4897      28.9233
450018............................       1.5156       1.0048      26.7999      30.2383      30.7798      29.2592
450020............................       0.9414            *      18.3047            *            *      18.3047
450021............................       1.8775       0.9795      29.1350      29.5658      31.2631      29.9537
450023............................       1.4776       0.8204      22.0558      25.4450      25.5456      24.3102
450024............................       1.6726       0.9144      24.4195      26.9113      28.1995      26.5982
450028............................       1.6122       0.9577      26.8250      29.1438      30.7386      28.7980
450029............................       1.6195       0.8484      23.2995      25.0602      26.9317      25.0099
450031............................       1.4016       0.9795      27.9626      29.0824      30.3520      29.1122
450032............................       1.2877       0.8615      27.0748      21.5084      25.5763      24.5156
450033............................       1.6325       0.9577      28.4781      29.2468      29.9792      29.1869
450034............................       1.5788       0.8587      24.1589      26.5313      27.6906      26.1014
450035............................       1.4933       1.0048      26.2838      28.0668      28.8961      27.7041
450037............................       1.6443       0.8875      24.2684      26.6207      28.3379      26.4148
450039............................       1.4633       0.9681      24.7347      26.7503      28.2052      26.5789
450040............................       1.8073       0.8678      24.9590      25.4734      26.8399      25.7395
450042............................       1.7896       0.8598      24.1181      26.6382      26.5414      25.7894
450044............................       1.7520       0.9795      29.4308      31.0381      29.4295      29.9719
450046............................       1.6190       0.8460      23.4907      24.8947      25.5895      24.6756
450047............................       0.8462       0.9577      19.8221      21.8824      23.8397      21.9016
450050............................       0.8661            *      23.3044            *            *      23.3044
450051............................       1.9226       0.9795      28.0411      28.8829      29.9034      28.9706
450052............................       0.9462       0.8204      19.7774      22.6448      22.9956      21.3913
450053............................       0.9303            *      21.9082            *            *      21.9082
450054............................       1.7987       0.8308      24.2782      27.5399      26.5580      26.0520
450055............................       1.0496       0.8204      22.1979      22.9245      23.6359      22.9294
450056............................       1.7616       0.9518      27.0530      28.3092      31.5925      28.7714
450058............................       1.5924       0.8916      25.9653      26.6926      26.9903      26.5543
450059............................       1.3101       0.9518      26.6535      26.8325      27.3949      26.9660
450064............................       1.4743       0.9681      23.8748      26.8355      28.2780      26.2937
450068............................       2.1568       1.0048      27.9633      29.5876      30.5075      29.3731
450072............................       1.2060       1.0048      24.0166      25.8619      27.0747      25.6777
450073............................       0.8869       0.8204      21.7337      26.9446      26.0900      24.8080
450076............................       1.6718            *            *            *            *            *
450078............................       0.9157       0.8204      15.8968      21.4716      20.0665      18.9487
450079............................       1.6354       0.9795      28.1096      30.2420      30.8882      29.6870
450080............................       1.2459       0.8875      22.9836      27.9191      26.2251      25.5990
450082............................       1.1501       0.8204      22.0442      23.9025      24.1995      23.3896
450083............................       1.8302       0.9190      25.8214      27.4955      32.6432      28.5954
450085............................       1.0618       0.8204      22.0840      24.3637      25.6398      24.0602
450087............................       1.4149       0.9681      29.1587      30.0095      31.2651      30.1449
450090............................       1.2358       0.8855      19.4245      21.3837      21.8819      20.8844
450092............................       1.1888       0.8204      23.2071      24.9917      26.0863      24.7978
450094............................          ***            *      25.2434            *            *      25.2434
450096............................          ***            *      24.1618      26.5103      28.1877      26.1057
450097............................       1.4833       1.0048      26.4965      29.0142      29.8695      28.4563
450098............................       0.9764            *      22.6626            *            *      22.6626
450099............................       1.2850       0.9141      26.6796      31.3495      31.8214      29.8896
450101............................       1.6845       0.8598      23.6905      25.4409      26.7429      25.2714
450102............................       1.7567       0.9190      24.5503      25.6318      26.4138      25.5264
450104............................       1.1914       0.8916      23.8469      24.6169      28.8008      25.7423
450107............................       1.5656       0.9144      25.9326      27.6064      27.8167      27.1281
450108............................       1.2022       0.8916      19.4935      21.6557      19.3203      20.1279
450113............................          ***            *      54.6663            *            *      54.6663
450119............................       1.3063       0.9140      25.7008      27.8027      31.0620      28.0085
450121............................          ***            *      25.7051      29.1296      27.7456      27.5362
450123............................       1.2264       0.8587      21.2154      24.9674      26.2404      24.0842
450124............................       1.8765       0.9518      27.4198      28.2571      30.9581      28.8840
450126............................       1.3815       1.0048      28.3032      29.3768      29.6165      29.1427
450128............................       1.2607       0.9140      23.3633      25.1122      26.3380      24.9423
450130............................       1.1616       0.8916      21.5226      24.3295      24.3816      23.4123

[[Page 24908]]

 
450131............................          ***            *      23.7098      25.9494            *      24.6979
450132............................       1.5741       0.9959      28.6954      30.1620      31.9964      30.2610
450133............................       1.5650       1.0016      26.8344      28.4647      31.0158      28.7726
450135............................       1.7036       0.9681      26.0755      27.8983      30.1366      28.0785
450137............................       1.7292       0.9681      30.4254      31.4950      31.9628      31.3189
450143............................       0.9894       0.9518      21.8705      23.4592      23.6800      23.0239
450144............................       1.0806       0.8762      21.3289      26.2881      29.4336      25.2664
450147............................       1.5058       0.8204      23.9771      24.3562      24.7217      24.3816
450148............................       1.2596       0.9681      25.3498      27.0894      29.6769      27.2881
450151............................          ***            *      22.2915      23.9558      26.1922      24.2420
450152............................       1.2210       0.8308      22.7463      23.3428      23.1056      23.0676
450154............................       1.3960       0.8204      21.2021      21.7237      22.9324      21.9516
450155............................       1.1128       0.8204      18.0588      21.7604      24.8023      21.2754
450162............................       1.3172       0.8678      30.9903      33.3285      32.9269      32.4564
450163............................       1.0672       0.8257      23.1400      24.1267      24.7829      24.0364
450165............................       1.1659       0.8916      24.3242      28.6490      29.1799      27.3444
450176............................       1.3543       0.9140      20.9297      23.1284      24.4427      22.7685
450177............................       1.1710       0.8204      21.3322      23.7624      24.4026      23.1595
450178............................       0.9841       0.9527      24.7301      27.8405      27.1083      26.5644
450184............................       1.5603       1.0048      26.7821      28.5399      29.7402      28.3456
450187............................       1.1820       1.0048      25.6787      28.3243      27.7355      27.2563
450188............................       0.9378       0.8204      20.4070      23.0595      23.2229      22.2784
450191............................       1.1685       0.9518      26.0298      26.5863      28.3929      27.0034
450192............................       1.1362       0.8475      22.5880      24.1186      26.5577      24.4507
450193............................       2.0914       1.0048      32.2964      34.4545      36.4769      34.4405
450194............................       1.3698       0.8417      24.8972      22.9605      24.3528      24.0549
450196............................       1.4362       0.9681      24.7557      24.0161      23.4570      24.1008
450200............................       1.5832       0.8204      23.5344      23.5012      25.6410      24.1113
450201............................       0.9691       0.8204      20.9810      23.2510      23.2742      22.5445
450203............................       1.1773       0.9646      24.1675      26.5237      27.8762      26.2137
450209............................       1.9557       0.9141      26.0958      27.5668      30.4681      27.9965
450210............................       0.9541       0.8354      19.9832      21.8722      22.5708      21.5253
450211............................       1.3229       0.8875      23.8230      28.4581      28.3715      26.9028
450213............................       1.9199       0.8916      23.9676      25.9169      26.8539      25.6070
450214............................       1.2475       1.0048      25.9598      27.4357      28.1262      27.1815
450219............................       0.9710       0.8204      21.7934      21.9207      23.9627      22.5466
450221............................       1.1296       0.8204      20.3186      19.3793      21.3691      20.3727
450222............................       1.6669       1.0048      27.4426      30.0314      30.3786      29.2826
450224............................       1.3681       0.9190      24.1956      26.8302      28.4367      26.4253
450229............................       1.6513       0.8244      21.4459      24.4450      25.1327      23.6486
450231............................       1.6695       0.9141      25.2852      27.1674      26.9773      26.4819
450234............................       1.0260       0.8204      18.4451      20.6889      20.4622      19.9270
450235............................       1.0130       0.8204      21.5138      23.5212      21.8936      22.3093
450236............................       1.0590       0.8593      22.0788      23.5426      22.9579      22.8801
450237............................       1.6297       0.8916      24.8901      25.7939      30.5876      26.8886
450239............................       0.9810       0.8308      21.1945      21.2586      19.1354      20.4357
450241............................       1.0075       0.8204      18.7958      20.8732      21.3480      20.3076
450243............................       0.9797       0.8204      15.4636      15.4510      17.2294      16.0640
450253............................       0.9225       1.0048      20.6124      24.2435      24.1019      23.0154
450270............................       1.1797       0.8475      14.4325      15.2190      19.8112      16.4138
450271............................       1.2059       0.9646      21.7719      22.7035      24.1257      22.9106
450272............................       1.2098       0.9518      25.7392      26.2576      27.0499      26.3724
450276............................          ***            *      16.6319            *            *      16.6319
450280............................       1.4750       0.9795      28.7233      29.9730      31.6561      30.1306
450283............................       1.0410       0.9681      20.9679      22.7938      24.1724      22.6240
450289............................       1.4241       1.0048      28.5665      32.2645      33.6901      31.5939
450292............................       1.2711       0.9795      25.0411      26.3242      26.8105      26.0606
450293............................       0.8636       0.8204      21.3135      23.6413      24.0753      22.9676
450296............................       1.1007       1.0048      27.9690      30.4324      31.5551      30.0325
450299............................       1.6637       0.9177      26.4933      27.5797      28.4163      27.4987
450306............................       0.9556       0.8244      15.9855      21.4558      22.9398      19.7033

[[Page 24909]]

 
450315............................       1.8055       0.9795            *      37.1721            *      37.1721
450324............................       1.5715       0.9681      24.9128      25.1633      26.6082      25.5438
450330............................       1.2148       1.0048      25.5820      26.0771      27.1088      26.2637
450340............................       1.3764       0.8663      24.0637      25.0344      25.6777      24.9272
450346............................       1.4306       0.8587      22.2468      23.6072      23.8975      23.2898
450347............................       1.1980       1.0048      27.2203      28.7667      30.6500      28.8612
450348............................       1.0409       0.8204      18.7675      21.6787      21.0437      20.5420
450351............................       1.2643       0.9646      25.6859      26.5388      29.2557      27.1709
450352............................       1.1040       0.9795      24.8012      26.2281      27.2978      26.1097
450353............................          ***            *      24.4454      27.0248      28.2683      26.5977
450358............................       1.9691       1.0048      30.4280      31.4926      32.5905      31.5502
450362............................          ***            *      25.4372            *            *      25.4372
450369............................       1.0332       0.8204      18.4848      19.9148      22.9249      20.4404
450370............................       1.1948       0.8445      20.0832      25.5834      26.3438      23.8025
450372............................       1.3682       0.9795      28.3359      30.8886      30.9228      30.0232
450373............................       0.8647       0.8204      22.2213      24.8286      27.0704      24.8199
450374............................       0.9938            *      23.2283            *            *      23.2283
450378............................       1.4683       1.0048      30.7684      30.3883      32.2274      31.1285
450379............................       1.3342       0.9795      30.6071      33.7521      35.3777      33.1813
450381............................       0.9328            *      22.0482            *            *      22.0482
450388............................       1.6608       0.8916      25.8674      27.4328      27.9807      27.1010
450389............................       1.1532       0.9681      23.8764      25.6732      26.9621      25.5400
450393............................       0.5363       0.9681      18.4551      21.9347            *      19.7864
450395............................       1.0563       1.0048      24.8656      27.5189      26.7686      26.4980
450399............................       0.8955       0.8204      18.2074      20.3528      22.1687      20.1538
450400............................       1.0787       0.8204      23.1739      23.6358      26.2840      24.2918
450403............................       1.3144       0.9795      29.3063      29.0359      29.8626      29.4101
450411............................       1.0097       0.8204      19.6086      20.9372      21.5711      20.7282
450417............................       0.8612            *      20.0351            *            *      20.0351
450418............................          ***            *      26.8434      28.4362            *      27.5264
450419............................       1.2715       0.9681      31.0405      31.9966      34.2413      32.4898
450422............................       1.2225       0.9795      30.6659      34.4331      31.3421      32.1009
450424............................       1.3427       1.0048      28.3149      28.2463      30.7204      29.0895
450431............................       1.5890       0.9518      25.2477      26.3263      27.3917      26.3384
450438............................       1.1315       1.0048      21.9350      27.8659      26.5110      25.2161
450446............................       0.6348       1.0048      14.3132      17.0691      17.2849      16.0873
450447............................       1.2629       0.9681      23.5047      25.4200      26.5230      25.1012
450451............................       1.1286       0.8741      23.3043      24.6201      27.7093      25.1820
450460............................       0.9637       0.8252      20.5811      22.4227      24.9806      22.7331
450462............................       1.7172       0.9795      27.8923      29.6069      30.1441      29.2303
450465............................       1.1120       1.0048      22.4183      26.2759      27.0808      25.3172
450469............................       1.4925       0.9681      28.7890      26.3262      26.3408      27.1795
450475............................       1.0926       0.8875      23.5596      23.0942      24.4820      23.6936
450484............................       1.3680       0.8875      25.3527      26.7242      28.3900      26.8376
450488............................       1.1517       0.8875      23.9144      22.3981      23.7940      23.3805
450489............................       0.9935       0.8204      21.4771      23.4806      25.2611      23.4854
450497............................       1.0139       0.8599      18.8344      22.0918      23.1798      21.3680
450498............................       0.9453       0.8204      17.7822      18.6563      20.2424      18.8921
450508............................       1.5948       0.8875      23.9572      28.4471      27.2884      26.5810
450514............................          ***            *      22.6552      26.3704      26.9571      25.3918
450518............................       1.4362       0.8587      24.1194      28.1755      28.0142      26.7922
450530............................       1.2781       1.0048      28.7451      29.1349      29.9698      29.2956
450537............................       1.4003       0.9795      27.5856      27.7757      28.7442      28.0479
450539............................       1.1997       0.8275      21.0442      23.1829      24.2118      22.7454
450547............................       0.9677       0.8399      21.6542      23.7820      34.3322      25.8915
450558............................       1.8248       0.8244      26.1551      26.9407      28.0643      27.0629
450563............................       1.5242       0.9681      28.7289      30.8332      32.0505      30.6110
450565............................       1.2509       0.8685      23.8846      26.7942      28.1669      26.2638
450571............................       1.6017       0.8663      22.7703      25.2108      27.4577      25.0804
450573............................       1.1244       0.8319      20.1479      22.0797      22.1565      21.5134
450578............................       0.9614       0.8204      20.2696      22.5167      25.0487      22.6269

[[Page 24910]]

 
450580............................       1.0846       0.8204      21.1574      22.3886      23.8964      22.4730
450584............................       1.1129       0.8204      21.0808      20.5257      22.5149      21.3615
450586............................       0.9359       0.8204      16.1003      18.9107      20.6563      18.6521
450587............................       1.2013       0.8204      20.4512      23.1202      25.0153      22.8383
450591............................       1.2535       1.0048      23.9992      25.7031      27.0806      25.5834
450596............................       1.2190       0.9646      25.3317      27.4011      29.8448      27.4270
450597............................       0.9772       0.8204      23.1711      24.7853      24.2555      24.0721
450604............................       1.3487       0.8204      20.9514      24.4743      25.9097      23.8485
450605............................       0.9394       0.8460      22.2205      20.9276      23.9323      22.2907
450610............................       1.5913       1.0048      26.8710      27.7317      28.3923      27.6892
450615............................       0.9880       0.8204      20.3028      21.8442      24.1786      22.0818
450617............................       1.5099       1.0048      26.5026      28.0225      28.8304      27.8233
450620............................       1.0016       0.8204      17.7138      18.6183      20.3650      18.9167
450623............................       1.1755            *      28.3552            *            *      28.3552
450626............................          ***            *      26.8374            *            *      26.8374
450630............................       1.5447       1.0048      29.6796      29.1462      29.8420      29.5559
450634............................       1.7057       0.9795      28.1705      28.7312      30.3207      29.0783
450638............................       1.6763       1.0048      29.6184      30.6572      32.4988      30.8669
450639............................       1.4439       0.9681      29.2669      30.4019      32.6237      30.7769
450641............................       1.0317       0.8599      17.5845      19.4389      20.2439      19.0709
450643............................       1.3269       0.8484      21.1205      22.7355      24.3088      22.7006
450644............................       1.5884       1.0048      29.0186      29.7918      30.8220      29.9124
450646............................       1.4235       0.9144      23.8908      25.6313      26.8036      25.4367
450647............................       1.8302       0.9795      30.7334      30.6924      32.4230      31.2795
450651............................       1.4808       0.9795      32.4822      30.4484      31.9155      31.5983
450653............................       1.1658       0.8204      23.2603      25.2144      26.1733      24.8551
450654............................       0.9021       0.8204      19.9992      21.5002      22.5409      21.4221
450656............................       1.4166       0.8875      23.8280      25.5050      28.1462      25.7173
450658............................       0.9853       0.8204      20.5398      22.2293      24.7846      22.5182
450659............................       1.4617       1.0048      30.1727      31.5024      34.2303      31.8885
450661............................       1.1887       0.9959      23.2989      30.2610      30.0728      27.8676
450662............................       1.5737       0.9577      28.0913      29.0535      29.0508      28.7285
450665............................          ***            *      18.6054            *            *      18.6054
450668............................       1.5281       0.9144      26.2375      28.8635      30.6109      28.5359
450669............................       1.2115       0.9795      27.4507      27.9796      30.2655      28.6146
450670............................       1.4063       1.0048      25.1575      25.9638      26.4296      25.8782
450672............................       1.8206       0.9681      27.6359      30.1191      31.7990      29.9252
450674............................       1.0675       1.0048      28.4416      28.7101      29.8969      29.0121
450675............................       1.3872       0.9681      28.7765      28.9005      30.9547      29.5677
450677............................       1.2672       0.9681      27.3728      25.9555      27.5747      26.9441
450678............................       1.5041       0.9795      30.1500      31.1563      33.3407      31.5042
450683............................       1.1582       0.9795      24.6609      27.4925      21.1727      24.2963
450684............................       1.2927       1.0048      27.6789      29.3025      30.2122      29.1272
450686............................       1.5920       0.8678      23.2367      24.2331      26.1607      24.5665
450688............................       1.1942       0.9795      27.9057      26.8599      26.9879      27.2206
450690............................       1.3072       0.9190      28.2531      26.5528      26.1729      27.0373
450694............................       1.1612       0.8204      23.5789      23.9961      24.0008      23.8662
450697............................       1.4207       0.8916      23.7155      24.8667      26.4094      25.0094
450698............................       0.8996       0.8339      18.6494      20.0955      21.5692      20.0851
450702............................       1.7092       0.8875      25.6147      26.8384      26.3694      26.2786
450709............................       1.3571       1.0048      25.4855      26.8146      28.4214      26.8732
450711............................       1.4822       0.9140      28.0104      26.7472      27.5782      27.4494
450713............................       1.5798       0.9518      27.2801      28.8285      29.4951      28.5529
450715............................       1.2415       0.9795      28.0365      17.3991      17.0201      19.5798
450716............................       1.3493       1.0048      30.8440      32.3960      33.7175      32.3165
450718............................       1.3798       0.9518      27.3408      27.3215      28.1558      27.6252
450723............................       1.4651       0.9795      28.0812      28.5103      30.1696      28.9691
450730............................       1.3611       0.9795      29.9430      31.3324      32.7866      31.3503
450733............................          ***            *      26.4977            *            *      26.4977
450742............................       1.1915       0.9795      26.1189      27.2023      30.0561      27.8905
450743............................       1.4606       0.9795      27.3213      28.3362      28.4726      28.0740

[[Page 24911]]

 
450746............................       0.9236       0.8204      12.4748      20.6343      22.7521      18.2376
450747............................       1.2814       0.9190      22.2870      23.8314      25.8165      23.8624
450749............................       0.9915       0.8204      17.8227      20.0487      22.1526      19.9050
450751............................          ***            *      19.3267      18.7456      21.4208      19.9009
450754............................       0.9278       0.8204      20.8968      22.1819      24.7752      22.6387
450755............................       0.9399       0.8499      18.0092      19.8988      22.1950      20.0118
450758............................          ***            *      25.6547      28.7342      28.2792      27.5628
450760............................       1.0571       0.9144      24.6349      24.7489      25.1612      24.8383
450761............................       0.8818            *      15.7483            *            *      15.7483
450763............................       1.0706            *      22.4905            *            *      22.4905
450766............................       1.9343       0.9795      30.0441      30.8004      30.2340      30.3516
450770............................       1.2426       0.9518      20.3656      24.1647      23.7634      22.8145
450771............................       1.6724       0.9795      31.3924      30.7105      32.0501      31.3870
450774............................       1.6316       1.0048      24.9683      27.2080      25.7438      25.9776
450775............................       1.2937       1.0048      24.4006      28.1428      29.7897      27.3080
450779............................       1.2690       0.9681      26.9908      29.9674      31.8378      29.6435
450780............................       2.0333       0.8916      23.9516      26.7611      27.0062      25.8978
450788............................       1.5557       0.8460      25.4172      26.2840      28.3742      26.7014
450795............................       1.1878       1.0048      23.7510      25.2007      32.9739      27.3766
450796............................       1.7361       0.9141      27.9734      36.4073      37.8715      34.0484
450797............................       1.9643       1.0048      20.5379      24.8950      24.8592      23.1190
450801............................       1.4991       0.8204      23.0373      24.6328      25.3647      24.3609
450803............................       1.1833       1.0048      30.6093      28.9235      30.3031      29.9076
450804............................       1.9178       1.0048      26.0981      27.8775      29.1013      27.7076
450808............................       1.3363       0.9518      23.8067      21.9793      23.0296      22.9175
450809............................       1.5657       0.9518      26.3659      26.4223      27.3070      26.7163
450811............................       1.8168       0.9140      25.8491      27.2584      31.1988      27.9792
450813............................       1.1710       0.8916      25.5949      20.1710      22.9211      22.7699
450820............................       1.3272       1.0048      30.5288      31.4666      33.9016      32.1404
450822............................       1.2882       0.9795      31.1430      32.2968      32.2138      31.9065
450824............................       2.4916       0.9518      26.7803      31.2375      33.3605      30.5401
450825............................       1.3904       0.9140      20.2959      20.6457      25.1439      21.9852
450827............................       1.3898       0.8488      20.9704      23.7554      24.1907      23.0383
450828............................       1.3232       0.8204      22.3667      24.4740      24.8207      24.1285
450829............................          ***            *      19.5014      20.6016      19.5826      19.9024
450830............................       1.0196       0.9527      28.1617      28.5902      27.7967      28.1873
450831............................       1.4011       1.0048      22.7885      23.3880      23.9437      23.3300
450832............................       1.2713       1.0048      26.6628      26.5229      27.3292      26.8495
450833............................       1.3228       0.9795      26.0044      27.0133      27.9622      27.0354
450834............................       1.5862       0.9177      21.2204      20.9607      27.4845      22.7773
450838............................       1.1487       0.8319      15.8026      19.5754      18.9504      18.1883
450839............................       0.9901       0.8615      22.9711      25.8222      27.2151      25.2472
450840............................       1.2907       0.9795      31.1914      30.1743      32.2544      31.2220
450841............................       1.9217       0.9577      18.9468      20.9410      20.9412      20.3774
450844............................       1.3103       1.0048      28.7296      30.7887      33.7961      31.3320
450845............................       1.8427       0.9144      27.7461      29.4933      29.9243      29.0929
450847............................       1.2704       1.0048      27.6854      28.5548      29.7336      28.6773
450848............................       1.3004       1.0048      27.8100      29.5355      30.5537      29.3300
450850............................       1.1195       1.0016      22.1335      21.9266      31.9567      24.7538
450851............................       2.5569       0.9795      30.1213      32.6950      35.1080      32.6759
450852............................          ***            *      30.0191            *            *      30.0191
450853............................       1.9527       0.9795            *      36.1169      37.1028      36.6720
450854............................          ***            *            *      27.1868            *      27.1868
450855............................       1.5585       0.9577            *      30.8855      32.6866      31.8325
450856............................       1.9086       0.8916            *      39.0865      37.7287      38.3752
450857............................          ***            *            *      30.4632            *      30.4632
450860............................       1.9631       1.0048            *      24.0171      29.1020      26.9520
450861............................          ***            *            *      34.9290            *      34.9290
450862............................       1.4583       1.0048            *      31.2224      31.8086      31.4626
450863............................          ***            *            *      24.8825            *      24.8825
450864............................       2.0626       0.9190            *      23.3765      24.5033      24.0201

[[Page 24912]]

 
450865............................       1.0659       0.9518            *      29.1763      30.1175      29.6697
450866............................          ***            *            *      15.2959            *      15.2959
450867............................       1.1897       0.9518            *      28.2289      29.8401      29.0248
450868............................       1.8341       0.9959            *      27.9579      25.3483      26.8245
450869............................       2.0520       0.9140            *      22.6253      26.1586      24.9890
450870............................          ***            *            *      37.4364            *      37.4364
450871............................       1.8013       0.9518            *            *      28.6667      28.6667
450872............................       1.3856       0.9681            *            *      27.2839      27.2839
450873............................          ***            *            *            *      14.8808      14.8808
450874............................       1.5449       0.9795            *            *      34.6069      34.6069
450875............................       1.6403       0.9141            *            *      23.2771      23.2771
450876............................       2.0787       0.8678            *            *      28.4327      28.4327
450877............................       1.5503       0.9144            *            *      26.1823      26.1823
450878............................       2.5581       0.8916            *            *      31.4363      31.4363
450879............................       1.2943       0.8484            *            *      35.5585      35.5585
450880............................       1.6579       0.9681            *            *      35.9522      35.9522
450881............................          ***            *            *            *      24.5455      24.5455
450882............................          ***            *            *            *      27.8226      27.8226
450883............................       2.5235       0.9795            *            *      35.2632      35.2632
450884............................       0.9913       0.8925            *            *      27.8171      27.8171
450885............................       1.4982       0.9795            *            *      34.1144      34.1144
450886............................       1.9390       0.9670            *            *            *            *
450888............................       1.4581       0.9670            *            *            *            *
450889............................       1.5257       0.9795            *            *            *            *
450890............................       2.0977       0.9795            *            *            *            *
450891............................       1.3643       0.9795            *            *            *            *
450893............................       1.2518       0.9795            *            *            *            *
450894............................       1.7048       0.9795            *            *            *            *
450895............................          ***            *            *            *      18.4129      18.4129
460001............................       1.8847       0.9488      27.0757      28.7150      30.0024      28.5948
460003............................       1.5181       0.9482      26.1372      31.4135      32.3411      29.8766
460004............................       1.7332       0.9482      26.4498      28.2040      29.6502      28.1059
460005............................       1.4390       0.9482      23.5633      25.0239      26.0927      24.8850
460006............................       1.3709       0.9482      25.4787      27.1392      28.3673      27.0130
460007............................       1.3738       0.9546      25.6686      27.1308      28.0016      26.9924
460008............................       1.4054       0.9482      26.5672      29.5907      31.5474      29.1767
460009............................       1.9494       0.9482      26.2833      27.2885      28.3813      27.3950
460010............................       2.0931       0.9482      27.4648      29.0063      30.4873      29.0186
460011............................       1.3207       0.9388      23.4023      24.4402      24.9677      24.2736
460013............................       1.4115       0.9488      25.2448      27.7381      29.2708      27.3700
460014............................       1.1337       0.9482      24.1412      28.2647      29.5924      27.3264
460015............................       1.3650       0.9219      25.6576      27.2506      29.1301      27.3608
460017............................       1.3070       0.8631      23.0388      24.3030      26.1574      24.4631
460018............................       0.9383       0.8267      20.3756      22.0517      22.7973      21.8331
460019............................       1.1647       0.8267      19.9901      24.3756      23.2172      22.4666
460020............................       1.0141       0.8267      19.5669      18.5159      29.5332      21.7927
460021............................       1.6947       1.1205      26.3420      28.0291      29.5906      28.1994
460023............................       1.1933       0.9488      25.3094      26.9512      28.6509      26.9991
460026............................       1.0465       0.9388      24.1547      26.9295      27.9463      26.3205
460030............................       1.1799       0.8267      23.4679      23.5942      24.3597      23.8093
460033............................       0.9138       0.8267      22.0249      25.3422      26.6541      24.7026
460035............................       0.9491       0.8267      17.5723      20.6322      21.9077      20.1162
460036............................       1.4454            *      27.2866            *            *      27.2866
460037............................       0.8447            *      21.1035            *            *      21.1035
460039............................       1.0810       0.9219      28.5657      29.5651      30.4903      29.5979
460041............................       1.3613       0.9482      25.2744      26.4640      26.3798      26.0597
460042............................       1.3920       0.9482      22.9949      24.9454      26.8365      24.8864
460043............................       1.2796       0.9488      28.2089      28.2008      28.6673      28.3617
460044............................       1.3114       0.9482      26.6795      27.4928      28.7017      27.6432
460047............................       1.6716       0.9482      25.7920      28.2336      30.0498      27.9926
460049............................       1.9965       0.9482      24.5165      26.6702      28.5026      26.6084

[[Page 24913]]

 
460051............................       1.2358       0.9482      25.5881      27.0160      27.8836      26.8632
460052............................       1.6310       0.9488      25.3163      26.1629      27.1991      26.2809
460054............................       1.5970       0.9219      25.8668      24.9926      25.7860      25.5261
470001............................       1.2954       1.0782      27.7329      28.3017      29.7537      28.6008
470003............................       1.9062       1.0401      26.4919      28.1137      30.1959      28.2585
470005............................       1.3073       1.0401      29.8255      30.7872      33.1968      31.2956
470006............................       1.2524            *      26.9651            *            *      26.9651
470010............................          ***            *      26.1273            *            *      26.1273
470011............................       1.1764       1.0401      28.3911      28.1330      29.6899      28.7438
470012............................       1.1947       1.0401      24.3425      26.0225      27.0128      25.8090
470018............................       1.1133            *      28.3419            *            *      28.3419
470024............................       1.2025       1.0401      25.2427      27.0394      26.6344      26.3232
490001............................       1.0892       0.8095      21.9953      23.2174      24.0349      23.1144
490002............................       1.0509       0.8095      19.5613      20.8609      21.7073      20.6687
490003............................          ***            *      27.3456            *            *      27.3456
490004............................       1.3087       0.9353      25.4597      27.1676      27.8236      26.8453
490005............................       1.6418       1.0679      28.5744      29.8215      30.5335      29.6408
490007............................       2.1943       0.8785      26.2481      27.6572      29.3084      27.7570
490009............................       2.0098       0.9555      29.0740      30.4722      29.9383      29.8425
490011............................       1.5283       0.8785      24.5687      26.4766      27.4750      26.2046
490012............................       1.0128       0.8095      19.2276      21.0605      22.9898      21.0346
490013............................       1.3401       0.8490      22.4771      24.7521      25.5532      24.2689
490017............................       1.5004       0.8785      24.6845      25.8216      27.5878      26.0263
490018............................       1.3289       0.9353      24.5196      26.2510      27.3895      26.0937
490019............................       1.1905       1.0679      25.9761      25.9885      25.8263      25.9276
490020............................       1.2411       0.9238      24.8001      27.3142      29.4572      27.1534
490021............................       1.4774       0.8490      24.6440      25.7938      26.5838      25.6856
490022............................       1.4247       1.0679      28.0749      32.2676      30.1180      30.1134
490023............................       1.3034       1.0679      29.7774      30.3416      30.9919      30.3865
490024............................       1.7719       0.9441      23.0982      26.1125      30.6195      26.5180
490027............................       1.0552       0.8095      18.9409      24.0288      22.9996      21.9117
490031............................          ***            *      22.0579            *            *      22.0579
490032............................       1.9589       0.9238      25.1381      25.2654      28.5886      26.3873
490033............................       1.1071       1.0679      30.0909      31.2922      31.8266      31.1174
490037............................       1.2023       0.8095      21.3035      24.7711      25.2813      23.7322
490038............................       1.2572       0.8095      22.3976      21.8509      22.6326      22.2914
490040............................       1.4793       1.0679      32.8738      32.6564      34.1837      33.2336
490041............................       1.5146       0.8785      24.5738      26.0897      27.1598      25.9088
490042............................       1.2796       0.9190      21.8749      24.4650      25.3578      23.9261
490043............................       1.2498       1.0679      30.8871      33.7096      35.8792      33.5666
490044............................       1.4529       0.8785      20.8352      23.3527      23.3777      22.5138
490045............................       1.2636       1.0679      28.8279      32.0937      30.3765      30.3674
490046............................       1.5194       0.8785      25.6328      26.6517      27.9583      26.7669
490047............................       1.2301            *      22.5423            *            *      22.5423
490048............................       1.4151       0.8490      25.0097      26.2828      26.7581      26.0497
490050............................       1.4886       1.0679      30.5037      31.3885      32.3078      31.4093
490052............................       1.6969       0.8785      22.8889      23.5973      25.0037      23.8192
490053............................       1.2119       0.8095      21.8432      23.3315      23.7979      22.9784
490057............................       1.6179       0.8785      26.1128      26.6898      27.5153      26.7785
490059............................       1.6454       0.9238      28.7276      27.3611      30.8668      28.9526
490060............................       1.0540       0.8095      22.4201      23.6113      24.3180      23.4563
490063............................       1.8510       1.0679      30.3632      31.3619      31.6067      31.1276
490066............................       1.3614       0.8785      24.7146      27.8250      29.6170      27.4591
490067............................       1.2603       0.9238      22.9188      24.9021      25.9475      24.5479
490069............................       1.6015       0.9238      26.8791      27.3181      29.1513      27.7948
490071............................       1.3203       0.9238      28.4381      29.7186      31.6505      29.9219
490073............................       2.0908       1.0679      31.7743      33.1829      36.6050      33.5942
490075............................       1.4310       0.8486      23.8191      25.2022      26.3059      25.1154
490077............................       1.4141       0.9555      26.0800      26.6806      28.1502      26.9962
490079............................       1.2496       0.9083      23.4728      25.3103      25.2294      24.6362
490084............................       1.1764       0.8240      24.5965      24.9007      25.7656      25.0947

[[Page 24914]]

 
490088............................       1.1004       0.8490      22.4186      24.1471      24.8101      23.7857
490089............................       1.1026       0.9441      22.6461      24.9438      25.7992      24.4734
490090............................       1.1074       0.8095      22.2907      25.1157      26.3608      24.4717
490092............................       1.0927       0.9238      23.8655      23.3439      25.7387      24.2720
490093............................       1.4711       0.8785      25.0751      25.6531      26.7886      25.8819
490094............................       0.9852       0.9238      26.5726      28.2165      28.9146      27.8967
490097............................       1.0622       0.9238      23.8005      26.5322      27.1435      25.8270
490098............................       1.2549       0.8095      21.7231      23.2782      25.1610      23.3955
490101............................       1.4013       1.0679      30.4285      31.2377      32.3688      31.3628
490104............................       0.7733       0.9238      17.3295            *      17.0546      17.1727
490105............................       0.7178       0.8095      24.7922      25.5329      26.3828      25.5156
490106............................       0.9111       0.9353      23.0199      23.8334      25.7350      23.7423
490107............................       1.3335       1.0679      29.7000      32.2672      33.5401      31.8912
490108............................       1.0684       0.8490      22.4345      22.9076      23.3193      22.8875
490109............................       0.8787       0.9238      21.9877      22.7854      24.2291      22.9552
490110............................       1.3524       0.8422      22.5974      24.2887      24.9849      24.0081
490111............................       1.1951       0.8095      22.0199      22.1476      22.8937      22.3629
490112............................       1.7156       0.9238      26.6453      27.1932      29.0813      27.6671
490113............................       1.3105       1.0679      29.5698      31.8177      32.4544      31.3269
490114............................       1.1475       0.8095      20.9116      22.5255      22.1360      21.8649
490115............................       1.1533       0.8095      21.4666      22.4058      23.7163      22.5107
490116............................       1.1776       0.8095      22.9017      24.2258      24.3840      23.8562
490117............................       1.1522       0.8095      18.0277      19.6398      18.1119      18.6014
490118............................       1.6600       0.9238      27.4050      27.6749      29.0567      28.0590
490119............................       1.3035       0.8785      25.2549      26.5756      27.8859      26.6077
490120............................       1.3981       0.8785      24.4434      25.8795      26.0093      25.4236
490122............................       1.5549       1.0679      31.0449      32.0743      33.3710      32.1670
490123............................       1.1545       0.8095      23.9233      24.3490      24.2251      24.1637
490126............................       1.1651       0.8095      22.2859      23.6690      24.0884      23.3590
490127............................       1.1307       0.8095      20.4289      21.3735      23.4863      21.6178
490130............................       1.2696       0.8785      22.8512      23.9982      25.3343      24.0812
490133............................          ***            *      26.5684            *            *      26.5684
490134............................       0.7623       0.8095            *            *      33.2227      33.2227
490135............................       0.7016       0.9441            *            *      25.9889      25.9889
490136............................       1.4665       0.9238            *            *            *            *
490137............................       1.2895       0.8785            *            *            *            *
500001............................       1.6372       1.1351      29.3707      31.1605      33.0888      31.2052
500002............................       1.4278       1.0565      25.3347      27.6400      29.1442      27.3385
500003............................       1.3314       1.1202      29.6341      30.6939      32.1259      30.7329
500005............................       1.7732       1.1351      32.0972      33.5117      34.8686      33.4895
500007............................       1.3448       1.1202      28.0476      29.2869      30.5261      29.3452
500008............................       1.8942       1.1351      31.8837      32.6052      33.5666      32.7102
500011............................       1.3613       1.1351      30.6508      31.4514      32.6218      31.5867
500012............................       1.7433       1.0565      30.6856      30.0509      33.8239      31.3893
500014............................       1.6985       1.1351      33.7536      36.1380      36.5850      35.5229
500015............................       1.4709       1.1351      32.0592      34.5877      35.6715      34.1465
500016............................       1.6475       1.1202      31.4222      31.4905      32.9165      31.9509
500019............................       1.2779       1.0705      28.6669      30.5594      31.6230      30.2717
500021............................       1.2936       1.1202      30.1690      30.7927      32.4667      31.1930
500024............................       1.7694       1.1060      30.7917      32.6171      36.1640      33.1799
500025............................       1.8307       1.1351      34.7252      37.7952      40.6368      37.5370
500026............................       1.3949       1.1351      33.2937      32.8369      34.5879      33.5879
500027............................       1.5119       1.1351      34.2175      34.6164      39.2906      36.0226
500030............................       1.6945       1.1264      32.7446      32.4426      34.9165      33.4025
500031............................       1.2753       1.1325      31.2186      32.8833      33.2375      32.4927
500033............................       1.3149       1.0565      29.4627      30.6292      31.9177      30.6609
500036............................       1.3431       1.0565      27.0072      28.7096      30.5911      28.8233
500037............................       1.0254       1.0565      26.9969      28.1056      31.2642      28.7442
500039............................       1.4951       1.1202      29.8808      32.2245      33.5585      31.9341
500041............................       1.4362       1.1233      26.7829      30.3627      34.1983      30.2983
500044............................       1.9634       1.0565      30.3164      29.0214      31.0921      30.1178

[[Page 24915]]

 
500049............................       1.3525       1.0565      27.1819      27.7170      29.8189      28.3097
500050............................       1.4984       1.1233      29.9791      32.6751      33.7695      32.1377
500051............................       1.7936       1.1351      31.9406      32.5764      34.7579      33.0980
500052............................       1.4374       1.1351            *            *            *            *
500053............................       1.2887       1.0565      28.4130      28.2901      30.2803      28.9863
500054............................       1.9955       1.0565      30.8067      31.6595      32.4524      31.6451
500058............................       1.6535       1.0565      30.4699      30.7487      30.7029      30.6482
500060............................       1.3750       1.1351      34.1523      37.4869      38.7650      36.8212
500064............................       1.7330       1.1351      31.5371      31.6112      32.3570      31.8420
500072............................       1.2310       1.0826      33.4863      31.2000      32.5263      32.3947
500077............................       1.4551       1.0565      29.4199      31.6153      33.2185      31.3933
500079............................       1.3757       1.1202      29.6623      31.3280      32.5802      31.1943
500084............................       1.3885       1.1351      29.3484      30.2411      32.7883      30.8053
500088............................       1.3961       1.1351      33.4302      35.3770      36.7929      35.2125
500108............................       1.6412       1.1202      29.4244      31.8483      34.3853      31.9453
500119............................       1.3894       1.0565      30.9999      29.7028      31.2216      30.6353
500122............................       1.3587            *      30.1396            *            *      30.1396
500124............................       1.4290       1.1351      31.5438      32.3505      34.4763      32.8201
500129............................       1.5751       1.1202      30.7536      32.1102      34.4437      32.4983
500134............................       0.4907       1.1351      26.8607      27.2428      28.1308      27.5250
500138............................       0.8731            *            *            *            *            *
500139............................       1.5216       1.1060      31.6591      33.9739      35.2459      33.5975
500141............................       1.3178       1.1351      30.5456      31.3308      33.7520      31.9219
500143............................       0.4729       1.1060      22.1419      23.6766      25.3064      23.6837
500147............................       0.8772            *      24.5744            *            *      24.5744
500148............................       1.1794       1.0565      22.2161      26.4206      37.7820      30.2226
500150............................       1.2175       1.1233            *            *            *            *
510001............................       1.9235       0.8388      23.4477      25.2973      25.8670      24.9189
510002............................       1.2868       0.9190      25.9597      23.8921      23.7257      24.4599
510006............................       1.3373       0.8244      23.5727      24.9627      24.8754      24.4761
510007............................       1.7217       0.8845      25.2835      24.7264      26.7129      25.5735
510008............................       1.3063       0.9259      24.6959      26.3554      27.5208      26.2143
510012............................       0.9607       0.7568      18.2845      18.8984      20.8441      19.3184
510013............................       1.1241       0.7568      20.8782      22.7882      22.8762      22.1595
510018............................       1.0603       0.8294      20.5556      22.4597      22.8896      21.9850
510022............................       1.8404       0.8397      24.2125      26.9511      26.8298      25.9931
510023............................       1.2851       0.7893      20.4908      20.6435      21.0931      20.7442
510024............................       1.8413       0.8388      24.0444      25.5634      26.6600      25.4522
510026............................       0.9974       0.7568      16.6192      17.9908      19.0716      17.8791
510028............................          ***            *      21.7135            *            *      21.7135
510029............................       1.3222       0.8397      22.4556      22.7104      24.0871      23.0837
510030............................       1.0974       0.8244      21.5583      24.3936      23.7105      23.2332
510031............................       1.4320       0.8397      21.7637      23.2624      24.0220      22.9918
510033............................       1.7286       0.8238      23.0305      22.6189      24.0772      23.2692
510038............................       1.0547       0.7568      17.2832      20.6565      20.9131      19.6268
510039............................       1.2513       0.7568      19.5468      19.8751      20.4713      19.9553
510046............................       1.3473       0.7744      21.2540      22.1712      22.7403      22.0415
510047............................       1.1464       0.8388      24.0954      27.1214      27.6830      26.2412
510048............................       1.1744       0.7568      17.5096      18.8576      22.7921      19.5218
510050............................       1.6023       0.7568      19.9766      21.0772      21.8994      20.9834
510053............................       1.1036       0.7568      20.8608      22.3318      21.5331      21.5796
510055............................       1.5345       0.8845      30.7868      28.4615      29.4112      29.5183
510058............................       1.3454       0.8238      22.6976      23.9015      25.1425      23.9213
510059............................       0.7138       0.8397      21.9551      22.1435      20.8799      21.6736
510062............................       1.1596       0.8294      23.3216      26.2296      26.5027      25.3360
510067............................       1.1080       0.7568      21.2099      25.0437      25.2094      23.8467
510068............................       1.1378            *      23.1011            *            *      23.1011
510070............................       1.2252       0.8294      23.2382      23.5639      23.9714      23.5982
510071............................       1.3169       0.7744      23.1685      23.4508      23.2773      23.3001
510072............................       1.1600       0.7568      20.1997      20.5146      19.4366      20.0240
510077............................       1.0539       0.8706      23.6584      24.5010      25.9500      24.6968

[[Page 24916]]

 
510082............................       1.1114       0.7568      19.1878      19.9081      20.3265      19.7900
510085............................       1.2935       0.8397      23.7174      26.3877      26.2593      25.5454
510086............................       1.1756       0.7568      17.5933      19.8735      19.2574      18.9116
510089............................          ***            *      27.7061            *            *      27.7061
510090............................       1.8498       0.8845            *            *            *            *
520002............................       1.3411       1.0011      24.9950      27.7705      29.0603      27.3244
520004............................       1.3936       0.9704      25.4639      27.6530      28.9833      27.3808
520008............................       1.5354       1.0296      29.8353      30.7553      33.8038      31.4979
520009............................       1.7192       0.9635      26.1503      27.4044      28.8585      27.4835
520011............................       1.3034       0.9635      25.2747      26.6268      27.2708      26.4030
520013............................       1.4596       0.9635      26.6225      29.0018      30.1823      28.6557
520017............................       1.1205       0.9635      24.6677      28.4699      29.3257      27.4741
520019............................       1.3648       0.9635      26.7433      28.6971      29.8641      28.5157
520021............................       1.3025       1.0455      26.6935      28.4182      29.1110      28.1498
520027............................       1.3706       1.0296      27.6771      31.4284      32.4107      30.5705
520028............................       1.3493       1.1002      25.4164      26.7260      28.0802      26.7497
520030............................       1.7235       1.0011      27.0184      29.4678      30.5699      29.0605
520033............................       1.2657       0.9635      25.0853      28.0662      29.0213      27.5155
520034............................       1.2320       0.9635      23.9850      26.1094      26.8901      25.6373
520035............................       1.3589       0.9718      24.7767      27.3276      28.1023      26.7456
520037............................       1.8171       1.0011      29.7234      30.1799      32.2126      30.7297
520038............................       1.2386       1.0296      26.6470      29.3134      29.6455      28.5972
520040............................       1.2129       1.0296      27.2325      29.1262      31.2019      29.0313
520041............................       1.0714       1.1181      22.7595      23.5495      25.3745      23.9555
520044............................       1.3514       0.9718      26.0191      27.3685      28.2371      27.2569
520045............................       1.6541       0.9635      26.0030      27.3336      29.3743      27.5624
520048............................       1.5682       0.9635      25.1724      26.8080      29.1861      26.9820
520049............................       2.1341       0.9635      25.9256      26.9851      28.0930      26.9956
520051............................       1.5581       1.0296      28.4880      31.9949      31.3100      30.6580
520057............................       1.1719       0.9819      25.3745      27.7528      29.1146      27.4372
520059............................       1.3032       1.0287      28.0907      29.5801      30.4575      29.3881
520060............................       1.3697       0.9635      23.8817      24.8638      26.3170      25.0791
520062............................       1.2461       1.0296      28.2215      28.8510      32.8572      30.1180
520063............................       1.1387       1.0296      27.4100      29.0993      30.3381      28.9449
520064............................       1.5995       1.0296      28.6101      30.3225      31.5710      30.0467
520066............................       1.4385       0.9813      27.1657      29.2088      31.0608      29.1271
520068............................          ***            *      24.8184            *            *      24.8184
520070............................       1.7753       0.9635      24.8935      27.6771      28.0835      26.9326
520071............................       1.1682       1.0296      27.6202      30.0262      30.6902      29.4705
520075............................       1.5608       0.9635      27.1699      29.2920      30.1577      28.8340
520076............................       1.2408       1.1002      26.1697      27.3335      27.4423      26.9220
520078............................       1.5176       1.0296      27.5989      29.9837      31.6930      29.7364
520083............................       1.7380       1.1181      28.8407      30.8826      32.7720      30.8982
520087............................       1.7746       0.9704      27.3374      28.5810      30.5643      28.8727
520088............................       1.4249       0.9892      26.9936      30.7450      30.6626      29.5642
520089............................       1.5701       1.1181      30.0448      33.8793      33.4077      32.4828
520091............................       1.2952       0.9635      24.6320      25.4593      27.3437      25.8208
520094............................          ***            *      25.7567            *            *      25.7567
520095............................       1.2940       1.1002      26.7863      30.4216      32.0328      29.8101
520096............................       1.3768       0.9824      24.5758      27.8896      29.5966      27.4533
520097............................       1.3988       0.9635      26.3321      29.1479      30.0078      28.4894
520098............................       2.0280       1.1181      30.6150      32.5785      36.5735      33.3161
520100............................       1.2790       0.9813      26.2161      29.3243      29.6404      28.4022
520102............................       1.1731       1.0296      26.8234      29.1680      30.7969      28.9921
520103............................       1.5503       1.0296      27.9147      30.3165      32.6253      30.3606
520107............................       1.2785       0.9721      28.3431      28.9878      29.4173      28.9353
520109............................       1.0385       0.9635      23.3271      24.7228      25.0675      24.3755
520113............................       1.3265       0.9635      27.4135      31.4708      33.3448      30.7246
520116............................       1.2670       1.0296      26.9902      27.9688      30.2148      28.3943
520132............................          ***            *      23.1941      25.0006      27.3413      25.0303
520136............................       1.7254       1.0296      27.7703      30.6522      32.2056      30.1520

[[Page 24917]]

 
520138............................       1.8836       1.0296      28.4394      30.8016      31.6560      30.2955
520139............................       1.2882       1.0296      26.5110      28.8870      30.4880      28.6146
520140............................       0.3793            *      28.4433      31.0043      31.0603      30.2033
520152............................       1.0909            *      24.9392      29.7308            *      27.4042
520160............................       1.8643       0.9635      25.7588      27.9548      29.7288      27.8043
520170............................       1.4772       1.0296      27.2221      30.4309      31.4684      29.7182
520173............................       1.0835       0.9635      28.0995      29.2429      31.0590      29.4644
520177............................       1.6145       1.0296      30.7317      31.4555      32.5695      31.6043
520178............................       1.0240            *      20.2666            *            *      20.2666
520189............................       1.2031       1.0455      28.4720      28.0014      29.0284      28.4995
520193............................       1.6998       0.9635      26.0885      27.8113      29.2005      27.7864
520194............................       1.7148       1.0296      24.9408      30.1668      31.4969      28.9141
520195............................       0.3556       1.0296      36.6973      36.3116      36.2864      36.4358
520196............................       1.6798       0.9635      35.1043      36.9266      31.1197      34.0263
520197............................          ***            *            *            *      30.1026      30.1026
520198............................       1.4193       0.9635            *            *      28.5962      28.5962
520199............................       2.2788       1.0296            *            *      36.5679      36.5679
520200............................       0.9180            *            *            *            *            *
520201............................       0.6866            *            *            *            *            *
520202............................       1.4519       1.0011            *            *            *            *
530002............................       1.1242       0.9214      26.8356      28.3063      29.2066      28.1166
530006............................       1.1836       0.9214      24.9318      27.2421      29.2091      27.0634
530007............................          ***            *      20.4391            *            *      20.4391
530008............................       1.1673       0.9214      23.8589      24.0090      26.5170      24.7922
530009............................       0.9239       0.9214      26.8316      24.6719      25.9366      25.7848
530010............................       1.3065       0.9214      25.8482      25.9852      27.4111      26.4398
530011............................       1.1127       0.9214      24.8245      27.8772      27.8600      26.9105
530012............................       1.7049       0.9277      25.2526      26.9582      28.7554      26.9872
530014............................       1.5650       0.9219      24.5947      26.7156      28.5771      26.7011
530015............................       1.1585       0.9352      27.6876      29.8310      31.1119      29.5109
530017............................       1.1052       0.9214      25.3362      29.8503      31.1044      28.7212
530023............................          ***            *      21.3813            *            *      21.3813
530025............................       1.2406       0.9214      28.6938      24.4392      29.3697      27.4106
530032............................       1.0164       0.9214      25.7728      23.9004      24.6562     24.7327
----------------------------------------------------------------------------------------------------------------
\1\ Based on salaries adjusted occupational mix, according to the calculation in section II.D.6. of the preamble
  to this final rule.
\2\ The transfer-adjusted case-mix index is based on the billed DRG on the FY 2006 MedPAR.
* Denotes wage data not available for the provider for that year.
** Based on the sum of the salaries and hours computed for Federal FYs 2006, 2007, and 2008.
*** Denotes MedPAR data not available for the provider for FY 2006.












  Federal Register / Vol. 72, No. 85 / Thursday, May 3, 2007 / Proposed 
Rules  

[[Page 24917]]




 Table 3A.--FY 2008 and 3-Year* Average Hourly Wage for Uurban Areas by
                                  CBSA
 [*Based on the salaries and hours computed for Federal FYs 2006, 2007,
                               and 2008.]
------------------------------------------------------------------------
                                                  FY 2008       3-Year
     CBSA code               Urban area           average      average
                                                hourly wage  hourly wage
------------------------------------------------------------------------
10180..............  Abilene, TX..............      25.5538      24.1331
10380..............  Aguadilla-Isabela-San          10.2251      11.4341
                      Sebasti[aacute]n, PR.
10420..............  Akron, OH................      27.1423      25.9140
10500..............  Albany, GA...............      26.5075      25.8661
10580..............  Albany-Schenectady-Troy,       26.8799      25.7658
                      NY.
10740..............  Albuquerque, NM..........      30.1918      28.6362
10780..............  Alexandria, LA...........      24.6475      23.5445
10900..............  Allentown-Bethlehem-           31.0725      29.5625
                      Easton, PA-NJ.
11020..............  Altoona, PA..............      25.8968      25.4011
11100..............  Amarillo, TX.............      28.3367      27.1348
11180..............  Ames, IA.................      30.9401      28.8517
11260..............  Anchorage, AK............      36.4624      35.0341
11300..............  Anderson, IN.............      27.8019      26.0238
11340..............  Anderson, SC.............      28.1687      26.6066
11460..............  Ann Arbor, MI............      32.5597      31.5914
11500..............  Anniston-Oxford, AL......      24.7339      23.2894
11540..............  Appleton, WI.............      29.3844      27.6794

[[Page 24918]]

 
11700..............  Asheville, NC............      28.5462      27.3747
12020..............  Athens-Clarke County, GA.      32.6801      28.9702
12060..............  Atlanta-Sandy Springs-         30.5185      28.9861
                      Marietta, GA.
12100..............  Atlantic City, NJ........      37.4892      34.9547
12220..............  Auburn-Opelika, AL.......      25.0667      23.9196
12260..............  Augusta-Richmond County,       29.7570      28.5673
                      GA-SC.
12420..............  Austin-Round Rock, TX....      29.5055      27.8771
12540..............  Bakersfield, CA..........      35.1655      32.3553
12580..............  Baltimore-Towson, MD.....      31.3329      29.4975
12620..............  Bangor, ME...............      30.5654      29.0449
12700..............  Barnstable Town, MA......      39.1116      37.3016
12940..............  Baton Rouge, LA..........      24.8394      24.3027
12980..............  Battle Creek, MI.........      31.1266      28.7337
13020..............  Bay City, MI.............      27.9569      27.3833
13140..............  Beaumont-Port Arthur, TX.      26.6188      25.3168
13380..............  Bellingham, WA...........      34.9165      33.4025
13460..............  Bend, OR.................      32.8324      31.4061
13644..............  Bethesda-Gaithersburg-         32.4256      32.2302
                      Frederick, MD.
13740..............  Billings, MT.............      27.5180      26.3023
13780..............  Binghamton, NY...........      28.1230      26.2431
13820..............  Birmingham-Hoover, AL....      27.5033      26.3180
13900..............  Bismarck, ND.............      22.5429      21.8622
13980..............  Blacksburg-Christiansburg-     25.0343      23.9362
                      Radford, VA.
14020..............  Bloomington, IN..........      28.9114      26.4833
14060..............  Bloomington-Normal, IL...      29.4126      27.2841
14260..............  Boise City-Nampa, ID.....      29.4529      27.5811
14484..............  Boston-Quincy, MA........      36.2971      34.5496
14500..............  Boulder, CO..............      31.3644      29.5797
14540..............  Bowling Green, KY........      25.0757      24.0238
14740..............  Bremerton-Silverdale, WA.      33.5585      31.9341
14860..............  Bridgeport-Stamford-           39.9455      37.7175
                      Norwalk, CT.
15180..............  Brownsville-Harlingen, TX      29.6861      28.6894
15260..............  Brunswick, GA............      30.2808      29.1365
15380..............  Buffalo-Niagara Falls, NY      29.7130      28.1438
15500..............  Burlington, NC...........      26.6539      25.6456
15540..............  Burlington-South               29.7238      28.0154
                      Burlington, VT.
15764..............  Cambridge-Newton-              34.6193      32.8465
                      Framingham, MA.
15804..............  Camden, NJ...............      32.6154      31.0734
15940..............  Canton-Massillon, OH.....      27.6520      26.5054
15980..............  Cape Coral-Fort Myers, FL      29.4170      27.9198
16180..............  Carson City, NV..........      29.0596      29.0305
16220..............  Casper, WY...............      28.7554      26.9872
16300..............  Cedar Rapids, IA.........      26.9340      25.8161
16580..............  Champaign-Urbana, IL.....      28.8897      28.0705
16620..............  Charleston, WV...........      26.0301      25.1455
16700..............  Charleston-North               28.3391      27.1402
                      Charleston, SC.
16740..............  Charlotte-Gastonia-            29.4846      28.2167
                      Concord, NC-SC.
16820..............  Charlottesville, VA......      29.6186      29.3212
16860..............  Chattanooga, TN-GA.......      27.7965      26.6064
16940..............  Cheyenne, WY.............      28.5771      26.7011
16974..............  Chicago-Naperville-            32.4104      31.4301
                      Joliet, IL.
17020..............  Chico, CA................      34.8348      32.3528
17140..............  Cincinnati-Middletown, OH-     29.9257      28.3705
                      KY-IN.
17300..............  Clarksville, TN-KY.......      25.4889      24.5649
17420..............  Cleveland, TN............      25.3391      24.1812
17460..............  Cleveland-Elyria-Mentor,       29.0283      27.5817
                      OH.
17660..............  Coeur d'Alene, ID........      29.0137      27.8488
17780..............  College Station-Bryan, TX      28.4460      26.5695
17820..............  Colorado Springs, CO.....      29.3600      27.9536
17860..............  Columbia, MO.............      26.4878      24.9744
17900..............  Columbia, SC.............      27.2473      26.4178
17980..............  Columbus, GA-AL..........      27.9688      25.7747
18020..............  Columbus, IN.............      29.8515      28.2562
18140..............  Columbus, OH.............      31.1465      29.5977
18580..............  Corpus Christi, TX.......      26.2244      25.0629
18700..............  Corvallis, OR............      33.1920      32.2199
19060..............  Cumberland, MD-WV........      24.6964      24.8721
19124..............  Dallas-Plano-Irving, TX..      30.3645      29.5263
19140..............  Dalton, GA...............      26.6179      26.1939

[[Page 24919]]

 
19180..............  Danville, IL.............      28.6735      27.3133
19260..............  Danville, VA.............      26.3059      25.1154
19340..............  Davenport-Moline-Rock          27.2960      25.9226
                      Island, IA-IL.
19380..............  Dayton, OH...............      28.7758      27.1442
19460..............  Decatur, AL..............      24.4009      24.0134
19500..............  Decatur, IL..............      25.1642      24.0538
19660..............  Deltona-Daytona Beach-         27.7363      27.0490
                      Ormond Beach, FL.
19740..............  Denver-Aurora, CO........      32.5162      31.4369
19780..............  Des Moines-West Des            28.4004      27.5531
                      Moines, IA.
19804..............  Detroit-Livonia-Dearborn,      31.1509      30.3767
                      MI.
20020..............  Dothan, AL...............      22.9355      22.3197
20100..............  Dover, DE................      32.2239      29.9990
20220..............  Dubuque, IA..............      27.5076      26.4788
20260..............  Duluth, MN-WI............      31.4670      30.1024
20500..............  Durham, NC...............      30.4233      29.2561
20740..............  Eau Claire, WI...........      29.1319      27.8408
20764..............  Edison, NJ...............      34.3248      32.9557
20940..............  El Centro, CA............      28.4214      26.8331
21060..............  Elizabethtown, KY........      26.7267      25.6686
21140..............  Elkhart-Goshen, IN.......      29.2579      28.0411
21300..............  Elmira, NY...............      25.8434      24.6042
21340..............  El Paso, TX..............      28.3459      26.9978
21500..............  Erie, PA.................      26.3706      25.6869
21660..............  Eugene-Springfield, OR...      34.1215      32.3046
21780..............  Evansville, IN-KY........      26.2541      25.6720
21820..............  Fairbanks, AK............      33.9363      32.8387
21940..............  Fajardo, PR..............      12.7755      12.1173
22020..............  Fargo, ND-MN.............      24.6368      24.1979
22140..............  Farmington, NM...........      28.7944      25.7110
22180..............  Fayetteville, NC.........      30.7692      28.3815
22220..............  Fayetteville-Springdale-       27.5150      26.2034
                      Rogers, AR-MO.
22380..............  Flagstaff, AZ............      35.8265      34.6818
22420..............  Flint, MI................      34.3384      32.0516
22500..............  Florence, SC.............      26.5418      25.8347
22520..............  Florence-Muscle Shoals,        24.6505      23.6965
                      AL.
22540..............  Fond du Lac, WI..........      30.6626      29.5642
22660..............  Fort Collins-Loveland, CO      29.6510      28.4242
22744..............  Fort Lauderdale-Pompano        31.1393      30.0154
                      Beach-Deerfield Beach,
                      FL.
22900..............  Fort Smith, AR-OK........      24.9728      23.7472
23020..............  Fort Walton Beach-             26.8666      25.7305
                      Crestview-Destin, FL.
23060..............  Fort Wayne, IN...........      28.0400      27.6656
23104..............  Fort Worth-Arlington, TX.      29.9000      28.3094
23420..............  Fresno, CA...............      34.2325      32.2418
23460..............  Gadsden, AL..............      25.1998      23.7672
23540..............  Gainesville, FL..........      28.8449      27.7112
23580..............  Gainesville, GA..........      29.2101      27.2811
23844..............  Gary, IN.................      28.6613      27.6146
24020..............  Glens Falls, NY..........      26.4297      25.3758
24140..............  Goldsboro, NC............      28.7525      26.8565
24220..............  Grand Forks, ND-MN.......      23.9585      23.1800
24300..............  Grand Junction, CO.......      30.0980      28.4996
24340..............  Grand Rapids-Wyoming, MI.      29.0748      27.9448
24500..............  Great Falls, MT..........      26.4350      25.6359
24540..............  Greeley, CO..............      30.9980      29.1621
24580..............  Green Bay, WI............      29.4038      28.1020
24660..............  Greensboro-High Point, NC      28.2420      26.8372
24780..............  Greenville, NC...........      28.7422      27.6117
24860..............  Greenville-Mauldin-            29.9557      28.7860
                      Easley, SC.
25020..............  Guayama, PR..............      09.1324      09.2033
25060..............  Gulfport-Biloxi, MS......      26.7144      25.8323
25180..............  Hagerstown-Martinsburg,        28.7017      27.6848
                      MD-WV.
25260..............  Hanford-Corcoran, CA.....      33.0694      30.9554
25420..............  Harrisburg-Carlisle, PA..      28.6428      27.5304
25500..............  Harrisonburg, VA.........      27.8236      26.8453
25540..............  Hartford-West Hartford-        33.9586      32.5097
                      East Hartford, CT.
25620..............  Hattiesburg, MS..........      23.3662      22.3924
25860..............  Hickory-Lenoir-Morganton,      27.8269      26.5087
                      NC.
25980..............  \1\Hinesville-Fort         ...........  ...........
                      Stewart, GA.
26100..............  Holland-Grand Haven, MI..      28.1052      26.9690

[[Page 24920]]

 
26180..............  Honolulu, HI.............      34.9939      32.9065
26300..............  Hot Springs, AR..........      28.2398      26.5588
26380..............  Houma-Bayou Cane-              24.7338      23.6332
                      Thibodaux, LA.
26420..............  Houston- Sugar Land-           31.1464      29.7094
                      Baytown, TX.
26580..............  Huntington-Ashland, WV-KY-     27.4177      26.7237
                      OH.
26620..............  Huntsville, AL...........      28.4420      26.8784
26820..............  Idaho Falls, ID..........      28.6678      27.2911
26900..............  Indianapolis-Carmel, IN..      30.1383      28.9656
26980..............  Iowa City, IA............      29.2276      28.3307
27060..............  Ithaca, NY...............      29.5522      28.8425
27100..............  Jackson, MI..............      29.3419      28.0558
27140..............  Jackson, MS..............      24.9313      24.1807
27180..............  Jackson, TN..............      26.6283      25.9384
27260..............  Jacksonville, FL.........      28.2991      27.3023
27340..............  Jacksonville, NC.........      25.6323      24.5577
27500..............  Janesville, WI...........      30.4182      28.8010
27620..............  Jefferson City, MO.......      26.9868      25.3369
27740..............  Johnson City, TN.........      24.0384      23.4502
27780..............  Johnstown, PA............      23.6933      24.1218
27860..............  Jonesboro, AR............      24.5409      23.3826
27900..............  Joplin, MO...............      28.8838      26.2169
28020..............  Kalamazoo-Portage, MI....      32.5642      31.2112
28100..............  Kankakee-Bradley, IL.....      36.1982      31.8459
28140..............  Kansas City, MO-KS.......      28.8920      27.7054
28420..............  Kennewick-Richland-Pasco,      30.5712      30.0865
                      WA.
28660..............  Killeen-Temple-Fort Hood,      25.7516      25.4181
                      TX.
28700..............  Kingsport-Bristol-             24.1118      23.5801
                      Bristol, TN-VA.
28740..............  Kingston, NY.............      29.5032      27.8057
28940..............  Knoxville, TN............      24.9295      24.3432
29020..............  Kokomo, IN...............      29.3510      28.2549
29100..............  La Crosse, WI-MN.........      30.0801      28.4068
29140..............  Lafayette, IN............      26.9108      25.7887
29180..............  Lafayette, LA............      25.7276      24.7355
29340..............  Lake Charles, LA.........      24.1373      23.1806
29404..............  Lake County-Kenosha            31.8873      30.9559
                      County, IL-WI.
29420..............  \2\Lake Havasu City-           28.9023      27.6036
                      Kingman, AZ.
29460..............  Lakeland, FL.............      27.3993      26.4643
29540..............  Lancaster, PA............      29.5748      28.7392
29620..............  Lansing-East Lansing, MI.      31.1620      29.4193
29700..............  Laredo, TX...............      26.2982      24.3954
29740..............  Las Cruces, NM...........      26.4505      25.6128
29820..............  Las Vegas-Paradise, NV...      35.4313      33.5557
29940..............  Lawrence, KS.............      25.4425      24.7034
30020..............  Lawton, OK...............      26.0576      24.4695
30140..............  Lebanon, PA..............      25.4393      25.2120
30300..............  Lewiston, ID-WA..........      28.6132      28.2893
30340..............  Lewiston-Auburn, ME......      28.8104      27.4892
30460..............  Lexington-Fayette, KY....      27.9807      26.6659
30620..............  Lima, OH.................      28.7195      26.9710
30700..............  Lincoln, NE..............      30.4893      29.5435
30780..............  Little Rock-North Little       27.7885      27.0599
                      Rock-Conway, AR.
30860..............  Logan, UT-ID.............      28.4774      27.0281
30980..............  Longview, TX.............      27.2722      26.0005
31020..............  Longview, WA.............      34.1983      30.2983
31084..............  Los Angeles-Long Beach-        36.0596      34.6113
                      Glendale, CA.
31140..............  Louisville-Jefferson           28.0357      27.0524
                      County, KY-IN.
31180..............  Lubbock, TX..............      26.8986      25.6168
31340..............  Lynchburg, VA............      26.2578      25.3812
31420..............  Macon, GA................      30.2300      28.6691
31460..............  Madera, CA...............      26.0875      25.2903
31540..............  Madison, WI..............      34.6597      32.2701
31700..............  Manchester-Nashua, NH....      30.9773      30.1064
31900..............  Mansfield, OH............      28.5629      27.8928
32420..............  Mayaguez, PR.............      11.3424      11.2954
32580..............  McAllen-Edinburg-Mission,      28.3334      26.4909
                      TX.
32780..............  Medford, OR..............      31.9390      30.8468
32820..............  Memphis, TN-MS-AR........      28.7998      27.5984
32900..............  Merced, CA...............      37.0756      33.9058
33124..............  Miami-Miami Beach-             31.0677      29.1861
                      Kendall, FL.

[[Page 24921]]

 
33140..............  Michigan City-La Porte,        27.2497      26.8086
                      IN.
33260..............  Midland, TX..............      31.0460      28.6440
33340..............  Milwaukee-Waukesha-West        31.9156      30.3227
                      Allis, WI.
33460..............  Minneapolis-St. Paul-          33.9752      32.3063
                      Bloomington, MN-WI.
33540..............  Missoula, MT.............      26.9875      26.3725
33660..............  Mobile, AL...............      24.6422      23.3322
33700..............  Modesto, CA..............      36.8586      35.0384
33740..............  Monroe, LA...............      24.4029      23.5967
33780..............  Monroe, MI...............      29.3700      28.3176
33860..............  Montgomery, AL...........      25.9300      24.5421
34060..............  Morgantown, WV...........      26.0745      25.0602
34100..............  Morristown, TN...........      22.9428      22.9786
34580..............  Mount Vernon-Anacortes,        31.5880      30.3305
                      WA.
34620..............  Muncie, IN...............      24.8038      24.8594
34740..............  Muskegon-Norton Shores,        30.7959      29.3584
                      MI.
34820..............  Myrtle Beach-Conway-North      26.8331      26.0529
                      Myrtle Beach, SC.
34900..............  Napa, CA.................      42.8545      38.8227
34940..............  Naples-Marco Island, FL..      30.2428      29.5403
34980..............  Nashville-Davidson-            29.9892      28.8467
                      Murfreesboro-Franklin,.
35004..............  Nassau-Suffolk, NY.......      39.6471      37.9525
35084..............  Newark-Union, NJ-PA......      36.2090      34.7675
35300..............  New Haven-Milford, CT....      37.0244      35.4080
35380..............  New Orleans-Metairie-          27.0691      25.9597
                      Kenner, LA.
35644..............  New York-White Plains-         40.9653      39.1524
                      Wayne, NY-NJ.
35660..............  Niles-Benton Harbor, MI..      28.3260      26.5609
35980..............  Norwich-New London, CT...      35.7729      34.4608
36084..............  Oakland-Fremont-Hayward,       47.2281      45.3887
                      CA.
36100..............  Ocala, FL................      26.6182      25.7575
36140..............  Ocean City, NJ...........      33.3167      31.8219
36220..............  Odessa, TX...............      30.8710      29.4945
36260..............  Ogden-Clearfield, UT.....      28.0897      26.7604
36420..............  Oklahoma City, OK........      27.1668      26.2084
36500..............  Olympia, WA..............      35.5354      32.8563
36540..............  Omaha-Council Bluffs, NE-      29.1986      27.9651
                      IA.
36740..............  Orlando-Kissimmee, FL....      29.0828      28.0089
36780..............  Oshkosh-Neenah, WI.......      29.1236      27.4235
36980..............  Owensboro, KY............      27.2813      25.9999
37100..............  Oxnard-Thousand Oaks-          35.2562      33.6195
                      Ventura, CA.
37340..............  Palm Bay-Melbourne-            29.0897      28.3339
                      Titusville, FL.
37380..............  \2\Palm Coast, FL........      27.0971      27.5184
37460..............  Panama City-Lynn Haven,        25.7289      24.1673
                      FL.
37620..............  Parkersburg-Marietta-          25.5355      24.2911
                      Vienna, WV-OH.
37700..............  Pascagoula, MS...........      26.4838      24.5080
37764..............  Peabody, MA (Formerly,         31.6602      30.7561
                      Essex County, MA).
37860..............  Pensacola-Ferry Pass-          25.1925      23.7365
                      Brent, FL.
37900..............  Peoria, IL...............      29.0576      26.9647
37964..............  Philadelphia, PA.........      33.8074      32.4521
38060..............  Phoenix-Mesa-Scottsdale,       31.3564      29.9787
                      AZ.
38220..............  Pine Bluff, AR...........      25.2804      25.1908
38300..............  Pittsburgh, PA...........      26.0038      25.3862
38340..............  Pittsfield, MA...........      31.2160      30.0714
38540..............  Pocatello, ID............      28.3768      27.2635
38660..............  Ponce, PR................      12.8969      13.5329
38860..............  Portland-South Portland-       31.0222      29.7900
                      Biddeford, ME.
38900..............  Portland-Vancouver-            34.8208      33.1815
                      Beaverton, OR-WA.
38940..............  Port St. Lucie, FL.......      30.9663      29.5522
39100..............  Poughkeepsie-Newburgh-         33.6441      32.2649
                      Middletown, NY.
39140..............  Prescott, AZ.............      30.7280      29.1556
39300..............  Providence-New Bedford-        33.0234      31.8841
                      Fall River, RI-MA.
39340..............  Provo-Orem, UT...........      29.4108      28.0315
39380..............  Pueblo, CO...............      27.0881      25.6375
39460..............  Punta Gorda, FL..........      29.6415      28.1419
39540..............  Racine, WI...............      29.7218      27.6179
39580..............  Raleigh-Cary, NC.........      29.0544      28.3348
39660..............  Rapid City, SD...........      26.9357      25.9831
39740..............  Reading, PA..............      29.1969      28.3935
39820..............  Redding, CA..............      39.7597      36.7887
39900..............  Reno-Sparks, NV..........      34.2896      33.6154
40060..............  Richmond, VA.............      28.6347      27.1477

[[Page 24922]]

 
40140..............  Riverside-San Bernardino-      33.2757      32.0240
                      Ontario, CA.
40220..............  Roanoke, VA..............      29.2663      26.3177
40340..............  Rochester, MN............      33.3540      32.6100
40380..............  Rochester, NY............      27.5839      26.7250
40420..............  Rockford, IL.............      29.9396      29.2179
40484..............  Rockingham County-             31.1882      30.1242
                      Strafford County, NH.
40580..............  Rocky Mount, NC..........      27.9510      26.4642
40660..............  Rome, GA.................      29.6009      28.2852
40900..............  Sacramento--Arden-Arcade--     40.2929      38.4229
                      Roseville, CA.
40980..............  Saginaw-Saginaw Township       28.2929      27.0559
                      North, MI.
41060..............  St. Cloud, MN............      34.2927      31.6151
41100..............  St. George, UT...........      29.5906      28.1994
41140..............  St. Joseph, MO-KS........      27.3734      28.2406
41180..............  St. Louis, MO-IL.........      27.5406      26.4397
41420..............  Salem, OR................      32.2483      30.6937
41500..............  Salinas, CA..............      44.6611      42.1515
41540..............  Salisbury, MD............      27.6293      26.4517
41620..............  Salt Lake City, UT.......      29.3945      28.0053
41660..............  San Angelo, TX...........      26.8517      25.0303
41700..............  San Antonio, TX..........      27.6376      26.4378
41740..............  San Diego-Carlsbad-San         34.4952      33.2115
                      Marcos, CA.
41780..............  Sandusky, OH.............      27.1537      26.6087
41884..............  San Francisco-San Mateo-       45.7716      44.5272
                      Redwood City, CA.
41900..............  San Germ[aacute]n-Cabo         14.2741      13.8608
                      Rojo, PR.
41940..............  San Jose-Sunnyvale-Santa       47.5716      45.1683
                      Clara, CA.
41980..............  San Juan-Caguas-Guaynabo,      14.0009      13.3929
                      PR.
42020..............  San Luis Obispo-Paso           36.9259      33.8666
                      Robles, CA.
42044..............  Santa Ana-Anaheim-Irvine,      35.8808      33.9972
                      CA.
42060..............  Santa Barbara-Santa Maria-     35.4727      33.4432
                      Goleta, CA.
42100..............  Santa Cruz-Watsonville,        48.5637      45.3017
                      CA.
42140..............  Santa Fe, NM.............      33.1322      31.9531
42220..............  Santa Rosa-Petaluma, CA..      44.2225      41.4919
42260..............  Sarasota-Bradenton-            30.2493      28.7208
                      Venice, FL.
42340..............  Savannah, GA.............      27.8554      27.1733
42540..............  Scranton-Wilkes-Barre, PA      25.8844      24.7507
42644..............  Seattle-Bellevue-Everett,      35.1860      33.6677
                      WA.
42680..............  Sebastian-Vero Beach, FL.      30.0922      28.6105
43100..............  Sheboygan, WI............      28.0832      26.7407
43300..............  Sherman-Denison, TX......      26.4564      26.2405
43340..............  Shreveport-Bossier City,       26.7055      25.8214
                      LA.
43580..............  Sioux City, IA-NE-SD.....      28.5808      27.2053
43620..............  Sioux Falls, SD..........      29.6276      28.1066
43780..............  South Bend-Mishawaka, IN-      29.9084      28.9199
                      MI.
43900..............  Spartanburg, SC..........      28.9299      27.1549
44060..............  Spokane, WA..............      32.1950      31.1767
44100..............  Springfield, IL..........      27.7341      26.2610
44140..............  Springfield, MA..........      31.7303      30.1941
44180..............  Springfield, MO..........      28.5068      25.6242
44220..............  Springfield, OH..........      26.3899      25.0448
44300..............  State College, PA........      26.7336      25.2069
44700..............  Stockton, CA.............      36.3757      34.0601
44940..............  Sumter, SC...............      27.5115      25.3139
45060..............  Syracuse, NY.............      30.7252      28.8799
45104..............  Tacoma, WA...............      33.9097      31.9619
45220..............  Tallahassee, FL..........      27.9967      26.3266
45300..............  Tampa-St. Petersburg-          28.2629      27.2055
                      Clearwater, FL.
45460..............  Terre Haute, IN..........      27.3665      25.3379
45500..............  Texarkana, TX-Texarkana,       25.2054      24.1254
                      AR.
45780..............  Toledo, OH...............      28.7526      27.8529
45820..............  Topeka, KS...............      26.5384      25.8360
45940..............  Trenton-Ewing, NJ........      33.2291      31.9683
46060..............  Tucson, AZ...............      29.4005      27.5680
46140..............  Tulsa, OK................      26.3616      25.0135
46220..............  Tuscaloosa, AL...........      26.4544      25.5476
46340..............  Tyler, TX................      28.4878      26.8718
46540..............  Utica-Rome, NY...........      27.1982      25.5595
46660..............  Valdosta, GA.............      25.4416      25.1421
46700..............  Vallejo-Fairfield, CA....      44.6372      43.5597
47020..............  Victoria, TX.............      25.1770      24.3401

[[Page 24923]]

 
47220..............  Vineland-Millville-            33.0209      30.4618
                      Bridgeton, NJ.
47260..............  Virginia Beach-Norfolk-        27.2314      26.0029
                      Newport News, VA-NC.
47300..............  Visalia-Porterville, CA..      31.6337      30.0704
47380..............  Waco, TX.................      26.6527      25.4923
47580..............  Warner Robins, GA........      29.8152      26.8109
47644..............  Warren-Troy-Farmington         31.1213      29.5882
                      Hills, MI.
47894..............  Washington-Arlington-          33.1020      32.0904
                      Alexandria, DC-VA-MD-WV.
47940..............  Waterloo-Cedar Falls, IA.      27.0404      25.5291
48140..............  Wausau, WI...............      30.5699      29.0605
48260..............  Weirton-Steubenville, WV-      24.4652      23.3430
                      OH.
48300..............  Wenatchee, WA............      34.9702      31.3439
48424..............  West Palm Beach-Boca           29.7173      28.7189
                      Raton-Boynton Beach,.
48540..............  Wheeling, WV-OH..........      21.7311      20.9330
48620..............  Wichita, KS..............      27.9249      26.7367
48660..............  Wichita Falls, TX........      26.3114      24.9937
48700..............  Williamsport, PA.........      24.6486      23.9556
48864..............  Wilmington, DE-MD-NJ.....      33.0781      31.3150
48900..............  Wilmington, NC...........      28.9440      28.2419
49020..............  Winchester, VA-WV........      30.5335      29.6408
49180..............  Winston-Salem, NC........      28.1564      26.9277
49340..............  Worcester, MA............      35.1528      32.7168
49420..............  Yakima, WA...............      31.6557      29.7156
49500..............  Yauco, PR................      09.9275      11.1279
49620..............  York-Hanover, PA.........      28.8489      27.7627
49660..............  Youngstown-Warren-             27.8858      25.9934
                      Boardman, OH-PA.
49700..............  Yuba City, CA............      32.6357      31.5710
49740..............  Yuma, AZ.................      29.3504     27.3749
------------------------------------------------------------------------
\1\ This area has no average hourly wage because there are no short-
  term, acute care hospitals in the area.
\2\ This is a new CBSA for fiscal year 2008. To calculate the 3-year
  average hourly wage for this new area, we included the hospitals' data
  from their previous geographic location for fiscal year 2006 and
  fiscal year 2007.


  Table 3B.--FY 2008 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 2006, 2007, and 2008]
------------------------------------------------------------------------
                                                  FY 2008       3-Year
     CBSA code             Nonurban area          average      average
                                                hourly wage  hourly wage
------------------------------------------------------------------------
01.................  Alabama..................      23.5521      22.3676
02.................  Alaska...................      36.6306      33.8985
03.................  Arizona..................      27.8285      26.2195
04.................  Arkansas.................      23.2785      22.1149
05.................  California...............      35.9780      33.1876
06.................  Colorado.................      29.2965      27.4981
07.................  Connecticut..............      36.3353      34.8991
08.................  Delaware.................      30.2968      28.8250
10.................  Florida..................      26.6274      25.5376
11.................  Georgia..................      24.3756      23.0319
12.................  Hawaii...................      33.3239      31.5165
13.................  Idaho....................      24.4240      23.6078
14.................  Illinois.................      25.8984      24.5999
15.................  Indiana..................      26.6535      25.3496
16.................  Iowa.....................      26.2882      25.1297
17.................  Kansas...................      24.6946      23.6039
18.................  Kentucky.................      24.2146      23.0381
19.................  Louisiana................      23.5312      22.3366
20.................  Maine....................      26.0760      25.2175
21.................  Maryland.................      27.6395      26.7366
22.................  Massachusetts \1\........  ...........  ...........
23.................  Michigan.................      27.5837      26.4032
24.................  Minnesota................      28.5541      27.0433
25.................  Mississippi..............      24.5289      23.0377
26.................  Missouri.................      25.0101      23.6921
27.................  Montana..................      25.8421      25.3487
28.................  Nebraska.................      27.1777      25.6347
29.................  Nevada...................      30.0298      27.4114
30.................  New Hampshire............      33.8547      32.1650
31.................  New Jersey \1\...........  ...........  ...........

[[Page 24924]]

 
32.................  New Mexico...............      27.7898      25.6380
33.................  New York.................      25.8757      24.4927
34.................  North Carolina...........      26.6830      25.3984
35.................  North Dakota.............      22.6664      21.5961
36.................  Ohio.....................      26.9698      25.8025
37.................  Oklahoma.................      23.8387      22.7968
38.................  Oregon...................      30.7212      28.9514
39.................  Pennsylvania.............      25.8767      24.5786
40.................  Puerto Rico \1\..........  ...........  ...........
41.................  Rhode Island \1\.........  ...........  ...........
42.................  South Carolina...........      27.2502      25.7842
43.................  South Dakota.............      25.8592      24.7950
44.................  Tennessee................      24.3749      23.4834
45.................  Texas....................      25.4299      24.0807
46.................  Utah.....................      25.6240      24.2425
47.................  Vermont..................      30.2045      28.6321
49.................  Virginia.................      25.0426      23.8317
50.................  Washington...............      31.5068      30.3826
51.................  West Virginia............      23.4572      22.6937
52.................  Wisconsin................      29.8668      28.3189
53.................  Wyoming..................      28.5623     27.0729
------------------------------------------------------------------------
\1\ All counties within the State or territory are classified as urban.


Table 4A.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
                      Urban Areas by CBSA--FY 2008
------------------------------------------------------------------------
                         Urban area (constituent       Wage
      CBSA code                 counties)             index       GAF
------------------------------------------------------------------------
10180................  Abilene, TX................     0.8244     0.8761
                        Callahan County, TX.......
                        Jones County, TX..........
                        Taylor County, TX.........
10380................  Aguadilla-Isabela-San           0.3298     0.4678
                        Sebasti[aacute]n, PR.
                        Aguada Municipio, PR......
                        Aguadilla Municipio, PR...
                        A[ntilde]asco Municipio,
                        PR.
                        Isabela Municipio, PR.....
                        Lares Municipio, PR.......
                        Moca Municipio, PR........
                        Rinc[oacute]n Municipio,
                        PR.
                        San Sebasti[aacute]n
                        Municipio, PR.
10420................  Akron, OH..................     0.8854     0.9200
                        Portage County, OH........
                        Summit County, OH.........
10500................  Albany, GA.................     0.8671     0.9070
                        Baker County, GA..........
                        Dougherty County, GA......
                        Lee County, GA............
                        Terrell County, GA........
                        Worth County, GA..........
10580................  Albany-Schenectady-Troy, NY     0.8672     0.9070
                        Albany County, NY.........
                        Rensselaer County, NY.....
                        Saratoga County, NY.......
                        Schenectady County, NY....
                        Schoharie County, NY......
10740................  Albuquerque, NM............     0.9740     0.9821
                        Bernalillo County, NM.....
                        Sandoval County, NM.......
                        Torrance County, NM.......
                        Valencia County, NM.......
10780................  Alexandria, LA.............     0.7982     0.8570
                        Grant Parish, LA..........
                        Rapides Parish, LA........
10900................  Allentown-Bethlehem-Easton,     1.0024     1.0016
                        PA-NJ.
                        Warren County, NJ.........
                        Carbon County, PA.........

[[Page 24925]]

 
                        Lehigh County, PA.........
                        Northampton County, PA....
11020................  \2\ Altoona, PA............     0.8366     0.8850
                        Blair County, PA..........
11100................  Amarillo, TX...............     0.9141     0.9403
                        Armstrong County, TX......
                        Carson County, TX.........
                        Potter County, TX.........
                        Randall County, TX........
11180................  Ames, IA...................     0.9982     0.9988
                        Story County, IA..........
11260................  Anchorage, AK..............     1.1840     1.1226
                        Anchorage Municipality, AK
                        Matanuska-Susitna Borough,
                        AK.
11300................  Anderson, IN...............     0.8969     0.9282
                        Madison County, IN........
11340................  Anderson, SC...............     0.9087     0.9365
                        Anderson County, SC.......
11460................  Ann Arbor, MI..............     1.0504     1.0342
                        Washtenaw County, MI......
11500................  Anniston-Oxford, AL........     0.8042     0.8614
                        Calhoun County, AL........
11540................  \2\ Appleton, WI...........     0.9635     0.9749
                        Calumet County, WI........
                        Outagamie County, WI......
11700................  Asheville, NC..............     0.9209     0.9451
                        Buncombe County, NC.......
                        Haywood County, NC........
                        Henderson County, NC......
                        Madison County, NC........
12020................  Athens-Clarke County, GA...     1.0543     1.0369
                        Clarke County, GA.........
                        Madison County, GA........
                        Oconee County, GA.........
                        Oglethorpe County, GA.....
12060................  \1\ Atlanta-Sandy Springs-      0.9845     0.9894
                        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.......
                        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..........     1.2095     1.1391
                        Atlantic County, NJ.......
12220................  Auburn-Opelika, AL.........     0.8086     0.8646
                        Lee County, AL............
12260................  Augusta-Richmond County, GA-    0.9600     0.9724
                        SC.
                        Burke County, GA..........

[[Page 24926]]

 
                        Columbia County, GA.......
                        McDuffie County, GA.......
                        Richmond County, GA.......
                        Aiken County, SC..........
                        Edgefield County, SC......
12420................  \1\ Austin-Round Rock, TX..     0.9518     0.9667
                        Bastrop County, TX........
                        Caldwell County, TX.......
                        Hays County, TX...........
                        Travis County, TX.........
                        Williamson County, TX.....
12540................  \2\ Bakersfield, CA........     1.1607     1.1074
                        Kern County, CA...........
12580................  \1\ Baltimore-Towson, MD...     1.0108     1.0074
                        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.................     0.9860     0.9904
                        Penobscot County, ME......
12700................  Barnstable Town, MA........     1.2617     1.1726
                        Barnstable County, MA.....
12940................  Baton Rouge, LA............     0.8014     0.8593
                        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...........     1.0042     1.0029
                        Calhoun County, MI........
13020................  Bay City, MI...............     0.9399     0.9584
                        Bay County, MI............
13140................  Beaumont-Port Arthur, TX...     0.8587     0.9009
                        Hardin County, TX.........
                        Jefferson County, TX......
                        Orange County, TX.........
13380................  Bellingham, WA.............     1.1264     1.0849
                        Whatcom County, WA........
13460................  Bend, OR...................     1.0592     1.0402
                        Deschutes County, OR......
13644................  \1\ Bethesda-Gaithersburg-      1.0990     1.0668
                        Frederick, MD.
                        Frederick County, MD......
                        Montgomery County, MD.....
13740................  Billings, MT...............     0.8877     0.9217
                        Carbon County, MT.........
                        Yellowstone County, MT....
13780................  Binghamton, NY.............     0.9072     0.9355
                        Broome County, NY.........
                        Tioga County, NY..........
13820................  \1\ Birmingham-Hoover, AL..     0.8873     0.9214
                        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...............     0.7329     0.8083
                        Burleigh County, ND.......
                        Morton County, ND.........
13980................  \2\ Blacksburg-                 0.8095     0.8653
                        Christiansburg-Radford, VA.
                        Giles County, VA..........
                        Montgomery County, VA.....

[[Page 24927]]

 
                        Pulaski County, VA........
                        Radford City, VA..........
14020................  Bloomington, IN............     0.9327     0.9534
                        Greene County, IN.........
                        Monroe County, IN.........
                        Owen County, IN...........
14060................  Bloomington-Normal, IL.....     0.9488     0.9646
                        McLean County, IL.........
14260................  Boise City-Nampa, ID.......     0.9501     0.9656
                        Ada County, ID............
                        Boise County, ID..........
                        Canyon County, ID.........
                        Gem County, ID............
                        Owyhee County, ID.........
14484................  \1\ Boston-Quincy, MA......     1.1710     1.1142
                        Norfolk County, MA........
                        Plymouth County, MA.......
                        Suffolk County, MA........
14500................  Boulder, CO................     1.0118     1.0081
                        Boulder County, CO........
14540................  Bowling Green, KY..........     0.8089     0.8648
                        Edmonson County, KY.......
                        Warren County, KY.........
14740................  Bremerton-Silverdale, WA...     1.0826     1.0559
                        Kitsap County, WA.........
14860................  Bridgeport-Stamford-            1.2886     1.1896
                        Norwalk, CT.
                        Fairfield County, CT......
15180................  Brownsville-Harlingen, TX..     0.9577     0.9708
                        Cameron County, TX........
15260................  Brunswick, GA..............     0.9768     0.9841
                        Brantley County, GA.......
                        Glynn County, GA..........
                        McIntosh County, GA.......
15380................  \1\ Buffalo-Niagara Falls,      0.9586     0.9715
                        NY.
                        Erie County, NY...........
                        Niagara County, NY........
15500................  \2\ Burlington, NC.........     0.8608     0.9024
                        Alamance County, NC.......
15540................  \2\ Burlington-South            1.0401     1.0273
                        Burlington, VT.
                        Chittenden County, VT.....
                        Franklin County, VT.......
                        Grand Isle County, VT.....
15764................  \1\ Cambridge-Newton-           1.1168     1.0786
                        Framingham, MA.
                        Middlesex County, MA......
15804................  \1\ Camden, NJ.............     1.0522     1.0355
                        Burlington County, NJ.....
                        Camden County, NJ.........
                        Gloucester County, NJ.....
15940................  Canton-Massillon, OH.......     0.8921     0.9248
                        Carroll County, OH........
                        Stark County, OH..........
15980................  Cape Coral-Fort Myers, FL..     0.9490     0.9648
                        Lee County, FL............
16180................  \2\ Carson City, NV........     0.9688     0.9785
                        Carson City, NV...........
16220................  Casper, WY.................     0.9277     0.9499
                        Natrona County, WY........
16300................  Cedar Rapids, IA...........     0.8689     0.9083
                        Benton County, IA.........
                        Jones County, IA..........
                        Linn County, IA...........
16580................  Champaign-Urbana, IL.......     0.9320     0.9529
                        Champaign County, IL......
                        Ford County, IL...........
                        Piatt County, IL..........
16620................  Charleston, WV.............     0.8397     0.8872
                        Boone County, WV..........
                        Clay County, WV...........
                        Kanawha County, WV........
                        Lincoln County, WV........

[[Page 24928]]

 
                        Putnam County, WV.........
16700................  Charleston-North                0.9144     0.9406
                        Charleston, SC.
                        Berkeley County, SC.......
                        Charleston County, SC.....
                        Dorchester County, SC.....
16740................  \1\ Charlotte-Gastonia-         0.9512     0.9663
                        Concord, NC-SC.
                        Anson County, NC..........
                        Cabarrus County, NC.......
                        Gaston County, NC.........
                        Mecklenburg County, NC....
                        Union County, NC..........
                        York County, SC...........
16820................  Charlottesville, VA........     0.9555     0.9693
                        Albemarle County, VA......
                        Fluvanna County, VA.......
                        Greene County, VA.........
                        Nelson County, VA.........
                        Charlottesville City, VA..
16860................  Chattanooga, TN-GA.........     0.8967     0.9281
                        Catoosa County, GA........
                        Dade County, GA...........
                        Walker County, GA.........
                        Hamilton County, TN.......
                        Marion County, TN.........
                        Sequatchie County, TN.....
16940................  Cheyenne, WY...............     0.9219     0.9458
                        Laramie County, WY........
16974................  \1\ Chicago-Naperville-         1.0455     1.0309
                        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..............     1.1607     1.1074
                        Butte County, CA..........
17140................  \1\ Cincinnati-Middletown,      0.9654     0.9762
                        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.......
                        Hamilton County, OH.......
                        Warren County, OH.........
17300................  Clarksville, TN-KY.........     0.8223     0.8746
                        Christian County, KY......
                        Trigg County, KY..........
                        Montgomery County, TN.....
                        Stewart County, TN........
17420................  Cleveland, TN..............     0.8174     0.8710
                        Bradley County, TN........
                        Polk County, TN...........
17460................  \1\ Cleveland-Elyria-           0.9365     0.9561
                        Mentor, OH.
                        Cuyahoga County, OH.......
                        Geauga County, OH.........
                        Lake County, OH...........
                        Lorain County, OH.........
                        Medina County, OH.........
17660................  Coeur d'Alene, ID..........     0.9360     0.9557
                        Kootenai County, ID.......

[[Page 24929]]

 
17780................  College Station-Bryan, TX..     0.9177     0.9429
                        Brazos County, TX.........
                        Burleson County, TX.......
                        Robertson County, TX......
17820................  Colorado Springs, CO.......     0.9471     0.9635
                        El Paso County, CO........
                        Teller County, CO.........
17860................  Columbia, MO...............     0.8545     0.8979
                        Boone County, MO..........
                        Howard County, MO.........
17900................  \2\ Columbia, SC...........     0.8791     0.9155
                        Calhoun County, SC........
                        Fairfield County, SC......
                        Kershaw County, SC........
                        Lexington County, SC......
                        Richland County, SC.......
                        Saluda County, SC.........
17980................  Columbus, GA-AL............     0.9023     0.9320
                        Russell County, AL........
                        Chattahoochee County, GA..
                        Harris County, GA.........
                        Marion County, GA.........
                        Muscogee County, GA.......
18020................  Columbus, IN...............     0.9630     0.9745
                        Bartholomew County, IN....
18140................  \1\ Columbus, OH...........     1.0048     1.0033
                        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.........     0.8460     0.8918
                        Aransas County, TX........
                        Nueces County, TX.........
                        San Patricio County, TX...
18700................  Corvallis, OR..............     1.0708     1.0480
                        Benton County, OR.........
19060................  \2\ Cumberland, MD-WV (MD       0.8917     0.9245
                        Hospitals).
                        Allegany County, MD.......
                        Mineral County, WV........
19060................  Cumberland, MD-WV (WV           0.7967     0.8559
                        Hospitals).
                        Allegany County, MD.......
                        Mineral County, WV........
19124................  \1\ Dallas-Plano-Irving, TX     0.9795     0.9859
                        Collin County, TX.........
                        Dallas County, TX.........
                        Delta County, TX..........
                        Denton County, TX.........
                        Ellis County, TX..........
                        Hunt County, TX...........
                        Kaufman County, TX........
                        Rockwall County, TX.......
19140................  Dalton, GA.................     0.8587     0.9009
                        Murray County, GA.........
                        Whitfield County, GA......
19180................  Danville, IL...............     0.9250     0.9480
                        Vermilion County, IL......
19260................  Danville, VA...............     0.8486     0.8937
                        Pittsylvania County, VA...
                        Danville City, VA.........
19340................  Davenport-Moline-Rock           0.8898     0.9232
                        Island, IA-IL.
                        Henry County, IL..........
                        Mercer County, IL.........
                        Rock Island County, IL....
                        Scott County, IA..........
19380................  Dayton, OH.................     0.9283     0.9503
                        Greene County, OH.........

[[Page 24930]]

 
                        Miami County, OH..........
                        Montgomery County, OH.....
                        Preble County, OH.........
19460................  Decatur, AL................     0.7927     0.8529
                        Lawrence County, AL.......
                        Morgan County, AL.........
19500................  \2\ Decatur, IL............     0.8355     0.8842
                        Macon County, IL..........
19660................  Deltona-Daytona Beach-          0.8948     0.9267
                        Ormond Beach, FL.
                        Volusia County, FL........
19740................  \1\ Denver-Aurora, CO......     1.0490     1.0333
                        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-West Des Moines,     0.9162     0.9418
                        IA.
                        Dallas County, IA.........
                        Guthrie County, IA........
                        Madison County, IA........
                        Polk County, IA...........
                        Warren County, IA.........
19804................  \1\ Detroit-Livonia-            1.0091     1.0062
                        Dearborn, MI.
                        Wayne County, MI..........
20020................  \2\ Dothan, AL.............     0.7598     0.8285
                        Geneva County, AL.........
                        Henry County, AL..........
                        Houston County, AL........
20100................  Dover, DE..................     1.0396     1.0270
                        Kent County, DE...........
20220................  Dubuque, IA................     0.8874     0.9215
                        Dubuque County, IA........
20260................  Duluth, MN-WI..............     1.0151     1.0103
                        Carlton County, MN........
                        St. Louis County, MN......
                        Douglas County, WI........
20500................  Durham, NC.................     0.9814     0.9872
                        Chatham County, NC........
                        Durham County, NC.........
                        Orange County, NC.........
                        Person County, NC.........
20740................  \2\ Eau Claire, WI.........     0.9635     0.9749
                        Chippewa County, WI.......
                        Eau Claire County, WI.....
20764................  \1\ Edison, NJ.............     1.1131     1.0761
                        Middlesex County, NJ......
                        Monmouth County, NJ.......
                        Ocean County, NJ..........
                        Somerset County, NJ.......
20940................  \2\ El Centro, CA..........     1.1607     1.1074
                        Imperial County, CA.......
21060................  Elizabethtown, KY..........     0.8622     0.9035
                        Hardin County, KY.........
                        Larue County, KY..........
21140................  Elkhart-Goshen, IN.........     0.9438     0.9612
                        Elkhart County, IN........
21300................  \2\ Elmira, NY.............     0.8440     0.8903
                        Chemung County, NY........
21340................  El Paso, TX................     0.9144     0.9406
                        El Paso County, TX........
21500................  Erie, PA...................     0.8507     0.8952
                        Erie County, PA...........
21660................  Eugene-Springfield, OR.....     1.1008     1.0680
                        Lane County, OR...........
21780................  \2\ Evansville, IN-KY (IN       0.8599     0.9018
                        Hospitals).

[[Page 24931]]

 
                        Gibson County, IN.........
                        Posey County, IN..........
                        Vanderburgh County, IN....
                        Warrick County, IN........
                        Henderson County, KY......
                        Webster County, KY........
21780................  Evansville, IN-KY (KY           0.8469     0.8924
                        Hospitals).
                        Gibson County, IN.........
                        Posey County, IN..........
                        Vanderburgh County, IN....
                        Warrick County, IN........
                        Henderson County, KY......
                        Webster County, KY........
21820................  \2\ Fairbanks, AK..........     1.1817     1.1211
                        Fairbanks North Star
                        Borough, AK.
21940................  Fajardo, PR................     0.4121     0.5449
                        Ceiba Municipio, PR.......
                        Fajardo Municipio, PR.....
                        Luquillo Municipio, PR....
22020................  \2\ Fargo, ND-MN (MN            0.9212     0.9453
                        Hospitals).
                        Clay County, MN...........
                        Cass County, ND...........
22020................  Fargo, ND-MN (ND Hospitals)     0.8189     0.8721
                        Clay County, MN...........
                        Cass County, ND...........
22140................  Farmington, NM.............     0.9289     0.9507
                        San Juan County, NM.......
22180................  Fayetteville, NC...........     0.9926     0.9949
                        Cumberland County, NC.....
                        Hoke County, NC...........
22220................  Fayetteville-Springdale-        0.8876     0.9216
                        Rogers, AR-MO.
                        Benton County, AR.........
                        Madison County, AR........
                        Washington County, AR.....
                        McDonald County, MO.......
22380................  Flagstaff, AZ..............     1.1558     1.1042
                        Coconino County, AZ.......
22420................  Flint, MI..................     1.1078     1.0726
                        Genesee County, MI........
22500................  \2\ Florence, SC...........     0.8791     0.9155
                        Darlington County, SC.....
                        Florence County, SC.......
22520................  Florence-Muscle Shoals, AL.     0.7971     0.8562
                        Colbert County, AL........
                        Lauderdale County, AL.....
22540................  Fond du Lac, WI............     0.9892     0.9926
                        Fond du Lac County, WI....
22660................  Fort Collins-Loveland, CO..     0.9577     0.9708
                        Larimer County, CO........
22744................  \1\ Fort Lauderdale-Pompano     1.0245     1.0167
                        Beach-Deerfield Beach, FL.
                        Broward County, FL........
22900................  Fort Smith, AR-OK..........     0.8056     0.8624
                        Crawford County, AR.......
                        Franklin County, AR.......
                        Sebastian County, AR......
                        Le Flore County, OK.......
                        Sequoyah County, OK.......
23020................  \2\ Fort Walton Beach-          0.8749     0.9125
                        Crestview-Destin, FL.
                        Okaloosa County, FL.......
23060................  Fort Wayne, IN.............     0.9046     0.9336
                        Allen County, IN..........
                        Wells County, IN..........
                        Whitley County, IN........
23104................  \1\ Fort Worth-Arlington,       0.9646     0.9756
                        TX.
                        Johnson County, TX........
                        Parker County, TX.........
                        Tarrant County, TX........
                        Wise County, TX...........
23420................  \2\ Fresno, CA.............     1.1607     1.1074
                        Fresno County, CA.........

[[Page 24932]]

 
23460................  Gadsden, AL................     0.8129     0.8677
                        Etowah County, AL.........
23540................  Gainesville, FL............     0.9306     0.9519
                        Alachua County, FL........
                        Gilchrist County, FL......
23580................  Gainesville, GA............     0.9423     0.9601
                        Hall County, GA...........
23844................  Gary, IN...................     0.9246     0.9477
                        Jasper County, IN.........
                        Lake County, IN...........
                        Newton County, IN.........
                        Porter County, IN.........
24020................  Glens Falls, NY............     0.8526     0.8965
                        Warren County, NY.........
                        Washington County, NY.....
24140................  Goldsboro, NC..............     0.9276     0.9498
                        Wayne County, NC..........
24220................  \2\ Grand Forks, ND-MN (MN      0.9212     0.9453
                        Hospitals).
                        Polk County, MN...........
                        Grand Forks County, ND....
24220................  Grand Forks, ND-MN (ND          0.7729     0.8383
                        Hospitals).
                        Polk County, MN...........
                        Grand Forks County, ND....
24300................  Grand Junction, CO.........     1.0141     1.0096
                        Mesa County, CO...........
24340................  Grand Rapids-Wyoming, MI...     0.9380     0.9571
                        Barry County, MI..........
                        Ionia County, MI..........
                        Kent County, MI...........
                        Newaygo County, MI........
24500................  Great Falls, MT............     0.8765     0.9137
                        Cascade County, MT........
24540................  Greeley, CO................     1.0000     1.0000
                        Weld County, CO...........
24580................  \2\ Green Bay, WI..........     0.9635     0.9749
                        Brown County, WI..........
                        Kewaunee County, WI.......
                        Oconto County, WI.........
24660................  Greensboro-High Point, NC..     0.9111     0.9382
                        Guilford County, NC.......
                        Randolph County, NC.......
                        Rockingham County, NC.....
24780................  Greenville, NC.............     0.9272     0.9496
                        Greene County, NC.........
                        Pitt County, NC...........
24860................  Greenville-Mauldin-Easley,      0.9664     0.9769
                        SC.
                        Greenville County, SC.....
                        Laurens County, SC........
                        Pickens County, SC........
25020................  Guayama, PR................     0.2946     0.4330
                        Arroyo Municipio, PR......
                        Guayama Municipio, PR.....
                        Patillas Municipio, PR....
25060................  Gulfport-Biloxi, MS........     0.8618     0.9032
                        Hancock County, MS........
                        Harrison County, MS.......
                        Stone County, MS..........
25180................  Hagerstown-Martinsburg, MD-     0.9259     0.9486
                        WV.
                        Washington County, MD.....
                        Berkeley County, WV.......
                        Morgan County, WV.........
25260................  \2\ Hanford-Corcoran, CA...     1.1607     1.1074
                        Kings County, CA..........
25420................  Harrisburg-Carlisle, PA....     0.9240     0.9473
                        Cumberland County, PA.....
                        Dauphin County, PA........
                        Perry County, PA..........
25500................  Harrisonburg, VA...........     0.8976     0.9287
                        Rockingham County, VA.....
                        Harrisonburg City, VA.....

[[Page 24933]]

 
25540................  \1\ \2\ Hartford-West           1.2439     1.1612
                        Hartford-East Hartford, CT.
                        Hartford County, CT.......
                        Litchfield County, CT.....
                        Middlesex County, CT......
                        Tolland County, CT........
25620................  \2\ Hattiesburg, MS........     0.7915     0.8520
                        Forrest County, MS........
                        Lamar County, MS..........
                        Perry County, MS..........
25860................  Hickory-Lenoir-Morganton,       0.8977     0.9288
                        NC.
                        Alexander County, NC......
                        Burke County, NC..........
                        Caldwell County, NC.......
                        Catawba County, NC........
25980................  Hinesville-Fort Stewart, GA     0.7864     0.8483
                        Liberty County, GA........
                        Long County, GA...........
26100................  Holland-Grand Haven, MI....     0.9066     0.9351
                        Ottawa County, MI.........
26180................  Honolulu, HI...............     1.1289     1.0866
                        Honolulu County, HI.......
26300................  Hot Springs, AR............     0.9110     0.9382
                        Garland County, AR........
26380................  Houma-Bayou Cane-Thibodaux,     0.7980     0.8568
                        LA.
                        Lafourche Parish, LA......
                        Terrebonne Parish, LA.....
26420................  \1\ Houston-Sugar Land-         1.0048     1.0033
                        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-      0.8845     0.9194
                        OH.
                        Boyd County, KY...........
                        Greenup County, KY........
                        Lawrence County, OH.......
                        Cabell County, WV.........
                        Wayne County, WV..........
26620................  Huntsville, AL.............     0.9175     0.9427
                        Limestone County, AL......
                        Madison County, AL........
26820................  Idaho Falls, ID............     0.9352     0.9552
                        Bonneville County, ID.....
                        Jefferson County, ID......
26900................  \1\ Indianapolis-Carmel, IN     0.9723     0.9809
                        Boone County, IN..........
                        Brown County, IN..........
                        Hamilton County, IN.......
                        Hancock County, IN........
                        Hendricks County, IN......
                        Johnson County, IN........
                        Marion County, IN.........
                        Morgan County, IN.........
                        Putnam County, IN.........
                        Shelby County, IN.........
26980................  Iowa City, IA..............     0.9428     0.9605
                        Johnson County, IA........
                        Washington County, IA.....
27060................  Ithaca, NY.................     0.9715     0.9804
                        Tompkins County, NY.......
27100................  Jackson, MI................     0.9465     0.9630
                        Jackson County, MI........
27140................  Jackson, MS................     0.8273     0.8782
                        Copiah County, MS.........
                        Hinds County, MS..........

[[Page 24934]]

 
                        Madison County, MS........
                        Rankin County, MS.........
                        Simpson County, MS........
27180................  Jackson, TN................     0.8590     0.9012
                        Chester County, TN........
                        Madison County, TN........
27260................  \1\ Jacksonville, FL.......     0.9129     0.9395
                        Baker County, FL..........
                        Clay County, FL...........
                        Duval County, FL..........
                        Nassau County, FL.........
                        St. Johns County, FL......
27340................  \2\ Jacksonville, NC.......     0.8608     0.9024
                        Onslow County, NC.........
27500................  Janesville, WI.............     0.9813     0.9872
                        Rock County, WI...........
27620................  Jefferson City, MO.........     0.8706     0.9095
                        Callaway County, MO.......
                        Cole County, MO...........
                        Moniteau County, MO.......
                        Osage County, MO..........
27740................  \2\ Johnson City, TN.......     0.7916     0.8521
                        Carter County, TN.........
                        Unicoi County, TN.........
                        Washington County, TN.....
27780................  \2\ Johnstown, PA..........     0.8366     0.8850
                        Cambria County, PA........
27860................  Jonesboro, AR..............     0.8507     0.8952
                        Craighead County, AR......
                        Poinsett County, AR.......
27900................  Joplin, MO.................     0.9318     0.9528
                        Jasper County, MO.........
                        Newton County, MO.........
28020................  Kalamazoo-Portage, MI......     1.0505     1.0343
                        Kalamazoo County, MI......
                        Van Buren County, MI......
28100................  Kankakee-Bradley, IL.......     1.1678     1.1121
                        Kankakee County, IL.......
28140................  \1\ Kansas City, MO-KS.....     0.9321     0.9530
                        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................  \2\ Kennewick-Richland-         1.0565     1.0384
                        Pasco, WA.
                        Benton County, WA.........
                        Franklin County, WA.......
28660................  Killeen-Temple-Fort Hood,       0.8308     0.8808
                        TX.
                        Bell County, TX...........
                        Coryell County, TX........
                        Lampasas County, TX.......
28700................  \2\ Kingsport-Bristol-          0.7916     0.8521
                        Bristol, TN-VA (TN
                        Hospitals).
                        Hawkins County, TN........
                        Sullivan County, TN.......
                        Bristol City, VA..........
                        Scott County, VA..........
                        Washington County, VA.....
28700................  \2\ Kingsport-Bristol-          0.8095     0.8653
                        Bristol, TN-VA (VA
                        Hospitals).
                        Hawkins County, TN........
                        Sullivan County, TN.......

[[Page 24935]]

 
                        Bristol City, VA..........
                        Scott County, VA..........
                        Washington County, VA.....
28740................  Kingston, NY...............     0.9518     0.9667
                        Ulster County, NY.........
28940................  Knoxville, TN..............     0.8042     0.8614
                        Anderson County, TN.......
                        Blount County, TN.........
                        Knox County, TN...........
                        Loudon County, TN.........
                        Union County, TN..........
29020................  Kokomo, IN.................     0.9468     0.9633
                        Howard County, IN.........
                        Tipton County, IN.........
29100................  La Crosse, WI-MN...........     0.9704     0.9796
                        Houston County, MN........
                        La Crosse County, WI......
29140................  Lafayette, IN..............     0.8682     0.9078
                        Benton County, IN.........
                        Carroll County, IN........
                        Tippecanoe County, IN.....
29180................  Lafayette, LA..............     0.8323     0.8819
                        Lafayette Parish, LA......
                        St. Martin Parish, LA.....
29340................  Lake Charles, LA...........     0.7787     0.8426
                        Calcasieu Parish, LA......
                        Cameron Parish, LA........
29404................  Lake County-Kenosha County,     1.0287     1.0196
                        IL-WI.
                        Lake County, IL...........
                        Kenosha County, WI........
29420................  \2\ Lake Havasu City-           0.9386     0.9575
                        Kingman, AZ.
                        Mohave County, AZ.........
29460................  Lakeland, FL...............     0.8839     0.9190
                        Polk County, FL...........
29540................  Lancaster, PA..............     0.9589     0.9717
                        Lancaster County, PA......
29620................  Lansing-East Lansing, MI...     1.0053     1.0036
                        Clinton County, MI........
                        Eaton County, MI..........
                        Ingham County, MI.........
29700................  Laredo, TX.................     0.8484     0.8935
                        Webb County, TX...........
29740................  \2\ Las Cruces, NM.........     0.8965     0.9279
                        Dona Ana County, NM.......
29820................  \1\ Las Vegas-Paradise, NV.     1.1431     1.0959
                        Clark County, NV..........
29940................  Lawrence, KS...............     0.8208     0.8735
                        Douglas County, KS........
30020................  Lawton, OK.................     0.8406     0.8879
                        Comanche County, OK.......
30140................  \2\ Lebanon, PA............     0.8366     0.8850
                        Lebanon County, PA........
30300................  Lewiston, ID-WA (ID             0.9231     0.9467
                        Hospitals).
                        Nez Perce County, ID......
                        Asotin County, WA.........
30300................  \2\ Lewiston, ID-WA (WA         1.0565     1.0384
                        Hospitals).
                        Nez Perce County, ID......
                        Asotin County, WA.........
30340................  Lewiston-Auburn, ME........     0.9295     0.9512
                        Androscoggin County, ME...
30460................  Lexington-Fayette, KY......     0.9027     0.9323
                        Bourbon County, KY........
                        Clark County, KY..........
                        Fayette County, KY........
                        Jessamine County, KY......
                        Scott County, KY..........
                        Woodford County, KY.......
30620................  Lima, OH...................     0.9312     0.9524
                        Allen County, OH..........
30700................  Lincoln, NE................     0.9836     0.9887

[[Page 24936]]

 
                        Lancaster County, NE......
                        Seward County, NE.........
30780................  Little Rock-North Little        0.8965     0.9279
                        Rock-Conway, AR.
                        Faulkner County, AR.......
                        Grant County, AR..........
                        Lonoke County, AR.........
                        Perry County, AR..........
                        Pulaski County, AR........
                        Saline County, AR.........
30860................  Logan, UT-ID...............     0.9219     0.9458
                        Franklin County, ID.......
                        Cache County, UT..........
30980................  Longview, TX...............     0.8875     0.9215
                        Gregg County, TX..........
                        Rusk County, TX...........
                        Upshur County, TX.........
31020................  Longview, WA...............     1.1033     1.0696
                        Cowlitz County, WA........
31084................  \1\ Los Angeles-Long Beach-     1.1633     1.1091
                        Glendale, CA.
                        Los Angeles County, CA....
31140................  \1\ Louisville-Jefferson        0.9045     0.9336
                        County, KY-IN.
                        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................     0.8678     0.9075
                        Crosby County, TX.........
                        Lubbock County, TX........
31340................  Lynchburg, VA..............     0.8490     0.8940
                        Amherst County, VA........
                        Appomattox County, VA.....
                        Bedford County, VA........
                        Campbell County, VA.......
                        Bedford City, VA..........
                        Lynchburg City, VA........
31420................  Macon, GA..................     0.9752     0.9829
                        Bibb County, GA...........
                        Crawford County, GA.......
                        Jones County, GA..........
                        Monroe County, GA.........
                        Twiggs County, GA.........
31460................  \2\ Madera, CA.............     1.1607     1.1074
                        Madera County, CA.........
31540................  Madison, WI................     1.1181     1.0794
                        Columbia County, WI.......
                        Dane County, WI...........
                        Iowa County, WI...........
31700................  \2\ Manchester-Nashua, NH..     1.1266     1.0851
                        Hillsborough County, NH...
                        Merrimack County, NH......
31900................  Mansfield, OH..............     0.9214     0.9455
                        Richland County, OH.......
32420................  Mayag[uuml]ez, PR..........     0.3659     0.5023
                        Hormigueros Municipio, PR.
                        Mayag[uuml]ez Municipio,
                        PR.
32580................  McAllen-Edinburg-Mission,       0.9140     0.9403
                        TX.
                        Hidalgo County, TX........
32780................  Medford, OR................     1.0304     1.0207
                        Jackson County, OR........
32820................  \1\ Memphis, TN-MS-AR......     0.9291     0.9509
                        Crittenden County, AR.....

[[Page 24937]]

 
                        DeSoto County, MS.........
                        Marshall County, MS.......
                        Tate County, MS...........
                        Tunica County, MS.........
                        Fayette County, TN........
                        Shelby County, TN.........
                        Tipton County, TN.........
32900................  Merced, CA.................     1.1961     1.1305
                        Merced County, CA.........
33124................  \1\ Miami-Miami Beach-          1.0023     1.0016
                        Kendall, FL.
                        Miami-Dade County, FL.....
33140................  Michigan City-La Porte, IN.     0.8791     0.9155
                        LaPorte County, IN........
33260................  Midland, TX................     1.0016     1.0011
                        Midland County, TX........
33340................  \1\ Milwaukee-Waukesha-West     1.0296     1.0202
                        Allis, WI.
                        Milwaukee County, WI......
                        Ozaukee County, WI........
                        Washington County, WI.....
                        Waukesha County, WI.......
33460................  \1\ Minneapolis-St. Paul-       1.0961     1.0649
                        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...............     0.8737     0.9117
                        Missoula County, MT.......
33660................  Mobile, AL.................     0.7950     0.8546
                        Mobile County, AL.........
33700................  Modesto, CA................     1.1989     1.1323
                        Stanislaus County, CA.....
33740................  Monroe, LA.................     0.7872     0.8489
                        Ouachita Parish, LA.......
                        Union Parish, LA..........
33780................  Monroe, MI.................     0.9475     0.9637
                        Monroe County, MI.........
33860................  Montgomery, AL.............     0.8366     0.8850
                        Autauga County, AL........
                        Elmore County, AL.........
                        Lowndes County, AL........
                        Montgomery County, AL.....
34060................  Morgantown, WV.............     0.8411     0.8883
                        Monongalia County, WV.....
                        Preston County, WV........
34100................  \2\ Morristown, TN.........     0.7916     0.8521
                        Grainger County, TN.......
                        Hamblen County, TN........
                        Jefferson County, TN......
34580................  \2\ Mount Vernon-Anacortes,     1.0565     1.0384
                        WA.
                        Skagit County, WA.........
34620................  \2\ Muncie, IN.............     0.8599     0.9018
                        Delaware County, IN.......
34740................  Muskegon-Norton Shores, MI.     0.9935     0.9955
                        Muskegon County, MI.......
34820................  \2\ Myrtle Beach-Conway-        0.8791     0.9155
                        North Myrtle Beach, SC.
                        Horry County, SC..........
34900................  Napa, CA...................     1.3825     1.2483
                        Napa County, CA...........
34940................  Naples-Marco Island, FL....     0.9756     0.9832
                        Collier County, FL........
34980................  \1\ Nashville-Davidson-         0.9675     0.9776
                        Murfreesboro-Franklin, TN.

[[Page 24938]]

 
                        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.....     1.2791     1.1836
                        Nassau County, NY.........
                        Suffolk County, NY........
35084................  \1\ Newark-Union, NJ-PA....     1.1681     1.1123
                        Essex County, NJ..........
                        Hunterdon County, NJ......
                        Morris County, NJ.........
                        Sussex County, NJ.........
                        Union County, NJ..........
                        Pike County, PA...........
35300................  \2\ New Haven-Milford, CT..     1.2439     1.1612
                        New Haven County, CT......
35380................  \1\ New Orleans-Metairie-       0.8732     0.9113
                        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-      1.3215     1.2103
                        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................  Niles-Benton Harbor, MI....     0.9138     0.9401
                        Berrien County, MI........
35980................  \2\ Norwich-New London, CT.     1.2439     1.1612
                        New London County, CT.....
36084................  \1\ Oakland-Fremont-            1.5299     1.3380
                        Hayward, CA.
                        Alameda County, CA........
                        Contra Costa County, CA...
36100................  \2\ Ocala, FL..............     0.8749     0.9125
                        Marion County, FL.........
36140................  Ocean City, NJ.............     1.0749     1.0507
                        Cape May County, NJ.......
36220................  Odessa, TX.................     0.9959     0.9972
                        Ector County, TX..........
36260................  Ogden-Clearfield, UT.......     0.9061     0.9347
                        Davis County, UT..........
                        Morgan County, UT.........
                        Weber County, UT..........
36420................  \1\ Oklahoma City, OK......     0.8764     0.9136
                        Canadian County, OK.......
                        Cleveland County, OK......
                        Grady County, OK..........
                        Lincoln County, OK........
                        Logan County, OK..........
                        McClain County, OK........
                        Oklahoma County, OK.......

[[Page 24939]]

 
36500................  Olympia, WA................     1.1463     1.0980
                        Thurston County, WA.......
36540................  Omaha-Council Bluffs, NE-IA     0.9419     0.9598
                        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..     0.9383     0.9573
                        Lake County, FL...........
                        Orange County, FL.........
                        Osceola County, FL........
                        Seminole County, FL.......
36780................  \2\ Oshkosh-Neenah, WI.....     0.9635     0.9749
                        Winnebago County, WI......
36980................  Owensboro, KY..............     0.8801     0.9163
                        Daviess County, KY........
                        Hancock County, KY........
                        McLean County, KY.........
37100................  \2\ Oxnard-Thousand Oaks-       1.1607     1.1074
                        Ventura, CA.
                        Ventura County, CA........
37340................  Palm Bay-Melbourne-             0.9385     0.9575
                        Titusville, FL.
                        Brevard County, FL........
37380................  \2\ Palm Coast, FL.........     0.8749     0.9125
                        Flager County, FL.........
37460................  \2\ Panama City-Lynn Haven,     0.8749     0.9125
                        FL.
                        Bay County, FL............
37620................  \2\ Parkersburg-Marietta-       0.8701     0.9091
                        Vienna, WV-OH (OH
                        Hospitals).
                        Washington County, OH.....
                        Pleasants County, WV......
                        Wirt County, WV...........
                        Wood County, WV...........
37620................  Parkersburg-Marietta-           0.8238     0.8757
                        Vienna, WV-OH (WV
                        Hospitals).
                        Washington County, OH.....
                        Pleasants County, WV......
                        Wirt County, WV...........
                        Wood County, WV...........
37700................  Pascagoula, MS.............     0.8544     0.8978
                        George County, MS.........
                        Jackson County, MS........
37764................  Peabody, MA................     1.0214     1.0146
                        Essex County, MA..........
37860................  \2\ Pensacola-Ferry Pass-       0.8749     0.9125
                        Brent, FL.
                        Escambia County, FL.......
                        Santa Rosa County, FL.....
37900................  Peoria, IL.................     0.9374     0.9567
                        Marshall County, IL.......
                        Peoria County, IL.........
                        Stark County, IL..........
                        Tazewell County, IL.......
                        Woodford County, IL.......
37964................  \1\ Philadelphia, PA.......     1.0906     1.0612
                        Bucks County, PA..........
                        Chester County, PA........
                        Delaware County, PA.......
                        Montgomery County, PA.....
                        Philadelphia County, PA...
38060................  \1\ Phoenix-Mesa-               1.0115     1.0079
                        Scottsdale, AZ.
                        Maricopa County, AZ.......
                        Pinal County, AZ..........
38220................  Pine Bluff, AR.............     0.8155     0.8696
                        Cleveland County, AR......
                        Jefferson County, AR......
                        Lincoln County, AR........
38300................  \1\ Pittsburgh, PA.........     0.8388     0.8866
                        Allegheny County, PA......
                        Armstrong County, PA......

[[Page 24940]]

 
                        Beaver County, PA.........
                        Butler County, PA.........
                        Fayette County, PA........
                        Washington County, PA.....
                        Westmoreland County, PA...
38340................  Pittsfield, MA.............     1.0071     1.0049
                        Berkshire County, MA......
38540................  Pocatello, ID..............     0.9158     0.9415
                        Bannock County, ID........
                        Power County, ID..........
38660................  Ponce, PR..................     0.4161     0.5486
                        Juana D[iacute]az
                        Municipio, PR.
                        Ponce Municipio, PR.......
                        Villalba Municipio, PR....
38860................  Portland-South Portland-        1.0008     1.0005
                        Biddeford, ME.
                        Cumberland County, ME.....
                        Sagadahoc County, ME......
                        York County, ME...........
38900................  \1\ Portland-Vancouver-         1.1233     1.0829
                        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, FL.........     0.9990     0.9993
                        Martin County, FL.........
                        St. Lucie County, FL......
39100................  Poughkeepsie-Newburgh-          1.0853     1.0577
                        Middletown, NY.
                        Dutchess County, NY.......
                        Orange County, NY.........
39140................  Prescott, AZ...............     0.9913     0.9940
                        Yavapai County, AZ........
39300................  \1\ Providence-New Bedford-     1.0654     1.0443
                        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.............     0.9488     0.9646
                        Juab County, UT...........
                        Utah County, UT...........
39380................  \2\ Pueblo, CO.............     0.9451     0.9621
                        Pueblo County, CO.........
39460................  Punta Gorda, FL............     0.9562     0.9698
                        Charlotte County, FL......
39540................  \2\ Racine, WI.............     0.9635     0.9749
                        Racine County, WI.........
39580................  Raleigh-Cary, NC...........     0.9373     0.9566
                        Franklin County, NC.......
                        Johnston County, NC.......
                        Wake County, NC...........
39660................  Rapid City, SD.............     0.8690     0.9083
                        Meade County, SD..........
                        Pennington County, SD.....
39740................  Reading, PA................     0.9419     0.9598
                        Berks County, PA..........
39820................  Redding, CA................     1.2826     1.1858
                        Shasta County, CA.........
39900................  Reno-Sparks, NV............     1.1062     1.0716
                        Storey County, NV.........
                        Washoe County, NV.........
40060................  \1\ Richmond, VA...........     0.9238     0.9472
                        Amelia County, VA.........
                        Caroline County, VA.......
                        Charles City County, VA...
                        Chesterfield County, VA...
                        Cumberland County, VA.....

[[Page 24941]]

 
                        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            1.1607     1.1074
                        Bernardino-Ontario, CA.
                        Riverside County, CA......
                        San Bernardino County, CA.
40220................  Roanoke, VA................     0.9441     0.9614
                        Botetourt County, VA......
                        Craig County, VA..........
                        Franklin County, VA.......
                        Roanoke County, VA........
                        Roanoke City, VA..........
                        Salem City, VA............
40340................  Rochester, MN..............     1.0761     1.0515
                        Dodge County, MN..........
                        Olmsted County, MN........
                        Wabasha County, MN........
40380................  \1\ Rochester, NY..........     0.8899     0.9232
                        Livingston County, NY.....
                        Monroe County, NY.........
                        Ontario County, NY........
                        Orleans County, NY........
                        Wayne County, NY..........
40420................  Rockford, IL...............     0.9659     0.9765
                        Boone County, IL..........
                        Winnebago County, IL......
40484................  \2\ Rockingham County-          1.1266     1.0851
                        Strafford County, NH.
                        Rockingham County, NH.....
                        Strafford County, NH......
40580................  Rocky Mount, NC............     0.9017     0.9316
                        Nash County, NC...........
40660................  Rome, GA...................     0.9549     0.9689
                        Floyd County, GA..........
40900................  \1\ Sacramento--Arden-          1.2999     1.1968
                        Arcade--Roseville, CA.
                        El Dorado County, CA......
                        Placer County, CA.........
                        Sacramento County, CA.....
                        Yolo County, CA...........
40980................  Saginaw-Saginaw Township        0.9127     0.9394
                        North, MI.
                        Saginaw County, MI........
41060................  St. Cloud, MN..............     1.1063     1.0716
                        Benton County, MN.........
                        Stearns County, MN........
41100................  St. George, UT.............     0.9546     0.9687
                        Washington County, UT.....
41140................  St. Joseph, MO-KS..........     0.8831     0.9184
                        Doniphan County, KS.......
                        Andrew County, MO.........
                        Buchanan County, MO.......
                        DeKalb County, MO.........
41180................  \1\ St. Louis, MO-IL.......     0.8885     0.9222
                        Bond County, IL...........
                        Calhoun County, IL........
                        Clinton County, IL........
                        Jersey County, IL.........
                        Macoupin County, IL.......
                        Madison County, IL........
                        Monroe County, IL.........

[[Page 24942]]

 
                        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..................     1.0404     1.0275
                        Marion County, OR.........
                        Polk County, OR...........
41500................  Salinas, CA................     1.4408     1.2841
                        Monterey County, CA.......
41540................  \2\ Salisbury, MD..........     0.8917     0.9245
                        Somerset County, MD.......
                        Wicomico County, MD.......
41620................  Salt Lake City, UT.........     0.9482     0.9642
                        Salt Lake County, UT......
                        Summit County, UT.........
                        Tooele County, UT.........
41660................  San Angelo, TX.............     0.8663     0.9064
                        Irion County, TX..........
                        Tom Green County, TX......
41700................  \1\ San Antonio, TX........     0.8916     0.9244
                        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, 2\ San Diego-Carlsbad-      1.1607     1.1074
                        San Marcos, CA.
                        San Diego County, CA......
41780................  Sandusky, OH...............     0.8760     0.9133
                        Erie County, OH...........
41884................  \1\ San Francisco-San Mateo-    1.4766     1.3059
                        Redwood City, CA.
                        Marin County, CA..........
                        San Francisco County, CA..
                        San Mateo County, CA......
41900................  San Germ[aacute]n-Cabo          0.4605     0.5880
                        Rojo, PR.
                        Cabo Rojo Municipio, PR...
                        Lajas Municipio, PR.......
                        Sabana Grande Municipio,
                        PR.
                        San Germ[aacute]n
                        Municipio, PR.
41940................  \1\ San Jose-Sunnyvale-         1.5378     1.3427
                        Santa Clara, CA.
                        San Benito County, CA.....
                        Santa Clara County, CA....
41980................  \1\ San Juan-Caguas-            0.4517     0.5803
                        Guaynabo, PR.
                        Aguas Buenas Municipio, PR
                        Aibonito Municipio, PR....
                        Arecibo Municipio, PR.....
                        Barceloneta Municipio, PR.
                        Barranquitas Municipio, PR
                        Bayam[oacute]n Municipio,
                        PR.
                        Caguas Municipio, PR......
                        Camuy Municipio, PR.......
                        Can[oacute]vanas
                        Municipio, PR.
                        Carolina Municipio, PR....
                        Cata[ntilde]o Municipio,
                        PR.
                        Cayey Municipio, PR.......
                        Ciales Municipio, PR......
                        Cidra Municipio, PR.......
                        Comer[iacute]o Municipio,
                        PR.
                        Corozal Municipio, PR.....
                        Dorado Municipio, PR......
                        Florida Municipio, PR.....
                        Guaynabo Municipio, PR....

[[Page 24943]]

 
                        Gurabo Municipio, PR......
                        Hatillo Municipio, PR.....
                        Humacao Municipio, PR.....
                        Juncos Municipio, PR......
                        Las Piedras Municipio, PR.
                        Lo[iacute]za Municipio, PR
                        Manat[iacute] Municipio,
                        PR.
                        Maunabo Municipio, PR.....
                        Morovis Municipio, PR.....
                        Naguabo Municipio, PR.....
                        Naranjito Municipio, PR...
                        Orocovis Municipio, PR....
                        Quebradillas Municipio, PR
                        R[iacute]o Grande
                        Municipio, PR.
                        San Juan Municipio, PR....
                        San Lorenzo Municipio, PR.
                        Toa Alta Municipio, PR....
                        Toa Baja Municipio, PR....
                        Trujillo Alto Municipio,
                        PR.
                        Vega Alta Municipio, PR...
                        Vega Baja Municipio, PR...
                        Yabucoa Municipio, PR.....
42020................  San Luis Obispo-Paso            1.1912     1.1273
                        Robles, CA.
                        San Luis Obispo County, CA
42044................  \1, 2\ Santa Ana-Anaheim-       1.1607     1.1074
                        Irvine, CA.
                        Orange County, CA.........
42060................  \2\ Santa Barbara-Santa         1.1607     1.1074
                        Maria-Goleta, CA.
                        Santa Barbara County, CA..
42100................  Santa Cruz-Watsonville, CA.     1.5667     1.3600
                        Santa Cruz County, CA.....
42140................  Santa Fe, NM...............     1.0689     1.0467
                        Santa Fe County, NM.......
42220................  Santa Rosa-Petaluma, CA....     1.4266     1.2755
                        Sonoma County, CA.........
42260................  Sarasota-Bradenton-Venice,      0.9758     0.9834
                        FL.
                        Manatee County, FL........
                        Sarasota County, FL.......
42340................  Savannah, GA...............     0.8987     0.9295
                        Bryan County, GA..........
                        Chatham County, GA........
                        Effingham County, GA......
42540................  \2\ Scranton--Wilkes-Barre,     0.8366     0.8850
                        PA.
                        Lackawanna County, PA.....
                        Luzerne County, PA........
                        Wyoming County, PA........
42644................  \1\ Seattle-Bellevue-           1.1351     1.0907
                        Everett, WA.
                        King County, WA...........
                        Snohomish County, WA......
42680................  Sebastian-Vero Beach, FL...     0.9708     0.9799
                        Indian River County, FL...
43100................  \2\ Sheboygan, WI..........     0.9635     0.9749
                        Sheboygan County, WI......
43300................  Sherman-Denison, TX........     0.8535     0.8972
                        Grayson County, TX........
43340................  Shreveport-Bossier City, LA     0.8615     0.9029
                        Bossier Parish, LA........
                        Caddo Parish, LA..........
                        De Soto Parish, LA........
43580................  Sioux City, IA-NE-SD.......     0.9220     0.9459
                        Woodbury County, IA.......
                        Dakota County, NE.........
                        Dixon County, NE..........
                        Union County, SD..........
43620................  Sioux Falls, SD............     0.9558     0.9695
                        Lincoln County, SD........
                        McCook County, SD.........
                        Minnehaha County, SD......
                        Turner County, SD.........
43780................  South Bend-Mishawaka, IN-MI     0.9649     0.9758
                        St. Joseph County, IN.....

[[Page 24944]]

 
                        Cass County, MI...........
43900................  Spartanburg, SC............     0.9334     0.9539
                        Spartanburg County, SC....
44060................  \2\ Spokane, WA............     1.0565     1.0384
                        Spokane County, WA........
44100................  Springfield, IL............     0.8947     0.9266
                        Menard County, IL.........
                        Sangamon County, IL.......
44140................  Springfield, MA............     1.0236     1.0161
                        Franklin County, MA.......
                        Hampden County, MA........
                        Hampshire County, MA......
44180................  Springfield, MO............     0.9196     0.9442
                        Christian County, MO......
                        Dallas County, MO.........
                        Greene County, MO.........
                        Polk County, MO...........
                        Webster County, MO........
44220................  \2\ Springfield, OH........     0.8701     0.9091
                        Clark County, OH..........
44300................  State College, PA..........     0.8625     0.9037
                        Centre County, PA.........
44700................  Stockton, CA...............     1.1735     1.1158
                        San Joaquin County, CA....
44940................  Sumter, SC.................     0.8875     0.9215
                        Sumter County, SC.........
45060................  Syracuse, NY...............     0.9912     0.9940
                        Madison County, NY........
                        Onondaga County, NY.......
                        Oswego County, NY.........
45104................  Tacoma, WA.................     1.1060     1.0714
                        Pierce County, WA.........
45220................  Tallahassee, FL............     0.9032     0.9327
                        Gadsden County, FL........
                        Jefferson County, FL......
                        Leon County, FL...........
                        Wakulla County, FL........
45300................  \1\ Tampa-St. Petersburg-       0.9174     0.9427
                        Clearwater, FL.
                        Hernando County, FL.......
                        Hillsborough County, FL...
                        Pasco County, FL..........
                        Pinellas County, FL.......
45460................  Terre Haute, IN............     0.8828     0.9182
                        Clay County, IN...........
                        Sullivan County, IN.......
                        Vermillion County, IN.....
                        Vigo County, IN...........
45500................  Texarkana, TX-Texarkana, AR     0.8131     0.8679
                        (AR Hospitals).
                        Miller County, AR.........
                        Bowie County, TX..........
45500................  \2\ Texarkana, TX-              0.8204     0.8732
                        Texarkana, AR (TX
                        Hospitals).
                        Miller County, AR.........
                        Bowie County, TX..........
45780................  Toledo, OH.................     0.9276     0.9498
                        Fulton County, OH.........
                        Lucas County, OH..........
                        Ottawa County, OH.........
                        Wood County, OH...........
45820................  Topeka, KS.................     0.8561     0.8991
                        Jackson County, KS........
                        Jefferson County, KS......
                        Osage County, KS..........
                        Shawnee County, KS........
                        Wabaunsee County, KS......
45940................  Trenton-Ewing, NJ..........     1.0720     1.0488
                        Mercer County, NJ.........
46060................  Tucson, AZ.................     0.9484     0.9644
                        Pima County, AZ...........
46140................  Tulsa, OK..................     0.8504     0.8950
                        Creek County, OK..........

[[Page 24945]]

 
                        Okmulgee County, OK.......
                        Osage County, OK..........
                        Pawnee County, OK.........
                        Rogers County, OK.........
                        Tulsa County, OK..........
                        Wagoner County, OK........
46220................  Tuscaloosa, AL.............     0.8534     0.8971
                        Greene County, AL.........
                        Hale County, AL...........
                        Tuscaloosa County, AL.....
46340................  Tyler, TX..................     0.9190     0.9438
                        Smith County, TX..........
46540................  Utica-Rome, NY.............     0.8774     0.9143
                        Herkimer County, NY.......
                        Oneida County, NY.........
46660................  Valdosta, GA...............     0.8208     0.8735
                        Brooks County, GA.........
                        Echols County, GA.........
                        Lanier County, GA.........
                        Lowndes County, GA........
46700................  Vallejo-Fairfield, CA......     1.4400     1.2837
                        Solano County, CA.........
47020................  \2\ Victoria, TX...........     0.8204     0.8732
                        Calhoun County, TX........
                        Goliad County, TX.........
                        Victoria County, TX.......
47220................  Vineland-Millville-             1.0653     1.0443
                        Bridgeton, NJ.
                        Cumberland County, NJ.....
47260................  \1\ Virginia Beach-Norfolk-     0.8785     0.9151
                        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     1.1607     1.1074
                        Tulare County, CA.........
47380................  Waco, TX...................     0.8598     0.9017
                        McLennan County, TX.......
47580................  Warner Robins, GA..........     0.9619     0.9737
                        Houston County, GA........
47644................  \1\ Warren-Troy-Farmington      1.0040     1.0027
                        Hills, MI.
                        Lapeer County, MI.........
                        Livingston County, MI.....
                        Macomb County, MI.........
                        Oakland County, MI........
                        St. Clair County, MI......
47894................  \1\ Washington-Arlington-       1.0679     1.0460
                        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.......

[[Page 24946]]

 
                        Warren County, VA.........
                        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...     0.8891     0.9227
                        Black Hawk County, IA.....
                        Bremer County, IA.........
                        Grundy County, IA.........
48140................  Wausau, WI.................     1.0011     1.0008
                        Marathon County, WI.......
48260................  \2\ Weirton-Steubenville,       0.8701     0.9091
                        WV-OH (OH Hospitals).
                        Jefferson County, OH......
                        Brooke County, WV.........
                        Hancock County, WV........
48260................  Weirton-Steubenville, WV-OH     0.7893     0.8504
                        (WV Hospitals).
                        Jefferson County, OH......
                        Brooke County, WV.........
                        Hancock County, WV........
48300................  Wenatchee, WA..............     1.1281     1.0860
                        Chelan County, WA.........
                        Douglas County, WA........
48424................  \1\ West Palm Beach-Boca        0.9587     0.9715
                        Raton-Boynton Beach, FL.
                        Palm Beach County, FL.....
48540................  \2\ Wheeling, WV-OH (OH         0.8701     0.9091
                        Hospitals).
                        Belmont County, OH........
                        Marshall County, WV.......
                        Ohio County, WV...........
48540................  \2\ Wheeling, WV-OH (WV         0.7568     0.8263
                        Hospitals).
                        Belmont County, OH........
                        Marshall County, WV.......
                        Ohio County, WV...........
48620................  Wichita, KS................     0.9009     0.9310
                        Butler County, KS.........
                        Harvey County, KS.........
                        Sedgwick County, KS.......
                        Sumner County, KS.........
48660................  Wichita Falls, TX..........     0.8488     0.8938
                        Archer County, TX.........
                        Clay County, TX...........
                        Wichita County, TX........
48700................  \2\ Williamsport, PA.......     0.8366     0.8850
                        Lycoming County, PA.......
48864................  Wilmington, DE-MD-NJ.......     1.0752     1.0509
                        New Castle County, DE.....
                        Cecil County, MD..........
                        Salem County, NJ..........
48900................  Wilmington, NC.............     0.9338     0.9542
                        Brunswick County, NC......
                        New Hanover County, NC....
                        Pender County, NC.........
49020................  Winchester, VA-WV..........     0.9850     0.9897
                        Frederick County, VA......
                        Winchester City, VA.......
                        Hampshire County, WV......
49180................  Winston-Salem, NC..........     0.9083     0.9363
                        Davie County, NC..........
                        Forsyth County, NC........
                        Stokes County, NC.........
                        Yadkin County, NC.........
49340................  Worcester, MA..............     1.1341     1.0900
                        Worcester County, MA......
49420................  \2\ Yakima, WA.............     1.0565     1.0384
                        Yakima County, WA.........
49500................  Yauco, PR..................     0.3203     0.4586
                        Gu[aacute]nica Municipio,
                        PR.
                        Guayanilla Municipio, PR..

[[Page 24947]]

 
                        Pe[ntilde]uelas Municipio,
                        PR.
                        Yauco Municipio, PR.......
49620................  York-Hanover, PA...........     0.9307     0.9520
                        York County, PA...........
49660................  Youngstown-Warren-Boardman,     0.8996     0.9301
                        OH-PA.
                        Mahoning County, OH.......
                        Trumbull County, OH.......
                        Mercer County, PA.........
49700................  \2\ Yuba City, CA..........     1.1607     1.1074
                        Sutter County, CA.........
                        Yuba County, CA...........
49740................  Yuma, AZ...................     0.9468     0.9633
                        Yuma County, AZ ..........
------------------------------------------------------------------------
\1\ Large urban area.
\2\ Hospitals geographically located in the area are assigned the
  statewide rural wage index for FY 2008.


 Table 4B.--Wage Index and Capital Geographic Adjustment (GAF) for Rural
                         Areas by CBSA--FY 2008
------------------------------------------------------------------------
                                                       Wage
      CBSA code               Nonurban area           index       GAF
------------------------------------------------------------------------
01...................  Alabama....................     0.7598     0.8285
02...................  Alaska.....................     1.1817     1.1211
03...................  Arizona....................     0.9386     0.9575
04...................  Arkansas...................     0.7519     0.8226
05...................  California.................     1.1607     1.1074
06...................  Colorado...................     0.9451     0.9621
07...................  Connecticut................     1.2439     1.1612
08...................  Delaware...................     0.9825     0.9880
10...................  Florida....................     0.8749     0.9125
11...................  Georgia....................     0.7864     0.8483
12...................  Hawaii.....................     1.0751     1.0508
13...................  Idaho......................     0.7879     0.8494
14...................  Illinois...................     0.8355     0.8842
15...................  Indiana....................     0.8599     0.9018
16...................  Iowa.......................     0.8480     0.8932
17...................  Kansas.....................     0.7989     0.8575
18...................  Kentucky...................     0.7812     0.8444
19...................  Louisiana..................     0.7591     0.8280
20...................  Maine......................     0.8412     0.8883
21...................  Maryland...................     0.8917     0.9245
22...................  Massachusetts..............     0.9739     0.9821
23...................  Michigan...................     0.8899     0.9232
24...................  Minnesota..................     0.9212     0.9453
25...................  Mississippi................     0.7915     0.8520
26...................  Missouri...................     0.8145     0.8689
27...................  Montana....................     0.8337     0.8829
28...................  Nebraska...................     0.8848     0.9196
29...................  Nevada.....................     0.9688     0.9785
30...................  New Hampshire..............     1.1266     1.0851
31...................  New Jersey \1\.............  .........  .........
32...................  New Mexico.................     0.8965     0.9279
33...................  New York...................     0.8440     0.8903
34...................  North Carolina.............     0.8608     0.9024
35...................  North Dakota...............     0.7313     0.8071
36...................  Ohio.......................     0.8701     0.9091
37...................  Oklahoma...................     0.7702     0.8363
38...................  Oregon.....................     0.9950     0.9966
39...................  Pennsylvania...............     0.8366     0.8850
40...................  Puerto Rico \1\............  .........  .........
41...................  Rhode Island \1\...........  .........  .........
42...................  South Carolina.............     0.8791     0.9155
43...................  South Dakota...............     0.8343     0.8833
44...................  Tennessee..................     0.7916     0.8521
45...................  Texas......................     0.8204     0.8732
46...................  Utah.......................     0.8267     0.8778
47...................  Vermont....................     1.0401     1.0273
49...................  Virginia...................     0.8095     0.8653
50...................  Washington.................     1.0565     1.0384

[[Page 24948]]

 
51...................  West Virginia..............     0.7568     0.8263
52...................  Wisconsin..................     0.9635     0.9749
53...................  Wyoming....................     0.9214    0.9455
------------------------------------------------------------------------
\1\ All counties in the State or Territory are classified as urban.


Table 4C.--Wage Index and Capital Geographic Adjustment Factor (GAF) for
            Hospitals That Are Reclassified by CBSA--FY 2008
------------------------------------------------------------------------
                                                       Wage
      CBSA code                    Area               index       GAF
------------------------------------------------------------------------
10420................  Akron, OH..................     0.8854     0.9200
10500................  Albany, GA.................     0.8671     0.9070
10580................  Albany-Schenectady-Troy, NY     0.8672     0.9070
10740................  Albuquerque, NM............     0.9740     0.9821
10780................  Alexandria, LA.............     0.7982     0.8570
10900................  Allentown-Bethlehem-Easton,     1.0024     1.0016
                        PAN-J.
11100................  Amarillo, TX...............     0.9141     0.9403
11180................  Ames, IA...................     0.9227     0.9464
11260................  Anchorage, AK..............     1.1840     1.1226
11460................  Ann Arbor, MI..............     1.0138     1.0094
11500................  Anniston-Oxford, AL........     0.8042     0.8614
12060................  Atlanta-Sandy Springs-          0.9845     0.9894
                        Marietta, GA.
12420................  Austin-Round Rock, TX......     0.9518     0.9667
12580................  Baltimore-Towson, MD.......     1.0108     1.0074
12620................  Bangor, ME.................     0.9860     0.9904
12940................  Baton Rouge, LA............     0.8014     0.8593
13020................  Bay City, MI...............     0.9399     0.9584
13644................  Bethesda-Gaithersburg-          1.0990     1.0668
                        Frederick, MD.
13780................  Binghamton, NY.............     0.8779     0.9147
13820................  Birmingham-Hoover, AL......     0.8737     0.9117
13900................  Bismarck, ND...............     0.7329     0.8083
13980................  Blacksburg-Christiansburg-      0.7744     0.8394
                        Radford, VA.
14020................  Bloomington, IN............     0.8828     0.9182
14484................  Boston-Quincy, MA..........     1.1256     1.0844
14540................  Bowling Green, KY..........     0.8089     0.8648
14740................  Bremerton-Silverdale, WA...     1.0826     1.0559
14860................  Bridgeport-Stamford-            1.2380     1.1574
                        Norwalk, CT.
15380................  Buffalo-Niagara Falls, NY..     0.9586     0.9715
15540................  Burlington-South                0.9589     0.9717
                        Burlington, VT.
15764................  Cambridge-Newton-               1.1266     1.0851
                        Framingham, MA.
15940................  Canton-Massillon, OH.......     0.8810     0.9169
16180................  Carson City, NV............     0.9688     0.9785
16620................  Charleston, WV.............     0.8294     0.8798
16700................  Charleston-North                0.9144     0.9406
                        Charleston, SC.
16740................  Charlotte-Gastonia-Concord,     0.9348     0.9549
                        NC-SC.
16820................  Charlottesville, VA........     0.9353     0.9552
16860................  Chattanooga, TN-GA.........     0.8967     0.9281
16974................  Chicago-Naperville-Joliet,      1.0455     1.0309
                        IL.
17140................  Cincinnati-Middletown, OH-      0.9654     0.9762
                        KY-IN.
17300................  Clarksville, TN-KY.........     0.8116     0.8668
17460................  Cleveland-Elyria-Mentor, OH     0.9238     0.9472
17780................  College Station-Bryan, TX..     0.9177     0.9429
17860................  Columbia, MO...............     0.8545     0.8979
17980................  Columbus, GA-AL............     0.8594     0.9014
18140................  Columbus, OH...............     0.9840     0.9890
18700................  Corvallis, OR..............     1.0322     1.0219
19124................  Dallas-Plano-Irving, TX....     0.9681     0.9780
19340................  Davenport-Moline-Rock           0.8898     0.9232
                        Island, IA-IL.
19380................  Dayton, OH.................     0.9283     0.9503
19460................  Decatur, AL................     0.7927     0.8529
19740................  Denver-Aurora, CO..........     1.0490     1.0333
19804................  Detroit-Livonia-Dearborn,       1.0091     1.0062
                        MI.
20100................  Dover, DE..................     1.0023     1.0016
20260................  Duluth, MN-WI..............     1.0020     1.0014
20500................  Durham, NC.................     0.9603     0.9726
20764................  Edison, NJ.................     1.1131     1.0761
21060................  Elizabethtown, KY..........     0.7983     0.8570
21500................  Erie, PA...................     0.8440     0.8903

[[Page 24949]]

 
21660................  Eugene-Springfield, OR.....     1.0713     1.0483
21780................  Evansville, IN-KY (KY           0.8127     0.8676
                        Hospitals).
21780................  Evansville, IN-KY (IN           0.8599     0.9018
                        Hospitals).
22020................  Fargo, ND-MN (ND Hospitals)     0.8189     0.8721
22020................  Fargo, ND-MN (SD Hospitals)     0.8343     0.8833
22180................  Fayetteville, NC...........     0.9600     0.9724
22220................  Fayetteville-Springdale-        0.8719     0.9104
                        Rogers, AR-MO.
22380................  Flagstaff, AZ..............     1.1310     1.0880
22420................  Flint, MI..................     1.0272     1.0185
22520................  Florence-Muscle Shoals, AL.     0.7971     0.8562
22540................  Fond du Lac, WI............     0.9721     0.9808
22660................  Fort Collins-Loveland, CO..     0.9577     0.9708
22744................  Fort Lauderdale-Pompano         1.0245     1.0167
                        Beach-Deerfield Beach, FL.
23020................  Fort Walton Beach-Crestview-    0.8749     0.9125
                        Destin, FL.
23060................  Fort Wayne, IN.............     0.9046     0.9336
23104................  Fort Worth-Arlington, TX...     0.9646     0.9756
23540................  Gainesville, FL............     0.9306     0.9519
23844................  Gary, IN...................     0.9246     0.9477
24300................  Grand Junction, CO.........     1.0141     1.0096
24340................  Grand Rapids-Wyoming, MI...     0.9380     0.9571
24500................  Great Falls, MT............     0.8765     0.9137
24540................  Greeley, CO................     0.9746     0.9825
24580................  Green Bay, WI (MI               0.9339     0.9542
                        Hospitals).
24580................  Green Bay, WI (WI               0.9635     0.9749
                        Hospitals).
24660................  Greensboro-High Point, NC..     0.9111     0.9382
24780................  Greenville, NC.............     0.9272     0.9496
24860................  Greenville-Mauldin-Easley,      0.9386     0.9575
                        SC.
25060................  Gulfport-Biloxi, MS........     0.8223     0.8746
25420................  Harrisburg-Carlisle, PA....     0.9130     0.9396
25540................  Hartford-West Hartford-East     1.2439     1.1612
                        Hartford, CT (CT
                        Hospitals).
25540................  Hartford-West Hartford-East     1.0955     1.0645
                        Hartford, CT (MA
                        Hospitals).
25860................  Hickory-Lenoir-Morganton,       0.8819     0.9175
                        NC.
26100................  Holland-Grand Haven, MI....     0.9066     0.9351
26180................  Honolulu, HI...............     1.1289     1.0866
26420................  Houston-Sugar Land-Baytown,     1.0048     1.0033
                        TX.
26580................  Huntington-Ashland, WV-KY-      0.8706     0.9095
                        OH.
26620................  Huntsville, AL.............     0.8760     0.9133
26820................  Idaho Falls, ID............     0.9352     0.9552
26900................  Indianapolis-Carmel, IN....     0.9723     0.9809
26980................  Iowa City, IA..............     0.9142     0.9404
27060................  Ithaca, NY.................     0.9715     0.9804
27140................  Jackson, MS................     0.8273     0.8782
27180................  Jackson, TN................     0.8432     0.8898
27260................  Jacksonville, FL...........     0.9129     0.9395
27620................  Jefferson City, MO.........     0.8706     0.9095
27780................  Johnstown, PA..............     0.8366     0.8850
27860................  Jonesboro, AR..............     0.8507     0.8952
27900................  Joplin, MO.................     0.9040     0.9332
28020................  Kalamazoo-Portage, MI......     1.0151     1.0103
28100................  Kankakee-Bradley, IL.......     1.1678     1.1121
28140................  Kansas City, MO-KS.........     0.9321     0.9530
28420................  Kennewick-Richland-Pasco,       0.9620     0.9738
                        WA (ID Hospitals).
28420................  Kennewick-Richland-Pasco,       1.0565     1.0384
                        WA (WA Hospitals).
28700................  Kingsport-Bristol-Bristol,      0.7840     0.8465
                        TN-VA (KY Hospitals).
28700................  Kingsport-Bristol-Bristol,      0.7916     0.8521
                        TN-VA (TN Hospitals).
28700................  Kingsport-Bristol-Bristol,      0.8095     0.8653
                        TN-VA (VA Hospitals).
28740................  Kingston, NY...............     0.9231     0.9467
28940................  Knoxville, TN..............     0.8042     0.8614
29180................  Lafayette, LA..............     0.8323     0.8819
29404................  Lake County-Kenosha County,     1.0287     1.0196
                        IL-WI.
29460................  Lakeland, FL...............     0.8839     0.9190
29540................  Lancaster, PA..............     0.9589     0.9717
29620................  Lansing-East Lansing, MI...     0.9933     0.9954
29740................  Las Cruces, NM.............     0.8965     0.9279
29820................  Las Vegas-Paradise, NV.....     1.1205     1.0810
30020................  Lawton, OK.................     0.8071     0.8635
30460................  Lexington-Fayette, KY......     0.8815     0.9173
30620................  Lima, OH...................     0.9312     0.9524
30700................  Lincoln, NE................     0.9603     0.9726
30780................  Little Rock-North Little        0.8720     0.9105
                        Rock-Conway, AR.

[[Page 24950]]

 
30860................  Logan, UT-ID...............     0.9219     0.9458
30980................  Longview, TX...............     0.8875     0.9215
31084................  Los Angeles-Long Beach-         1.1607     1.1074
                        Santa Ana, CA.
31140................  Louisville-Jefferson            0.9045     0.9336
                        County, KY-IN.
31340................  Lynchburg, VA..............     0.8490     0.8940
31420................  Macon, GA..................     0.9571     0.9704
31540................  Madison, WI................     1.1002     1.0676
31700................  Manchester-Nashua, NH......     1.1266     1.0851
32780................  Medford, OR................     1.0151     1.0103
32820................  Memphis, TN-MS-AR..........     0.8951     0.9269
33124................  Miami-Miami Beach-Kendall,      1.0023     1.0016
                        FL.
33340................  Milwaukee-Waukesha-West         1.0296     1.0202
                        Allis, WI.
33460................  Minneapolis-St. Paul-           1.0961     1.0649
                        Bloomington, MN-WI.
33540................  Missoula, MT...............     0.8737     0.9117
33660................  Mobile, AL.................     0.7950     0.8546
33700................  Modesto, CA................     1.1989     1.1323
33740................  Monroe, LA.................     0.7766     0.8410
33860................  Montgomery, AL.............     0.8366     0.8850
34060................  Morgantown, WV.............     0.8244     0.8761
34740................  Muskegon-Norton Shores, MI.     0.9472     0.9635
34820................  Myrtle Beach-Conway-North       0.8791     0.9155
                        Myrtle Beach, SC.
34980................  Nashville-Davidson-             0.9407     0.9590
                        Murfreesboro-Franklin, TN.
35004................  Nassau-Suffolk, NY.........     1.2565     1.1692
35084................  Newark-Union, NJPA.........     1.1578     1.1055
35300................  New Haven-Milford, CT......     1.2439     1.1612
35380................  New Orleans-Metairie-           0.8732     0.9113
                        Kenner, LA.
35644................  New York-White Plains-          1.2993     1.1964
                        Wayne, NY-NJ.
35980................  Norwich-New London, CT.....     1.1794     1.1196
36084................  Oakland-Fremont-Hayward, CA     1.5299     1.3380
36140................  Ocean City, NJ.............     1.0358     1.0244
36220................  Odessa, TX.................     0.9527     0.9674
36420................  Oklahoma City, OK..........     0.8764     0.9136
36500................  Olympia, WA................     1.1325     1.0889
36740................  Orlando-Kissimmee, FL......     0.9245     0.9477
37700................  Pascagoula, MS.............     0.8544     0.8978
37860................  Pensacola-Ferry Pass-Brent,     0.8127     0.8676
                        FL.
37900................  Peoria, IL.................     0.9217     0.9457
37964................  Philadelphia, PA...........     1.0777     1.0526
38220................  Pine Bluff, AR.............     0.7959     0.8553
38300................  Pittsburgh, PA (PA and WV       0.8388     0.8866
                        Hospitals).
38300................  Pittsburgh, PA (OH              0.8701     0.9091
                        Hospitals).
38340................  Pittsfield, MA.............     1.0401     1.0273
38540................  Pocatello, ID..............     0.9158     0.9415
38860................  Portland-South Portland-        0.9601     0.9725
                        Biddeford, ME.
38900................  Portland-Vancouver-             1.1233     1.0829
                        Beaverton, OR-WA.
38940................  Port St. Lucie, FL.........     0.9990     0.9993
39100................  Poughkeepsie-Newburgh-          1.0644     1.0437
                        Middletown, NY.
39140................  Prescott, AZ...............     0.9534     0.9678
39340................  Provo-Orem, UT.............     0.9388     0.9577
39580................  Raleigh-Cary, NC...........     0.9373     0.9566
39740................  Reading, PA................     0.9419     0.9598
39820................  Redding, CA................     1.2666     1.1757
39900................  Reno-Sparks, NV............     1.0851     1.0575
40060................  Richmond, VA...............     0.9238     0.9472
40220................  Roanoke, VA................     0.9190     0.9438
40340................  Rochester, MN..............     1.0761     1.0515
40380................  Rochester, NY..............     0.8899     0.9232
40420................  Rockford, IL...............     0.9659     0.9765
40484................  Rockingham County, NH......     1.0179     1.0122
40660................  Rome, GA...................     0.9391     0.9579
40900................  Sacramento-Arden-Arcade-        1.2853     1.1875
                        Roseville, CA.
40980................  Saginaw-Saginaw Township        0.8979     0.9289
                        North, MI.
41060................  St. Cloud, MN..............     1.0390     1.0265
41100................  St. George, UT.............     0.9546     0.9687
41140................  St. Joseph, MO-KS..........     0.8831     0.9184
41180................  St. Louis, MO-IL...........     0.8885     0.9222
41620................  Salt Lake City, UT (UT          0.9482     0.9642
                        Hospitals).
41620................  Salt Lake City, UT (NV          0.9688     0.9785
                        Hospitals).
41700................  San Antonio, TX............     0.8916     0.9244
41884................  San Francisco-San Mateo-        1.4766     1.3059
                        Redwood City, CA.

[[Page 24951]]

 
41940................  San Jose-Sunnyvale-Santa        1.5378     1.3427
                        Clara, CA.
41980................  San Juan-Caguas-Guaynabo,       0.4517     0.5803
                        PR.
42044................  Santa Ana-Anaheim-Irvine,       1.1607     1.1074
                        CA.
42140................  Santa Fe, NM...............     1.0376     1.0256
42220................  Santa Rosa-Petaluma, CA....     1.3959     1.2566
42260................  Sarasota-Bradenton-Venice,      0.9758     0.9834
                        FL.
42340................  Savannah, GA...............     0.8987     0.9295
42644................  Seattle-Bellevue-Everett,       1.1202     1.0808
                        WA.
42680................  Sebastian-Vero Beach, FL...     0.9482     0.9642
43300................  Sherman-Denison, TX........     0.8535     0.8972
43340................  Shreveport-Bossier City, LA     0.8615     0.9029
43580................  Sioux City, IA-NE-SD.......     0.8848     0.9196
43620................  Sioux Falls, SD............     0.9395     0.9582
43780................  South Bend-Mishawaka, IN-MI     0.9488     0.9646
43900................  Spartanburg, SC............     0.9334     0.9539
44060................  Spokane, WA................     1.0220     1.0150
44180................  Springfield, MO............     0.8943     0.9264
44940................  Sumter, SC.................     0.8791     0.9155
45060................  Syracuse, NY...............     0.9577     0.9708
45104................  Tacoma, WA.................     1.1060     1.0714
45220................  Tallahassee, FL............     0.8458     0.8916
45300................  Tampa-St. Petersburg-           0.9174     0.9427
                        Clearwater, FL.
45500................  Texarkana, TX-Texarkana, AR     0.8131     0.8679
45780................  Toledo, OH.................     0.9276     0.9498
45820................  Topeka, KS.................     0.8455     0.8914
46140................  Tulsa, OK..................     0.8504     0.8950
46220................  Tuscaloosa, AL.............     0.8166     0.8705
46340................  Tyler, TX..................     0.9190     0.9438
46700................  Vallejo-Fairfield, CA......     1.4200     1.2714
47260................  Virginia Beach-Norfolk-         0.8785     0.9151
                        Newport News, VA.
47894................  Washington-Arlington-           1.0679     1.0460
                        Alexandria DC-VA.
47940................  Waterloo-Cedar Falls, IA...     0.8891     0.9227
48140................  Wausau, WI.................     1.0011     1.0008
48620................  Wichita, KS................     0.8761     0.9134
48700................  Williamsport, PA...........     0.8366     0.8850
48864................  Wilmington, DE-MD-NJ.......     1.0752     1.0509
48900................  Wilmington, NC.............     0.9172     0.9425
49180................  Winston-Salem, NC..........     0.9083     0.9363
49660................  Youngstown-Warren-Boardman,     0.8775     0.9144
                        OH-PA.
03...................  Rural Arizona..............     0.9386     0.9575
04...................  Rural Arkansas.............     0.7591     0.8280
05...................  Rural California...........     1.1607     1.1074
07...................  Rural Connecticut..........     1.2439     1.1612
10...................  Rural Florida..............     0.8749     0.9125
14...................  Rural Illinois.............     0.8355     0.8842
16...................  Rural Iowa.................     0.8480     0.8932
17...................  Rural Kansas...............     0.7989     0.8575
22...................  Rural Massachusetts........     0.9739     0.9821
23...................  Rural Michigan.............     0.8899     0.9232
25...................  Rural Mississippi..........     0.7915     0.8520
26...................  Rural Missouri.............     0.8145     0.8689
29...................  Rural Nevada...............     0.8780     0.9148
30...................  Rural New Hampshire........     1.0782     1.0529
33...................  Rural New York.............     0.8440     0.8903
34...................  Rural North Carolina.......     0.8608     0.9024
36...................  Rural Ohio.................     0.8701     0.9091
37...................  Rural Oklahoma.............     0.7702     0.8363
38...................  Rural Oregon...............     0.9950     0.9966
39...................  Rural Pennsylvania (PA          0.8366     0.8850
                        Hospitals).
39...................  Rural Pennsylvania (NY          0.8440     0.8903
                        Hospitals).
44...................  Rural Tennessee............     0.7916     0.8521
45...................  Rural Texas................     0.8204     0.8732
47...................  Rural Vermont..............     0.9431     0.9607
49...................  Rural Virginia.............     0.8095     0.8653
50...................  Rural Washington...........     1.0565     1.0384
52...................  Rural Wisconsin............     0.9635     0.9749
53...................  Rural Wyoming..............     0.9049     0.9339
------------------------------------------------------------------------


[[Page 24952]]


        Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA--FY 2008
----------------------------------------------------------------------------------------------------------------
                                                                              Wage index--
      CBSA code                    Area                Wage       GAF         reclassified     GAF--reclassified
                                                      index                    hospitals           hospitals
----------------------------------------------------------------------------------------------------------------
10380................  Aguadilla-Isabela-San           0.7690     0.8354  ...................  .................
                        Sebasti[aacute]n, PR.
21940................  Fajardo, PR................     0.9543     0.9685  ...................  .................
25020................  Guayama, PR................     0.6904     0.7759  ...................  .................
32420................  Mayag[uuml]ez, PR..........     0.8532     0.8970  ...................  .................
38660................  Ponce, PR..................     0.9692     0.9788  ...................  .................
41900................  San Germ[aacute]n-Cabo          1.0616     1.0418  ...................  .................
                        Rojo, PR.
41980................  San Juan-Caguas-Guaynabo,       1.0437     1.0297             1.0437              1.0297
                        PR.
49500................  Yauco, PR..................     0.7478     0.8195  ...................  .................
----------------------------------------------------------------------------------------------------------------

    The following list represents all hospitals that are eligible to 
have their wage index increased by the outmigration adjustment listed 
in this table. Hospitals cannot receive the outmigration adjustment if 
they are reclassified under section 1886(d)(10) of the Act or 
redesignated under section 1886(d)(8) of the Act. Hospitals that have 
already been reclassified under section 1886(d)(10) of the Act or 
redesignated under section 1886(d)(8(B)) of the Act are designated with 
an asterisk. We will automatically assume that hospitals that have 
already been reclassified under section 1886(d)(10) of the Act or 
redesignated under section 1886(d)(8) of the Act wish to retain their 
reclassification/redesignation status and waive the application of the 
outmigration adjustment. Section 1886(d)(10) hospitals that wish to 
receive the outmigration adjustment, rather than their 
reclassification, should follow the termination/withdrawal procedures 
specified in 42 CFR 412.273 and section III.I.3. of the preamble of 
this proposed rule. Otherwise, they will be deemed to have waived the 
outmigration adjustment. Hospitals redesignated under section 
1886(d)(8) of the Act will be deemed to have waived the outmigration 
adjustment, unless they explicitly notify CMS that they elect to 
receive the outmigration adjustment instead within 45 days from the 
publication of this proposed rule. These notifications should be sent 
to the following address: Centers for Medicare and Medicaid Services, 
Center for Medicare Management, Attention: Wage Index Adjustment 
Waivers, Division of Acute Care, Room C40806, 7500 Security Boulevard, 
Baltimore, MD 21244-1850.

                                  Table 4J.--Out-Migration Adjustment--FY 2008
 
----------------------------------------------------------------------------------------------------------------
                                     Reclassified for    Out-migration     Qualifying county
            Provider No.                  FY 2008         Adjustment              name             County code
----------------------------------------------------------------------------------------------------------------
010005.............................                 *            0.0322  MARSHALL.............             01470
010008.............................  ................            0.0245  CRENSHAW.............             01200
010009.............................                 *            0.0177  MORGAN...............             01510
010010.............................                 *            0.0322  MARSHALL.............             01470
010012.............................                 *            0.0182  DE KALB..............             01240
010015.............................  ................            0.0043  CLARKE...............             01120
010022.............................                 *            0.1106  CHEROKEE.............             01090
010025.............................                 *            0.0188  CHAMBERS.............             01080
010029.............................                 *            0.0281  LEE..................             01400
010032.............................  ................            0.0320  RANDOLPH.............             01550
010035.............................                 *            0.0263  CULLMAN..............             01210
010038.............................  ................            0.0038  CALHOUN..............             01070
010045.............................                 *            0.0216  FAYETTE..............             01280
010047.............................  ................            0.0179  BUTLER...............             01060
010052.............................  ................            0.0124  TALLAPOOSA...........             01610
010054.............................                 *            0.0177  MORGAN...............             01510
010061.............................  ................            0.0566  JACKSON..............             01350
010065.............................                 *            0.0124  TALLAPOOSA...........             01610
010078.............................  ................            0.0038  CALHOUN..............             01070
010083.............................                 *            0.0125  BALDWIN..............             01010
010085.............................                 *            0.0177  MORGAN...............             01510
010091.............................  ................            0.0043  CLARKE...............             01120
010100.............................                 *            0.0125  BALDWIN..............             01010
010101.............................                 *            0.0209  TALLADEGA............             01600
010109.............................  ................            0.0369  PICKENS..............             01530
010110.............................  ................            0.0303  BULLOCK..............             01050
010125.............................  ................            0.0471  WINSTON..............             01660
010128.............................  ................            0.0043  CLARKE...............             01120
010129.............................  ................            0.0125  BALDWIN..............             01010
010138.............................  ................            0.0113  SUMTER...............             01590
010143.............................                 *            0.0263  CULLMAN..............             01210
010146.............................  ................            0.0038  CALHOUN..............             01070
010150.............................                 *            0.0179  BUTLER...............             01060
010158.............................                 *            0.0067  FRANKLIN.............             01290
010164.............................                 *            0.0209  TALLADEGA............             01600

[[Page 24953]]

 
030040.............................  ................            0.0012  SANTA CRUZ...........             03110
030067.............................  ................            0.0230  LAPAZ................             03055
040014.............................                 *            0.0163  WHITE................             04720
040019.............................                 *            0.0254  ST. FRANCIS..........             04610
040039.............................                 *            0.0172  GREENE...............             04270
040047.............................  ................            0.0117  RANDOLPH.............             04600
040067.............................  ................            0.0008  COLUMBIA.............             04130
040071.............................                 *            0.0149  JEFFERSON............             04340
040076.............................                 *            0.1001  HOT SPRING...........             04290
040081.............................  ................            0.0358  PIKE.................             04540
040100.............................                 *            0.0163  WHITE................             04720
050002.............................  ................            0.0009  ALAMEDA..............             05000
050007.............................  ................            0.0140  SAN MATEO............             05510
050009.............................                 *            0.0196  NAPA.................             05380
050013.............................                 *            0.0196  NAPA.................             05380
050014.............................                 *            0.0147  AMADOR...............             05020
050042.............................                 *            0.0184  TEHAMA...............             05620
050043.............................  ................            0.0009  ALAMEDA..............             05000
050069.............................                 *            0.0006  ORANGE...............             05400
050070.............................  ................            0.0140  SAN MATEO............             05510
050073.............................                 *            0.0169  SOLANO...............             05580
050075.............................  ................            0.0009  ALAMEDA..............             05000
050084.............................  ................            0.0135  SAN JOAQUIN..........             05490
050089.............................                 *            0.0005  SAN BERNARDINO.......             05460
050090.............................                 *            0.0085  SONOMA...............             05590
050099.............................                 *            0.0005  SAN BERNARDINO.......             05460
050101.............................                 *            0.0169  SOLANO...............             05580
050113.............................  ................            0.0140  SAN MATEO............             05510
050118.............................                 *            0.0135  SAN JOAQUIN..........             05490
050122.............................  ................            0.0135  SAN JOAQUIN..........             05490
050129.............................                 *            0.0005  SAN BERNARDINO.......             05460
050133.............................                 *            0.0186  YUBA.................             05680
050136.............................                 *            0.0085  SONOMA...............             05590
050140.............................                 *            0.0005  SAN BERNARDINO.......             05460
050150.............................                 *            0.0357  NEVADA...............             05390
050167.............................  ................            0.0135  SAN JOAQUIN..........             05490
050168.............................                 *            0.0006  ORANGE...............             05400
050173.............................                 *            0.0006  ORANGE...............             05400
050174.............................                 *            0.0085  SONOMA...............             05590
050193.............................                 *            0.0006  ORANGE...............             05400
050195.............................  ................            0.0009  ALAMEDA..............             05000
050197.............................                 *            0.0140  SAN MATEO............             05510
050211.............................  ................            0.0009  ALAMEDA..............             05000
050224.............................                 *            0.0006  ORANGE...............             05400
050226.............................                 *            0.0006  ORANGE...............             05400
050230.............................                 *            0.0006  ORANGE...............             05400
050245.............................                 *            0.0005  SAN BERNARDINO.......             05460
050264.............................  ................            0.0009  ALAMEDA..............             05000
050272.............................                 *            0.0005  SAN BERNARDINO.......             05460
050279.............................                 *            0.0005  SAN BERNARDINO.......             05460
050283.............................  ................            0.0009  ALAMEDA..............             05000
050289.............................  ................            0.0140  SAN MATEO............             05510
050291.............................                 *            0.0085  SONOMA...............             05590
050298.............................                 *            0.0005  SAN BERNARDINO.......             05460
050300.............................                 *            0.0005  SAN BERNARDINO.......             05460
050305.............................  ................            0.0009  ALAMEDA..............             05000
050313.............................  ................            0.0135  SAN JOAQUIN..........             05490
050320.............................  ................            0.0009  ALAMEDA..............             05000
050325.............................  ................            0.0046  TUOLUMNE.............             05650
050327.............................                 *            0.0005  SAN BERNARDINO.......             05460
050335.............................  ................            0.0046  TUOLUMNE.............             05650
050336.............................  ................            0.0135  SAN JOAQUIN..........             05490
050348.............................                 *            0.0006  ORANGE...............             05400
050366.............................  ................            0.0025  CALAVERAS............             05040
050367.............................                 *            0.0169  SOLANO...............             05580
050385.............................                 *            0.0085  SONOMA...............             05590
050426.............................                 *            0.0006  ORANGE...............             05400
050444.............................  ................            0.0229  MERCED...............             05340
050476.............................                 *            0.0275  LAKE.................             05160
050488.............................  ................            0.0009  ALAMEDA..............             05000

[[Page 24954]]

 
050494.............................                 *            0.0357  NEVADA...............             05390
050512.............................  ................            0.0009  ALAMEDA..............             05000
050517.............................                 *            0.0005  SAN BERNARDINO.......             05460
050526.............................                 *            0.0006  ORANGE...............             05400
050528.............................                 *            0.0229  MERCED...............             05340
050541.............................                 *            0.0140  SAN MATEO............             05510
050543.............................                 *            0.0006  ORANGE...............             05400
050547.............................                 *            0.0085  SONOMA...............             05590
050548.............................                 *            0.0006  ORANGE...............             05400
050551.............................                 *            0.0006  ORANGE...............             05400
050567.............................                 *            0.0006  ORANGE...............             05400
050570.............................                 *            0.0006  ORANGE...............             05400
050580.............................                 *            0.0006  ORANGE...............             05400
050584.............................                 *            0.0005  SAN BERNARDINO.......             05460
050586.............................                 *            0.0005  SAN BERNARDINO.......             05460
050589.............................                 *            0.0006  ORANGE...............             05400
050603.............................                 *            0.0006  ORANGE...............             05400
050609.............................                 *            0.0006  ORANGE...............             05400
050618.............................                 *            0.0005  SAN BERNARDINO.......             05460
050667.............................                 *            0.0196  NAPA.................             05380
050678.............................                 *            0.0006  ORANGE...............             05400
050680.............................                 *            0.0169  SOLANO...............             05580
050690.............................                 *            0.0085  SONOMA...............             05590
050693.............................                 *            0.0006  ORANGE...............             05400
050707.............................  ................            0.0140  SAN MATEO............             05510
050720.............................                 *            0.0006  ORANGE...............             05400
050744.............................  ................            0.0006  ORANGE...............             05400
050745.............................  ................            0.0006  ORANGE...............             05400
050746.............................  ................            0.0006  ORANGE...............             05400
050747.............................  ................            0.0006  ORANGE...............             05400
050748.............................  ................            0.0135  SAN JOAQUIN..........             05490
050754.............................  ................            0.0140  SAN MATEO............             05510
050756.............................  ................            0.0005  SAN BERNARDINO.......             05460
060001.............................                 *            0.0045  WELD.................             06610
060003.............................                 *            0.0075  BOULDER..............             06060
060010.............................  ................            0.0087  LARIMER..............             06340
060027.............................                 *            0.0075  BOULDER..............             06060
060030.............................  ................            0.0087  LARIMER..............             06340
060103.............................                 *            0.0075  BOULDER..............             06060
060116.............................                 *            0.0075  BOULDER..............             06060
080001.............................                 *            0.0018  NEW CASTLE...........             08010
080003.............................                 *            0.0018  NEW CASTLE...........             08010
100014.............................                 *            0.0059  VOLUSIA..............             10630
100017.............................                 *            0.0059  VOLUSIA..............             10630
100045.............................                 *            0.0059  VOLUSIA..............             10630
100047.............................                 *            0.0026  CHARLOTTE............             10070
100068.............................                 *            0.0059  VOLUSIA..............             10630
100072.............................                 *            0.0059  VOLUSIA..............             10630
100077.............................                 *            0.0026  CHARLOTTE............             10070
100118.............................                 *            0.0179  FLAGLER..............             10170
100232.............................                 *            0.0057  PUTNAM...............             10530
100236.............................                 *            0.0026  CHARLOTTE............             10070
100252.............................                 *            0.0146  OKEECHOBEE...........             10460
100290.............................  ................            0.0390  SUMTER...............             10590
110023.............................                 *            0.0416  GORDON...............             11500
110029.............................                 *            0.0056  HALL.................             11550
110040.............................                 *            0.1727  JACKSON..............             11610
110041.............................                 *            0.0624  HABERSHAM............             11540
110100.............................  ................            0.0789  JEFFERSON............             11620
110101.............................  ................            0.0067  COOK.................             11311
110142.............................  ................            0.0202  EVANS................             11441
110146.............................                 *            0.0438  CAMDEN...............             11170
110150.............................                 *            0.0227  BALDWIN..............             11030
110187.............................                 *            0.0643  LUMPKIN..............             11701
110190.............................  ................            0.0242  MACON................             11710
110205.............................  ................            0.0514  GILMER...............             11471
130024.............................  ................            0.0422  BONNER...............             13080
130049.............................                 *            0.0319  KOOTENAI.............             13270
130066.............................  ................            0.0319  KOOTENAI.............             13270
130067.............................                 *            0.0697  BINGHAM..............             13050

[[Page 24955]]

 
130068.............................  ................            0.0319  KOOTENAI.............             13270
140001.............................  ................            0.0362  FULTON...............             14370
140026.............................  ................            0.0288  LA SALLE.............             14580
140043.............................                 *            0.0055  WHITESIDE............             14988
140058.............................                 *            0.0125  MORGAN...............             14770
140110.............................                 *            0.0288  LA SALLE.............             14580
140160.............................                 *            0.0302  STEPHENSON...........             14970
140161.............................                 *            0.0193  LIVINGSTON...........             14610
140167.............................                 *            0.1054  IROQUOIS.............             14460
140234.............................  ................            0.0288  LA SALLE.............             14580
150006.............................                 *            0.0085  LA PORTE.............             15450
150015.............................  ................            0.0085  LA PORTE.............             15450
150022.............................  ................            0.0151  MONTGOMERY...........             15530
150030.............................                 *            0.0186  HENRY................             15320
150072.............................  ................            0.0101  CASS.................             15080
150076.............................                 *            0.0210  MARSHALL.............             15490
150088.............................                 *            0.0111  MADISON..............             15470
150091.............................                 *            0.0047  HUNTINGTON...........             15340
150102.............................                 *            0.0103  STARKE...............             15740
150113.............................                 *            0.0111  MADISON..............             15470
150133.............................                 *            0.0167  KOSCIUSKO............             15420
150146.............................                 *            0.0081  NOBLE................             15560
160013.............................  ................            0.0179  MUSCATINE............             16690
160032.............................  ................            0.0235  JASPER...............             16490
160080.............................                 *            0.0066  CLINTON..............             16220
170137.............................                 *            0.0387  DOUGLAS..............             17220
170150.............................  ................            0.0176  COWLEY...............             17170
180012.............................                 *            0.0081  HARDIN...............             18460
180017.............................                 *            0.0035  BARREN...............             18040
180049.............................                 *            0.0497  MADISON..............             18750
180064.............................  ................            0.0320  MONTGOMERY...........             18860
180066.............................                 *            0.0450  LOGAN................             18700
180070.............................  ................            0.0240  GRAYSON..............             18420
180079.............................  ................            0.0264  HARRISON.............             18480
190003.............................                 *            0.0085  IBERIA...............             19220
190015.............................                 *            0.0231  TANGIPAHOA...........             19520
190017.............................                 *            0.0184  ST. LANDRY...........             19480
190034.............................  ................            0.0188  VERMILION............             19560
190044.............................  ................            0.0259  ACADIA...............             19000
190050.............................  ................            0.0044  BEAUREGARD...........             19050
190053.............................  ................            0.0100  JEFFRSON DAVIS.......             19260
190054.............................  ................            0.0085  IBERIA...............             19220
190078.............................  ................            0.0184  ST. LANDRY...........             19480
190086.............................                 *            0.0050  LINCOLN..............             19300
190088.............................                 *            0.0410  WEBSTER..............             19590
190099.............................                 *            0.0189  AVOYELLES............             19040
190106.............................                 *            0.0101  ALLEN................             19010
190116.............................  ................            0.0084  MOREHOUSE............             19330
190133.............................  ................            0.0101  ALLEN................             19010
190140.............................  ................            0.0034  FRANKLIN.............             19200
190144.............................                 *            0.0410  WEBSTER..............             19590
190145.............................  ................            0.0090  LA SALLE.............             19290
190184.............................                 *            0.0075  CALDWELL.............             19100
190190.............................  ................            0.0075  CALDWELL.............             19100
190191.............................                 *            0.0184  ST. LANDRY...........             19480
190246.............................  ................            0.0075  CALDWELL.............             19100
190257.............................  ................            0.0050  LINCOLN..............             19300
200024.............................                 *            0.0092  ANDROSCOGGIN.........             20000
200032.............................  ................            0.0316  OXFORD...............             20080
200034.............................                 *            0.0092  ANDROSCOGGIN.........             20000
200050.............................                 *            0.0223  HANCOCK..............             20040
210001.............................  ................            0.0184  WASHINGTON...........             21210
210023.............................  ................            0.0070  ANNE ARUNDEL.........             21010
210028.............................  ................            0.0356  ST. MARYS............             21180
210043.............................  ................            0.0070  ANNE ARUNDEL.........             21010
220002.............................                 *            0.0235  MIDDLESEX............             22090
220010.............................                 *            0.0461  ESSEX................             22040
220011.............................                 *            0.0235  MIDDLESEX............             22090
220029.............................                 *            0.0461  ESSEX................             22040
220033.............................                 *            0.0461  ESSEX................             22040

[[Page 24956]]

 
220035.............................                 *            0.0461  ESSEX................             22040
220049.............................                 *            0.0235  MIDDLESEX............             22090
220063.............................                 *            0.0235  MIDDLESEX............             22090
220070.............................                 *            0.0235  MIDDLESEX............             22090
220080.............................                 *            0.0461  ESSEX................             22040
220082.............................                 *            0.0235  MIDDLESEX............             22090
220084.............................                 *            0.0235  MIDDLESEX............             22090
220098.............................                 *            0.0235  MIDDLESEX............             22090
220101.............................                 *            0.0235  MIDDLESEX............             22090
220105.............................                 *            0.0235  MIDDLESEX............             22090
220171.............................                 *            0.0235  MIDDLESEX............             22090
220174.............................                 *            0.0461  ESSEX................             22040
230003.............................                 *            0.0217  OTTAWA...............             23690
230005.............................  ................            0.0473  LENAWEE..............             23450
230013.............................                 *            0.0023  OAKLAND..............             23620
230015.............................  ................            0.0297  ST. JOSEPH...........             23740
230019.............................                 *            0.0023  OAKLAND..............             23620
230021.............................                 *            0.0099  BERRIEN..............             23100
230022.............................                 *            0.0212  BRANCH...............             23110
230029.............................                 *            0.0023  OAKLAND..............             23620
230035.............................                 *            0.0096  MONTCALM.............             23580
230037.............................                 *            0.0211  HILLSDALE............             23290
230047.............................                 *            0.0018  MACOMB...............             23490
230069.............................                 *            0.0208  LIVINGSTON...........             23460
230071.............................                 *            0.0023  OAKLAND..............             23620
230072.............................                 *            0.0217  OTTAWA...............             23690
230075.............................  ................            0.0048  CALHOUN..............             23120
230078.............................                 *            0.0099  BERRIEN..............             23100
230092.............................                 *            0.0221  JACKSON..............             23370
230093.............................  ................            0.0060  MECOSTA..............             23530
230096.............................                 *            0.0297  ST. JOSEPH...........             23740
230099.............................                 *            0.0230  MONROE...............             23570
230121.............................                 *            0.0695  SHIAWASSEE...........             23770
230130.............................                 *            0.0023  OAKLAND..............             23620
230151.............................                 *            0.0023  OAKLAND..............             23620
230174.............................                 *            0.0217  OTTAWA...............             23690
230195.............................                 *            0.0018  MACOMB...............             23490
230204.............................                 *            0.0018  MACOMB...............             23490
230207.............................                 *            0.0023  OAKLAND..............             23620
230208.............................                 *            0.0096  MONTCALM.............             23580
230217.............................                 *            0.0048  CALHOUN..............             23120
230222.............................                 *            0.0037  MIDLAND..............             23550
230223.............................                 *            0.0023  OAKLAND..............             23620
230227.............................                 *            0.0018  MACOMB...............             23490
230254.............................                 *            0.0023  OAKLAND..............             23620
230257.............................                 *            0.0018  MACOMB...............             23490
230264.............................                 *            0.0018  MACOMB...............             23490
230269.............................                 *            0.0023  OAKLAND..............             23620
230277.............................                 *            0.0023  OAKLAND..............             23620
230279.............................                 *            0.0208  LIVINGSTON...........             23460
240018.............................  ................            0.0873  GOODHUE..............             24240
240044.............................  ................            0.0671  WINONA...............             24840
240064.............................                 *            0.0130  ITASCA...............             24300
240069.............................                 *            0.0301  STEELE...............             24730
240071.............................                 *            0.0377  RICE.................             24650
240117.............................  ................            0.0593  MOWER................             24490
240211.............................  ................            0.0386  PINE.................             24570
250023.............................                 *            0.0430  PEARL RIVER..........             25540
250040.............................                 *            0.0022  JACKSON..............             25290
250117.............................                 *            0.0430  PEARL RIVER..........             25540
250128.............................  ................            0.0393  PANOLA...............             25530
250160.............................  ................            0.0393  PANOLA...............             25530
260059.............................  ................            0.0127  LACLEDE..............             26520
260064.............................                 *            0.0092  AUDRAIN..............             26030
260097.............................  ................            0.0295  JOHNSON..............             26500
270081.............................  ................            0.0236  MUSSELSHELL..........             27320
280077.............................  ................            0.0057  DODGE................             28260
280123.............................  ................            0.0118  GAGE.................             28330
290002.............................                 *            0.0280  LYON.................             29090
310002.............................                 *            0.0264  ESSEX................             31200

[[Page 24957]]

 
310009.............................                 *            0.0264  ESSEX................             31200
310010.............................                 *            0.0159  MERCER...............             31260
310013.............................                 *            0.0264  ESSEX................             31200
310018.............................                 *            0.0264  ESSEX................             31200
310021.............................  ................            0.0159  MERCER...............             31260
310031.............................                 *            0.0130  BURLINGTON...........             31150
310032.............................                 *            0.0027  CUMBERLAND...........             31190
310038.............................                 *            0.0368  MIDDLESEX............             31270
310039.............................                 *            0.0368  MIDDLESEX............             31270
310044.............................                 *            0.0159  MERCER...............             31260
310054.............................                 *            0.0264  ESSEX................             31200
310057.............................  ................            0.0130  BURLINGTON...........             31150
310061.............................  ................            0.0130  BURLINGTON...........             31150
310070.............................                 *            0.0368  MIDDLESEX............             31270
310076.............................                 *            0.0264  ESSEX................             31200
310083.............................                 *            0.0264  ESSEX................             31200
310092.............................                 *            0.0159  MERCER...............             31260
310093.............................                 *            0.0264  ESSEX................             31200
310096.............................                 *            0.0264  ESSEX................             31200
310108.............................                 *            0.0368  MIDDLESEX............             31270
310110.............................  ................            0.0159  MERCER...............             31260
310119.............................                 *            0.0264  ESSEX................             31200
310127.............................  ................            0.0130  BURLINGTON...........             31150
320003.............................                 *            0.0480  SAN MIGUEL...........             32230
320011.............................  ................            0.0337  RIO ARRIBA...........             32190
320018.............................  ................            0.0025  DONA ANA.............             32060
320085.............................  ................            0.0025  DONA ANA.............             32060
330004.............................                 *            0.0615  ULSTER...............             33740
330008.............................                 *            0.0102  WYOMING..............             33900
330010.............................  ................            0.0042  MONTGOMERY...........             33380
330027.............................                 *            0.0148  NASSAU...............             33400
330033.............................  ................            0.0205  CHENANGO.............             33080
330047.............................  ................            0.0042  MONTGOMERY...........             33380
330073.............................                 *            0.0122  GENESEE..............             33290
330094.............................                 *            0.0463  COLUMBIA.............             33200
330103.............................  ................            0.0121  CATTARAUGUS..........             33040
330106.............................                 *            0.0148  NASSAU...............             33400
330126.............................                 *            0.0675  ORANGE...............             33540
330132.............................                 *            0.0121  CATTARAUGUS..........             33040
330135.............................                 *            0.0675  ORANGE...............             33540
330167.............................                 *            0.0148  NASSAU...............             33400
330175.............................  ................            0.0241  CORTLAND.............             33210
330181.............................                 *            0.0148  NASSAU...............             33400
330182.............................                 *            0.0148  NASSAU...............             33400
330191.............................                 *            0.0017  WARREN...............             33750
330198.............................                 *            0.0148  NASSAU...............             33400
330205.............................                 *            0.0675  ORANGE...............             33540
330224.............................                 *            0.0615  ULSTER...............             33740
330225.............................                 *            0.0148  NASSAU...............             33400
330235.............................                 *            0.0281  CAYUGA...............             33050
330259.............................                 *            0.0148  NASSAU...............             33400
330264.............................                 *            0.0675  ORANGE...............             33540
330331.............................                 *            0.0148  NASSAU...............             33400
330332.............................                 *            0.0148  NASSAU...............             33400
330372.............................                 *            0.0148  NASSAU...............             33400
330386.............................                 *            0.0687  SULLIVAN.............             33710
340020.............................  ................            0.0143  LEE..................             34520
340021.............................                 *            0.0162  CLEVELAND............             34220
340024.............................  ................            0.0171  SAMPSON..............             34810
340027.............................                 *            0.0125  LENOIR...............             34530
340037.............................  ................            0.0162  CLEVELAND............             34220
340038.............................                 *            0.0253  BEAUFORT.............             34060
340039.............................                 *            0.0101  IREDELL..............             34480
340068.............................                 *            0.0094  COLUMBUS.............             34230
340069.............................                 *            0.0083  WAKE.................             34910
340070.............................                 *            0.0417  ALAMANCE.............             34000
340071.............................                 *            0.0168  HARNETT..............             34420
340073.............................                 *            0.0083  WAKE.................             34910
340085.............................  ................            0.0250  DAVIDSON.............             34280
340096.............................  ................            0.0250  DAVIDSON.............             34280

[[Page 24958]]

 
340104.............................                 *            0.0162  CLEVELAND............             34220
340114.............................                 *            0.0083  WAKE.................             34910
340124.............................                 *            0.0168  HARNETT..............             34420
340126.............................                 *            0.0084  WILSON...............             34970
340129.............................                 *            0.0101  IREDELL..............             34480
340133.............................  ................            0.0242  MARTIN...............             34580
340138.............................                 *            0.0083  WAKE.................             34910
340144.............................                 *            0.0101  IREDELL..............             34480
340145.............................                 *            0.0337  LINCOLN..............             34540
340151.............................  ................            0.0053  HALIFAX..............             34410
340173.............................                 *            0.0083  WAKE.................             34910
360002.............................  ................            0.0142  ASHLAND..............             36020
360010.............................                 *            0.0075  TUSCARAWAS...........             36800
360013.............................                 *            0.0135  SHELBY...............             36760
360025.............................                 *            0.0073  ERIE.................             36220
360036.............................                 *            0.0168  WAYNE................             36860
360040.............................  ................            0.0392  KNOX.................             36430
360044.............................  ................            0.0123  DARKE................             36190
360065.............................                 *            0.0077  HURON................             36400
360071.............................  ................            0.0035  VAN WERT.............             36820
360086.............................                 *            0.0187  CLARK................             36110
360096.............................                 *            0.0071  COLUMBIANA...........             36140
360107.............................                 *            0.0095  SANDUSKY.............             36730
360125.............................                 *            0.0137  ASHTABULA............             36030
360156.............................  ................            0.0095  SANDUSKY.............             36730
360175.............................                 *            0.0175  CLINTON..............             36130
360185.............................                 *            0.0071  COLUMBIANA...........             36140
360187.............................                 *            0.0187  CLARK................             36110
360245.............................                 *            0.0137  ASHTABULA............             36030
370014.............................                 *            0.0363  BRYAN................             37060
370015.............................                 *            0.0369  MAYES................             37480
370023.............................  ................            0.0090  STEPHENS.............             37680
370065.............................  ................            0.0097  CRAIG................             37170
370072.............................  ................            0.0260  LATIMER..............             37380
370083.............................  ................            0.0051  PUSHMATAHA...........             37630
370100.............................  ................            0.0101  CHOCTAW..............             37110
370149.............................                 *            0.0292  POTTAWATOMIE.........             37620
370156.............................  ................            0.0122  GARVIN...............             37240
370169.............................  ................            0.0164  MCINTOSH.............             37450
370172.............................  ................            0.0260  LATIMER..............             37380
370214.............................  ................            0.0122  GARVIN...............             37240
380022.............................                 *            0.0069  LINN.................             38210
390008.............................  ................            0.0055  LAWRENCE.............             39450
390016.............................                 *            0.0055  LAWRENCE.............             39450
390030.............................                 *            0.0163  SCHUYLKILL...........             39650
390031.............................                 *            0.0163  SCHUYLKILL...........             39650
390044.............................                 *            0.0191  BERKS................             39110
390052.............................  ................            0.0044  CLEARFIELD...........             39230
390065.............................                 *            0.0489  ADAMS................             39000
390066.............................                 *            0.0364  LEBANON..............             39460
390086.............................                 *            0.0044  CLEARFIELD...........             39230
390096.............................                 *            0.0191  BERKS................             39110
390113.............................                 *            0.0049  CRAWFORD.............             39260
390122.............................  ................            0.0049  CRAWFORD.............             39260
390138.............................                 *            0.0212  FRANKLIN.............             39350
390146.............................  ................            0.0019  WARREN...............             39740
390150.............................                 *            0.0019  GREENE...............             39370
390151.............................                 *            0.0212  FRANKLIN.............             39350
390181.............................                 *            0.0163  SCHUYLKILL...........             39650
390183.............................                 *            0.0163  SCHUYLKILL...........             39650
390201.............................                 *            0.1091  MONROE...............             39550
390313.............................                 *            0.0163  SCHUYLKILL...........             39650
420007.............................                 *            0.0037  SPARTANBURG..........             42410
420019.............................  ................            0.0142  CHESTER..............             42110
420027.............................                 *            0.0145  ANDERSON.............             42030
420030.............................                 *            0.0051  COLLETON.............             42140
420039.............................                 *            0.0148  UNION................             42430
420043.............................  ................            0.0132  CHEROKEE.............             42100
420062.............................                 *            0.0096  CHESTERFIELD.........             42120
420069.............................                 *            0.0023  CLARENDON............             42130

[[Page 24959]]

 
420083.............................                 *            0.0037  SPARTANBURG..........             42410
430008.............................  ................            0.0537  BROOKINGS............             43050
430048.............................                 *            0.0055  LAWRENCE.............             43400
430094.............................  ................            0.0055  LAWRENCE.............             43400
440007.............................  ................            0.0226  COFFEE...............             44150
440008.............................                 *            0.0449  HENDERSON............             44380
440016.............................  ................            0.0144  CARROLL..............             44080
440024.............................                 *            0.0230  BRADLEY..............             44050
440030.............................  ................            0.0015  HAMBLEN..............             44310
440031.............................  ................            0.0025  ROANE................             44720
440033.............................  ................            0.0036  CAMPBELL.............             44060
440035.............................                 *            0.0309  MONTGOMERY...........             44620
440047.............................  ................            0.0338  GIBSON...............             44260
440051.............................  ................            0.0071  MCNAIRY..............             44540
440057.............................  ................            0.0028  CLAIBORNE............             44120
440060.............................                 *            0.0338  GIBSON...............             44260
440067.............................                 *            0.0015  HAMBLEN..............             44310
440070.............................  ................            0.0109  DECATUR..............             44190
440081.............................  ................            0.0069  SEVIER...............             44770
440084.............................  ................            0.0034  MONROE...............             44610
440109.............................  ................            0.0070  HARDIN...............             44350
440115.............................  ................            0.0338  GIBSON...............             44260
440137.............................  ................            0.0763  BEDFORD..............             44010
440144.............................                 *            0.0226  COFFEE...............             44150
440148.............................                 *            0.0306  DE KALB..............             44200
440174.............................  ................            0.0310  HAYWOOD..............             44370
440180.............................  ................            0.0036  CAMPBELL.............             44060
440181.............................  ................            0.0361  HARDEMAN.............             44340
440182.............................  ................            0.0144  CARROLL..............             44080
440185.............................                 *            0.0230  BRADLEY..............             44050
450032.............................                 *            0.0253  HARRISON.............             45620
450039.............................                 *            0.0024  TARRANT..............             45910
450052.............................                 *            0.0276  BOSQUE...............             45160
450059.............................                 *            0.0074  COMAL................             45320
450064.............................                 *            0.0024  TARRANT..............             45910
450087.............................                 *            0.0024  TARRANT..............             45910
450090.............................  ................            0.0651  COOKE................             45340
450099.............................                 *            0.0143  GRAY.................             45563
450135.............................                 *            0.0024  TARRANT..............             45910
450137.............................                 *            0.0024  TARRANT..............             45910
450144.............................  ................            0.0558  ANDREWS..............             45010
450163.............................  ................            0.0053  KLEBERG..............             45743
450192.............................  ................            0.0271  HILL.................             45651
450194.............................  ................            0.0213  CHEROKEE.............             45281
450210.............................  ................            0.0150  PANOLA...............             45842
450224.............................                 *            0.0195  WOOD.................             45974
450236.............................  ................            0.0389  HOPKINS..............             45654
450270.............................  ................            0.0271  HILL.................             45651
450283.............................                 *            0.0655  VAN ZANDT............             45947
450347.............................                 *            0.0379  WALKER...............             45949
450348.............................                 *            0.0058  FALLS................             45500
450370.............................  ................            0.0241  COLORADO.............             45312
450389.............................                 *            0.0619  HENDERSON............             45640
450395.............................                 *            0.0452  POLK.................             45850
450419.............................                 *            0.0024  TARRANT..............             45910
450438.............................                 *            0.0241  COLORADO.............             45312
450451.............................  ................            0.0537  SOMERVELL............             45893
450460.............................  ................            0.0048  TYLER................             45942
450497.............................  ................            0.0395  MONTAGUE.............             45800
450539.............................  ................            0.0071  HALE.................             45582
450547.............................  ................            0.0195  WOOD.................             45974
450563.............................                 *            0.0024  TARRANT..............             45910
450565.............................  ................            0.0481  PALO PINTO...........             45841
450573.............................  ................            0.0115  JASPER...............             45690
450596.............................                 *            0.0744  HOOD.................             45653
450639.............................                 *            0.0024  TARRANT..............             45910
450641.............................  ................            0.0395  MONTAGUE.............             45800
450672.............................                 *            0.0024  TARRANT..............             45910
450675.............................                 *            0.0024  TARRANT..............             45910
450677.............................                 *            0.0024  TARRANT..............             45910

[[Page 24960]]

 
450698.............................  ................            0.0135  LAMB.................             45751
450747.............................                 *            0.0127  ANDERSON.............             45000
450755.............................  ................            0.0295  HOCKLEY..............             45652
450770.............................                 *            0.0182  MILAM................             45795
450779.............................                 *            0.0024  TARRANT..............             45910
450813.............................                 *            0.0127  ANDERSON.............             45000
450838.............................  ................            0.0115  JASPER...............             45690
450872.............................                 *            0.0024  TARRANT..............             45910
450880.............................                 *            0.0024  TARRANT..............             45910
450884.............................  ................            0.0050  UPSHUR...............             45943
450886.............................  ................            0.0024  TARRANT..............             45910
450888.............................  ................            0.0024  TARRANT..............             45910
460017.............................  ................            0.0364  BOX ELDER............             46010
460039.............................                 *            0.0364  BOX ELDER............             46010
490019.............................                 *            0.1081  CULPEPER.............             49230
490084.............................  ................            0.0145  ESSEX................             49280
490110.............................  ................            0.0327  MONTGOMERY...........             49600
500003.............................                 *            0.0164  SKAGIT...............             50280
500007.............................                 *            0.0164  SKAGIT...............             50280
500019.............................  ................            0.0140  LEWIS................             50200
500039.............................                 *            0.0101  KITSAP...............             50170
500041.............................                 *            0.0020  COWLITZ..............             50070
510018.............................                 *            0.0187  JACKSON..............             51170
510047.............................                 *            0.0270  MARION...............             51240
520028.............................                 *            0.0297  GREEN................             52220
520035.............................  ................            0.0083  SHEBOYGAN............             52580
520044.............................  ................            0.0083  SHEBOYGAN............             52580
520057.............................  ................            0.0184  SAUK.................             52550
520059.............................                 *            0.0189  RACINE...............             52500
520060.............................                 *            0.0048  GREEN LAKE...........             52230
520071.............................                 *            0.0174  JEFFERSON............             52270
520076.............................                 *            0.0159  DODGE................             52130
520095.............................                 *            0.0184  SAUK.................             52550
520096.............................  ................            0.0189  RACINE...............             52500
520102.............................                 *            0.0242  WALWORTH.............             52630
520116.............................                 *            0.0174  JEFFERSON............             52270
----------------------------------------------------------------------------------------------------------------


Table 5.--List of Proposed Medicare Severity-Diagnosis Related Groups (MS-DRGs), Relative Weighting Factors, and Geometric and Arithmetic Mean Length of
                                                                          Stay
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                                                                                                                   Geometric  Arithmetic
                      FY 2008 proposed      FY 2008 proposed                                                                         mean        mean
      MS-DRG         rule post-acute DRG  rule special pay DRG    MDC           TYPE               MS-DRG title         Weights    length of   length of
                                                                                                                                     stay        stay
--------------------------------------------------------------------------------------------------------------------------------------------------------
1.................  NO..................  NO..................     PRE  SURG................  Heart transplant or        23.6378        30.5        44.2
                                                                                               implant of heart
                                                                                               assist system w MCC.
2.................  NO..................  NO..................     PRE  SURG................  Heart transplant or        11.2998        16.0        22.8
                                                                                               implant of heart
                                                                                               assist system w/o MCC.
3.................  YES.................  NO..................     PRE  SURG................  ECMO or trach w MV 96+     18.6118        36.2        43.2
                                                                                               hrs or PDX exc face,
                                                                                               mouth & neck w maj
                                                                                               O.R.
4.................  YES.................  NO..................     PRE  SURG................  Trach w MV 96+ hrs or      11.5312        26.2        31.3
                                                                                               PDX exc face, mouth &
                                                                                               neck w/o maj O.R.
5.................  NO..................  NO..................     PRE  SURG................  Liver transplant w MCC     10.3032        17.0        22.6
                                                                                               or intestinal
                                                                                               transplant.
6.................  NO..................  NO..................     PRE  SURG................  Liver transplant w/o        4.7075         8.7        10.0
                                                                                               MCC.
7.................  NO..................  NO..................     PRE  SURG................  Lung transplant.......      7.6379        14.6        17.3
8.................  NO..................  NO..................     PRE  SURG................  Simultaneous pancreas/      5.0633        10.2        11.9
                                                                                               kidney transplant.
9.................  NO..................  NO..................     PRE  SURG................  Bone marrow transplant      6.1059        18.1        21.6
10................  NO..................  NO..................     PRE  SURG................  Pancreas transplant...      3.6839         9.1        10.2
11................  NO..................  NO..................     PRE  SURG................  Tracheostomy for face,      4.8010        13.0        16.3
                                                                                               mouth & neck
                                                                                               diagnoses w MCC.
12................  NO..................  NO..................     PRE  SURG................  Tracheostomy for face,      2.9948         9.0        10.9
                                                                                               mouth & neck
                                                                                               diagnoses w CC.
13................  NO..................  NO..................     PRE  SURG................  Tracheostomy for face,      1.8882         6.1         7.3
                                                                                               mouth & neck
                                                                                               diagnoses w/o CC/MCC.
20................  NO..................  NO..................      01  SURG................  Intracranial vascular       8.2109        15.4        19.2
                                                                                               procedures w PDX
                                                                                               hemorrhage w MCC.

[[Page 24961]]

 
21................  NO..................  NO..................      01  SURG................  Intracranial vascular       6.1724        13.4        15.6
                                                                                               procedures w PDX
                                                                                               hemorrhage w CC.
22................  NO..................  NO..................      01  SURG................  Intracranial vascular       4.1017         7.9         9.7
                                                                                               procedures w PDX
                                                                                               hemorrhage w/o CC/MCC.
23................  NO..................  NO..................      01  SURG................  Craniotomy w major          5.1123         9.8        13.7
                                                                                               device implant or
                                                                                               acute complex CNS PDX
                                                                                               w MCC.
24................  NO..................  NO..................      01  SURG................  Craniotomy w major          3.4316         6.1         8.7
                                                                                               device implant or
                                                                                               acute complex CNS PDX
                                                                                               w/o MCC.
25................  YES.................  NO..................      01  SURG................  Craniotomy &                4.9933        10.7        13.8
                                                                                               endovascular
                                                                                               intracranial
                                                                                               procedures w MCC.
26................  YES.................  NO..................      01  SURG................  Craniotomy &                2.9515         6.7         8.4
                                                                                               endovascular
                                                                                               intracranial
                                                                                               procedures w CC.
27................  YES.................  NO..................      01  SURG................  Craniotomy &                2.0380         3.6         4.7
                                                                                               endovascular
                                                                                               intracranial
                                                                                               procedures w/o CC/MCC.
28................  NO..................  NO..................      01  SURG................  Spinal procedures w         4.9251        10.9        14.7
                                                                                               MCC.
29................  NO..................  NO..................      01  SURG................  Spinal procedures w CC      2.5965         5.7         7.7
30................  NO..................  NO..................      01  SURG................  Spinal procedures w/o       1.5278         2.7         3.7
                                                                                               CC/MCC.
31................  NO..................  NO..................      01  SURG................  Ventricular shunt           3.8505         9.2        13.2
                                                                                               procedures w MCC.
32................  NO..................  NO..................      01  SURG................  Ventricular shunt           1.7502         3.9         5.8
                                                                                               procedures w CC.
33................  NO..................  NO..................      01  SURG................  Ventricular shunt           1.2661         2.3         3.1
                                                                                               procedures w/o CC/MCC.
34................  NO..................  NO..................      01  SURG................  Carotid artery stent        3.2158         4.8         7.3
                                                                                               procedure w MCC.
35................  NO..................  NO..................      01  SURG................  Carotid artery stent        2.0186         2.0         3.0
                                                                                               procedure w CC.
36................  NO..................  NO..................      01  SURG................  Carotid artery stent        1.5746         1.3         1.6
                                                                                               procedure w/o CC/MCC.
37................  NO..................  NO..................      01  SURG................  Extracranial                3.0383         6.0         8.7
                                                                                               procedures w MCC.
38................  NO..................  NO..................      01  SURG................  Extracranial                1.5518         2.6         3.8
                                                                                               procedures w CC.
39................  NO..................  NO..................      01  SURG................  Extracranial                1.0172         1.5         1.9
                                                                                               procedures w/o CC/MCC.
40................  YES.................  YES.................      01  SURG................  Periph & cranial nerve      3.8181        10.4        14.0
                                                                                               & other nerv syst
                                                                                               proc w MCC.
41................  YES.................  YES.................      01  SURG................  Periph & cranial nerve      2.1436         5.6         7.5
                                                                                               & other nerv syst
                                                                                               proc w CC.
42................  YES.................  YES.................      01  SURG................  Periph & cranial nerve      1.6878         2.5         3.7
                                                                                               & other nerv syst
                                                                                               proc w/o CC/MCC.
52................  NO..................  NO..................      01  MED.................  Spinal disorders &          1.5118         4.9         6.8
                                                                                               injuries w CC/MCC.
53................  NO..................  NO..................      01  MED.................  Spinal disorders &          0.9105         3.2         4.0
                                                                                               injuries w/o CC/MCC.
54................  YES.................  NO..................      01  MED.................  Nervous system              1.6182         5.5         7.4
                                                                                               neoplasms w MCC.
55................  YES.................  NO..................      01  MED.................  Nervous system              1.0567         3.9         5.1
                                                                                               neoplasms w/o MCC.
56................  YES.................  NO..................      01  MED.................  Degenerative nervous        1.6121         6.2         8.2
                                                                                               system disorders w
                                                                                               MCC.
57................  YES.................  NO..................      01  MED.................  Degenerative nervous        0.8403         4.0         5.0
                                                                                               system disorders w/o
                                                                                               MCC.
58................  NO..................  NO..................      01  MED.................  Multiple sclerosis &        1.6022         5.8         8.0
                                                                                               cerebellar ataxia w
                                                                                               MCC.
59................  NO..................  NO..................      01  MED.................  Multiple sclerosis &        0.9288         4.3         5.2
                                                                                               cerebellar ataxia w
                                                                                               CC.
60................  NO..................  NO..................      01  MED.................  Multiple sclerosis &        0.7126         3.4         4.1
                                                                                               cerebellar ataxia w/o
                                                                                               CC/MCC.
61................  NO..................  NO..................      01  MED.................  Acute ischemic stroke       2.9195         7.4         9.8
                                                                                               w use of thrombolytic
                                                                                               agent w MCC.
62................  NO..................  NO..................      01  MED.................  Acute ischemic stroke       1.9977         5.4         6.4
                                                                                               w use of thrombolytic
                                                                                               agent w CC.
63................  NO..................  NO..................      01  MED.................  Acute ischemic stroke       1.5581         4.0         4.6
                                                                                               w use of thrombolytic
                                                                                               agent w/o CC/MCC.
64................  YES.................  NO..................      01  MED.................  Intracranial                1.9072         5.9         7.9
                                                                                               hemorrhage or
                                                                                               cerebral infarction w
                                                                                               MCC.
65................  YES.................  NO..................      01  MED.................  Intracranial                1.1841         4.5         5.4
                                                                                               hemorrhage or
                                                                                               cerebral infarction w
                                                                                               CC.
66................  YES.................  NO..................      01  MED.................  Intracranial                0.8588         3.2         3.8
                                                                                               hemorrhage or
                                                                                               cerebral infarction w/
                                                                                               o CC/MCC.
67................  NO..................  NO..................      01  MED.................  Nonspecific cva &           1.5069         4.8         6.2
                                                                                               precerebral occlusion
                                                                                               w/o infarct w MCC.
68................  NO..................  NO..................      01  MED.................  Nonspecific cva &           0.8855         2.8         3.6
                                                                                               precerebral occlusion
                                                                                               w/o infarct w/o MCC.
69................  NO..................  NO..................      01  MED.................  Transient ischemia....      0.7372         2.5         3.1
70................  YES.................  NO..................      01  MED.................  Nonspecific                 1.8674         6.3         8.2
                                                                                               cerebrovascular
                                                                                               disorders w MCC.
71................  YES.................  NO..................      01  MED.................  Nonspecific                 1.1698         4.6         5.8
                                                                                               cerebrovascular
                                                                                               disorders w CC.

[[Page 24962]]

 
72................  YES.................  NO..................      01  MED.................  Nonspecific                 0.8275         3.0         3.8
                                                                                               cerebrovascular
                                                                                               disorders w/o CC/MCC.
73................  NO..................  NO..................      01  MED.................  Cranial & peripheral        1.3298         4.8         6.4
                                                                                               nerve disorders w MCC.
74................  NO..................  NO..................      01  MED.................  Cranial & peripheral        0.8482         3.4         4.4
                                                                                               nerve disorders w/o
                                                                                               MCC.
75................  NO..................  NO..................      01  MED.................  Viral meningitis w CC/      1.7156         6.1         7.7
                                                                                               MCC.
76................  NO..................  NO..................      01  MED.................  Viral meningitis w/o        0.9367         3.5         4.2
                                                                                               CC/MCC.
77................  NO..................  NO..................      01  MED.................  Hypertensive                1.7374         5.6         7.2
                                                                                               encephalopathy w MCC.
78................  NO..................  NO..................      01  MED.................  Hypertensive                1.0221         3.8         4.6
                                                                                               encephalopathy w CC.
79................  NO..................  NO..................      01  MED.................  Hypertensive                0.8041         2.9         3.5
                                                                                               encephalopathy w/o CC/
                                                                                               MCC.
80................  NO..................  NO..................      01  MED.................  Nontraumatic stupor &       1.0699         3.6         4.9
                                                                                               coma w MCC.
81................  NO..................  NO..................      01  MED.................  Nontraumatic stupor &       0.6932         2.7         3.4
                                                                                               coma w/o MCC.
82................  NO..................  NO..................      01  MED.................  Traumatic stupor &          2.0060         3.9         6.4
                                                                                               coma, coma >1 hr w
                                                                                               MCC.
83................  NO..................  NO..................      01  MED.................  Traumatic stupor &          1.3451         3.8         5.3
                                                                                               coma, coma >1 hr w CC.
84................  NO..................  NO..................      01  MED.................  Traumatic stupor &          0.8999         2.3         3.1
                                                                                               coma, coma >1 hr w/o
                                                                                               CC/MCC.
85................  YES.................  NO..................      01  MED.................  Traumatic stupor &          2.0578         6.0         8.2
                                                                                               coma, coma <1 hr w
                                                                                               MCC.
86................  YES.................  NO..................      01  MED.................  Traumatic stupor &          1.1911         4.1         5.3
                                                                                               coma, coma <1 hr w CC.
87................  YES.................  NO..................      01  MED.................  Traumatic stupor &          0.8097         2.7         3.4
                                                                                               coma, coma <1 hr w/o
                                                                                               CC/MCC.
88................  NO..................  NO..................      01  MED.................  Concussion w MCC......      1.5966         4.3         6.1
89................  NO..................  NO..................      01  MED.................  Concussion w CC.......      0.9494         3.0         3.8
90................  NO..................  NO..................      01  MED.................  Concussion w/o CC/MCC.      0.6755         2.0         2.5
91................  YES.................  NO..................      01  MED.................  Other disorders of          1.6189         4.9         6.8
                                                                                               nervous system w MCC.
92................  YES.................  NO..................      01  MED.................  Other disorders of          0.9082         3.6         4.5
                                                                                               nervous system w CC.
93................  YES.................  NO..................      01  MED.................  Other disorders of          0.6805         2.6         3.2
                                                                                               nervous system w/o CC/
                                                                                               MCC.
94................  NO..................  NO..................      01  MED.................  Bacterial &                 3.5061        10.3        12.9
                                                                                               tuberculous
                                                                                               infections of nervous
                                                                                               system w MCC.
95................  NO..................  NO..................      01  MED.................  Bacterial &                 2.3341         7.7         9.4
                                                                                               tuberculous
                                                                                               infections of nervous
                                                                                               system w CC.
96................  NO..................  NO..................      01  MED.................  Bacterial &                 1.9369         5.1         6.3
                                                                                               tuberculous
                                                                                               infections of nervous
                                                                                               system w/o CC/MCC.
97................  NO..................  NO..................      01  MED.................  Non-bacterial infect        3.0776         9.6        12.0
                                                                                               of nervous sys exc
                                                                                               viral meningitis w
                                                                                               MCC.
98................  NO..................  NO..................      01  MED.................  Non-bacterial infect        1.8380         7.0         8.7
                                                                                               of nervous sys exc
                                                                                               viral meningitis w CC.
99................  NO..................  NO..................      01  MED.................  Non-bacterial infect        1.3644         5.2         6.4
                                                                                               of nervous sys exc
                                                                                               viral meningitis w/o
                                                                                               CC/MCC.
100...............  YES.................  NO..................      01  MED.................  Seizures w MCC........      1.5034         4.8         6.4
101...............  YES.................  NO..................      01  MED.................  Seizures w/o MCC......      0.7674         3.0         3.7
102...............  NO..................  NO..................      01  MED.................  Headaches w MCC.......      1.0425         3.6         5.1
103...............  NO..................  NO..................      01  MED.................  Headaches w/o MCC.....      0.6534         2.5         3.2
113...............  NO..................  NO..................      02  SURG................  Orbital procedures w        1.6088         3.9         5.6
                                                                                               CC/MCC.
114...............  NO..................  NO..................      02  SURG................  Orbital procedures w/o      0.8349         2.0         2.7
                                                                                               CC/MCC.
15................  NO..................  NO..................      02  SURG................  Extraocular procedures      1.0782         3.3         4.5
                                                                                               except orbit.
116...............  NO..................  NO..................      02  SURG................  Intraocular procedures      1.0167         2.2         3.5
                                                                                               w CC/MCC.
117...............  NO..................  NO..................      02  SURG................  Intraocular procedures      0.6329         1.5         2.0
                                                                                               w/o CC/MCC.
121...............  NO..................  NO..................      02  MED.................  Acute major eye             1.0166         4.7         5.9
                                                                                               infections w CC/MCC.
122...............  NO..................  NO..................      02  MED.................  Acute major eye             0.5585         3.4         4.1
                                                                                               infections w/o CC/MCC.
123...............  NO..................  NO..................      02  MED.................  Neurological eye            0.7168         2.4         2.9
                                                                                               disorders.
124...............  NO..................  NO..................      02  MED.................  Other disorders of the      1.1057         4.0         5.3
                                                                                               eye w MCC.
125...............  NO..................  NO..................      02  MED.................  Other disorders of the      0.6561         2.7         3.5
                                                                                               eye w/o MCC.
129...............  NO..................  NO..................      03  SURG................  Major head & neck           1.9117         3.6         5.1
                                                                                               procedures w CC/MCC
                                                                                               or major device.
130...............  NO..................  NO..................      03  SURG................  Major head & neck           1.1754         2.5         3.2
                                                                                               procedures w/o CC/MCC.
131...............  NO..................  NO..................      03  SURG................  Cranial/facial              1.8374         3.9         5.6
                                                                                               procedures w CC/MCC.
132...............  NO..................  NO..................      03  SURG................  Cranial/facial              1.0808         2.1         2.6
                                                                                               procedures w/o CC/MCC.
133...............  NO..................  NO..................      03  SURG................  Other ear, nose, mouth      1.7401         4.1         6.4
                                                                                               & throat O.R.
                                                                                               procedures w CC/MCC.

[[Page 24963]]

 
134...............  NO..................  NO..................      03  SURG................  Other ear, nose, mouth      0.7834         1.8         2.3
                                                                                               & throat O.R.
                                                                                               procedures w/o CC/MCC.
135...............  NO..................  NO..................      03  SURG................  Sinus & mastoid             1.8091         4.0         6.1
                                                                                               procedures w CC/MCC.
136...............  NO..................  NO..................      03  SURG................  Sinus & mastoid             0.9299         1.7         2.3
                                                                                               procedures w/o CC/MCC.
137...............  NO..................  NO..................      03  SURG................  Mouth procedures w CC/      1.3963         3.7         5.4
                                                                                               MCC.
138...............  NO..................  NO..................      03  SURG................  Mouth procedures w/o        0.7922         1.9         2.4
                                                                                               CC/MCC.
139...............  NO..................  NO..................      03  SURG................  Salivary gland              0.8585         1.5         1.9
                                                                                               procedures.
146...............  NO..................  NO..................      03  MED.................  Ear, nose, mouth &          2.2573         7.1        10.2
                                                                                               throat malignancy w
                                                                                               MCC.
147...............  NO..................  NO..................      03  MED.................  Ear, nose, mouth &          1.1662         4.2         5.8
                                                                                               throat malignancy w
                                                                                               CC.
148...............  NO..................  NO..................      03  MED.................  Ear, nose, mouth &          0.7281         2.5         3.5
                                                                                               throat malignancy w/o
                                                                                               CC/MCC.
149...............  NO..................  NO..................      03  MED.................  Dysequilibrium........      0.6154         2.2         2.7
150...............  NO..................  NO..................      03  MED.................  Epistaxis w MCC.......      1.3003         4.0         5.5
151...............  NO..................  NO..................      03  MED.................  Epistaxis w/o MCC.....      0.5760         2.3         2.9
152...............  NO..................  NO..................      03  MED.................  Otitis media & URI w        0.9462         3.7         4.7
                                                                                               MCC.
153...............  NO..................  NO..................      03  MED.................  Otitis media & URI w/o      0.6048         2.8         3.4
                                                                                               MCC.
154...............  NO..................  NO..................      03  MED.................  Nasal trauma &              1.3989         4.9         6.5
                                                                                               deformity w MCC.
155...............  NO..................  NO..................      03  MED.................  Nasal trauma &              0.8749         3.6         4.6
                                                                                               deformity w CC.
156...............  NO..................  NO..................      03  MED.................  Nasal trauma &              0.6360         2.5         3.2
                                                                                               deformity w/o CC/MCC.
157...............  NO..................  NO..................      03  MED.................  Dental & Oral Diseases      1.4922         5.0         6.9
                                                                                               w MCC.
158...............  NO..................  NO..................      03  MED.................  Dental & Oral Diseases      0.8634         3.4         4.5
                                                                                               w CC.
159...............  NO..................  NO..................      03  MED.................  Dental & Oral Diseases      0.6046         2.4         3.1
                                                                                               w/o CC/MCC.
163...............  YES.................  NO..................      04  SURG................  Major chest procedures      5.0199        12.7        15.4
                                                                                               w MCC.
164...............  YES.................  NO..................      04  SURG................  Major chest procedures      2.5482         7.0         8.5
                                                                                               w CC.
165...............  YES.................  NO..................      04  SURG................  Major chest procedures      1.7780         4.5         5.4
                                                                                               w/o CC/MCC.
166...............  YES.................  NO..................      04  SURG................  Other resp system O.R.      3.7734        10.6        13.4
                                                                                               procedures w MCC.
167...............  YES.................  NO..................      04  SURG................  Other resp system O.R.      2.0778         6.7         8.3
                                                                                               procedures w CC.
168...............  YES.................  NO..................      04  SURG................  Other resp system O.R.      1.3566         4.1         5.5
                                                                                               procedures w/o CC/MCC.
175...............  YES.................  NO..................      04  MED.................  Pulmonary embolism w        1.6160         6.4         7.6
                                                                                               MCC.
176...............  YES.................  NO..................      04  MED.................  Pulmonary embolism w/o      1.0969         4.9         5.6
                                                                                               MCC.
177...............  YES.................  NO..................      04  MED.................  Respiratory infections      2.0518         7.6         9.5
                                                                                               & inflammations w MCC.
178...............  YES.................  NO..................      04  MED.................  Respiratory infections      1.5058         6.3         7.7
                                                                                               & inflammations w CC.
179...............  YES.................  NO..................      04  MED.................  Respiratory infections      1.0484         4.8         5.8
                                                                                               & inflammations w/o
                                                                                               CC/MCC.
180...............  NO..................  NO..................      04  MED.................  Respiratory neoplasms       1.7205         6.1         8.0
                                                                                               w MCC.
181...............  NO..................  NO..................      04  MED.................  Respiratory neoplasms       1.2288         4.6         6.0
                                                                                               w CC.
182...............  NO..................  NO..................      04  MED.................  Respiratory neoplasms       0.8973         3.3         4.3
                                                                                               w/o CC/MCC.
183...............  NO..................  NO..................      04  MED.................  Major chest trauma w        1.5059         5.7         7.2
                                                                                               MCC.
184...............  NO..................  NO..................      04  MED.................  Major chest trauma w        0.9082         3.8         4.7
                                                                                               CC.
185...............  NO..................  NO..................      04  MED.................  Major chest trauma w/o      0.6322         2.7         3.3
                                                                                               CC/MCC.
186...............  YES.................  NO..................      04  MED.................  Pleural effusion w MCC      1.6338         6.0         7.7
187...............  YES.................  NO..................      04  MED.................  Pleural effusion w CC.      1.1228         4.4         5.6
188...............  YES.................  NO..................      04  MED.................  Pleural effusion w/o        0.8350         3.3         4.2
                                                                                               CC/MCC.
189...............  NO..................  NO..................      04  MED.................  Pulmonary edema &           1.3833         4.9         6.3
                                                                                               respiratory failure.
190...............  YES.................  NO..................      04  MED.................  Chronic obstructive         1.3448         5.3         6.6
                                                                                               pulmonary disease w
                                                                                               MCC.
191...............  YES.................  NO..................      04  MED.................  Chronic obstructive         1.0024         4.3         5.2
                                                                                               pulmonary disease w
                                                                                               CC.
192...............  YES.................  NO..................      04  MED.................  Chronic obstructive         0.7484         3.4         4.1
                                                                                               pulmonary disease w/o
                                                                                               CC/MCC.
193...............  YES.................  NO..................      04  MED.................  Simple pneumonia &          1.4737         5.7         7.0
                                                                                               pleurisy w MCC.
194...............  YES.................  NO..................      04  MED.................  Simple pneumonia &          1.0280         4.5         5.4
                                                                                               pleurisy w CC.
195...............  YES.................  NO..................      04  MED.................  Simple pneumonia &          0.7461         3.6         4.2
                                                                                               pleurisy w/o CC/MCC.
196...............  YES.................  NO..................      04  MED.................  Interstitial lung           1.5597         6.0         7.5
                                                                                               disease w MCC.
197...............  YES.................  NO..................      04  MED.................  Interstitial lung           1.1041         4.5         5.5
                                                                                               disease w CC.
198...............  YES.................  NO..................      04  MED.................  Interstitial lung           0.8423         3.5         4.3
                                                                                               disease w/o CC/MCC.
199...............  NO..................  NO..................      04  MED.................  Pneumothorax w MCC....      1.7928         6.7         8.5
200...............  NO..................  NO..................      04  MED.................  Pneumothorax w CC.....      1.0158         4.0         5.2
201...............  NO..................  NO..................      04  MED.................  Pneumothorax w/o CC/        0.7356         3.2         4.1
                                                                                               MCC.
202...............  NO..................  NO..................      04  MED.................  Bronchitis & asthma w       0.8324         3.6         4.5
                                                                                               CC/MCC.
203...............  NO..................  NO..................      04  MED.................  Bronchitis & asthma w/      0.6040         2.9         3.5
                                                                                               o CC/MCC.
204...............  NO..................  NO..................      04  MED.................  Respiratory signs &         0.6685         2.2         2.9
                                                                                               symptoms.

[[Page 24964]]

 
205...............  YES.................  NO..................      04  MED.................  Other respiratory           1.2260         4.4         5.8
                                                                                               system diagnoses w
                                                                                               MCC.
206...............  YES.................  NO..................      04  MED.................  Other respiratory           0.7438         2.7         3.5
                                                                                               system diagnoses w/o
                                                                                               MCC.
207...............  YES.................  NO..................      04  MED.................  Respiratory system          5.1817        13.0        15.3
                                                                                               diagnosis w
                                                                                               ventilator support
                                                                                               96+ hours.
208...............  NO..................  NO..................      04  MED.................  Respiratory system          2.2694         5.3         7.4
                                                                                               diagnosis w
                                                                                               ventilator support
                                                                                               <96 hours.
215...............  NO..................  NO..................      05  SURG................  Other heart assist         11.3007         6.3        12.2
                                                                                               system implant.
216...............  YES.................  NO..................      05  SURG................  Cardiac valve & oth        10.1554        16.5        19.3
                                                                                               maj cardiothoracic
                                                                                               proc w card cath w
                                                                                               MCC.
217...............  YES.................  NO..................      05  SURG................  Cardiac valve & oth         6.7770        11.2        12.6
                                                                                               maj cardiothoracic
                                                                                               proc w card cath w CC.
218...............  YES.................  NO..................      05  SURG................  Cardiac valve & oth         5.3817         8.5         9.2
                                                                                               maj cardiothoracic
                                                                                               proc w card cath w/o
                                                                                               CC/MCC.
219...............  YES.................  YES.................      05  SURG................  Cardiac valve & oth         8.0521        12.0        14.7
                                                                                               maj cardiothoracic
                                                                                               proc w/o card cath w
                                                                                               MCC.
220...............  YES.................  YES.................      05  SURG................  Cardiac valve & oth         5.2148         7.7         8.8
                                                                                               maj cardiothoracic
                                                                                               proc w/o card cath w
                                                                                               CC.
221...............  YES.................  YES.................      05  SURG................  Cardiac valve & oth         4.2664         6.1         6.5
                                                                                               maj cardiothoracic
                                                                                               proc w/o card cath w/
                                                                                               o CC/MCC.
222...............  NO..................  NO..................      05  SURG................  Cardiac defib implant       8.7087        10.8        13.3
                                                                                               w cardiac cath w AMI/
                                                                                               HF/shock w MCC.
223...............  NO..................  NO..................      05  SURG................  Cardiac defib implant       6.4941         5.0         6.6
                                                                                               w cardiac cath w AMI/
                                                                                               HF/shock w/o MCC.
224...............  NO..................  NO..................      05  SURG................  Cardiac defib implant       8.0293         9.2        11.5
                                                                                               w cardiac cath w/o
                                                                                               AMI/HF/shock w MCC.
225...............  NO..................  NO..................      05  SURG................  Cardiac defib implant       6.0000         4.6         5.8
                                                                                               w cardiac cath w/o
                                                                                               AMI/HF/shock w/o MCC.
226...............  NO..................  NO..................      05  SURG................  Cardiac defibrillator       6.6475         6.2         9.4
                                                                                               implant w/o cardiac
                                                                                               cath w MCC.
227...............  NO..................  NO..................      05  SURG................  Cardiac defibrillator       4.9179         1.8         2.8
                                                                                               implant w/o cardiac
                                                                                               cath w/o MCC.
228...............  YES.................  NO..................      05  SURG................  Other cardiothoracic        7.6611        12.4        15.1
                                                                                               procedures w MCC.
229...............  YES.................  NO..................      05  SURG................  Other cardiothoracic        4.9100         8.1         9.3
                                                                                               procedures w CC.
230...............  YES.................  NO..................      05  SURG................  Other cardiothoracic        3.8738         5.8         6.7
                                                                                               procedures w/o CC/MCC.
231...............  NO..................  NO..................      05  SURG................  Coronary bypass w PTCA      7.8839        10.8        13.2
                                                                                               w MCC.
232...............  NO..................  NO..................      05  SURG................  Coronary bypass w PTCA      5.7100         8.1         9.0
                                                                                               w/o MCC.
233...............  YES.................  NO..................      05  SURG................  Coronary bypass w           7.1576        12.9        14.7
                                                                                               cardiac cath w MCC.
234...............  YES.................  NO..................      05  SURG................  Coronary bypass w           4.6250         8.3         9.0
                                                                                               cardiac cath w/o MCC.
235...............  YES.................  NO..................      05  SURG................  Coronary bypass w/o         5.8085        10.0        11.9
                                                                                               cardiac cath w MCC.
236...............  YES.................  NO..................      05  SURG................  Coronary bypass w/o         3.5360         6.1         6.7
                                                                                               cardiac cath w/o MCC.
237...............  NO..................  NO..................      05  SURG................  Major cardiovascular        5.1414         8.3        11.6
                                                                                               procedures w MCC.
238...............  NO..................  NO..................      05  SURG................  Major cardiovascular        2.8491         3.4         4.9
                                                                                               procedures w/o MCC.
239...............  YES.................  NO..................      05  SURG................  Amputation for circ         4.4948        13.6        16.9
                                                                                               sys disorders exc
                                                                                               upper limb & toe w
                                                                                               MCC.
240...............  YES.................  NO..................      05  SURG................  Amputation for circ         2.6343         9.4        11.4
                                                                                               sys disorders exc
                                                                                               upper limb & toe w CC.
241...............  YES.................  NO..................      05  SURG................  Amputation for circ         1.6041         6.2         7.4
                                                                                               sys disorders exc
                                                                                               upper limb & toe w/o
                                                                                               CC/MCC.
242...............  YES.................  NO..................      05  SURG................  Permanent cardiac           3.7363         7.1         9.1
                                                                                               pacemaker implant w
                                                                                               MCC.
243...............  YES.................  NO..................      05  SURG................  Permanent cardiac           2.5922         3.9         5.2
                                                                                               pacemaker implant w
                                                                                               CC.
244...............  YES.................  NO..................      05  SURG................  Permanent cardiac           2.0181         2.2         3.0
                                                                                               pacemaker implant w/o
                                                                                               CC/MCC.
245...............  NO..................  NO..................      05  SURG................  AICD lead & generator       3.1597         2.1         3.3
                                                                                               procedures.
246...............  NO..................  NO..................      05  SURG................  PercutAneous                3.3910         4.4         6.3
                                                                                               cardiovascular proc w
                                                                                               drugeluting stent w
                                                                                               MCC.
247...............  NO..................  NO..................      05  SURG................  PercutAneous                2.0829         1.7         2.2
                                                                                               cardiovascular proc w
                                                                                               drugeluting stent w/o
                                                                                               MCC.
248...............  NO..................  NO..................      05  SURG................  PercutAneous                2.9777         4.7         6.5
                                                                                               cardiovasc proc w non
                                                                                               drugeluting stent w
                                                                                               MCC.
249...............  NO..................  NO..................      05  SURG................  PercutAneous                1.7813         1.9         2.5
                                                                                               cardiovasc proc w non
                                                                                               drugeluting stent w/o
                                                                                               MCC.
250...............  NO..................  NO..................      05  SURG................  Perc cardiovasc proc w/     2.8561         5.3         7.5
                                                                                               o coronary artery
                                                                                               stent or AMI w MCC.

[[Page 24965]]

 
251...............  NO..................  NO..................      05  SURG................  Perc cardiovasc proc w/     1.6341         2.1         3.0
                                                                                               o coronary artery
                                                                                               stent or AMI w/o MCC.
252...............  NO..................  NO..................      05  SURG................  Other vascular              2.9234         5.7         8.8
                                                                                               procedures w MCC.
253...............  NO..................  NO..................      05  SURG................  Other vascular              2.2669         4.3         6.3
                                                                                               procedures w CC.
254...............  NO..................  NO..................      05  SURG................  Other vascular              1.5412         2.1         2.9
                                                                                               procedures w/o CC/MCC.
255...............  YES.................  NO..................      05  SURG................  Upper limb & toe            2.4736         8.0        10.5
                                                                                               amputation for circ
                                                                                               system disorders w
                                                                                               MCC.
256...............  YES.................  NO..................      05  SURG................  Upper limb & toe            1.5502         6.2         7.9
                                                                                               amputation for circ
                                                                                               system disorders w CC.
257...............  YES.................  NO..................      05  SURG................  Upper limb & toe            0.9882         3.9         5.2
                                                                                               amputation for circ
                                                                                               system disorders w/o
                                                                                               CC/MCC.
258...............  NO..................  NO..................      05  SURG................  Cardiac pacemaker           2.9077         5.5         7.6
                                                                                               device replacement w
                                                                                               MCC.
259...............  NO..................  NO..................      05  SURG................  Cardiac pacemaker           1.6063         1.9         2.6
                                                                                               device replacement w/
                                                                                               o MCC.
260...............  NO..................  NO..................      05  SURG................  Cardiac pacemaker           2.9653         7.3        10.3
                                                                                               revision except
                                                                                               device replacement w
                                                                                               MCC.
261...............  NO..................  NO..................      05  SURG................  Cardiac pacemaker           1.3133         2.8         4.0
                                                                                               revision except
                                                                                               device replacement w
                                                                                               CC.
262...............  NO..................  NO..................      05  SURG................  Cardiac pacemaker           0.9197         1.9         2.5
                                                                                               revision except
                                                                                               device replacement w/
                                                                                               o CC/MCC.
263...............  NO..................  NO..................      05  SURG................  Vein ligation &             1.5146         3.5         5.5
                                                                                               stripping.
264...............  YES.................  NO..................      05  SURG................  Other circulatory           2.4755         6.1         9.2
                                                                                               system O.R.
                                                                                               procedures.
280...............  YES.................  NO..................      05  MED.................  Acute myocardial            1.9690         6.4         7.8
                                                                                               infarction,
                                                                                               discharged alive w
                                                                                               MCC.
281...............  YES.................  NO..................      05  MED.................  Acute myocardial            1.2675         4.2         5.1
                                                                                               infarction,
                                                                                               discharged alive w CC.
282...............  YES.................  NO..................      05  MED.................  Acute myocardial            0.9121         2.7         3.4
                                                                                               infarction,
                                                                                               discharged alive w/o
                                                                                               CC/MCC.
283...............  NO..................  NO..................      05  MED.................  Acute myocardial            1.7404         3.4         5.5
                                                                                               infarction, expired w
                                                                                               MCC.
284...............  NO..................  NO..................      05  MED.................  Acute myocardial            1.0037         2.3         3.5
                                                                                               infarction, expired w
                                                                                               CC.
285...............  NO..................  NO..................      05  MED.................  Acute myocardial            0.6679         1.7         2.3
                                                                                               infarction, expired w/
                                                                                               o CC/MCC.
286...............  NO..................  NO..................      05  MED.................  Circulatory disorders       2.0464         5.3         7.1
                                                                                               except AMI, w card
                                                                                               cath w MCC.
287...............  NO..................  NO..................      05  MED.................  Circulatory disorders       1.0939         2.5         3.2
                                                                                               except AMI, w card
                                                                                               cath w/o MCC.
288...............  YES.................  NO..................      05  MED.................  Acute & subacute            3.1146        10.4        12.8
                                                                                               endocarditis w MCC.
289...............  YES.................  NO..................      05  MED.................  Acute & subacute            1.9306         7.7         9.2
                                                                                               endocarditis w CC.
290...............  YES.................  NO..................      05  MED.................  Acute & subacute            1.2534         5.6         6.9
                                                                                               endocarditis w/o CC/
                                                                                               MCC.
291...............  YES.................  NO..................      05  MED.................  Heart failure & shock       1.4850         5.3         6.8
                                                                                               w MCC.
292...............  YES.................  NO..................      05  MED.................  Heart failure & shock       1.0216         4.3         5.2
                                                                                               w CC.
293...............  YES.................  NO..................      05  MED.................  Heart failure & shock       0.7317         3.1         3.8
                                                                                               w/o CC/MCC.
294...............  NO..................  NO..................      05  MED.................  Deep vein                   0.9403         4.6         5.6
                                                                                               thrombophlebitis w CC/
                                                                                               MCC.
295...............  NO..................  NO..................      05  MED.................  Deep vein                   0.5995         3.8         4.4
                                                                                               thrombophlebitis w/o
                                                                                               CC/MCC.
296...............  NO..................  NO..................      05  MED.................  Cardiac arrest,             1.3021         2.0         3.3
                                                                                               unexplained w MCC.
297...............  NO..................  NO..................      05  MED.................  Cardiac arrest,             0.7673         1.5         2.0
                                                                                               unexplained w CC.
298...............  NO..................  NO..................      05  MED.................  Cardiac arrest,             0.4932         1.2         1.5
                                                                                               unexplained w/o CC/
                                                                                               MCC.
299...............  YES.................  NO..................      05  MED.................  Peripheral vascular         1.4537         5.4         7.1
                                                                                               disorders w MCC.
300...............  YES.................  NO..................      05  MED.................  Peripheral vascular         0.9234         4.3         5.3
                                                                                               disorders w CC.
301...............  YES.................  NO..................      05  MED.................  Peripheral vascular         0.6535         3.1         3.8
                                                                                               disorders w/o CC/MCC.
302...............  NO..................  NO..................      05  MED.................  Atherosclerosis w MCC.      1.0240         3.3         4.4
303...............  NO..................  NO..................      05  MED.................  Atherosclerosis w/o         0.5972         2.1         2.6
                                                                                               MCC.
304...............  NO..................  NO..................      05  MED.................  Hypertension w MCC....      1.0693         4.0         5.3
305...............  NO..................  NO..................      05  MED.................  Hypertension w/o MCC..      0.5937         2.3         2.9
306...............  NO..................  NO..................      05  MED.................  Cardiac congenital &        1.4448         4.7         6.5
                                                                                               valvular disorders w
                                                                                               MCC.
307...............  NO..................  NO..................      05  MED.................  Cardiac congenital &        0.7582         2.8         3.5
                                                                                               valvular disorders w/
                                                                                               o MCC.
308...............  NO..................  NO..................      05  MED.................  Cardiac arrhythmia &        1.3406         4.3         5.8
                                                                                               conduction disorders
                                                                                               w MCC.
309...............  NO..................  NO..................      05  MED.................  Cardiac arrhythmia &        0.8421         3.2         4.0
                                                                                               conduction disorders
                                                                                               w CC.
310...............  NO..................  NO..................      05  MED.................  Cardiac arrhythmia &        0.5917         2.3         2.8
                                                                                               conduction disorders
                                                                                               w/o CC/MCC.
311...............  NO..................  NO..................      05  MED.................  Angina pectoris.......      0.5209         1.9         2.3

[[Page 24966]]

 
312...............  NO..................  NO..................      05  MED.................  Syncope & collapse....      0.7198         2.5         3.2
313...............  NO..................  NO..................      05  MED.................  Chest pain............      0.5588         1.7         2.1
314...............  YES.................  NO..................      05  MED.................  Other circulatory           1.7436         5.3         7.3
                                                                                               system diagnoses w
                                                                                               MCC.
315...............  YES.................  NO..................      05  MED.................  Other circulatory           0.9947         3.7         4.8
                                                                                               system diagnoses w CC.
316...............  YES.................  NO..................      05  MED.................  Other circulatory           0.6650         2.4         3.1
                                                                                               system diagnoses w/o
                                                                                               CC/MCC.
326...............  YES.................  NO..................      06  SURG................  Stomach, esophageal &       5.9079        13.9        17.7
                                                                                               duodenal proc w MCC.
327...............  YES.................  NO..................      06  SURG................  Stomach, esophageal &       2.8426         8.2        10.5
                                                                                               duodenal proc w CC.
328...............  YES.................  NO..................      06  SURG................  Stomach, esophageal &       1.4776         3.4         4.6
                                                                                               duodenal proc w/o CC/
                                                                                               MCC.
329...............  YES.................  NO..................      06  SURG................  Major small & large         5.1551        13.3        16.4
                                                                                               bowel procedures w
                                                                                               MCC.
330...............  YES.................  NO..................      06  SURG................  Major small & large         2.5597         8.6        10.0
                                                                                               bowel procedures w CC.
331...............  YES.................  NO..................      06  SURG................  Major small & large         1.6155         5.5         6.1
                                                                                               bowel procedures w/o
                                                                                               CC/MCC.
332...............  YES.................  NO..................      06  SURG................  Rectal resection w MCC      4.6624        12.7        15.2
333...............  YES.................  NO..................      06  SURG................  Rectal resection w CC.      2.4296         8.0         9.1
334...............  YES.................  NO..................      06  SURG................  Rectal resection w/o        1.5965         5.0         5.7
                                                                                               CC/MCC.
335...............  YES.................  NO..................      06  SURG................  Peritoneal                  4.2165        12.2        14.7
                                                                                               adhesiolysis w MCC.
336...............  YES.................  NO..................      06  SURG................  Peritoneal                  2.2499         7.8         9.4
                                                                                               adhesiolysis w CC.
337...............  YES.................  NO..................      06  SURG................  Peritoneal                  1.4712         4.5         5.7
                                                                                               adhesiolysis w/o CC/
                                                                                               MCC.
338...............  NO..................  NO..................      06  SURG................  Appendectomy w              3.3316         9.1        10.9
                                                                                               complicated principal
                                                                                               diag w MCC.
339...............  NO..................  NO..................      06  SURG................  Appendectomy w              1.8705         6.2         7.2
                                                                                               complicated principal
                                                                                               diag w CC.
340...............  NO..................  NO..................      06  SURG................  Appendectomy w              1.2680         3.6         4.3
                                                                                               complicated principal
                                                                                               diag w/o CC/MCC.
341...............  NO..................  NO..................      06  SURG................  Appendectomy w/o            2.3828         5.4         7.3
                                                                                               complicated principal
                                                                                               diag w MCC.
342...............  NO..................  NO..................      06  SURG................  Appendectomy w/o            1.3623         3.4         4.4
                                                                                               complicated principal
                                                                                               diag w CC.
343...............  NO..................  NO..................      06  SURG................  Appendectomy w/o            0.9442         1.9         2.3
                                                                                               complicated principal
                                                                                               diag w/o CC/MCC.
344...............  NO..................  NO..................      06  SURG................  Minor small & large         3.1864         9.4        12.1
                                                                                               bowel procedures w
                                                                                               MCC.
345...............  NO..................  NO..................      06  SURG................  Minor small & large         1.6018         6.3         7.3
                                                                                               bowel procedures w CC.
346...............  NO..................  NO..................      06  SURG................  Minor small & large         1.1496         4.5         5.0
                                                                                               bowel procedures w/o
                                                                                               CC/MCC.
347...............  NO..................  NO..................      06  SURG................  Anal & stomal               2.1945         6.2         8.4
                                                                                               procedures w MCC.
348...............  NO..................  NO..................      06  SURG................  Anal & stomal               1.2723         4.2         5.6
                                                                                               procedures w CC.
349...............  NO..................  NO..................      06  SURG................  Anal & stomal               0.7728         2.4         3.1
                                                                                               procedures w/o CC/MCC.
350...............  NO..................  NO..................      06  SURG................  Inguinal & femoral          2.3797         5.9         8.1
                                                                                               hernia procedures w
                                                                                               MCC.
351...............  NO..................  NO..................      06  SURG................  Inguinal & femoral          1.2299         3.5         4.7
                                                                                               hernia procedures w
                                                                                               CC.
352...............  NO..................  NO..................      06  SURG................  Inguinal & femoral          0.7910         1.9         2.5
                                                                                               hernia procedures w/o
                                                                                               CC/MCC.
353...............  NO..................  NO..................      06  SURG................  Hernia procedures           2.5720         6.6         8.7
                                                                                               except inguinal &
                                                                                               femoral w MCC.
354...............  NO..................  NO..................      06  SURG................  Hernia procedures           1.3793         4.0         5.1
                                                                                               except inguinal &
                                                                                               femoral w CC.
355...............  NO..................  NO..................      06  SURG................  Hernia procedures           0.9375         2.3         2.9
                                                                                               except inguinal &
                                                                                               femoral w/o CC/MCC.
356...............  YES.................  NO..................      06  SURG................  Other digestive system      3.8336        10.0        13.7
                                                                                               O.R. procedures w MCC.
357...............  YES.................  NO..................      06  SURG................  Other digestive system      2.1324         6.3         8.3
                                                                                               O.R. procedures w CC.
358...............  YES.................  NO..................      06  SURG................  Other digestive system      1.4045         3.6         4.7
                                                                                               O.R. procedures w/o
                                                                                               CC/MCC.
368...............  NO..................  NO..................      06  MED.................  Major esophageal            1.6379         5.1         6.7
                                                                                               disorders w MCC.
369...............  NO..................  NO..................      06  MED.................  Major esophageal            1.0821         3.9         4.8
                                                                                               disorders w CC.
370...............  NO..................  NO..................      06  MED.................  Major esophageal            0.8138         2.9         3.4
                                                                                               disorders w/o CC/MCC.
371...............  YES.................  NO..................      06  MED.................  Major gastrointestinal      1.8831         6.9         9.0
                                                                                               disorders &
                                                                                               peritoneal infections
                                                                                               w MCC.

[[Page 24967]]

 
372...............  YES.................  NO..................      06  MED.................  Major gastrointestinal      1.2657         5.8         7.0
                                                                                               disorders &
                                                                                               peritoneal infections
                                                                                               w CC.
373...............  YES.................  NO..................      06  MED.................  Major gastrointestinal      0.8644         4.3         5.1
                                                                                               disorders &
                                                                                               peritoneal infections
                                                                                               w/o CC/MCC.
374...............  YES.................  NO..................      06  MED.................  Digestive malignancy w      2.0243         6.7         9.0
                                                                                               MCC.
375...............  YES.................  NO..................      06  MED.................  Digestive malignancy w      1.2489         4.7         6.1
                                                                                               CC.
376...............  YES.................  NO..................      06  MED.................  Digestive malignancy w/     0.8688         3.2         4.1
                                                                                               o CC/MCC.
377...............  YES.................  NO..................      06  MED.................  G.I. hemorrhage w MCC.      1.6119         5.2         6.6
378...............  YES.................  NO..................      06  MED.................  G.I. hemorrhage w CC..      1.0451         3.9         4.8
379...............  YES.................  NO..................      06  MED.................  G.I. hemorrhage w/o CC/     0.7745         3.0         3.5
                                                                                               MCC.
380...............  YES.................  NO..................      06  MED.................  Complicated peptic          1.7245         5.7         7.4
                                                                                               ulcer w MCC.
381...............  YES.................  NO..................      06  MED.................  Complicated peptic          1.1612         4.4         5.4
                                                                                               ulcer w CC.
382...............  YES.................  NO..................      06  MED.................  Complicated peptic          0.8139         3.1         3.7
                                                                                               ulcer w/o CC/MCC.
383...............  NO..................  NO..................      06  MED.................  Uncomplicated peptic        1.2971         4.6         5.9
                                                                                               ulcer w MCC.
384...............  NO..................  NO..................      06  MED.................  Uncomplicated peptic        0.8274         3.2         3.9
                                                                                               ulcer w/o MCC.
385...............  NO..................  NO..................      06  MED.................  Inflammatory bowel          1.8700         6.7         9.0
                                                                                               disease w MCC.
386...............  NO..................  NO..................      06  MED.................  Inflammatory bowel          1.0592         4.6         5.8
                                                                                               disease w CC.
387...............  NO..................  NO..................      06  MED.................  Inflammatory bowel          0.8063         3.6         4.4
                                                                                               disease w/o CC/MCC.
388...............  YES.................  NO..................      06  MED.................  G.I. obstruction w MCC      1.5834         5.7         7.6
389...............  YES.................  NO..................      06  MED.................  G.I. obstruction w CC.      0.9405         4.1         5.1
390...............  YES.................  NO..................      06  MED.................  G.I. obstruction w/o        0.6490         3.0         3.6
                                                                                               CC/MCC.
391...............  NO..................  NO..................      06  MED.................  Esophagitis, gastroent      1.1256         4.1         5.5
                                                                                               & misc digest
                                                                                               disorders w MCC.
392...............  NO..................  NO..................      06  MED.................  Esophagitis, gastroent      0.6920         2.8         3.6
                                                                                               & misc digest
                                                                                               disorders w/o MCC.
393...............  NO..................  NO..................      06  MED.................  Other digestive system      1.5389         5.0         7.0
                                                                                               diagnoses w MCC.
394...............  NO..................  NO..................      06  MED.................  Other digestive system      0.9667         3.9         5.0
                                                                                               diagnoses w CC.
395...............  NO..................  NO..................      06  MED.................  Other digestive system      0.6878         2.7         3.4
                                                                                               diagnoses w/o CC/MCC.
405...............  YES.................  NO..................      07  SURG................  Pancreas, liver &           5.7069        13.3        17.8
                                                                                               shunt procedures w
                                                                                               MCC.
406...............  YES.................  NO..................      07  SURG................  Pancreas, liver &           2.7512         7.2         9.6
                                                                                               shunt procedures w CC.
407...............  YES.................  NO..................      07  SURG................  Pancreas, liver &           1.7634         4.3         5.6
                                                                                               shunt procedures w/o
                                                                                               CC/MCC.
408...............  NO..................  NO..................      07  SURG................  Biliary tract proc          4.2285        12.1        14.9
                                                                                               except only cholecyst
                                                                                               w or w/o c.d.e. w MCC.
409...............  NO..................  NO..................      07  SURG................  Biliary tract proc          2.4974         8.3        10.0
                                                                                               except only cholecyst
                                                                                               w or w/o c.d.e. w CC.
410...............  NO..................  NO..................      07  SURG................  Biliary tract proc          1.7031         5.8         6.8
                                                                                               except only cholecyst
                                                                                               w or w/o c.d.e. w/o
                                                                                               CC/MCC.
411...............  NO..................  NO..................      07  SURG................  Cholecystectomy w           3.9469        10.9        13.1
                                                                                               c.d.e. w MCC.
412...............  NO..................  NO..................      07  SURG................  Cholecystectomy w           2.4190         7.6         8.9
                                                                                               c.d.e. w CC.
413...............  NO..................  NO..................      07  SURG................  Cholecystectomy w           1.7392         5.2         6.1
                                                                                               c.d.e. w/o CC/MCC.
414...............  YES.................  NO..................      07  SURG................  Cholecystectomy except      3.6536        10.0        12.1
                                                                                               by laparoscope w/o
                                                                                               c.d.e. w MCC.
415...............  YES.................  NO..................      07  SURG................  Cholecystectomy except      2.0589         6.7         7.8
                                                                                               by laparoscope w/o
                                                                                               c.d.e. w CC.
416...............  YES.................  NO..................      07  SURG................  Cholecystectomy except      1.3309         4.2         4.9
                                                                                               by laparoscope w/o
                                                                                               c.d.e. w/o CC/MCC.
417...............  NO..................  NO..................      07  SURG................  Laparoscopic                2.5133         6.6         8.4
                                                                                               cholecystectomy w/o
                                                                                               c.d.e. w MCC.
418...............  NO..................  NO..................      07  SURG................  Laparoscopic                1.6868         4.5         5.7
                                                                                               cholecystectomy w/o
                                                                                               c.d.e. w CC.
419...............  NO..................  NO..................      07  SURG................  Laparoscopic                1.1458         2.5         3.2
                                                                                               cholecystectomy w/o
                                                                                               c.d.e. w/o CC/MCC.
420...............  NO..................  NO..................      07  SURG................  Hepatobiliary               4.1023        10.1        14.1
                                                                                               diagnostic procedures
                                                                                               w MCC.
421...............  NO..................  NO..................      07  SURG................  Hepatobiliary               1.9241         5.6         7.9
                                                                                               diagnostic procedures
                                                                                               w CC.
422...............  NO..................  NO..................      07  SURG................  Hepatobiliary               1.1906         3.4         4.5
                                                                                               diagnostic procedures
                                                                                               w/o CC/MCC.
423...............  NO..................  NO..................      07  SURG................  Other hepatobiliary or      4.2038        11.4        15.4
                                                                                               pancreas O.R.
                                                                                               procedures w MCC.
424...............  NO..................  NO..................      07  SURG................  Other hepatobiliary or      2.4168         7.8        10.3
                                                                                               pancreas O.R.
                                                                                               procedures w CC.
425...............  NO..................  NO..................      07  SURG................  Other hepatobiliary or      1.6595         4.7         5.9
                                                                                               pancreas O.R.
                                                                                               procedures w/o CC/MCC.
432...............  NO..................  NO..................      07  MED.................  Cirrhosis & alcoholic       1.6308         5.2         6.9
                                                                                               hepatitis w MCC.
433...............  NO..................  NO..................      07  MED.................  Cirrhosis & alcoholic       0.9191         3.8         4.9
                                                                                               hepatitis w CC.
434...............  NO..................  NO..................      07  MED.................  Cirrhosis & alcoholic       0.6679         2.8         3.6
                                                                                               hepatitis w/o CC/MCC.

[[Page 24968]]

 
435...............  NO..................  NO..................      07  MED.................  Malignancy of               1.7244         5.8         7.7
                                                                                               hepatobiliary system
                                                                                               or pancreas w MCC.
436...............  NO..................  NO..................      07  MED.................  Malignancy of               1.1881         4.6         5.9
                                                                                               hepatobiliary system
                                                                                               or pancreas w CC.
437...............  NO..................  NO..................      07  MED.................  Malignancy of               0.9486         3.3         4.4
                                                                                               hepatobiliary system
                                                                                               or pancreas w/o CC/
                                                                                               MCC.
438...............  NO..................  NO..................      07  MED.................  Disorders of pancreas       1.7775         5.7         7.8
                                                                                               except malignancy w
                                                                                               MCC.
439...............  NO..................  NO..................      07  MED.................  Disorders of pancreas       1.0709         4.3         5.5
                                                                                               except malignancy w
                                                                                               CC.
440...............  NO..................  NO..................      07  MED.................  Disorders of pancreas       0.7280         3.2         3.9
                                                                                               except malignancy w/o
                                                                                               CC/MCC.
441...............  YES.................  NO..................      07  MED.................  Disorders of liver          1.5813         5.2         7.1
                                                                                               except malig,cirr,alc
                                                                                               hepa w MCC.
442...............  YES.................  NO..................      07  MED.................  Disorders of liver          0.9918         4.1         5.2
                                                                                               except malig,cirr,alc
                                                                                               hepa w CC.
443...............  YES.................  NO..................      07  MED.................  Disorders of liver          0.7215         3.1         3.9
                                                                                               except malig,cirr,alc
                                                                                               hepa w/o CC/MCC.
444...............  NO..................  NO..................      07  MED.................  Disorders of the            1.5675         5.2         6.7
                                                                                               biliary tract w MCC.
445...............  NO..................  NO..................      07  MED.................  Disorders of the            1.0589         3.9         4.9
                                                                                               biliary tract w CC.
446...............  NO..................  NO..................      07  MED.................  Disorders of the            0.7631         2.7         3.3
                                                                                               biliary tract w/o CC/
                                                                                               MCC.
453...............  NO..................  NO..................      08  SURG................  Combined anterior/         10.1153        12.7        15.9
                                                                                               posterior spinal
                                                                                               fusion w MCC.
454...............  NO..................  NO..................      08  SURG................  Combined anterior/          6.5111         7.0         8.7
                                                                                               posterior spinal
                                                                                               fusion w CC.
455...............  NO..................  NO..................      08  SURG................  Combined anterior/          4.8831         4.2         4.9
                                                                                               posterior spinal
                                                                                               fusion w/o CC/MCC.
456...............  NO..................  NO..................      08  SURG................  Spinal fusion exc cerv      8.2061        12.2        15.7
                                                                                               w spinal curv, malig
                                                                                               or 9+ fusions w MCC.
457...............  NO..................  NO..................      08  SURG................  Spinal fusion exc cerv      5.5526         6.8         8.3
                                                                                               w spinal curv, malig
                                                                                               or 9+ fusions w CC.
458...............  NO..................  NO..................      08  SURG................  Spinal fusion exc cerv      4.5646         4.2         4.8
                                                                                               w spinal curv, malig
                                                                                               or 9+ fusions w/o CC/
                                                                                               MCC.
459...............  YES.................  NO..................      08  SURG................  Spinal fusion except        5.8259         8.2        10.0
                                                                                               cervical w MCC.
460...............  YES.................  NO..................      08  SURG................  Spinal fusion except        3.4246         3.8         4.4
                                                                                               cervical w/o MCC.
461...............  NO..................  NO..................      08  SURG................  Bilateral or multiple       4.4292         7.0         8.4
                                                                                               major joint procs of
                                                                                               lower extremity w MCC.
462...............  NO..................  NO..................      08  SURG................  Bilateral or multiple       3.0007         3.9         4.3
                                                                                               major joint procs of
                                                                                               lower extremity w/o
                                                                                               MCC.
463...............  YES.................  NO..................      08  SURG................  Wnd debrid & skn grft       4.6953        14.0        18.3
                                                                                               exc hand, for
                                                                                               musculoconn tiss dis
                                                                                               w MCC.
464...............  YES.................  NO..................      08  SURG................  Wnd debrid & skn grft       2.5929         8.4        11.0
                                                                                               exc hand, for
                                                                                               musculoconn tiss dis
                                                                                               w CC.
465...............  YES.................  NO..................      08  SURG................  Wnd debrid & skn grft       1.5985         4.9         6.5
                                                                                               exc hand, for musculo-
                                                                                               conn tiss dis w/o CC/
                                                                                               MCC.
466...............  YES.................  NO..................      08  SURG................  Revision of hip or          4.3570         8.2        10.2
                                                                                               knee replacement w
                                                                                               MCC.
467...............  YES.................  NO..................      08  SURG................  Revision of hip or          2.9233         5.3         6.3
                                                                                               knee replacement w CC.
468...............  YES.................  NO..................      08  SURG................  Revision of hip or          2.2405         3.7         4.1
                                                                                               knee replacement w/o
                                                                                               CC/MCC.
469...............  YES.................  NO..................      08  SURG................  Major joint                 3.2932         7.5         8.9
                                                                                               replacement or
                                                                                               reattachment of lower
                                                                                               extremity w MCC.
470...............  YES.................  NO..................      08  SURG................  Major joint                 1.9422         3.8         4.0
                                                                                               replacement or
                                                                                               reattachment of lower
                                                                                               extremity w/o MCC.
471...............  NO..................  NO..................      08  SURG................  Cervical spinal fusion      4.3150         7.0        10.1
                                                                                               w MCC.
472...............  NO..................  NO..................      08  SURG................  Cervical spinal fusion      2.5303         2.9         4.4
                                                                                               w CC.
473...............  NO..................  NO..................      08  SURG................  Cervical spinal fusion      1.8721         1.6         2.0
                                                                                               w/o CC/MCC.
474...............  YES.................  NO..................      08  SURG................  Amputation for              3.3888        10.6        13.5
                                                                                               musculoskeletal sys &
                                                                                               conn tissue dis w MCC.
475...............  YES.................  NO..................      08  SURG................  Amputation for              1.9833         7.2         9.2
                                                                                               musculoskeletal sys &
                                                                                               conn tissue dis w CC.
476...............  YES.................  NO..................      08  SURG................  Amputation for              1.1111         4.0         5.2
                                                                                               musculoskeletal sys &
                                                                                               conn tissue dis w/o
                                                                                               CC/MCC.
477...............  YES.................  YES.................      08  SURG................  Biopsies of                 3.3833         9.9        12.8
                                                                                               musculoskeletal
                                                                                               system & connective
                                                                                               tissue w MCC.
478...............  YES.................  YES.................      08  SURG................  Biopsies of                 2.0553         4.9         7.0
                                                                                               musculoskeletal
                                                                                               system & connective
                                                                                               tissue w CC.

[[Page 24969]]

 
479...............  YES.................  YES.................      08  SURG................  Biopsies of                 1.4543         1.9         2.9
                                                                                               musculoskeletal
                                                                                               system & connective
                                                                                               tissue w/o CC/MCC.
480...............  YES.................  YES.................      08  SURG................  Hip & femur procedures      2.8506         8.2         9.7
                                                                                               except major joint w
                                                                                               MCC.
481...............  YES.................  YES.................      08  SURG................  Hip & femur procedures      1.8267         5.7         6.3
                                                                                               except major joint w
                                                                                               CC.
482...............  YES.................  YES.................      08  SURG................  Hip & femur procedures      1.4721         4.6         5.0
                                                                                               except major joint w/
                                                                                               o CC/MCC.
483...............  NO..................  NO..................      08  SURG................  Major joint & limb          2.1725         3.6         4.6
                                                                                               reattachment proc of
                                                                                               upper extremity w CC/
                                                                                               MCC.
484...............  NO..................  NO..................      08  SURG................  Major joint & limb          1.6673         2.2         2.5
                                                                                               reattachment proc of
                                                                                               upper extremity w/o
                                                                                               CC/MCC.
485...............  NO..................  NO..................      08  SURG................  Knee procedures w pdx       3.2946        10.4        12.7
                                                                                               of infection w MCC.
486...............  NO..................  NO..................      08  SURG................  Knee procedures w pdx       2.1122         7.0         8.4
                                                                                               of infection w CC.
487...............  NO..................  NO..................      08  SURG................  Knee procedures w pdx       1.5140         5.1         5.8
                                                                                               of infection w/o CC/
                                                                                               MCC.
488...............  NO..................  NO..................      08  SURG................  Knee procedures w/o         1.6962         4.3         5.7
                                                                                               pdx of infection w CC/
                                                                                               MCC.
489...............  NO..................  NO..................      08  SURG................  Knee procedures w/o         1.0796         2.6         3.1
                                                                                               pdx of infection w/o
                                                                                               CC/MCC.
490...............  NO..................  NO..................      08  SURG................  Back & neck procedures      1.6543         3.4         4.9
                                                                                               except spinal fusion
                                                                                               w CC/MCC or disc
                                                                                               devices.
491...............  NO..................  NO..................      08  SURG................  Back & neck procedures      0.9538         1.8         2.3
                                                                                               except spinal fusion
                                                                                               w/o CC/MCC.
492...............  YES.................  YES.................      08  SURG................  Lower extrem & humer        2.7254         7.1         8.9
                                                                                               proc except
                                                                                               hip,foot,femur w MCC.
493...............  YES.................  YES.................      08  SURG................  Lower extrem & humer        1.7402         4.5         5.5
                                                                                               proc except hip,
                                                                                               foot, femur w CC.
494...............  YES.................  YES.................      08  SURG................  Lower extrem & humer        1.2067         2.9         3.4
                                                                                               proc except hip,
                                                                                               foot, femur w/o CC/
                                                                                               MCC.
495...............  YES.................  NO..................      08  SURG................  Local excision &            3.2333         9.0        11.7
                                                                                               removal int fix
                                                                                               devices exc hip &
                                                                                               femur w MCC.
496...............  YES.................  NO..................      08  SURG................  Local excision &            1.7033         4.7         6.2
                                                                                               removal int fix
                                                                                               devices exc hip &
                                                                                               femur w CC.
497...............  YES.................  NO..................      08  SURG................  Local excision &            1.1384         2.4         3.3
                                                                                               removal int fix
                                                                                               devices exc hip &
                                                                                               femur w/o CC/MCC.
498...............  NO..................  NO..................      08  SURG................  Local excision &            2.0669         6.0         8.4
                                                                                               removal int fix
                                                                                               devices of hip &
                                                                                               femur w CC/MCC.
499...............  NO..................  NO..................      08  SURG................  Local excision &            0.9152         2.4         3.3
                                                                                               removal int fix
                                                                                               devices of hip &
                                                                                               femur w/o CC/MCC.
500...............  YES.................  YES.................      08  SURG................  Soft tissue procedures      3.0695         8.4        11.5
                                                                                               w MCC.
501...............  YES.................  YES.................      08  SURG................  Soft tissue procedures      1.4828         4.6         6.1
                                                                                               w CC.
502...............  YES.................  YES.................      08  SURG................  Soft tissue procedures      0.9295         2.3         3.0
                                                                                               w/o CC/MCC.
503...............  NO..................  NO..................      08  SURG................  Foot procedures w MCC.      2.1343         6.9         8.9
504...............  NO..................  NO..................      08  SURG................  Foot procedures w CC..      1.4821         5.1         6.5
505...............  NO..................  NO..................      08  SURG................  Foot procedures w/o CC/     0.9794         2.6         3.4
                                                                                               MCC.
506...............  NO..................  NO..................      08  SURG................  Major thumb or joint        0.9900         2.3         3.2
                                                                                               procedures.
507...............  NO..................  NO..................      08  SURG................  Major shoulder or           1.6307         3.8         5.3
                                                                                               elbow joint
                                                                                               procedures w CC/MCC.
508...............  NO..................  NO..................      08  SURG................  Major shoulder or           1.0467         1.7         2.1
                                                                                               elbow joint
                                                                                               procedures w/o CC/MCC.
509...............  NO..................  NO..................      08  SURG................  Arthroscopy...........      1.0441         2.0         2.9
510...............  NO..................  NO..................      08  SURG................  Shoulder, elbow or          2.0281         5.0         6.6
                                                                                               forearm proc, exc
                                                                                               major joint proc w
                                                                                               MCC.
511...............  NO..................  NO..................      08  SURG................  Shoulder, elbow or          1.2889         3.1         3.9
                                                                                               forearm proc, exc
                                                                                               major joint proc w CC.
512...............  NO..................  NO..................      08  SURG................  Shoulder, elbow or          0.9269         1.7         2.1
                                                                                               forearm proc, exc
                                                                                               major joint proc w/o
                                                                                               CC/MCC.
513...............  NO..................  NO..................      08  SURG................  Hand or wrist proc,         1.3544         3.7         5.1
                                                                                               except major thumb or
                                                                                               joint proc w CC/MCC.
514...............  NO..................  NO..................      08  SURG................  Hand or wrist proc,         0.8233         2.0         2.6
                                                                                               except major thumb or
                                                                                               joint proc w/o CC/MCC.
515...............  YES.................  YES.................      08  SURG................  Other musculoskelet         3.0667         8.4        11.1
                                                                                               sys & conn tiss O.R.
                                                                                               proc w MCC.
516...............  YES.................  YES.................      08  SURG................  Other musculoskelet         1.8221         4.5         6.1
                                                                                               sys & conn tiss O.R.
                                                                                               proc w CC.

[[Page 24970]]

 
517...............  YES.................  YES.................      08  SURG................  Other musculoskelet         1.3195         2.1         2.9
                                                                                               sys & conn tiss O.R.
                                                                                               proc w/o CC/MCC.
533...............  YES.................  NO..................      08  MED.................  Fractures of femur w        1.4317         5.5         7.2
                                                                                               MCC.
534...............  YES.................  NO..................      08  MED.................  Fractures of femur w/o      0.6905         3.4         4.2
                                                                                               MCC.
535...............  YES.................  NO..................      08  MED.................  Fractures of hip &          1.3683         5.1         6.6
                                                                                               pelvis w MCC.
536...............  YES.................  NO..................      08  MED.................  Fractures of hip &          0.6743         3.5         4.1
                                                                                               pelvis w/o MCC.
537...............  NO..................  NO..................      08  MED.................  Sprains, strains, &         0.8451         3.9         4.7
                                                                                               dislocations of hip,
                                                                                               pelvis & thigh w CC/
                                                                                               MCC.
538...............  NO..................  NO..................      08  MED.................  Sprains, strains, &         0.5424         2.6         3.1
                                                                                               dislocations of hip,
                                                                                               pelvis & thigh w/o CC/
                                                                                               MCC.
539...............  YES.................  NO..................      08  MED.................  Osteomyelitis w MCC...      2.0095         8.4        10.8
540...............  YES.................  NO..................      08  MED.................  Osteomyelitis w CC....      1.3085         6.2         7.6
541...............  YES.................  NO..................      08  MED.................  Osteomyelitis w/o CC/       0.9229         4.6         5.8
                                                                                               MCC.
542...............  YES.................  NO..................      08  MED.................  Pathological fractures      1.8245         7.1         9.0
                                                                                               & musculoskelet &
                                                                                               conn tiss malig w MCC.
543...............  YES.................  NO..................      08  MED.................  Pathological fractures      1.1004         5.0         6.2
                                                                                               & musculoskelet &
                                                                                               conn tiss malig w CC.
544...............  YES.................  NO..................      08  MED.................  Pathological fractures      0.7580         3.9         4.6
                                                                                               & musculoskelet &
                                                                                               conn tiss malig w/o
                                                                                               CC/MCC.
545...............  YES.................  NO..................      08  MED.................  Connective tissue           2.2353         6.7         9.2
                                                                                               disorders w MCC.
546...............  YES.................  NO..................      08  MED.................  Connective tissue           1.0595         4.4         5.6
                                                                                               disorders w CC.
547...............  YES.................  NO..................      08  MED.................  Connective tissue           0.7387         3.2         4.0
                                                                                               disorders w/o CC/MCC.
548...............  NO..................  NO..................      08  MED.................  Septic arthritis w MCC      1.8774         7.2         9.5
549...............  NO..................  NO..................      08  MED.................  Septic arthritis w CC.      1.1402         5.2         6.4
550...............  NO..................  NO..................      08  MED.................  Septic arthritis w/o        0.7637         3.7         4.6
                                                                                               CC/MCC.
551...............  YES.................  NO..................      08  MED.................  Medical back problems       1.5024         5.8         7.5
                                                                                               w MCC.
552...............  YES.................  NO..................      08  MED.................  Medical back problems       0.7526         3.5         4.2
                                                                                               w/o MCC.
553...............  NO..................  NO..................      08  MED.................  Bone diseases &             1.0922         4.8         6.1
                                                                                               arthropathies w MCC.
554...............  NO..................  NO..................      08  MED.................  Bone diseases &             0.6166         3.0         3.7
                                                                                               arthropathies w/o MCC.
555...............  NO..................  NO..................      08  MED.................  Signs & symptoms of         0.9488         3.6         4.9
                                                                                               musculoskeletal
                                                                                               system & conn tissue
                                                                                               w MCC.
556...............  NO..................  NO..................      08  MED.................  Signs & symptoms of         0.5771         2.5         3.2
                                                                                               musculoskeletal
                                                                                               system & conn tissue
                                                                                               w/o MCC.
557...............  YES.................  NO..................      08  MED.................  Tendonitis, myositis &      1.5172         5.7         7.2
                                                                                               bursitis w MCC.
558...............  YES.................  NO..................      08  MED.................  Tendonitis, myositis &      0.7900         3.6         4.3
                                                                                               bursitis w/o MCC.
559...............  YES.................  NO..................      08  MED.................  Aftercare,                  1.6221         5.6         7.7
                                                                                               musculoskeletal
                                                                                               system & connective
                                                                                               tissue w MCC.
560...............  YES.................  NO..................      08  MED.................  Aftercare,                  0.9149         3.8         4.9
                                                                                               musculoskeletal
                                                                                               system & connective
                                                                                               tissue w CC.
561...............  YES.................  NO..................      08  MED.................  Aftercare,                  0.5701         2.2         2.8
                                                                                               musculoskeletal
                                                                                               system & connective
                                                                                               tissue w/o CC/MCC.
562...............  YES.................  NO..................      08  MED.................  Fx, sprn, strn & disl       1.3859         5.3         6.8
                                                                                               except femur, hip,
                                                                                               pelvis & thigh w MCC.
563...............  YES.................  NO..................      08  MED.................  Fx, sprn, strn & disl       0.6597         3.2         3.8
                                                                                               except femur, hip,
                                                                                               pelvis & thigh w/o
                                                                                               MCC.
564...............  NO..................  NO..................      08  MED.................  Other musculoskeletal       1.4031         5.4         7.2
                                                                                               sys & connective
                                                                                               tissue diagnoses w
                                                                                               MCC.
565...............  NO..................  NO..................      08  MED.................  Other musculoskeletal       0.8829         4.0         5.1
                                                                                               sys & connective
                                                                                               tissue diagnoses w CC.
566...............  NO..................  NO..................      08  MED.................  Other musculoskeletal       0.6423         3.0         3.8
                                                                                               sys & connective
                                                                                               tissue diagnoses w/o
                                                                                               CC/MCC.
573...............  YES.................  NO..................      09  SURG................  Skin graft &/or debrid      3.2955        11.3        14.9
                                                                                               for skn ulcer or
                                                                                               cellulitis w MCC.
574...............  YES.................  NO..................      09  SURG................  Skin graft &/or debrid      1.9279         7.9        10.1
                                                                                               for skn ulcer or
                                                                                               cellulitis w CC.
575...............  YES.................  NO..................      09  SURG................  Skin graft &/or debrid      1.1628         5.0         6.2
                                                                                               for skn ulcer or
                                                                                               cellulitis w/o CC/MCC.
576...............  NO..................  NO..................      09  SURG................  Skin graft &/or debrid      3.2274         7.8        12.2
                                                                                               exc for skin ulcer or
                                                                                               cellulitis w MCC.
577...............  NO..................  NO..................      09  SURG................  Skin graft &/or debrid      1.5681         4.1         6.0
                                                                                               exc for skin ulcer or
                                                                                               cellulitis w CC.
578...............  NO..................  NO..................      09  SURG................  Skin graft &/or debrid      0.9412         2.5         3.5
                                                                                               exc for skin ulcer or
                                                                                               cellulitis w/o CC/MCC.
579...............  YES.................  NO..................      09  SURG................  Other skin, subcut          2.9032         9.1        12.0
                                                                                               tiss & breast proc w
                                                                                               MCC.
580...............  YES.................  NO..................      09  SURG................  Other skin, subcut          1.6213         5.7         7.5
                                                                                               tiss & breast proc w
                                                                                               CC.

[[Page 24971]]

 
581...............  YES.................  NO..................      09  SURG................  Other skin, subcut          0.9588         3.0         4.1
                                                                                               tiss & breast proc w/
                                                                                               o CC/MCC.
582...............  NO..................  NO..................      09  SURG................  Mastectomy for              0.9881         2.1         2.8
                                                                                               malignancy w CC/MCC.
583...............  NO..................  NO..................      09  SURG................  Mastectomy for              0.7441         1.5         1.8
                                                                                               malignancy w/o CC/MCC.
584...............  NO..................  NO..................      09  SURG................  Breast biopsy, local        1.2819         2.7         4.5
                                                                                               excision & other
                                                                                               breast procedures w
                                                                                               CC/MCC.
585...............  NO..................  NO..................      09  SURG................  Breast biopsy, local        0.7975         1.5         1.9
                                                                                               excision & other
                                                                                               breast procedures w/o
                                                                                               CC/MCC.
592...............  YES.................  NO..................      09  MED.................  Skin ulcers w MCC.....      1.7628         7.1         9.3
593...............  YES.................  NO..................      09  MED.................  Skin ulcers w CC......      1.0687         5.5         6.7
594...............  YES.................  NO..................      09  MED.................  Skin ulcers w/o CC/MCC      0.7221         4.1         5.0
595...............  NO..................  NO..................      09  MED.................  Major skin disorders w      1.7504         6.1         8.3
                                                                                               MCC.
596...............  NO..................  NO..................      09  MED.................  Major skin disorders w/     0.8037         3.8         4.8
                                                                                               o MCC.
597...............  NO..................  NO..................      09  MED.................  Malignant breast            1.6544         5.9         8.1
                                                                                               disorders w MCC.
598...............  NO..................  NO..................      09  MED.................  Malignant breast            1.0084         4.3         5.6
                                                                                               disorders w CC.
599...............  NO..................  NO..................      09  MED.................  Malignant breast            0.6089         2.6         3.6
                                                                                               disorders w/o CC/MCC.
600...............  NO..................  NO..................      09  MED.................  Non-malignant breast        0.9421         4.2         5.4
                                                                                               disorders w CC/MCC.
601...............  NO..................  NO..................      09  MED.................  Non-malignant breast        0.6207         3.1         3.8
                                                                                               disorders w/o CC/MCC.
602...............  YES.................  NO..................      09  MED.................  Cellulitis w MCC......      1.3689         5.7         7.2
603...............  YES.................  NO..................      09  MED.................  Cellulitis w/o MCC....      0.7698         4.0         4.8
604...............  NO..................  NO..................      09  MED.................  Trauma to the skin,         1.1521         4.2         5.4
                                                                                               subcut tiss & breast
                                                                                               w MCC.
605...............  NO..................  NO..................      09  MED.................  Trauma to the skin,         0.6584         2.8         3.5
                                                                                               subcut tiss & breast
                                                                                               w/o MCC.
606...............  NO..................  NO..................      09  MED.................  Minor skin disorders w      1.0928         4.2         5.9
                                                                                               MCC.
607...............  NO..................  NO..................      09  MED.................  Minor skin disorders w/     0.6163         2.9         3.8
                                                                                               o MCC.
614...............  NO..................  NO..................      10  SURG................  Adrenal & pituitary         2.4677         5.3         7.4
                                                                                               procedures w CC/MCC.
615...............  NO..................  NO..................      10  SURG................  Adrenal & pituitary         1.3907         2.8         3.4
                                                                                               procedures w/o CC/MCC.
616...............  YES.................  NO..................      10  SURG................  Amputat of lower limb       3.9552        13.8        16.6
                                                                                               for endocrine,
                                                                                               nutrit, & metabol dis
                                                                                               w MCC.
617...............  YES.................  NO..................      10  SURG................  Amputat of lower limb       2.0973         7.7         9.4
                                                                                               for endocrine,
                                                                                               nutrit, & metabol dis
                                                                                               w CC.
618...............  YES.................  NO..................      10  SURG................  Amputat of lower limb       1.3024         5.4         6.7
                                                                                               for endocrine,
                                                                                               nutrit, & metabol dis
                                                                                               w/o CC/MCC.
619...............  NO..................  NO..................      10  SURG................  O.R. procedures for         3.7048         6.4         9.3
                                                                                               obesity w MCC.
620...............  NO..................  NO..................      10  SURG................  O.R. procedures for         2.0768         3.4         4.3
                                                                                               obesity w CC.
621...............  NO..................  NO..................      10  SURG................  O.R. procedures for         1.5791         2.1         2.4
                                                                                               obesity w/o CC/MCC.
622...............  YES.................  NO..................      10  SURG................  Skin grafts & wound         3.2426        10.8        14.2
                                                                                               debrid for endoc,
                                                                                               nutrit & metab dis w
                                                                                               MCC.
623...............  YES.................  NO..................      10  SURG................  Skin grafts & wound         1.8784         7.3         9.2
                                                                                               debrid for endoc,
                                                                                               nutrit & metab dis w
                                                                                               CC.
624...............  YES.................  NO..................      10  SURG................  Skin grafts & wound         1.1114         4.8         6.1
                                                                                               debrid for endoc,
                                                                                               nutrit & metab dis w/
                                                                                               o CC/MCC.
625...............  NO..................  NO..................      10  SURG................  Thyroid, parathyroid &      2.2742         5.0         7.5
                                                                                               thyroglossal
                                                                                               procedures w MCC.
626...............  NO..................  NO..................      10  SURG................  Thyroid, parathyroid &      1.1509         2.2         3.3
                                                                                               thyroglossal
                                                                                               procedures w CC.
627...............  NO..................  NO..................      10  SURG................  Thyroid, parathyroid &      0.7404         1.3         1.6
                                                                                               thyroglossal
                                                                                               procedures w/o CC/MCC.
628...............  YES.................  NO..................      10  SURG................  Other endocrine,            3.3711         8.0        12.0
                                                                                               nutrit & metab O.R.
                                                                                               proc w MCC.
629...............  YES.................  NO..................      10  SURG................  Other endocrine,            2.2663         7.4         9.2
                                                                                               nutrit & metab O.R.
                                                                                               proc w CC.
630...............  YES.................  NO..................      10  SURG................  Other endocrine,            1.5036         4.0         5.5
                                                                                               nutrit & metab O.R.
                                                                                               proc w/o CC/MCC.
637...............  YES.................  NO..................      10  MED.................  Diabetes w MCC........      1.3914         4.8         6.3
638...............  YES.................  NO..................      10  MED.................  Diabetes w CC.........      0.8349         3.5         4.5
639...............  YES.................  NO..................      10  MED.................  Diabetes w/o CC/MCC...      0.5768         2.5         3.1
640...............  YES.................  NO..................      10  MED.................  Nutritional & misc          1.1366         4.2         5.7
                                                                                               metabolic disorders w
                                                                                               MCC.
641...............  YES.................  NO..................      10  MED.................  Nutritional & misc          0.6856         3.1         3.9
                                                                                               metabolic disorders w/
                                                                                               o MCC.
642...............  NO..................  NO..................      10  MED.................  Inborn errors of            1.0612         3.8         5.2
                                                                                               metabolism.
643...............  YES.................  NO..................      10  MED.................  Endocrine disorders w       1.6611         6.2         8.0
                                                                                               MCC.
644...............  YES.................  NO..................      10  MED.................  Endocrine disorders w       1.0256         4.5         5.5
                                                                                               CC.

[[Page 24972]]

 
645...............  YES.................  NO..................      10  MED.................  Endocrine disorders w/      0.7361         3.2         3.9
                                                                                               o CC/MCC.
652...............  NO..................  NO..................      11  SURG................  Kidney transplant.....      2.9875         6.7         7.9
653...............  YES.................  NO..................      11  SURG................  Major bladder               5.6554        14.1        17.5
                                                                                               procedures w MCC.
654...............  YES.................  NO..................      11  SURG................  Major bladder               2.9409         9.0        10.3
                                                                                               procedures w CC.
655...............  YES.................  NO..................      11  SURG................  Major bladder               1.9932         6.0         6.7
                                                                                               procedures w/o CC/MCC.
656...............  NO..................  NO..................      11  SURG................  Kidney & ureter             3.3280         8.4        10.8
                                                                                               procedures for
                                                                                               neoplasm w MCC.
657...............  NO..................  NO..................      11  SURG................  Kidney & ureter             1.8514         5.2         6.2
                                                                                               procedures
                                                                                               forneoplasm w CC.
658...............  NO..................  NO..................      11  SURG................  Kidney & ureter             1.3628         3.4         3.9
                                                                                               procedures for
                                                                                               neoplasm w/o CC/MCC.
659...............  YES.................  NO..................      11  SURG................  Kidney & ureter             3.2759         8.5        11.6
                                                                                               procedures for non-
                                                                                               neoplasm w MCC.
660...............  YES.................  NO..................      11  SURG................  Kidney & ureter             1.8525         5.0         6.7
                                                                                               procedures for non-
                                                                                               neoplasm w CC.
661...............  YES.................  NO..................      11  SURG................  Kidney & ureter             1.2497         2.8         3.6
                                                                                               procedures for non-
                                                                                               neoplasm w/o CC/MCC.
662...............  NO..................  NO..................      11  SURG................  Minor bladder               2.5929         7.3        10.5
                                                                                               procedures w MCC.
663...............  NO..................  NO..................      11  SURG................  Minor bladder               1.3800         3.6         5.2
                                                                                               procedures w CC.
664...............  NO..................  NO..................      11  SURG................  Minor bladder               0.9462         1.7         2.2
                                                                                               procedures w/o CC/MCC.
665...............  NO..................  NO..................      11  SURG................  Prostatectomy w MCC...      2.8312         9.3        12.2
666...............  NO..................  NO..................      11  SURG................  Prostatectomy w CC....      1.5177         4.2         6.4
667...............  NO..................  NO..................      11  SURG................  Prostatectomy w/o CC/       0.8075         2.1         2.9
                                                                                               MCC.
668...............  NO..................  NO..................      11  SURG................  Transurethral               2.1963         6.3         8.6
                                                                                               procedures w MCC.
669...............  NO..................  NO..................      11  SURG................  Transurethral               1.1980         3.1         4.4
                                                                                               procedures w CC.
670...............  NO..................  NO..................      11  SURG................  Transurethral               0.7731         1.9         2.6
                                                                                               procedures w/o CC/MCC.
671...............  NO..................  NO..................      11  SURG................  Urethral procedures w       1.4041         4.0         5.8
                                                                                               CC/MCC.
672...............  NO..................  NO..................      11  SURG................  Urethral procedures w/      0.7515         1.9         2.6
                                                                                               o CC/MCC.
673...............  NO..................  NO..................      11  SURG................  Other kidney & urinary      2.8645         6.0        10.1
                                                                                               tract procedures w
                                                                                               MCC.
674...............  NO..................  NO..................      11  SURG................  Other kidney & urinary      2.1903         4.5         7.3
                                                                                               tract procedures w CC.
675...............  NO..................  NO..................      11  SURG................  Other kidney & urinary      1.3402         1.7         2.6
                                                                                               tract procedures w/o
                                                                                               CC/MCC.
682...............  YES.................  NO..................      11  MED.................  Renal failure w MCC...      1.6772         5.5         7.4
683...............  YES.................  NO..................      11  MED.................  Renal failure w CC....      1.1655         4.8         6.0
684...............  YES.................  NO..................      11  MED.................  Renal failure w/o CC/       0.7764         3.3         4.1
                                                                                               MCC.
685...............  NO..................  NO..................      11  MED.................  Admit for renal             0.8496         2.4         3.5
                                                                                               dialysis.
686...............  NO..................  NO..................      11  MED.................  Kidney & urinary tract      1.7101         6.0         8.1
                                                                                               neoplasms w MCC.
687...............  NO..................  NO..................      11  MED.................  Kidney & urinary tract      1.0483         4.0         5.3
                                                                                               neoplasms w CC.
688...............  NO..................  NO..................      11  MED.................  Kidney & urinary tract      0.7032         2.6         3.3
                                                                                               neoplasms w/o CC/MCC.
689...............  YES.................  NO..................      11  MED.................  Kidney & urinary tract      1.2389         5.2         6.6
                                                                                               infections w MCC.
690...............  YES.................  NO..................      11  MED.................  Kidney & urinary tract      0.7621         3.6         4.4
                                                                                               infections w/o MCC.
691...............  NO..................  NO..................      11  MED.................  Urinary stones w esw        1.4666         3.0         4.2
                                                                                               lithotripsy w CC/MCC.
692...............  NO..................  NO..................      11  MED.................  Urinary stones w esw        1.0647         1.8         2.3
                                                                                               lithotripsy w/o CC/
                                                                                               MCC.
693...............  NO..................  NO..................      11  MED.................  Urinary stones w/o esw      1.2714         3.9         5.2
                                                                                               lithotripsy w MCC.
694...............  NO..................  NO..................      11  MED.................  Urinary stones w/o esw      0.6729         2.0         2.6
                                                                                               lithotripsy w/o MCC.
695...............  NO..................  NO..................      11  MED.................  Kidney & urinary tract      1.1689         4.3         5.7
                                                                                               signs & symptoms w
                                                                                               MCC.
696...............  NO..................  NO..................      11  MED.................  Kidney & urinary tract      0.6054         2.6         3.2
                                                                                               signs & symptoms w/o
                                                                                               MCC.
697...............  NO..................  NO..................      11  MED.................  Urethral stricture....      0.7231         2.4         3.3
698...............  YES.................  NO..................      11  MED.................  Other kidney & urinary      1.4706         5.3         6.9
                                                                                               tract diagnoses w MCC.
699...............  YES.................  NO..................      11  MED.................  Other kidney & urinary      0.9845         4.0         5.1
                                                                                               tract diagnoses w CC.
700...............  YES.................  NO..................      11  MED.................  Other kidney & urinary      0.7059         2.9         3.6
                                                                                               tract diagnoses w/o
                                                                                               CC/MCC.
707...............  NO..................  NO..................      12  SURG................  Major male pelvic           1.7114         3.8         4.9
                                                                                               procedures w CC/MCC.
708...............  NO..................  NO..................      12  SURG................  Major male pelvic           1.1515         2.1         2.4
                                                                                               procedures w/o CC/MCC.
709...............  NO..................  NO..................      12  SURG................  Penis procedures w CC/      1.9087         3.8         6.7
                                                                                               MCC.
710...............  NO..................  NO..................      12  SURG................  Penis procedures w/o        1.2258         1.5         1.9
                                                                                               CC/MCC.
711...............  NO..................  NO..................      12  SURG................  Testes procedures w CC/     1.9149         5.4         8.0
                                                                                               MCC.
712...............  NO..................  NO..................      12  SURG................  Testes procedures w/o       0.8141         2.2         3.0
                                                                                               CC/MCC.
713...............  NO..................  NO..................      12  SURG................  Transurethral               1.1007         2.9         4.1
                                                                                               prostatectomy w CC/
                                                                                               MCC.

[[Page 24973]]

 
714...............  NO..................  NO..................      12  SURG................  Transurethral               0.6342         1.7         2.0
                                                                                               prostatectomy w/o CC/
                                                                                               MCC.
715...............  NO..................  NO..................      12  SURG................  Other male                  1.8234         3.9         6.2
                                                                                               reproductive system
                                                                                               O.R. proc for
                                                                                               malignancy w CC/MCC.
716...............  NO..................  NO..................      12  SURG................  Other male                  1.0017         1.3         1.5
                                                                                               reproductive system
                                                                                               O.R. proc for
                                                                                               malignancy w/o CC/MCC.
717...............  NO..................  NO..................      12  SURG................  Other male                  1.8454         5.2         7.7
                                                                                               reproductive system
                                                                                               O.R. proc exc
                                                                                               malignancy w CC/MCC.
718...............  NO..................  NO..................      12  SURG................  Other male                  0.7902         2.1         2.8
                                                                                               reproductive system
                                                                                               O.R. proc exc
                                                                                               malignancy w/o CC/MCC.
722...............  NO..................  NO..................      12  MED.................  Malignancy, male            1.4829         5.6         7.5
                                                                                               reproductive system w
                                                                                               MCC.
723...............  NO..................  NO..................      12  MED.................  Malignancy, male            1.0428         4.2         5.5
                                                                                               reproductive system w
                                                                                               CC.
724...............  NO..................  NO..................      12  MED.................  Malignancy, male            0.6146         2.5         3.4
                                                                                               reproductive system w/
                                                                                               o CC/MCC.
725...............  NO..................  NO..................      12  MED.................  Benign prostatic            1.0622         4.3         5.6
                                                                                               hypertrophy w MCC.
726...............  NO..................  NO..................      12  MED.................  Benign prostatic            0.6648         2.8         3.5
                                                                                               hypertrophy w/o MCC.
727...............  NO..................  NO..................      12  MED.................  Inflammation of the         1.2681         5.1         6.6
                                                                                               male reproductive
                                                                                               system w MCC.
728...............  NO..................  NO..................      12  MED.................  Inflammation of the         0.6875         3.3         4.1
                                                                                               male reproductive
                                                                                               system w/o MCC.
729...............  NO..................  NO..................      12  MED.................  Other male                  1.0808         3.8         5.2
                                                                                               reproductive system
                                                                                               diagnoses w CC/MCC.
730...............  NO..................  NO..................      12  MED.................  Other male                  0.5860         2.5         3.3
                                                                                               reproductive system
                                                                                               diagnoses w/o CC/MCC.
734...............  NO..................  NO..................      13  SURG................  Pelvic evisceration,        2.2946         5.9         7.7
                                                                                               rad hysterectomy &
                                                                                               rad vulvectomy w CC/
                                                                                               MCC.
735...............  NO..................  NO..................      13  SURG................  Pelvic evisceration,        1.0226         3.0         3.5
                                                                                               rad hysterectomy &
                                                                                               rad vulvectomy w/o CC/
                                                                                               MCC.
736...............  NO..................  NO..................      13  SURG................  Uterine & adnexa proc       4.1656        11.6        13.9
                                                                                               for ovarian or
                                                                                               adnexal malignancy w
                                                                                               MCC.
737...............  NO..................  NO..................      13  SURG................  Uterine & adnexa proc       1.9738         6.3         7.4
                                                                                               for ovarian or
                                                                                               adnexal malignancy w
                                                                                               CC.
738...............  NO..................  NO..................      13  SURG................  Uterine & adnexa proc       1.1607         3.6         4.0
                                                                                               for ovarian or
                                                                                               adnexal malignancy w/
                                                                                               o CC/MCC.
739...............  NO..................  NO..................      13  SURG................  Uterine, adnexa proc        2.8464         7.9        10.2
                                                                                               for non-ovarian/
                                                                                               adnexal malig w MCC.
740...............  NO..................  NO..................      13  SURG................  Uterine, adnexa proc        1.3873         4.4         5.2
                                                                                               for non-ovarian/
                                                                                               adnexal malig w CC.
741...............  NO..................  NO..................      13  SURG................  Uterine, adnexa proc        0.9624         2.8         3.2
                                                                                               for non-ovarian/
                                                                                               adnexal malig w/o CC/
                                                                                               MCC.
742...............  NO..................  NO..................      13  SURG................  Uterine & adnexa proc       1.3758         3.6         4.7
                                                                                               for non-malignancy w
                                                                                               CC/MCC.
743...............  NO..................  NO..................      13  SURG................  Uterine & adnexa proc       0.8461         2.1         2.4
                                                                                               for non-malignancy w/
                                                                                               o CC/MCC.
744...............  NO..................  NO..................      13  SURG................  D&C, conization,            1.4153         4.1         5.9
                                                                                               laparascopy & tubal
                                                                                               interruption w CC/MCC.
745...............  NO..................  NO..................      13  SURG................  D&C, conization,            0.7416         2.1         2.6
                                                                                               laparascopy & tubal
                                                                                               interruption w/o CC/
                                                                                               MCC.
746...............  NO..................  NO..................      13  SURG................  Vagina, cervix & vulva      1.2205         3.0         4.2
                                                                                               procedures w CC/MCC.
747...............  NO..................  NO..................      13  SURG................  Vagina, cervix & vulva      0.8192         1.7         1.9
                                                                                               procedures w/o CC/MCC.
748...............  NO..................  NO..................      13  SURG................  Female reproductive         0.7966         1.5         1.8
                                                                                               system reconstructive
                                                                                               procedures.
749...............  NO..................  NO..................      13  SURG................  Other female                2.5201         7.1         9.9
                                                                                               reproductive system
                                                                                               O.R. procedures w CC/
                                                                                               MCC.
750...............  NO..................  NO..................      13  SURG................  Other female                0.9713         2.6         3.3
                                                                                               reproductive system
                                                                                               O.R. procedures w/o
                                                                                               CC/MCC.
754...............  NO..................  NO..................      13  MED.................  Malignancy, female          1.8553         6.4         8.9
                                                                                               reproductive system w
                                                                                               MCC.
755...............  NO..................  NO..................      13  MED.................  Malignancy, female          1.0847         4.2         5.7
                                                                                               reproductive system w
                                                                                               CC.
756...............  NO..................  NO..................      13  MED.................  Malignancy, female          0.6339         2.5         3.3
                                                                                               reproductive system w/
                                                                                               o CC/MCC.
757...............  NO..................  NO..................      13  MED.................  Infections, female          1.6992         6.8         8.9
                                                                                               reproductive system w
                                                                                               MCC.

[[Page 24974]]

 
758...............  NO..................  NO..................      13  MED.................  Infections, female          1.0758         4.9         6.2
                                                                                               reproductive system w
                                                                                               CC.
759...............  NO..................  NO..................      13  MED.................  Infections, female          0.7668         3.8         4.6
                                                                                               reproductive system w/
                                                                                               o CC/MCC.
760...............  NO..................  NO..................      13  MED.................  Menstrual & other           0.7794         3.0         3.8
                                                                                               female reproductive
                                                                                               system disorders w CC/
                                                                                               MCC.
761...............  NO..................  NO..................      13  MED.................  Menstrual & other           0.5041         2.0         2.5
                                                                                               female reproductive
                                                                                               system disorders w/o
                                                                                               CC/MCC.
765...............  NO..................  NO..................      14  SURG................  Cesarean section w CC/      0.9644         4.1         5.3
                                                                                               MCC.
766...............  NO..................  NO..................      14  SURG................  Cesarean section w/o        0.6422         3.0         3.2
                                                                                               CC/MCC.
767...............  NO..................  NO..................      14  SURG................  Vaginal delivery w          0.6419         2.5         2.9
                                                                                               sterilization &/or
                                                                                               D&C.
768...............  NO..................  NO..................      14  SURG................  Vaginal delivery w          1.6334         4.7         5.8
                                                                                               O.R. proc except
                                                                                               steril &/or D&C.
769...............  NO..................  NO..................      14  SURG................  Postpartum & post           1.9655         3.3         5.7
                                                                                               abortion diagnoses w
                                                                                               O.R. procedure.
770...............  NO..................  NO..................      14  SURG................  Abortion w D&C,             0.7598         1.6         2.7
                                                                                               aspiration curettage
                                                                                               or hysterotomy.
774...............  NO..................  NO..................      14  MED.................  Vaginal delivery w          0.5412         2.6         3.2
                                                                                               complicating
                                                                                               diagnoses.
775...............  NO..................  NO..................      14  MED.................  Vaginal delivery w/o        0.3953         2.1         2.3
                                                                                               complicating
                                                                                               diagnoses.
776...............  NO..................  NO..................      14  MED.................  Postpartum & post           0.6480         2.6         3.6
                                                                                               abortion diagnoses w/
                                                                                               o O.R. procedure.
777...............  NO..................  NO..................      14  MED.................  Ectopic pregnancy.....      0.7237         1.8         2.1
778...............  NO..................  NO..................      14  MED.................  Threatened abortion...      0.3775         2.0         2.8
779...............  NO..................  NO..................      14  MED.................  Abortion w/o D&C......      0.6006         1.7         2.6
780...............  NO..................  NO..................      14  MED.................  False labor...........      0.2935         1.3         2.7
781...............  NO..................  NO..................      14  MED.................  Other antepartum            0.5771         2.7         3.8
                                                                                               diagnoses w medical
                                                                                               complications.
782...............  NO..................  NO..................      14  MED.................  Other antepartum            0.4359         1.7         2.8
                                                                                               diagnoses w/o medical
                                                                                               complications.
789...............  NO..................  NO..................      15  MED.................  Neonates, died or           1.4246           *           *
                                                                                               transferred to
                                                                                               another acute care
                                                                                               facility.
790...............  NO..................  NO..................      15  MED.................  Extreme immaturity or       4.6977           *           *
                                                                                               respiratory distress
                                                                                               syndrome, neonate.
791...............  NO..................  NO..................      15  MED.................  Prematurity w major         3.2084           *           *
                                                                                               problems.
792...............  NO..................  NO..................      15  MED.................  Prematurity w/o major       1.9359           *           *
                                                                                               problems.
793...............  NO..................  NO..................      15  MED.................  Full term neonate w         3.2957           *           *
                                                                                               major problems.
794...............  NO..................  NO..................      15  MED.................  Neonate w other             1.1665           *           *
                                                                                               significant problems.
795...............  NO..................  NO..................      15  MED.................  Normal newborn........      0.1579           *           *
799...............  NO..................  NO..................      16  SURG................  Splenectomy w MCC.....      4.8444        10.8        14.3
800...............  NO..................  NO..................      16  SURG................  Splenectomy w CC......      2.5219         6.5         8.4
801...............  NO..................  NO..................      16  SURG................  Splenectomy w/o CC/MCC      1.6365         3.8         4.9
802...............  NO..................  NO..................      16  SURG................  Other O.R. proc of the      3.6564         9.2        12.8
                                                                                               blood & blood forming
                                                                                               organs w MCC.
803...............  NO..................  NO..................      16  SURG................  Other O.R. proc of the      1.6759         4.8         6.6
                                                                                               blood & blood forming
                                                                                               organs w CC.
804...............  NO..................  NO..................      16  SURG................  Other O.R. proc of the      0.9952         2.4         3.3
                                                                                               blood & blood forming
                                                                                               organs w/o CC/MCC.
808...............  YES.................  NO..................      16  MED.................  Major hematol/immun         1.9239         6.2         8.1
                                                                                               diag exc sickle cell
                                                                                               crisis & coagul w MCC.
809...............  YES.................  NO..................      16  MED.................  Major hematol/immun         1.0868         4.0         5.1
                                                                                               diag exc sickle cell
                                                                                               crisis & coagul w CC.
810...............  YES.................  NO..................      16  MED.................  Major hematol/immun         0.8426         3.1         4.0
                                                                                               diag exc sickle cell
                                                                                               crisis & coagul w/o
                                                                                               CC/MCC.
811...............  NO..................  NO..................      16  MED.................  Red blood cell              1.1761         4.0         5.6
                                                                                               disorders w MCC.
812...............  NO..................  NO..................      16  MED.................  Red blood cell              0.7332         2.8         3.7
                                                                                               disorders w/o MCC.
813...............  NO..................  NO..................      16  MED.................  Coagulation disorders.      1.3307         3.8         5.2
814...............  NO..................  NO..................      16  MED.................  Reticuloendothelial &       1.5585         5.4         7.2
                                                                                               immunity disorders w
                                                                                               MCC.
815...............  NO..................  NO..................      16  MED.................  Reticuloendothelial &       0.9778         3.9         4.9
                                                                                               immunity disorders w
                                                                                               CC.
816...............  NO..................  NO..................      16  MED.................  Reticuloendothelial &       0.7021         2.7         3.4
                                                                                               immunity disorders w/
                                                                                               o CC/MCC.
820...............  NO..................  NO..................      17  SURG................  Lymphoma & leukemia w       5.6599        13.8        18.4
                                                                                               major O.R. procedure
                                                                                               w MCC.
821...............  NO..................  NO..................      17  SURG................  Lymphoma & leukemia w       2.2223         5.4         7.8
                                                                                               major O.R. procedure
                                                                                               w CC.

[[Page 24975]]

 
822...............  NO..................  NO..................      17  SURG................  Lymphoma & leukemia w       1.2363         2.7         3.7
                                                                                               major O.R. procedure
                                                                                               w/o CC/MCC.
823...............  NO..................  NO..................      17  SURG................  Lymphoma & non-acute        4.0550        12.1        15.4
                                                                                               leukemia w other O.R.
                                                                                               proc w MCC.
824...............  NO..................  NO..................      17  SURG................  Lymphoma & non-acute        2.1337         6.6         8.9
                                                                                               leukemia w other O.R.
                                                                                               proc w CC.
825...............  NO..................  NO..................      17  SURG................  Lymphoma & non-acute        1.3321         3.3         4.8
                                                                                               leukemia w other O.R.
                                                                                               proc w/o CC/MCC.
826...............  NO..................  NO..................      17  SURG................  Myeloprolif disord or       5.0473        13.2        17.4
                                                                                               poorly diff neopl w
                                                                                               maj O.R. proc w MCC.
827...............  NO..................  NO..................      17  SURG................  Myeloprolif disord or       2.0842         5.8         7.6
                                                                                               poorly diff neopl w
                                                                                               maj O.R. proc w CC.
828...............  NO..................  NO..................      17  SURG................  Myeloprolif disord or       1.2241         3.0         3.8
                                                                                               poorly diff neopl w
                                                                                               maj O.R. proc w/o CC/
                                                                                               MCC.
829...............  NO..................  NO..................      17  SURG................  Myeloprolif disord or       2.6852         6.9        10.5
                                                                                               poorly diff neopl w
                                                                                               other O.R. proc w CC/
                                                                                               MCC.
830...............  NO..................  NO..................      17  SURG................  Myeloprolif disord or       1.0340         2.5         3.7
                                                                                               poorly diff neopl w
                                                                                               other O.R. proc w/o
                                                                                               CC/MCC.
834...............  NO..................  NO..................      17  MED.................  Acute leukemia w/o          3.9520         9.2        15.0
                                                                                               major O.R. procedure
                                                                                               w MCC.
835...............  NO..................  NO..................      17  MED.................  Acute leukemia w/o          1.8790         5.4         8.4
                                                                                               major O.R. procedure
                                                                                               w CC.
836...............  NO..................  NO..................      17  MED.................  Acute leukemia w/o          1.1326         3.4         5.1
                                                                                               major O.R. procedure
                                                                                               w/o CC/MCC.
837...............  NO..................  NO..................      17  MED.................  Chemo w acute leukemia      5.7668        17.2        22.7
                                                                                               as sdx or w high dose
                                                                                               chemo agent w MCC.
838...............  NO..................  NO..................      17  MED.................  Chemo w acute leukemia      2.3625         6.3         9.2
                                                                                               as sdx or w high dose
                                                                                               chemo agent w CC.
839...............  NO..................  NO..................      17  MED.................  Chemo w acute leukemia      1.2331         4.8         6.0
                                                                                               as sdx or w high dose
                                                                                               chemo agent w/o CC/
                                                                                               MCC.
840...............  YES.................  NO..................      17  MED.................  Lymphoma & non-acute        2.3808         7.1         9.8
                                                                                               leukemia w MCC.
841...............  YES.................  NO..................      17  MED.................  Lymphoma & non-acute        1.4326         5.1         6.7
                                                                                               leukemia w CC.
842...............  YES.................  NO..................      17  MED.................  Lymphoma & non-acute        0.9558         3.3         4.3
                                                                                               leukemia w/o CC/MCC.
843...............  NO..................  NO..................      17  MED.................  Other myeloprolif dis       1.9072         6.3         8.8
                                                                                               or poorly diff neopl
                                                                                               diag w MCC.
844...............  NO..................  NO..................      17  MED.................  Other myeloprolif dis       1.1252         4.5         6.0
                                                                                               or poorly diff neopl
                                                                                               diag w CC.
845...............  NO..................  NO..................      17  MED.................  Other myeloprolif dis       0.8433         3.3         4.3
                                                                                               or poorly diff neopl
                                                                                               diag w/o CC/MCC.
846...............  NO..................  NO..................      17  MED.................  Chemotherapy w/o acute      2.1956         5.8         8.5
                                                                                               leukemia as secondary
                                                                                               diagnosis w MCC.
847...............  NO..................  NO..................      17  MED.................  Chemotherapy w/o acute      0.9758         2.7         3.3
                                                                                               leukemia as secondary
                                                                                               diagnosis w CC.
848...............  NO..................  NO..................      17  MED.................  Chemotherapy w/o acute      0.7495         2.3         2.9
                                                                                               leukemia as secondary
                                                                                               diagnosis w/o CC/MCC.
849...............  NO..................  NO..................      17  MED.................  Radiotherapy..........      1.2491         4.3         6.0
853...............  YES.................  NO..................      18  SURG................  Infectious & parasitic      5.4321        13.4        17.4
                                                                                               diseases w O.R.
                                                                                               procedure w MCC.
854...............  YES.................  NO..................      18  SURG................  Infectious & parasitic      2.9346         9.5        11.5
                                                                                               diseases w O.R.
                                                                                               procedure w CC.
855...............  YES.................  NO..................      18  SURG................  Infectious & parasitic      1.8472         5.8         7.6
                                                                                               diseases w O.R.
                                                                                               procedure w/o CC/MCC.
856...............  YES.................  NO..................      18  SURG................  Postoperative or post-      4.9141        13.4        17.4
                                                                                               traumatic infections
                                                                                               w O.R. proc w MCC.
857...............  YES.................  NO..................      18  SURG................  Postoperative or post-      2.0895         7.3         9.3
                                                                                               traumatic infections
                                                                                               w O.R. proc w CC.
858...............  YES.................  NO..................      18  SURG................  Postoperative or post-      1.3418         5.0         6.3
                                                                                               traumatic infections
                                                                                               w O.R. proc w/o CC/
                                                                                               MCC.
862...............  YES.................  NO..................      18  MED.................  Postoperative & post-       1.8740         6.6         8.6
                                                                                               traumatic infections
                                                                                               w MCC.
863...............  YES.................  NO..................      18  MED.................  Postoperative & post-       0.9224         4.4         5.4
                                                                                               traumatic infections
                                                                                               w/o MCC.
864...............  NO..................  NO..................      18  MED.................  Fever of unknown            0.8171         3.2         4.1
                                                                                               origin.
865...............  NO..................  NO..................      18  MED.................  Viral illness w MCC...      1.5687         4.9         6.8
866...............  NO..................  NO..................      18  MED.................  Viral illness w/o MCC.      0.6691         2.8         3.5

[[Page 24976]]

 
867...............  YES.................  NO..................      18  MED.................  Other infectious &          2.5039         7.5        10.2
                                                                                               parasitic diseases
                                                                                               diagnoses w MCC.
868...............  YES.................  NO..................      18  MED.................  Other infectious &          1.1589         4.7         6.1
                                                                                               parasitic diseases
                                                                                               diagnoses w CC.
869...............  YES.................  NO..................      18  MED.................  Other infectious &          0.8295         3.6         4.4
                                                                                               parasitic diseases
                                                                                               diagnoses w/o CC/MCC.
870...............  YES.................  NO..................      18  MED.................  Septicemia w MV 96+         5.8269        13.0        15.7
                                                                                               hours.
871...............  YES.................  NO..................      18  MED.................  Septicemia w/o MV 96+       1.8811         5.8         7.8
                                                                                               hours w MCC.
872...............  YES.................  NO..................      18  MED.................  Septicemia w/o MV 96+       1.1304         4.8         5.9
                                                                                               hours w/o MCC.
876...............  NO..................  NO..................      19  SURG................  O.R. procedure w            2.4818         6.8        11.2
                                                                                               principal diagnoses
                                                                                               of mental illness.
880...............  NO..................  NO..................      19  MED.................  Acute adjustment            0.6104         2.4         3.2
                                                                                               reaction &
                                                                                               psychosocial
                                                                                               dysfunction.
881...............  NO..................  NO..................      19  MED.................  Depressive neuroses...      0.5320         3.1         4.2
882...............  NO..................  NO..................      19  MED.................  Neuroses except             0.5791         3.1         4.5
                                                                                               depressive.
883...............  NO..................  NO..................      19  MED.................  Disorders of                0.8908         4.6         7.4
                                                                                               personality & impulse
                                                                                               control.
884...............  YES.................  NO..................      19  MED.................  Organic disturbances &      0.8407         4.2         5.5
                                                                                               mental retardation.
885...............  NO..................  NO..................      19  MED.................  Psychoses.............      0.8183         5.6         7.6
886...............  NO..................  NO..................      19  MED.................  Behavioral &                0.7095         4.0         5.9
                                                                                               developmental
                                                                                               disorders.
887...............  NO..................  NO..................      19  MED.................  Other mental disorder       0.8075         3.1         4.6
                                                                                               diagnoses.
894...............  NO..................  NO..................      20  MED.................  Alcohol/drug abuse or       0.3712         2.1         2.9
                                                                                               dependence, left ama.
895...............  NO..................  NO..................      20  MED.................  Alcohol/drug abuse or        .7771         8.2        10.5
                                                                                               dependence w
                                                                                               rehabilitation
                                                                                               therapy.
896...............  YES.................  NO..................      20  MED.................  Alcohol/drug abuse or       1.2975         5.0         6.8
                                                                                               dependence w/o
                                                                                               rehabilitation
                                                                                               therapy w MCC.
897...............  YES.................  NO..................      20  MED.................  Alcohol/drug abuse or       0.5935         3.3         4.1
                                                                                               dependence w/o
                                                                                               rehabilitation
                                                                                               therapy w/o MCC.
901...............  NO..................  NO..................      21  SURG................  Wound debridements for      3.6765         9.3        14.5
                                                                                               injuries w MCC.
902...............  NO..................  NO..................      21  SURG................  Wound debridements for      1.7433         5.7         8.0
                                                                                               injuries w CC.
903...............  NO..................  NO..................      21  SURG................  Wound debridements for      1.0239         3.5         4.9
                                                                                               injuries w/o CC/MCC.
904...............  NO..................  NO..................      21  SURG................  Skin grafts for             2.9545         7.3        12.4
                                                                                               injuries w CC/MCC.
905...............  NO..................  NO..................      21  SURG................  Skin grafts for             1.0711         3.6         4.8
                                                                                               injuries w/o CC/MCC.
906...............  NO..................  NO..................      21  SURG................  Hand procedures for         0.9899         2.2         3.3
                                                                                               injuries.
907...............  YES.................  NO..................      21  SURG................  Other O.R. procedures       3.6201         8.4        12.0
                                                                                               for injuries w MCC.
908...............  YES.................  NO..................      21  SURG................  Other O.R. procedures       1.8922         5.3         7.2
                                                                                               for injuries w CC.
909...............  YES.................  NO..................      21  SURG................  Other O.R. procedures       1.1253         2.8         3.7
                                                                                               for injuries w/o CC/
                                                                                               MCC.
913...............  NO..................  NO..................      21  MED.................  Traumatic injury w MCC      1.3122         4.5         6.1
914...............  NO..................  NO..................      21  MED.................  Traumatic injury w/o        0.6590         2.7         3.4
                                                                                               MCC.
915...............  NO..................  NO..................      21  MED.................  Allergic reactions w        1.1882         3.3         4.6
                                                                                               MCC.
916...............  NO..................  NO..................      21  MED.................  Allergic reactions w/o      0.4531         1.7         2.1
                                                                                               MCC.
917...............  YES.................  NO..................      21  MED.................  Poisoning & toxic           1.4901         3.9         5.4
                                                                                               effects of drugs w
                                                                                               MCC.
918...............  YES.................  NO..................      21  MED.................  Poisoning & toxic           0.5940         2.1         2.7
                                                                                               effects of drugs w/o
                                                                                               MCC.
919...............  NO..................  NO..................      21  MED.................  Complications of            1.4806         4.5         6.3
                                                                                               treatment w MCC.
920...............  NO..................  NO..................      21  MED.................  Complications of            0.9200         3.4         4.5
                                                                                               treatment w CC.
921...............  NO..................  NO..................      21  MED.................  Complications of            0.6150         2.4         3.0
                                                                                               treatment w/o CC/MCC.
922...............  NO..................  NO..................      21  MED.................  Other injury,               1.4653         4.2         6.1
                                                                                               poisoning & toxic
                                                                                               effect diag w MCC.
923...............  NO..................  NO..................      21  MED.................  Other injury,               0.6493         2.4         3.3
                                                                                               poisoning & toxic
                                                                                               effect diag w/o MCC.
927...............  NO..................  NO..................      22  SURG................  Extensive burns or         12.7968        23.1        29.0
                                                                                               full thickness burns
                                                                                               w MV 96+ hrs w skin
                                                                                               graft.
928...............  NO..................  NO..................      22  SURG................  Full thickness burn w       4.7844        12.2        16.2
                                                                                               skin graft or inhal
                                                                                               inj w CC/MCC.
929...............  NO..................  NO..................      22  SURG................  Full thickness burn w       1.8538         5.6         7.8
                                                                                               skin graft or inhal
                                                                                               inj w/o CC/MCC.
933...............  NO..................  NO..................      22  MED.................  Extensive burns or          2.6367         2.7         5.9
                                                                                               full thickness burns
                                                                                               w MV 96+ hrs w/o skin
                                                                                               graft.
934...............  NO..................  NO..................      22  MED.................  Full thickness burn w/      1.3929         4.8         7.0
                                                                                               o skin grft or inhal
                                                                                               inj.
935...............  NO..................  NO..................      22  MED.................  Non-extensive burns...      1.2000         3.7         5.6
939...............  NO..................  NO..................      23  SURG................  O.R. proc w diagnoses       2.6958         7.5        11.0
                                                                                               of other contact w
                                                                                               health services w MCC.
940...............  NO..................  NO..................      23  SURG................  O.R. proc w diagnoses       1.7409         4.5         6.5
                                                                                               of other contact w
                                                                                               health services w CC.

[[Page 24977]]

 
941...............  NO..................  NO..................      23  SURG................  O.R. proc w diagnoses       1.0979         2.4         3.1
                                                                                               of other contact w
                                                                                               health services w/o
                                                                                               CC/MCC.
945...............  YES.................  NO..................      23  MED.................  Rehabilitation w CC/        1.1456         9.3        11.1
                                                                                               MCC.
946...............  YES.................  NO..................      23  MED.................  Rehabilitation w/o CC/      0.9009         7.3         8.1
                                                                                               MCC.
947...............  YES.................  NO..................      23  MED.................  Signs & symptoms w MCC      1.0303         3.9         5.1
948...............  YES.................  NO..................      23  MED.................  Signs & symptoms w/o        0.6298         2.8         3.4
                                                                                               MCC.
949...............  NO..................  NO..................      23  MED.................  Aftercare w CC/MCC....      0.7746         2.5         4.2
950...............  NO..................  NO..................      23  MED.................  Aftercare w/o CC/MCC..      0.5018         2.4         3.4
951...............  NO..................  NO..................      23  MED.................  Other factors               0.6104         2.1         3.7
                                                                                               influencing health
                                                                                               status.
955...............  NO..................  NO..................      24  SURG................  Craniotomy for              5.1127         8.6        12.3
                                                                                               multiple significant
                                                                                               trauma.
956...............  YES.................  YES.................      24  SURG................  Limb reattachment, hip      3.3955         7.9         9.7
                                                                                               & femur proc for
                                                                                               multiple significant
                                                                                               trauma.
957...............  NO..................  NO..................      24  SURG................  Other O.R. procedures       6.8026        11.6        16.9
                                                                                               for multiple
                                                                                               significant trauma w
                                                                                               MCC.
958...............  NO..................  NO..................      24  SURG................  Other O.R. procedures       4.3582         8.8        11.6
                                                                                               for multiple
                                                                                               significant trauma w
                                                                                               CC.
959...............  NO..................  NO..................      24  SURG................  Other O.R. procedures       3.1511         5.8         7.8
                                                                                               for multiple
                                                                                               significant trauma w/
                                                                                               o CC/MCC.
963...............  NO..................  NO..................      24  MED.................  Other multiple              2.7874         6.7         9.6
                                                                                               significant trauma w
                                                                                               MCC.
964...............  NO..................  NO..................      24  MED.................  Other multiple              1.6288         5.5         6.9
                                                                                               significant trauma w
                                                                                               CC.
965...............  NO..................  NO..................      24  MED.................  Other multiple              1.2426         3.8         4.7
                                                                                               significant trauma w/
                                                                                               o CC/MCC.
969...............  NO..................  NO..................      25  SURG................  HIV w extensive O.R.        5.6577        13.6        19.0
                                                                                               procedure w MCC.
970...............  NO..................  NO..................      25  SURG................  HIV w extensive O.R.        3.0430         8.2        11.8
                                                                                               procedure w/o MCC.
974...............  NO..................  NO..................      25  MED.................  HIV w major related         2.2553         6.5         9.4
                                                                                               condition w MCC.
975...............  NO..................  NO..................      25  MED.................  HIV w major related         1.5844         5.8         8.0
                                                                                               condition w CC.
976...............  NO..................  NO..................      25  MED.................  HIV w major related         1.0710         4.2         5.6
                                                                                               condition w/o CC/MCC.
977...............  NO..................  NO..................      25  MED.................  HIV w or w/o other          1.0477         3.8         5.2
                                                                                               related condition.
981...............  YES.................  NO..................  ......  SURG................  Extensive O.R.              5.0683        12.5        15.8
                                                                                               procedure unrelated
                                                                                               to principal
                                                                                               diagnosis w MCC.
982...............  YES.................  NO..................  ......  SURG................  Extensive O.R.              3.1457         8.2        10.3
                                                                                               procedure unrelated
                                                                                               to principal
                                                                                               diagnosis w CC.
983...............  YES.................  NO..................  ......  SURG................  Extensive O.R.              2.0435         4.1         5.6
                                                                                               procedure unrelated
                                                                                               to principal
                                                                                               diagnosis w/o CC/MCC.
984...............  NO..................  NO..................  ......  SURG................  Prostatic O.R.              3.3812        11.8        14.6
                                                                                               procedure unrelated
                                                                                               to principal
                                                                                               diagnosis w MCC.
985...............  NO..................  NO..................  ......  SURG................  Prostatic O.R.              2.1002         7.5         9.9
                                                                                               procedure unrelated
                                                                                               to principal
                                                                                               diagnosis w CC.
986...............  NO..................  NO..................  ......  SURG................  Prostatic O.R.              1.2417         3.6         5.2
                                                                                               procedure unrelated
                                                                                               to principal
                                                                                               diagnosis w/o CC/MCC.
987...............  YES.................  NO..................  ......  SURG................  Non-extensive O.R.          3.5163        10.4        13.6
                                                                                               proc unrelated to
                                                                                               principal diagnosis w
                                                                                               MCC.
988...............  YES.................  NO..................  ......  SURG................  Non-extensive O.R.          1.8823         6.1         8.1
                                                                                               proc unrelated to
                                                                                               principal diagnosis w
                                                                                               CC.
989...............  YES.................  NO..................  ......  SURG................  Non-extensive O.R.          1.1151         3.0         4.3
                                                                                               proc unrelated to
                                                                                               principal diagnosis w/
                                                                                               o CC/MCC.
998...............  NO..................  NO..................  ......  **..................  Principal diagnosis         0.0000         0.0         0.0
                                                                                               invalid as discharge
                                                                                               diagnosis.
999...............  NO..................  NO..................  ......  **..................  Ungroupable...........      0.0000         0.0        0.0
--------------------------------------------------------------------------------------------------------------------------------------------------------
MS-DRGs 998 and 999 contain cases that could not be assigned to valid DRGs.
Note: If there is no value or asterisk in either the geometric mean length of stay or the arithmetic mean length of stay columns, the volume of cases is
  insufficient to determine a meaningful computation of these statistics.


                     Table 6A.--New Diagnosis Codes
------------------------------------------------------------------------
Diagnosis code    Description       CC       MDC           MS-DRG
------------------------------------------------------------------------
040.41........  Infant botulism  Y              15  791 \1\, 793 \1\
                                 CC             18  867, 868, 869
040.42........  Wound botulism.  Y              18  867, 868, 869
                                 CC
058.10........  Roseola          N              15  791 \1\, 793 \1\
                 infantum,
                 unspecified.
                                 ........       18  865, 866
058.11........  Roseola          N              15  791 \1\, 793 \1\
                 infantum due
                 to human
                 herpes virus 6.
                                 ........       18  865, 866
058.12........  Roseola          N              15  791 \1\, 793 \1\
                 infantum due
                 to human
                 herpes virus 7.

[[Page 24978]]

 
                                 ........       18  865, 866
058.21........  Human herpes     Y               1  23, 24, 97, 98,
                 virus 6         MCC                99
                 encephalitis.
                                 ........       15  791 \1\, 793 \1\
                                 ........       25  974, 975, 976
058.29........  Other human      Y               1  23, 24,97, 98, 99
                 herpes virus    MCC
                 encephalitis.
                                                15  791 \1\, 793 \1\
                                                25  974, 975, 976
058.81........  Human herpes     N               9  606, 607
                 virus 6
                 infection.
058.82........  Human herpes     N               9  606, 607
                 virus 7
                 infection.
058.89........  Other human      N               9  606, 607
                 herpes virus
                 infection.
079.83........  Parvovirus B19.  Y              18  865, 866
                                 CC
200.30........  Marginal zone    Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 unspecified                        840, 841, 842
                 site,
                 extranodal and
                 solid organ
                 sites.
                                                25  974, 975, 976
200.31........  Marginal zone    Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 head, face,
                 and neck.
                                                25  974, 975, 976
200.32........  Marginal zone    Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 intrathoracic                      840, 841, 842
                 lymph nodes.
                                                25  974, 975, 976
200.33........  Marginal zone    Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 intraabdominal                     840, 841, 842
                 lymph nodes.
                                                25  974, 975, 976
200.34........  Marginal zone    Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 axilla and
                 upper limb.
                                                25  974, 975, 976
200.35........  Marginal zone    Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 inguinal
                 region and
                 lower limb.
                                                25  974, 975, 976
200.36........  Marginal zone    Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 intrapelvic                        840, 841, 842
                 lymph nodes.
                                                25  974, 975, 976
200.37........  Marginal zone    Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 spleen.                            840, 841, 842
                                                25  974, 975, 976
200.38........  Marginal zone    Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 multiple sites.
                                                25  974, 975, 976
200.40........  Mantle cell      Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 unspecified                        840, 841, 842
                 site,
                 extranodal and
                 solid organ
                 sites.
                                                25  974, 975, 976
200.41........  Mantle cell      Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 head, face,
                 and neck.
                                                25  974, 975, 976
200.42........  Mantle cell      Y              17  820, 821,822,
                 lymphoma,       CC                 823, 824, 825,
                 intrathoracic                      840, 841, 842
                 lymph nodes.
                                                25  974, 975, 976
200.43........  Mantle cell      Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 intra-                             840, 841, 842
                 abdominal
                 lymph nodes.
                                                25  974, 975, 976
200.44........  Mantle cell      Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 axilla and
                 upper limb.
                                                25  974, 975, 976

[[Page 24979]]

 
200.45........  Mantle cell      Y              17  820, 821, 822,
                 lymphoma,       ........           823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 inguinal
                 region and
                 lower limb.
                                                25  974, 975, 976
200.46........  Mantle cell      Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 intrapelvic                        840, 841, 842
                 lymph nodes.
                                                25  974, 975, 976
200.47........  Mantle cell      Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 spleen.                            840, 841, 842
                                                25  974, 975, 976
200.48........  Mantle cell      Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 multiple sites.
                                                25  974, 975, 976
200.50........  Primary central  Y              17  820, 821, 822,
                 nervous system  CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 unspecified
                 site,
                 extranodal and
                 solid organ
                 sites.
                                                25  974, 975, 976
200.51........  Primary central  Y              17  820, 821, 822,
                 nervous system  CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 lymph nodes of
                 head, face,
                 and neck.
                                                25  974, 975, 976
200.52........  Primary central  Y              17  820, 821, 822,
                 nervous system  CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 intrathoracic
                 lymph nodes.
                                                25  974, 975, 976
200.53........  Primary central  Y              17  820, 821, 822,
                 nervous system  CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 intra-
                 abdominal
                 lymph nodes.
                                                25  974, 975, 976
200.54........  Primary central  Y              17  820, 821, 822,
                 nervous system  CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 lymph nodes of
                 axilla and
                 upper limb.
                                                25  974, 975, 976
200.55........  Primary central  Y              17  820, 821, 822,
                 nervous system  CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 lymph nodes of
                 inguinal
                 region and
                 lower limb.
                                                25  974, 975, 976
200.56........  Primary central  Y              17  820, 821, 822,
                 nervous system  CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 intrapelvic
                 lymph nodes.
                                                25  974, 975, 976
200.57........  Primary central  Y              17  820, 821, 822,
                 nervous system  CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 spleen.
                                                25  974, 975, 976
200.58........  Primary central  Y              17  820, 821, 822,
                 nervous system  CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 lymph nodes of
                 multiple sites.
                                                25  974, 975, 976
200.60........  Anaplastic       Y              17  820, 821, 822,
                 large cell      CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 unspecified
                 site,
                 extranodal and
                 solid organ
                 sites.
                                                25  974, 975, 976
200.61........  Anaplastic       Y              17  820, 821, 822,
                 large cell      CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 lymph nodes of
                 head, face,
                 and neck.
                                                25  974, 975, 976
200.62........  Anaplastic       Y              17  820, 821, 822,
                 large cell      CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 intrathoracic
                 lymph nodes.
                                                25  974, 975, 976
200.63........  Anaplastic       Y              17  820, 821, 822,
                 large cell      CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 intra-
                 abdominal
                 lymph nodes.
                                                25  974, 975, 976
200.64........  Anaplastic       Y              17  820, 821, 822,
                 large cell      CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 lymph nodes of
                 axilla and
                 upper limb.

[[Page 24980]]

 
                                                25  974, 975, 976
200.65........  Anaplastic       Y              17  820, 821, 822,
                 large cell      CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 lymph nodes of
                 inguinal
                 region and
                 lower limb.
                                                25  974, 975, 976
200.66........  Anaplastic       Y              17  820, 821, 822,
                 large cell      CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 intrapelvic
                 lymph nodes.
                                                25  974, 975, 976
200.67........  Anaplastic       Y              17  820, 821, 822,
                 large cell      CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 spleen.
                                                25  974, 975, 976
200.68........  Anaplastic       Y              17  820, 821, 822,
                 large cell      CC                 823, 824, 825,
                 lymphoma,                          840, 841, 842
                 lymph nodes of
                 multiple sites.
                                                25  974, 975, 976
200.70........  Large cell       Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 unspecified                        840, 841, 842
                 site,
                 extranodal and
                 solid organ
                 sites.
                                                25  974, 975, 976
200.71........  Large cell       Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 head, face,
                 and neck.
                                                25  974, 975, 976
200.72........  Large cell       Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 intrathoracic                      840, 841, 842
                 lymph nodes.
                                                25  974, 975, 976
200.73........  Large cell       Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 intra-                             840, 841, 842
                 abdominal
                 lymph nodes.
                                                25  974, 975, 976
200.74........  Large cell       Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 axilla and
                 upper limb.
                                                25  974, 975, 976
200.75........  Large cell       Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 inguinal
                 region and
                 lower limb.
                                                25  974, 975, 976
200.76........  Large cell       Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 intrapelvic                        840, 841, 842
                 lymph nodes.
                                                25  974, 975, 976
200.77........  Large cell       Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 spleen.                            840, 841, 842
                                                25  974, 975, 976
200.78........  Large cell       Y              17  820, 821, 822,
                 lymphoma,       CC                 823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 multiple sites.
                                                25  974, 975, 976
202.70........  Peripheral T     Y              17  820, 821, 822,
                 cell lymphoma,  CC                 823, 824, 825,
                 unspecified                        840, 841, 842
                 site,
                 extranodal and
                 solid organ
                 sites.
                                                25  974, 975, 976
202.71........  Peripheral T     Y              17  820, 821, 822,
                 cell lymphoma,  CC                 823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 head, face,
                 and neck.
                                                25  974, 975, 976
202.72........  Peripheral T     Y              17  820, 821, 822,
                 cell lymphoma,  CC                 823, 824, 825,
                 intrathoracic                      840, 841, 842
                 lymph nodes.
                                                25  974, 975, 976
202.73........  Peripheral T     Y              17  820, 821, 822,
                 cell lymphoma,  CC                 823, 824, 825,
                 intra-                             840, 841, 842
                 abdominal
                 lymph nodes.
                                                25  974, 975, 976

[[Page 24981]]

 
202.74........  Peripheral T     Y              17  820, 821, 822,
                 cell lymphoma,  CC                 823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 axilla and
                 upper limb.
                                                25  974, 975, 976
202.75........  Peripheral T     Y              17  820, 821, 822,
                 cell lymphoma,  CC                 823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 inguinal
                 region and
                 lower limb.
                                                25  974, 975, 976
202.76........  Peripheral T     Y              17  820, 821, 822,
                 cell lymphoma,  CC                 823, 824, 825,
                 intrapelvic                        840, 841, 842
                 lymph nodes.
                                                25  974, 975, 976
202.77........  Peripheral T     Y              17  820, 821, 822,
                 cell lymphoma,  CC                 823, 824, 825,
                 spleen.                            840, 841, 842
                                                25  974, 975, 976
202.78........  Peripheral T     Y              17  820, 821, 822,
                 cell lymphoma,  CC                 823, 824, 825,
                 lymph nodes of                     840, 841, 842
                 multiple sites.
                                                25  974, 975, 976
233.30........  Carcinoma in     N              13  739, 740, 741,
                 situ,                              744, 745, 754,
                 unspecified                        755, 756
                 female genital
                 organ.
233.31........  Carcinoma in     N              13  739, 740, 741,
                 situ,vagina.                       744, 745, 754,
                                                    755, 756
233.32........  Carcinoma in     N              13  739, 740, 741,
                 situ,vulva.                        744, 745, 754,
                                                    755, 756
233.39........  Carcinoma in     N              13  739, 740, 741,
                 situ, other                        744, 745, 754,
                 female genital                     755, 756
                 organ.
255.41........  Glucocorticoid   Y              10  643, 644, 645
                 deficiency.
                                 CC
255.42........  Mineralocortico  Y              10  643, 644, 645
                 id deficiency.
                                 CC
258.01........  Multiple         N              10  643, 644, 645
                 endocrine
                 neoplasia
                 [MEN] type I.
258.02........  Multiple         N              10  643, 644, 645
                 endocrine
                 neoplasia
                 [MEN] type IIA.
258.03........  Multiple         N              10  643, 644, 645
                 endocrine
                 neoplasia
                 [MEN] type IIB.
284.81........  Red cell         Y              16  808, 809, 810
                 aplasia
                 (acquired)(adu
                 lt)(with
                 thymoma).
                                 MCC            25  977
284.89........  Other specified  Y              16  808, 809, 810
                 aplastic
                 anemias.
                                 MCC            25  977
288.66........  Bandemia.......  N              16  814, 815, 816
315.34........  Speech and       N              19  886
                 language
                 developmental
                 delay due to
                 hearing loss.
331.5.........  Idiopathic       Y               1  56, 57
                 normal          CC
                 pressure
                 hydrocephalus
                 (INPH).
359.21........  Myotonic         N               1  91, 92, 93
                 muscular
                 dystrophy.
359.22........  Myotonia         N               1  91, 92, 93
                 congenital.
359.23........  Myotonic         N               1  91, 92, 93
                 chondrodystrop
                 hy.
359.24........  Drug induced     N               1  91, 92, 93
                 myotonia.
359.29........  Other specified  N               1  91, 92, 93
                 myotonic
                 disorder.
364.81........  Floppy iris      N               2  124, 125
                 syndrome.
364.89........  Other disorders  N               2  124, 125
                 of iris and
                 ciliary body.
388.45........  Acquired         N              19  886
                 auditory
                 processing
                 disorder.
389.05........  Conductive       N               3  154, 155, 156
                 hearing loss,
                 unilateral.
389.06........  Conductive       N               3  154, 155, 156
                 hearing loss,
                 bilateral.
389.13........  Neural hearing   N               3  154, 155, 156
                 loss,
                 unilateral.
389.17........  Sensory hearing  N               3  154, 155, 156
                 loss,
                 unilateral.
389.20........  Mixed hearing    N               3  154, 155, 156
                 loss,
                 unspecified.
389.21........  Mixed hearing    N               3  154, 155, 156
                 loss,
                 unilateral.
389.22........  Mixed hearing    N               3  154, 155, 156
                 loss,
                 bilateral.
414.2.........  Chronic total    N               5  302, 303
                 occlusion of
                 coronary
                 artery.
415.12........  Septic           Y               4  175,176
                 pulmonary
                 embolism.
                                 MCC            15  791 \1\, 793 \1\
423.3.........  Cardiac          Y               5  314, 315, 316
                 tamponade.      CC
440.4.........  Chronic total    N               5  299, 300, 301
                 occlusion of
                 artery of the
                 extremities.
449...........  Septic arterial  Y               5  299, 300, 301
                 embolism.
                                 CC             15  791 \1\, 793 \1\
488...........  Influenza due    N               3  152, 153
                 to identified
                 avian
                 influenza
                 virus.

[[Page 24982]]

 
525.71........  Osseointegratio  N            PRE3  11, 12, 13,
                 n failure of                       157, 158, 159
                 dental implant.
525.72........  Post-            N            PRE3  11, 12, 13,
                 osseointegrati                     157, 158, 159
                 on biological
                 failure of
                 dental implant.
525.73........  Post-            N            PRE3  11, 12, 13,
                 osseointegrati                     157, 158, 159
                 on mechanical
                 failure of
                 dental implant.
525.79........  Other            N            PRE3  11, 12, 13,
                 endosseous                         157, 158, 159
                 dental implant
                 failure.
569.43........  Anal sphincter   N               6  393, 394, 395
                 tear (healed)
                 (old).
624.01........  Vulvar           N              13  742, 743, 760,
                 intraepithelia                     761
                 l neoplasia I
                 [VIN I].
624.02........  Vulvar           N              13  742, 743, 760,
                 intraepithelia                     761
                 l neoplasia II
                 [VIN II].
624.09........  Other dystrophy  N              13  742, 743, 760,
                 of vulva.                          761
629.82........  Acquired         N              13  742, 743, 760,
                 absence of                         761
                 both uterus
                 and cervix.
629.83........  Acquired         N              13  742, 743, 760,
                 absence of                         761
                 uterus, with
                 remaining
                 cervical stump.
629.84........  Acquired         N              13  742, 743, 760,
                 absence of                         761
                 cervix with
                 remaining
                 uterus.
664.60........  Anal sphincter   N              14  765, 766, 767,
                 tear                               768, 774, 775
                 complicating
                 delivery, not
                 associated
                 with third-
                 degree
                 perineal
                 laceration,
                 unspecified as
                 to episode of
                 care or not
                 applicable.
664.61........  Anal sphincter   Y              14  765, 766, 767,
                 tear            CC                 768, 774, 775
                 complicating
                 delivery, not
                 associated
                 with third-
                 degree
                 perineal
                 laceration,
                 delivered,
                 with or
                 without
                 mention of
                 antepartum
                 condition.
664.64........  Anal sphincter   Y              14  769, 776
                 tear            CC
                 complicating
                 delivery, not
                 associated
                 with third-
                 degree
                 perineal
                 laceration,
                 postpartum
                 condition or
                 complication.
733.45........  Aseptic          Y               8  553, 554
                 necrosis of
                 bone, jaw.
                                 CC
787.20........  Dysphagia,       N               6  391, 392
                 unspecified.
787.21........  Dysphagia, oral  N               6  391, 392
                 phase.
787.22........  Dysphagia,       N               6  391, 392
                 oropharyngeal
                 phase.
787.23........  Dysphagia,       N               6  391, 392
                 pharyngeal
                 phase.
787.24........  Dysphagia,       N               6  391, 392
                 pharyngoesopha
                 geal phase.
787.29........  Other dysphagia  N               6  391, 392
789.51........  Malignant        Y              23  947, 948
                 ascites.
789.59........  Other ascites..  Y              23  947, 948
                                 CC
V12.53........  Personal         N              23  951
                 history of
                 sudden cardiac
                 arrest.
V12.54........  Personal         N              23  951
                 history of
                 transient
                 ischemic
                 attack (TIA),
                 and cerebral
                 infarction
                 without
                 residual
                 deficits.
V13.22........  Personal         N              17  843, 844, 845
                 history of
                 cervical
                 dysplasia.
V16.52........  Family history   N              23  951
                 of malignant
                 neoplasm,
                 bladder.
V17.40........  Family history   N              23  951
                 of
                 cardiovascular
                 diseases,
                 unspecified.
V17.41........  Family history   N              23  951
                 of sudden
                 cardiac death
                 (SCD).
V17.49........  Family history   N              23  951
                 of other
                 cardiovascular
                 diseases.
V18.11........  Family history   N              23  951
                 of multiple
                 endocrine
                 neoplasia
                 [MEN] syndrome.
V18.19........  Family history   N              23  951
                 of other
                 endocrine and
                 metabolic
                 diseases.
V25.04........  Counseling and   N              23  951
                 instruction in
                 natural family
                 planning to
                 avoid
                 pregnancy.
V26.41........  Procreative      N              23  951
                 counseling and
                 advice using
                 natural family
                 planning.
V26.49........  Other            N              23  951
                 procreative
                 management,
                 counseling and
                 advice.
V26.81........  Encounter for    N              23  951
                 assisted
                 reproductive
                 fertility
                 procedure
                 cycle.
V26.89........  Other specified  N              23  951
                 procreative
                 management.
V49.85........  Dual sensory     N              23  951
                 impairment.
V68.01........  Disability       N              23  951
                 examination.
V68.09........  Other issue of   N              23  951
                 medical
                 certificates.
V72.12........  Encounter for    N              15  795 \2\
                 hearing
                 conservation
                 and treatment.
                                 ........       23  951
V73.81........  Special          N              23  951
                 screening
                 examination,
                 Human
                 papilloma
                 virus (HPV).
V84.81........  Genetic          N              23  951
                 susceptibility
                 to multiple
                 endocrine
                 neoplasia
                 [MEN].
V84.89........  Genetic          N              23  951
                 susceptibility
                 to other
                 disease.
------------------------------------------------------------------------
MCC--Major Complication or Comorbidity in MS-DRGs.
\1\ Secondary diagnosis of major problem.
\2\ On ``Only secondary diagnosis'' list.


                     Table 6B.--New Procedure Codes
------------------------------------------------------------------------
Procedure code    Description      O.R.      MDC           MS-DRG
------------------------------------------------------------------------
00.19.........  Disruption of    N                  ....................
                 blood brain
                 barrier via
                 infusion
                 [BBBD].

[[Page 24983]]

 
01.10.........  Intracranial     N                  ....................
                 pressure
                 monitoring.
01.16.........  Intracranial     N                  ....................
                 oxygen
                 monitoring.
01.17.........  Brain            N                  ....................
                 temperature
                 monitoring.
32.41.........  Thoracoscopic    Y               4  163, 164, 165
                 lobectomy of
                 lung.
                                 ........       21  907, 908, 909
                                 ........       24  957, 958, 959
32.49.........  Other lobectomy  Y               4  163, 164, 165
                 of lung.
                                 ........       21  907, 908, 909
                                 ........       24  957, 958, 959
33.20.........  Thoracoscopic    Y               4  166, 167, 168
                 lung biopsy.
                                 ........        5  264
                                 ........        8  515, 516, 517
                                 ........       11  673, 674, 675
                                 ........       17  823, 824, 825, 829,
                                                     830
34.06.........  Thoracoscopic    Y               4  166, 167, 168
                 drainage of
                 pleural cavity.
34.20.........  Thoracoscopic    Y               4  166, 167, 168
                 pleural biopsy.
34.52.........  Thoracoscopic    Y               4  163, 164, 165
                 decortication
                 of lung.
                                 ........       17  820, 821, 822,
                                                    826, 827, 828
                                 ........       21  907, 908, 909
                ...............  ........       24  957, 958, 959
70.53.........  Repair of        Y               6  329, 330, 331
                 cystocele and
                 rectocele with
                 graft or
                 prosthesis.
                                 ........       11  653, 654, 655
                                 ........       13  748
70.54.........  Repair of        Y              11  662, 663, 664
                 cystocele with
                 graft or
                 prosthesis.
                                 ........       13  748
70.55.........  Repair of        Y               6  329, 330, 331
                 rectocele with
                 graft or
                 prosthesis.
                                 ........       13  748
70.63.........  Vaginal          Y              13  748
                 construction
                 with graft or
                 prosthesis.
70.64.........  Vaginal          Y              13  748
                 reconstruction
                 with graft or
                 prosthesis.
                                 ........       21  907, 908, 909
                                 ........       24  957, 958, 959
70.78.........  Vaginal          Y              11  662, 663, 664
                 suspension and
                 fixation with
                 graft or
                 prosthesis.
                ...............  ........       13  748
70.93.........  Other            Y              13  746, 747
                 operations on
                 cul-de-sac
                 with graft or
                 prosthesis.
70.94.........  Insertion of     N                  ....................
                 biological
                 graft.
70.95.........  Insertion of     N                  ....................
                 synthetic
                 graft or
                 prosthesis.
88.59.........  Intra-operative  N                  ....................
                 fluorescence
                 vascular
                 angiography.
------------------------------------------------------------------------


                   Table 6C.--Invalid Diagnosis Codes
------------------------------------------------------------------------
Diagnosis code    Description       CC       MDC           CMS DRG
------------------------------------------------------------------------
233.3.........  Carcinoma in     N              13  354, 355, 363, 366,
                 situ,other and                      367
                 unspecified
                 female genital
                 organs.
255.4.........  Corticoadrenal   Y              10  300, 301
                 insufficiency.
258.0.........  Polyglandular    N              10  300, 301
                 activity in
                 multiple
                 endocrine
                 adenomatosis.
284.8.........  Other specified  Y              16  574
                 aplastic
                 anemias.
                ...............  ........       25  490
359.2.........  Myotonic         N               1  34, 35
                 disorders.
364.8.........  Other disorders  N               2  46, 47, 48
                 of iris and
                 ciliary body.
389.2.........  Mixed            N               3  73, 74
                 conductive and
                 sensorineural
                 hearing loss.
624.0.........  Dystrophy of     N              13  358, 359, 369
                 vulva.
787.2.........  Dysphagia......  N               6  182, 183, 184
789.5.........  Ascites........  Y              23  463, 464
V17.4.........  Family history   N              23  467
                 of other
                 cardiovascular
                 diseases.
V18.1.........  Family history   N              23  467
                 of other
                 endocrine and
                 metabolic
                 diseases.
V26.4.........  Procreative      N              23  467
                 management,
                 general
                 counseling and
                 advice.
V26.8.........  Other specified  N              23  467
                 procreative
                 management.
V68.0.........  Issue of         N              23  467
                 medical
                 certificates.
V84.8.........  Genetic          N              23  467
                 susceptibility
                 to other
                 disease.
------------------------------------------------------------------------

    The DRG assignments listed are based on the current code assignment 
in the CMS DRGs.

[[Page 24984]]



                   Table 6D.--Invalid Procedure Codes
------------------------------------------------------------------------
Procedure code     Description      OR       MDC           CMS DRG
------------------------------------------------------------------------
 32.4.........  Lobectomy of     Y               4  75
                 lung.                          21  442,443
                                                24  486
------------------------------------------------------------------------

    The DRG assignments listed are based on the current code assignment 
in the CMS DRGs.

                Table 6E.--Revised Diagnosis Code Titles
------------------------------------------------------------------------
Diagnosis code    Description        CC       MDC          MS-DRG
------------------------------------------------------------------------
 005.1........  Botulism food    Y              18  867, 868, 869
                 poisoning.      CC
 359.3........  Periodic          N              1  91, 92, 93
                 paralysis.
 389.14.......  Central hearing   N              3  154, 155, 156
                 loss.
389.18........  Sensorineural    N               3  154, 155,156
                 hearing loss,
                 bilateral.
 389.7........  Deaf,             N              3  154, 155, 156
                 nonspeaking,
                 not elsewhere
                 classifiable.
------------------------------------------------------------------------


                Table 6F.--Revised Procedure Code Titles
------------------------------------------------------------------------
Procedure code    Description       OR       MDC           MS-DRG
------------------------------------------------------------------------
00.74.........  Hip bearing      N
                 surface, metal-
                 on-
                 polyethylene.
00.75.........  Hip bearing      N
                 surface, metal-
                 on-metal.
00.76.........  Hip bearing      N
                 surface,
                 ceramic-on-
                 ceramic.
00.77.........  Hip bearing      N
                 surface,
                 ceramic-on-
                 polyethylene.
34.24.........  Other pleural    N
                 biopsy.
53.41.........  Repair of        Y               6  353, 354, 355 987,
                 umbilical                           988, 989
                 hernia with
                 graft or
                 prosthesis.
53.61.........  Incisional       Y               6  353, 354, 355
                 hernia repair                  21  907, 908, 909
                 with graft or                  24  957, 958, 959
                 prosthesis.                        987, 988, 989
53.69.........  Repair of other  Y              06  353, 354, 355
                 hernia of                          987, 988, 989
                 anterior
                 abdominal wall
                 with graft or
                 prosthesis.
99.14.........  Injection or     N
                 infusion of
                 gamma globulin.
------------------------------------------------------------------------


    Note: Diagnoses codes 42741 (Ventricular fibrillation), 4275 
(Cardiac arrest), 78551 (Cardiogenic shock), 78559 (Other shock 
without mention of trauma) and 7991 (Respiratory arrest) are 
assigned as a major CC only for patients discharged alive, otherwise 
they will be assigned as a non CC.


      TABLE 6J.--Major Complication and Comorbidity (Major CC) List
------------------------------------------------------------------------
         Diagnosis code                         Code title
------------------------------------------------------------------------
0031............................  Salmonella septicemia.
00321...........................  Salmonella meningitis.
00322...........................  Salmonella pneumonia.
0063............................  Amebic liver abscess.
0064............................  Amebic lung abscess.
0065............................  Amebic brain abscess.
01160...........................  Tuberculous pneumonia (any form),
                                   unspecified examination.
01161...........................  Tuberculous pneumonia (any form),
                                   bacteriological or histological
                                   examination not done.
01162...........................  Tuberculous pneumonia (any form),
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01163...........................  Tuberculous pneumonia (any form),
                                   tubercle bacilli found (in sputum) by
                                   microscopy.
01164...........................  Tuberculous pneumonia (any form),
                                   tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01165...........................  Tuberculous pneumonia (any form),
                                   tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01166...........................  Tuberculous pneumonia (any form),
                                   tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01300...........................  Tuberculous meningitis, unspecified
                                   examination.
01301...........................  Tuberculous meningitis,
                                   bacteriological or histological
                                   examination not done.

[[Page 24985]]

 
01302...........................  Tuberculous meningitis,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01303...........................  Tuberculous meningitis, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01304...........................  Tuberculous meningitis, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01305...........................  Tuberculous meningitis, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01306...........................  Tuberculous meningitis, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01310...........................  Tuberculoma of meninges, unspecified
                                   examination.
01311...........................  Tuberculoma of meninges,
                                   bacteriological or histological
                                   examination not done.
01312...........................  Tuberculoma of meninges,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01313...........................  Tuberculoma of meninges, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01314...........................  Tuberculoma of meninges, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01315...........................  Tuberculoma of meninges, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01316...........................  Tuberculoma of meninges, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01320...........................  Tuberculoma of brain, unspecified
                                   examination.
01321...........................  Tuberculoma of brain, bacteriological
                                   or histological examination not done.
01322...........................  Tuberculoma of brain, bacteriological
                                   or histological examination results
                                   unknown (at present).
01323...........................  Tuberculoma of brain, tubercle bacilli
                                   found (in sputum) by microscopy.
01324...........................  Tuberculoma of brain, tubercle bacilli
                                   not found (in sputum) by microscopy,
                                   but found by bacterial culture.
01325...........................  Tuberculoma of brain, tubercle bacilli
                                   not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01326...........................  Tuberculoma of brain, tubercle bacilli
                                   not found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01330...........................  Tuberculous abscess of brain,
                                   unspecified examination.
01331...........................  Tuberculous abscess of brain,
                                   bacteriological or histological
                                   examination not done.
01332...........................  Tuberculous abscess of brain,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01333...........................  Tuberculous abscess of brain, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01334...........................  Tuberculous abscess of brain, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01335...........................  Tuberculous abscess of brain, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01336...........................  Tuberculous abscess of brain, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01340...........................  Tuberculoma of spinal cord,
                                   unspecified examination.
01341...........................  Tuberculoma of spinal cord,
                                   bacteriological or histological
                                   examination not done.
01342...........................  Tuberculoma of spinal cord,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01343...........................  Tuberculoma of spinal cord, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01344...........................  Tuberculoma of spinal cord, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01345...........................  Tuberculoma of spinal cord, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01346...........................  Tuberculoma of spinal cord, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01350...........................  Tuberculous abscess of spinal cord,
                                   unspecified examination.
01351...........................  Tuberculous abscess of spinal cord,
                                   bacteriological or histological
                                   examination not done.
01352...........................  Tuberculous abscess of spinal cord,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01353...........................  Tuberculous abscess of spinal cord,
                                   tubercle bacilli found (in sputum) by
                                   microscopy.
01354...........................  Tuberculous abscess of spinal cord,
                                   tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01355...........................  Tuberculous abscess of spinal cord,
                                   tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01356...........................  Tuberculous abscess of spinal cord,
                                   tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01360...........................  Tuberculous encephalitis or myelitis,
                                   unspecified examination.
01361...........................  Tuberculous encephalitis or myelitis,
                                   bacteriological or histological
                                   examination not done.
01362...........................  Tuberculous encephalitis or myelitis,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01363...........................  Tuberculous encephalitis or myelitis,
                                   tubercle bacilli found (in sputum) by
                                   microscopy.
01364...........................  Tuberculous encephalitis or myelitis,
                                   tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01365...........................  Tuberculous encephalitis or myelitis,
                                   tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01366...........................  Tuberculous encephalitis or myelitis,
                                   tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01380...........................  Other specified tuberculosis of
                                   central nervous system, unspecified
                                   examination.
01381...........................  Other specified tuberculosis of
                                   central nervous system,
                                   bacteriological or histological
                                   examination not done.
01382...........................  Other specified tuberculosis of
                                   central nervous system,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01383...........................  Other specified tuberculosis of
                                   central nervous system, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01384...........................  Other specified tuberculosis of
                                   central nervous system, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.

[[Page 24986]]

 
01385...........................  Other specified tuberculosis of
                                   central nervous system, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01386...........................  Other specified tuberculosis of
                                   central nervous system, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01390...........................  Unspecified tuberculosis of central
                                   nervous system, unspecified
                                   examination.
01391...........................  Unspecified tuberculosis of central
                                   nervous system, bacteriological or
                                   histological examination not done.
01392...........................  Unspecified tuberculosis of central
                                   nervous system, bacteriological or
                                   histological examination results
                                   unknown (at present).
01393...........................  Unspecified tuberculosis of central
                                   nervous system, tubercle bacilli
                                   found (in sputum) by microscopy.
01394...........................  Unspecified tuberculosis of central
                                   nervous system, tubercle bacilli not
                                   found (in sputum) by microscopy, but
                                   found by bacterial culture.
01395...........................  Unspecified tuberculosis of central
                                   nervous system, tubercle bacilli not
                                   found by bacteriological examination,
                                   but tuberculosis confirmed
                                   histologically.
01396...........................  Unspecified tuberculosis of central
                                   nervous system, tubercle bacilli not
                                   found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01400...........................  Tuberculous peritonitis, unspecified
                                   examination.
01401...........................  Tuberculous peritonitis,
                                   bacteriological or histological
                                   examination not done.
01402...........................  Tuberculous peritonitis,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01403...........................  Tuberculous peritonitis, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01404...........................  Tuberculous peritonitis, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01405...........................  Tuberculous peritonitis, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01406...........................  Tuberculous peritonitis, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01800...........................  Acute miliary tuberculosis,
                                   unspecified examination.
01801...........................  Acute miliary tuberculosis,
                                   bacteriological or histological
                                   examination not done.
01802...........................  Acute miliary tuberculosis,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01803...........................  Acute miliary tuberculosis, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01804...........................  Acute miliary tuberculosis, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01805...........................  Acute miliary tuberculosis, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01806...........................  Acute miliary tuberculosis, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01880...........................  Other specified miliary tuberculosis,
                                   unspecified examination.
01881...........................  Other specified miliary tuberculosis,
                                   bacteriological or histological
                                   examination not done.
01882...........................  Other specified miliary tuberculosis,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01883...........................  Other specified miliary tuberculosis,
                                   tubercle bacilli found (in sputum) by
                                   microscopy.
01884...........................  Other specified miliary tuberculosis,
                                   tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01885...........................  Other specified miliary tuberculosis,
                                   tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01886...........................  Other specified miliary tuberculosis,
                                   tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01890...........................  Unspecified miliary tuberculosis,
                                   unspecified examination.
01891...........................  Unspecified miliary tuberculosis,
                                   bacteriological or histological
                                   examination not done.
01892...........................  Unspecified miliary tuberculosis,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01893...........................  Unspecified miliary tuberculosis,
                                   tubercle bacilli found (in sputum) by
                                   microscopy.
01894...........................  Unspecified miliary tuberculosis,
                                   tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01895...........................  Unspecified miliary tuberculosis,
                                   tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01896...........................  Unspecified miliary tuberculosis,
                                   tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
0200............................  Bubonic plague.
0201............................  Cellulocutaneous plague.
0202............................  Septicemic plague.
0203............................  Primary pneumonic plague.
0204............................  Secondary pneumonic plague.
0205............................  Pneumonic plague, unspecified.
0208............................  Other specified types of plague.
0209............................  Plague, unspecified.
0221............................  Pulmonary anthrax.
0223............................  Anthrax septicemia.
0360............................  Meningococcal meningitis.
0361............................  Meningococcal encephalitis.
0362............................  Meningococcemia.
0363............................  Waterhouse-friderichsen syndrome,
                                   meningococcal.
03640...........................  Meningococcal carditis, unspecified.
03641...........................  Meningococcal pericarditis.
03642...........................  Meningococcal endocarditis.
03643...........................  Meningococcal myocarditis.
037.............................  Tetanus.

[[Page 24987]]

 
0380............................  Streptococcal septicemia.
03810...........................  Staphylococcal septicemia,
                                   unspecified.
03811...........................  Staphylococcus aureus septicemia.
03819...........................  Other staphylococcal septicemia.
0382............................  Pneumococcal septicemia.
0383............................  Septicemia due to anaerobes.
03840...........................  Septicemia due to gram-negative
                                   organism, unspecified.
03841...........................  Septicemia due to hemophilus
                                   influenzae (h. influenzae).
03842...........................  Septicemia due to escherichia coli (e.
                                   coli).
03843...........................  Septicemia due to pseudomonas.
03844...........................  Septicemia due to serratia.
03849...........................  Other septicemia due to gram-negative
                                   organisms.
0388............................  Other specified septicemias.
0389............................  Unspecified septicemia.
0400............................  Gas gangrene.
04082...........................  Toxic shock syndrome.
042.............................  Human immunodeficiency virus (hiv)
                                   disease.
04500...........................  Acute paralytic poliomyelitis
                                   specified as bulbar, unspecified type
                                   of poliovirus.
04501...........................  Acute paralytic poliomyelitis
                                   specified as bulbar, poliovirus type
                                   i.
04502...........................  Acute paralytic poliomyelitis
                                   specified as bulbar, poliovirus type
                                   ii.
04503...........................  Acute paralytic poliomyelitis
                                   specified as bulbar, poliovirus type
                                   iii.
04510...........................  Acute poliomyelitis with other
                                   paralysis, unspecified type of
                                   poliovirus.
04511...........................  Acute poliomyelitis with other
                                   paralysis, poliovirus type i.
04512...........................  Acute poliomyelitis with other
                                   paralysis, poliovirus type ii.
04513...........................  Acute poliomyelitis with other
                                   paralysis, poliovirus type iii.
0520............................  Postvaricella encephalitis.
0521............................  Varicella (hemorrhagic) pneumonitis.
0522............................  Postvaricella myelitis.
0530............................  Herpes zoster with meningitis.
05314...........................  Herpes zoster myelitis.
0543............................  Herpetic meningoencephalitis.
0545............................  Herpetic septicemia.
05472...........................  Herpes simplex meningitis.
05474...........................  Herpes simplex myelitis.
0550............................  Postmeasles encephalitis.
0551............................  Postmeasles pneumonia.
05601...........................  Encephalomyelitis due to rubella.
05821...........................  Human herpes virus 6 encephalitis.
05829...........................  Other human herpes virus encephalitis.
0620............................  Japanese encephalitis.
0621............................  Western equine encephalitis.
0622............................  Eastern equine encephalitis.
0623............................  St. Louis encephalitis.
0624............................  Australian encephalitis.
0625............................  California virus encephalitis.
0628............................  Other specified mosquito-borne viral
                                   encephalitis.
0629............................  Mosquito-borne viral encephalitis,
                                   unspecified.
0630............................  Russian spring-summer (taiga)
                                   encephalitis.
0631............................  Louping ill.
0632............................  Central european encephalitis.
0638............................  Other specified tick-borne viral
                                   encephalitis.
0639............................  Tick-borne viral encephalitis,
                                   unspecified.
064.............................  Viral encephalitis transmitted by
                                   other and unspecified arthropods.
06640...........................  West Nile Fever, unspecified.
06641...........................  West Nile Fever with encephalitis.
06642...........................  West Nile Fever with other neurologic
                                   manifestation.
06649...........................  West Nile Fever with other
                                   complications.
0700............................  Viral hepatitis a with hepatic coma.
07020...........................  Viral hepatitis b with hepatic coma,
                                   acute or unspecified, without mention
                                   of hepatitis delta.
07021...........................  Viral hepatitis b with hepatic coma,
                                   acute or unspecified, with hepatitis
                                   delta.
07022...........................  Chronic viral hepatitis b with hepatic
                                   coma without hepatitis delta.
07023...........................  Chronic viral hepatitis b with hepatic
                                   coma with hepatitis delta.
07041...........................  Acute hepatitis C with hepatic coma.
07042...........................  Hepatitis delta without mention of
                                   active hepatitis b disease, with
                                   hepatic coma, hepatitis delta with
                                   hepatitis b carrier state.
07043...........................  Hepatitis e with hepatic coma.
07044...........................  Chronic hepatitis c with hepatic coma.
07049...........................  Other specified viral hepatitis with
                                   hepatic coma.
0706............................  Unspecified viral hepatitis with
                                   hepatic coma.
07071...........................  Unspecified viral hepatitis C with
                                   hepatic coma.
0721............................  Mumps meningitis.
0722............................  Mumps encephalitis.

[[Page 24988]]

 
0730............................  Ornithosis with pneumonia.
0840............................  Falciparum malaria (malignant
                                   tertian).
09041...........................  Congenital syphilitic encephalitis.
09042...........................  Congenital syphilitic meningitis.
09181...........................  Acute syphilitic meningitis
                                   (secondary).
0942............................  Syphilitic meningitis.
09481...........................  Syphilitic encephalitis.
09487...........................  Syphilitic ruptured cerebral aneurysm.
09882...........................  Gonococcal meningitis.
09883...........................  Gonococcal pericarditis.
09884...........................  Gonococcal endocarditis.
10081...........................  Leptospiral meningitis (aseptic).
1124............................  Candidiasis of lung.
1125............................  Disseminated candidiasis.
11281...........................  Candidal endocarditis.
11283...........................  Candidal meningitis.
1142............................  Coccidioidal meningitis.
11501...........................  Histoplasma capsulatum meningitis.
11503...........................  Histoplasma capsulatum pericarditis.
11504...........................  Histoplasma capsulatum endocarditis.
11505...........................  Histoplasma capsulatum pneumonia.
11511...........................  Histoplasma duboisii meningitis.
11513...........................  Histoplasma duboisii pericarditis.
11514...........................  Histoplasma duboisii endocarditis.
11515...........................  Histoplasma duboisii pneumonia.
11591...........................  Histoplasmosis meningitis,
                                   unspecified.
11593...........................  Histoplasmosis pericarditis,
                                   unspecified.
11594...........................  Histoplasmosis endocarditis.
11595...........................  Histoplasmosis pneumonia, unspecified.
1177............................  Zygomycosis (phycomycosis or
                                   mucormycosis).
1300............................  Meningoencephalitis due to
                                   toxoplasmosis.
1303............................  Myocarditis due to toxoplasmosis.
1304............................  Pneumonitis due to toxoplasmosis.
1308............................  Multisystemic disseminated
                                   toxoplasmosis.
1362............................  Specific infections by free-living
                                   amebae.
1363............................  Pneumocystosis.
24201...........................  Toxic diffuse goiter with mention of
                                   thyrotoxic crisis or storm.
24211...........................  Toxic uninodular goiter with mention
                                   of thyrotoxic crisis or storm.
24221...........................  Toxic multinodular goiter with mention
                                   of thyrotoxic crisis or storm.
24231...........................  Toxic nodular goiter, unspecified
                                   type, with mention of thyrotoxic
                                   crisis or storm.
24241...........................  Thyrotoxicosis from ectopic thyroid
                                   nodule with mention of thyrotoxic
                                   crisis or storm.
24281...........................  Thyrotoxicosis of other specified
                                   origin with mention of thyrotoxic
                                   crisis or storm.
24291...........................  Thyrotoxicosis without mention of
                                   goiter or other cause, with mention
                                   of thyrotoxic crisis or storm.
25010...........................  Diabetes with ketoacidosis, type II or
                                   unspecified type, not stated as
                                   uncontrolled.
25011...........................  Diabetes with ketoacidosis, type I
                                   [juvenile type], not stated as
                                   uncontrolled.
25012...........................  Diabetes with ketoacidosis, type II or
                                   unspecified type, uncontrolled.
25013...........................  Diabetes with ketoacidosis, type I
                                   [juvenile type], uncontrolled.
25020...........................  Diabetes with hyperosmolarity, type II
                                   or unspecified type, not stated as
                                   uncontrolled.
25021...........................  Diabetes with hyperosmolarity, type I
                                   [juvenile type], not stated as
                                   uncontrolled.
25022...........................  Diabetes with hyperosmolarity, type II
                                   or unspecified type, uncontrolled.
25023...........................  Diabetes with hyperosmolarity, type I
                                   [juvenile type], uncontrolled.
25030...........................  Diabetes with other coma, type II or
                                   unspecified type, not stated as
                                   uncontrolled.
25031...........................  Diabetes with other coma, type I
                                   [juvenile type], not stated as
                                   uncontrolled.
25032...........................  Diabetes with other coma, type II or
                                   unspecified type, uncontrolled.
25033...........................  Diabetes with other coma, type I
                                   [juvenile type], uncontrolled.
260.............................  Kwashiorkor.
261.............................  Nutritional marasmus.
262.............................  Other severe protein-calorie
                                   malnutrition.
27701...........................  Cystic fibrosis with meconium ileus.
27702...........................  Cystic fibrosis with pulmonary
                                   manifestations.
28242...........................  Sickle-Cell thalassemia with crisis.
28262...........................  Hb-ss disease with crisis.
28264...........................  Sickle-Cell/Hb-C disease with crisis.
28311...........................  Hemolytic-uremic syndrome.
28481...........................  Red cell aplasia
                                   (acquired)(adult)(with thymoma).
28489...........................  Other specified aplastic anemias.
2860............................  Congenital factor viii disorder.
2861............................  Congenital factor ix disorder.
2866............................  Defibrination syndrome.
3200............................  Hemophilus meningitis.
3201............................  Pneumococcal meningitis.
3202............................  Streptococcal meningitis.

[[Page 24989]]

 
3203............................  Staphylococcal meningitis.
3207............................  Meningitis in other bacterial diseases
                                   classified elsewhere.
32081...........................  Anaerobic meningitis.
32082...........................  Meningitis due to gram-negative
                                   bacteria, not elsewhere classified.
32089...........................  Meningitis due to other specified
                                   bacteria.
3209............................  Meningitis due to unspecified
                                   bacterium.
3210............................  Cryptococcal meningitis.
3211............................  Meningitis in other fungal diseases.
3212............................  Meningitis due to viruses not
                                   elsewhere classified.
3213............................  Meningitis due to trypanosomiasis.
3214............................  Meningitis in sarcoidosis.
3218............................  Meningitis due to other nonbacterial
                                   organisms classified elsewhere.
3220............................  Nonpyogenic meningitis.
3221............................  Eosinophilic meningitis.
3229............................  Meningitis, unspecified.
32301...........................  Encephalitis and encephalomyelitis in
                                   viral diseases classified elsewhere.
32302...........................  Myelitis in viral diseases classified
                                   elsewhere.
3231............................  Encephalitis, myelitis, and
                                   encephalomyelitis in rickettsial
                                   diseases classified elsewhere.
3232............................  Encephalitis, myelitis, and
                                   encephalomyelitis in protozoal
                                   diseases classified elsewhere.
32341...........................  Other encephalitis and
                                   encephalomyelitis due to infection
                                   classified elsewhere.
32342...........................  Other myelitis due to infection
                                   classified elsewhere.
32351...........................  Encephalitis and encephalomyelitis
                                   following immunization procedures.
32352...........................  Myelitis following immunization
                                   procedures.
32361...........................  Infectious acute disseminated
                                   encephalomyelitis (ADEM).
32362...........................  Other postinfectious encephalitis and
                                   encephalomyelitis.
32363...........................  Postinfectious myelitis.
32371...........................  Toxic encephalitis and
                                   encephalomyelitis.
32372...........................  Toxic myelitis.
32381...........................  Other causes of encephalitis and
                                   encephalomyelitis.
32382...........................  Other causes of myelitis.
3239............................  Unspecified causes of encephalitis,
                                   myelitis, and encephalomyelitis.
3240............................  Intracranial abscess.
3241............................  Intraspinal abscess.
3249............................  Intracranial and intraspinal abscess
                                   of unspecified site.
325.............................  Phlebitis and thrombophlebitis of
                                   intracranial venous sinuses.
33181...........................  Reye's syndrome.
33392...........................  Neuroleptic malignant syndrome.
3361............................  Vascular myelopathies.
3432............................  Congenital quadriplegia.
34400...........................  Quadriplegia, unspecified.
34401...........................  Quadriplegia, C1-C4, complete.
34402...........................  Quadriplegia, C1-C4, incomplete.
34403...........................  Quadriplegia, C5-C7, complete.
34404...........................  Quadriplegia, C5-C7, incomplete.
34409...........................  Other quadriplegia.
34481...........................  Locked-in state.
3453............................  Grand mal status, epileptic.
34830...........................  Encephalopathy, unspecified.
34831...........................  Metabolic encephalopathy.
34839...........................  Other encephalopathy.
3484............................  Compression of brain.
3485............................  Cerebral edema.
34982...........................  Toxic encephalopathy.
35801...........................  Myasthenia gravis with (acute)
                                   exacerbation.
41001...........................  Acute myocardial infarction of
                                   anterolateral wall, initial episode
                                   of care.
41011...........................  Acute myocardial infarction of other
                                   anterior wall, initial episode of
                                   care.
41021...........................  Acute myocardial infarction of
                                   inferolateral wall, initial episode
                                   of care.
41031...........................  Acute myocardial infarction of
                                   inferoposterior wall, initial episode
                                   of care.
41041...........................  Acute myocardial infarction of other
                                   inferior wall, initial episode of
                                   care.
41051...........................  Acute myocardial infarction of other
                                   lateral wall, initial episode of
                                   care.
41061...........................  True posterior wall infarction,
                                   initial episode of care.
41071...........................  Subendocardial infarction, initial
                                   episode of care.
41081...........................  Acute myocardial infarction of other
                                   specified sites, initial episode of
                                   care.
41091...........................  Acute myocardial infarction of
                                   unspecified site, initial episode of
                                   care.
41412...........................  Dissection of coronary artery.
4150............................  Acute cor pulmonale.
41511...........................  Iatrogenic pulmonary embolism and
                                   infarction.
41512...........................  Septic pulmonary embolism.
41519...........................  Other pulmonary embolism and
                                   infarction.
4210............................  Acute and subacute bacterial
                                   endocarditis.
4211............................  Acute and subacute infective
                                   endocarditis in diseases classified
                                   elsewhere.
4219............................  Acute endocarditis, unspecified.

[[Page 24990]]

 
4220............................  Acute myocarditis in diseases
                                   classified elsewhere.
42290...........................  Acute myocarditis, unspecified.
42291...........................  Idiopathic myocarditis.
42292...........................  Septic myocarditis.
42293...........................  Toxic myocarditis.
42299...........................  Other acute myocarditis.
42741...........................  Ventricular fibrillation.
42742...........................  Ventricular flutter.
4275............................  Cardiac arrest.
42821...........................  Acute systolic heart failure.
42823...........................  Acute on chronic systolic heart
                                   failure.
42831...........................  Acute diastolic heart failure.
42833...........................  Acute on chronic diastolic heart
                                   failure.
42841...........................  Acute combined systolic and diastolic
                                   heart failure.
42843...........................  Acute on chronic combined systolic and
                                   diastolic heart failure.
4295............................  Rupture of chordae tendineae.
4296............................  Rupture of papillary muscle.
430.............................  Subarachnoid hemorrhage.
431.............................  Intracerebral hemorrhage.
4320............................  Nontraumatic extradural hemorrhage.
4321............................  Subdural hemorrhage.
43301...........................  Occlusion and stenosis of basilar
                                   artery with cerebral infarction.
43311...........................  Occlusion and stenosis of carotid
                                   artery with cerebral infarction.
43321...........................  Occlusion and stenosis of vertebral
                                   artery with cerebral infarction.
43331...........................  Occlusion and stenosis of multiple and
                                   bilateral precerebral arteries with
                                   cerebral infarction.
43381...........................  Occlusion and stenosis of other
                                   specified precerebral artery with
                                   cerebral infarction.
43391...........................  Occlusion and stenosis of unspecified
                                   precerebral artery with cerebral
                                   infarction.
43401...........................  Cerebral thrombosis with cerebral
                                   infarction.
43411...........................  Cerebral embolism with cerebral
                                   infarction.
43491...........................  Cerebral artery occlusion, unspecified
                                   with cerebral infarction.
44100...........................  Dissection of aorta, unspecified site.
44101...........................  Dissection of aorta, thoracic.
44102...........................  Dissection of aorta, abdominal.
44103...........................  Dissection of aorta, thoracoabdominal.
4411............................  Thoracic aneurysm, ruptured.
4413............................  Abdominal aneurysm, ruptured.
4415............................  Aortic aneurysm of unspecified site,
                                   ruptured.
4416............................  Thoracoabdominal aneurysm, ruptured.
44321...........................  Dissection of carotid artery.
44322...........................  Dissection of iliac artery.
44323...........................  Dissection of renal artery.
44324...........................  Dissection of vertebral artery.
44329...........................  Dissection of other artery.
4466............................  Thrombotic microangiopathy.
452.............................  Portal vein thrombosis.
4530............................  Budd-chiari syndrome.
4532............................  Embolism and thrombosis of vena cava.
4560............................  Esophageal varices with bleeding.
45620...........................  Esophageal varices in diseases
                                   classified elsewhere, with bleeding.
46401...........................  Acute laryngitis with obstruction.
46411...........................  Acute tracheitis with obstruction.
46421...........................  Acute laryngotracheitis with
                                   obstruction.
46431...........................  Acute epiglottitis with obstruction.
46451...........................  Supraglottitis unspecified with
                                   obstruction.
4800............................  Pneumonia due to adenovirus.
4801............................  Pneumonia due to respiratory syncytial
                                   virus.
4802............................  Pneumonia due to parainfluenza virus.
4803............................  Pneumonia due to sars-associated
                                   coronavirus.
4808............................  Pneumonia due to other virus not
                                   elsewhere classified.
4809............................  Viral pneumonia, unspecified.
481.............................  Pneumococcal pneumonia [streptococcus
                                   pneumoniae pneumonia].
4820............................  Pneumonia due to klebsiella
                                   pneumoniae.
4821............................  Pneumonia due to pseudomonas.
4822............................  Pneumonia due to hemophilus influenzae
                                   (h. influenzae).
48230...........................  Pneumonia due to streptococcus,
                                   unspecified.
48231...........................  Pneumonia due to streptococcus, group
                                   a.
48232...........................  Pneumonia due to streptococcus, group
                                   b.
48239...........................  Pneumonia due to other streptococcus.
48240...........................  Pneumonia due to staphylococcus,
                                   unspecified.
48241...........................  Pneumonia due to staphylococcus
                                   aureus.
48249...........................  Other staphylococcus pneumonia.
48281...........................  Pneumonia due to anaerobes.

[[Page 24991]]

 
48282...........................  Pneumonia due to escherichia coli
                                   [e.coli].
48283...........................  Pneumonia due to other gram-negative
                                   bacteria.
48284...........................  Pneumonia due to legionnaires'
                                   disease.
48289...........................  Pneumonia due to other specified
                                   bacteria.
4829............................  Bacterial pneumonia, unspecified.
4830............................  Pneumonia due to mycoplasma
                                   pneumoniae.
4831............................  Pneumonia due to chlamydia.
4838............................  Pneumonia due to other specified
                                   organism.
4841............................  Pneumonia in cytomegalic inclusion
                                   disease.
4843............................  Pneumonia in whooping cough.
4845............................  Pneumonia in anthrax.
4846............................  Pneumonia in aspergillosis.
4847............................  Pneumonia in other systemic mycoses.
4848............................  Pneumonia in other infectious diseases
                                   classified elsewhere.
485.............................  Bronchopneumonia, organism
                                   unspecified.
486.............................  Pneumonia, organism unspecified.
4870............................  Influenza with pneumonia.
5061............................  Acute pulmonary edema due to fumes and
                                   vapors.
5070............................  Pneumonitis due to inhalation of food
                                   or vomitus.
5071............................  Pneumonitis due to inhalation of oils
                                   and essences.
5078............................  Pneumonitis due to other solids and
                                   liquids.
5100............................  Empyema with fistula.
5109............................  Empyema without mention of fistula.
5111............................  Pleurisy with effusion, with mention
                                   of a bacterial cause other than
                                   tuberculosis.
5118............................  Other specified forms of pleural
                                   effusion, except tuberculous.
5120............................  Spontaneous tension pneumothorax.
5130............................  Abscess of lung.
5131............................  Abscess of mediastinum.
5184............................  Acute edema of lung, unspecified.
5185............................  Pulmonary insufficiency following
                                   trauma and surgery.
51881...........................  Acute respiratory failure.
51884...........................  Acute and chronic respiratory failure.
5192............................  Mediastinitis.
53021...........................  Ulcer of esophagus with bleeding.
5304............................  Perforation of esophagus.
5307............................  Gastroesophageal laceration-hemorrhage
                                   syndrome.
53082...........................  Esophageal hemorrhage.
53084...........................  Tracheoesophageal fistula.
53100...........................  Acute gastric ulcer with hemorrhage,
                                   without mention of obstruction.
53101...........................  Acute gastric ulcer with hemorrhage,
                                   with obstruction.
53110...........................  Acute gastric ulcer with perforation,
                                   without mention of obstruction.
53111...........................  Acute gastric ulcer with perforation,
                                   with obstruction.
53120...........................  Acute gastric ulcer with hemorrhage
                                   and perforation, without mention of
                                   obstruction.
53121...........................  Acute gastric ulcer with hemorrhage
                                   and perforation, with obstruction.
53131...........................  Acute gastric ulcer without mention of
                                   hemorrhage or perforation, with
                                   obstruction.
53140...........................  Chronic or unspecified gastric ulcer
                                   with hemorrhage, without mention of
                                   obstruction.
53141...........................  Chronic or unspecified gastric ulcer
                                   with hemorrhage, with obstruction.
53150...........................  Chronic or unspecified gastric ulcer
                                   with perforation, without mention of
                                   obstruction.
53151...........................  Chronic or unspecified gastric ulcer
                                   with perforation, with obstruction.
53160...........................  Chronic or unspecified gastric ulcer
                                   with hemorrhage and perforation,
                                   without mention of obstruction.
53161...........................  Chronic or unspecified gastric ulcer
                                   with hemorrhage and perforation, with
                                   obstruction.
53171...........................  Chronic gastric ulcer without mention
                                   of hemorrhage or perforation, with
                                   obstruction.
53191...........................  Gastric ulcer, unspecified as acute or
                                   chronic, without mention of
                                   hemorrhage or perforation, with
                                   obstruction.
53200...........................  Acute duodenal ulcer with hemorrhage,
                                   without mention of obstruction.
53201...........................  Acute duodenal ulcer with hemorrhage,
                                   with obstruction.
53210...........................  Acute duodenal ulcer with perforation,
                                   without mention of obstruction.
53211...........................  Acute duodenal ulcer with perforation,
                                   with obstruction.
53220...........................  Acute duodenal ulcer with hemorrhage
                                   and perforation, without mention of
                                   obstruction.
53221...........................  Acute duodenal ulcer with hemorrhage
                                   and perforation, with obstruction.
53231...........................  Acute duodenal ulcer without mention
                                   of hemorrhage or perforation, with
                                   obstruction.
53240...........................  Chronic or unspecified duodenal ulcer
                                   with hemorrhage, without mention of
                                   obstruction.
53241...........................  Chronic or unspecified duodenal ulcer
                                   with hemorrhage, with obstruction.
53250...........................  Chronic or unspecified duodenal ulcer
                                   with perforation, without mention of
                                   obstruction.
53251...........................  Chronic or unspecified duodenal ulcer
                                   with perforation, with obstruction.
53260...........................  Chronic or unspecified duodenal ulcer
                                   with hemorrhage and perforation,
                                   without mention of obstruction.
53261...........................  Chronic or unspecified duodenal ulcer
                                   with hemorrhage and perforation, with
                                   obstruction.
53271...........................  Chronic duodenal ulcer without mention
                                   of hemorrhage or perforation, with
                                   obstruction.
53291...........................  Duodenal ulcer, unspecified as acute
                                   or chronic, without mention of
                                   hemorrhage or perforation, with
                                   obstruction.
53300...........................  Acute peptic ulcer of unspecified site
                                   with hemorrhage, without mention of
                                   obstruction.
53301...........................  Acute peptic ulcer of unspecified site
                                   with hemorrhage, with obstruction.
53310...........................  Acute peptic ulcer of unspecified site
                                   with perforation, without mention of
                                   obstruction.

[[Page 24992]]

 
53311...........................  Acute peptic ulcer of unspecified site
                                   with perforation, with obstruction.
53320...........................  Acute peptic ulcer of unspecified site
                                   with hemorrhage and perforation,
                                   without mention of obstruction.
53321...........................  Acute peptic ulcer of unspecified site
                                   with hemorrhage and perforation, with
                                   obstruction.
53331...........................  Acute peptic ulcer of unspecified site
                                   without mention of hemorrhage and
                                   perforation, with obstruction.
53340...........................  Chronic or unspecified peptic ulcer of
                                   unspecified site with hemorrhage,
                                   without mention of obstruction.
53341...........................  Chronic or unspecified peptic ulcer of
                                   unspecified site with hemorrhage,
                                   with obstruction.
53350...........................  Chronic or unspecified peptic ulcer of
                                   unspecified site with perforation,
                                   without mention of obstruction.
53351...........................  Chronic or unspecified peptic ulcer of
                                   unspecified site with perforation,
                                   with obstruction.
53360...........................  Chronic or unspecified peptic ulcer of
                                   unspecified site with hemorrhage and
                                   perforation, without mention of
                                   obstruction.
53361...........................  Chronic or unspecified peptic ulcer of
                                   unspecified site with hemorrhage and
                                   perforation, with obstruction.
53371...........................  Chronic peptic ulcer of unspecified
                                   site without mention of hemorrhage or
                                   perforation, with obstruction.
53391...........................  Peptic ulcer of unspecified site,
                                   unspecified as acute or chronic,
                                   without mention of hemorrhage or
                                   perforation, with obstruction.
53400...........................  Acute gastrojejunal ulcer with
                                   hemorrhage, without mention of
                                   obstruction.
53401...........................  Acute gastrojejunal ulcer, with
                                   hemorrhage, with obstruction.
53410...........................  Acute gastrojejunal ulcer with
                                   perforation, without mention of
                                   obstruction.
53411...........................  Acute gastrojejunal ulcer with
                                   perforation, with obstruction.
53420...........................  Acute gastrojejunal ulcer with
                                   hemorrhage and perforation, without
                                   mention of obstruction.
53421...........................  Acute gastrojejunal ulcer with
                                   hemorrhage and perforation, with
                                   obstruction.
53431...........................  Acute gastrojejunal ulcer without
                                   mention of hemorrhage or perforation,
                                   with obstruction.
53440...........................  Chronic or unspecified gastrojejunal
                                   ulcer with hemorrhage, without
                                   mention of obstruction.
53441...........................  Chronic or unspecified gastrojejunal
                                   ulcer, with hemorrhage, with
                                   obstruction.
53450...........................  Chronic or unspecified gastrojejunal
                                   ulcer with perforation, without
                                   mention of obstruction.
53451...........................  Chronic or unspecified gastrojejunal
                                   ulcer with perforation, with
                                   obstruction.
53460...........................  Chronic or unspecified gastrojejunal
                                   ulcer with hemorrhage and
                                   perforation, without mention of
                                   obstruction.
53461...........................  Chronic or unspecified gastrojejunal
                                   ulcer with hemorrhage and
                                   perforation, with obstruction.
53471...........................  Chronic gastrojejunal ulcer without
                                   mention of hemorrhage or perforation,
                                   with obstruction.
53491...........................  Gastrojejunal ulcer, unspecified as
                                   acute or chronic, without mention of
                                   hemorrhage or perforation, with
                                   obstruction.
53501...........................  Acute gastritis with hemorrhage.
53511...........................  Atrophic gastritis with hemorrhage.
53521...........................  Gastric mucosal hypertrophy with
                                   hemorrhage.
53531...........................  Alcoholic gastritis with hemorrhage.
53541...........................  Other specified gastritis with
                                   hemorrhage.
53551...........................  Unspecified gastritis and
                                   gastroduodenitis with hemorrhage.
53561...........................  Duodenitis with hemorrhage.
53783...........................  Angiodysplasia of stomach and duodenum
                                   with hemorrhage.
53784...........................  Dielulafoy lesion (hemorrhagic) of
                                   stomach and duodenum.
5400............................  Acute appendicitis with generalized
                                   peritonitis.
5401............................  Acute appendicitis with peritoneal
                                   abscess.
55000...........................  Unilateral or unspecified inguinal
                                   hernia, with gangrene.
55001...........................  Recurrent unilateral or unspecified
                                   inguinal hernia, with gangrene.
55002...........................  Bilateral inguinal hernia, with
                                   gangrene.
55003...........................  Recurrent bilateral inguinal hernia,
                                   with gangrene.
55100...........................  Unilateral or unspecified femoral
                                   hernia with gangrene.
55101...........................  Recurrent unilateral or unspecified
                                   femoral hernia with gangrene.
55102...........................  Bilateral femoral hernia with
                                   gangrene.
55103...........................  Recurrent bilateral femoral hernia
                                   with gangrene.
5511............................  Umbilical hernia with gangrene.
55120...........................  Unspecified ventral hernia with
                                   gangrene.
55121...........................  Incisional ventral hernia, with
                                   gangrene.
55129...........................  Other ventral hernia with gangrene.
5513............................  Diaphragmatic hernia with gangrene.
5518............................  Hernia of other specified sites, with
                                   gangrene.
5519............................  Hernia of unspecified site, with
                                   gangrene.
5570............................  Acute vascular insufficiency of
                                   intestine.
5602............................  Volvulus.
56202...........................  Diverticulosis of small intestine with
                                   hemorrhage.
56203...........................  Diverticulitis of small intestine with
                                   hemorrhage.
56212...........................  Diverticulosis of colon with
                                   hemorrhage.
56213...........................  Diverticulitis of colon with
                                   hemorrhage.
5670............................  Peritonitis in infectious diseases
                                   classified elsewhere.
5671............................  Pneumococcal peritonitis.
56721...........................  Peritonitis (acute) generalized.
56722...........................  Peritoneal abscess.
56723...........................  Spontaneous bacterial peritonitis.
56729...........................  Other suppurative peritonitis.
56731...........................  Psoas muscle abscess.
56738...........................  Other retroperitoneal abscess.
56739...........................  Other retroperitoneal infections.
56781...........................  Choleperitonitis.

[[Page 24993]]

 
56789...........................  Other specified peritonitis.
5679............................  Unspecified peritonitis.
56881...........................  Hemoperitoneum (nontraumatic).
56983...........................  Perforation of intestine.
56985...........................  Angiodysplasia of intestine with
                                   hemorrhage.
56986...........................  Dieulafoy lesion (hemorrhagic) of
                                   intestine.
570.............................  Acute and subacute necrosis of liver.
5720............................  Abscess of liver.
5721............................  Portal pyemia.
5722............................  Hepatic coma.
5724............................  Hepatorenal syndrome.
5734............................  Hepatic infarction.
57481...........................  Calculus of gallbladder and bile duct
                                   with acute and chronic cholecystitis,
                                   with obstruction.
5754............................  Perforation of gallbladder.
5762............................  Obstruction of bile duct.
5763............................  Perforation of bile duct.
5770............................  Acute pancreatitis.
5800............................  Acute glomerulonephritis with lesion
                                   of proliferative glomerulonephritis.
5804............................  Acute glomerulonephritis with lesion
                                   of rapidly progressive
                                   glomerulonephritis.
58081...........................  Acute glomerulonephritis in diseases
                                   classified elsewhere.
58089...........................  Acute glomerulonephritis with other
                                   specified pathological lesion in
                                   kidney.
5809............................  Acute glomerulonephritis with
                                   unspecified pathological lesion in
                                   kidney.
5834............................  Nephritis and nephropathy, not
                                   specified as acute or chronic, with
                                   lesion of rapidly progressive
                                   glomerulonephritis.
5836............................  Nephritis and nephropathy, not
                                   specified as acute or chronic, with
                                   lesion of renal cortical necrosis.
5845............................  Acute renal failure with lesion of
                                   tubular necrosis.
5846............................  Acute renal failure with lesion of
                                   renal cortical necrosis.
5847............................  Acute renal failure with lesion of
                                   renal medullary (papillary) necrosis.
5848............................  Acute renal failure with other
                                   specified pathological lesion in
                                   kidney.
5849............................  Acute renal failure, unspecified.
5856............................  End stage renal disease.
59011...........................  Acute pyelonephritis with lesion of
                                   renal medullary necrosis.
5902............................  Renal and perinephric abscess.
5966............................  Rupture of bladder, nontraumatic.
6145............................  Acute or unspecified pelvic
                                   peritonitis, female.
63430...........................  Spontaneous abortion, unspecified,
                                   complicated by renal failure.
63431...........................  Spontaneous abortion, incomplete,
                                   complicated by renal failure.
63432...........................  Spontaneous abortion, complete,
                                   complicated by renal failure.
63450...........................  Spontaneous abortion, unspecified,
                                   complicated by shock.
63451...........................  Spontaneous abortion, incomplete,
                                   complicated by shock.
63452...........................  Spontaneous abortion, complete,
                                   complicated by shock.
63461...........................  Spontaneous abortion, incomplete,
                                   complicated by embolism.
63462...........................  Spontaneous abortion, complete,
                                   complicated by embolism.
63530...........................  Legally induced abortion, unspecified,
                                   complicated by renal failure.
63531...........................  Legally induced abortion, incomplete,
                                   complicated by renal failure.
63532...........................  Legally induced abortion, complete,
                                   complicated by renal failure.
63550...........................  Legally induced abortion, unspecified,
                                   complicated by shock.
63551...........................  Legally induced abortion, incomplete,
                                   complicated by shock.
63552...........................  Legally induced abortion, complete,
                                   complicated by shock.
63560...........................  Legally induced abortion, unspecified,
                                   complicated by embolism.
63561...........................  Legally induced abortion, incomplete,
                                   complicated by embolism.
63562...........................  Legally induced abortion, complete,
                                   complicated by embolism.
63630...........................  Illegal abortion, unspecified,
                                   complicated by renal failure.
63631...........................  Illegal abortion, incomplete,
                                   complicated by renal failure.
63632...........................  Illegal abortion, complete,
                                   complicated by renal failure.
63650...........................  Illegal abortion, unspecified,
                                   complicated by shock.
63651...........................  Illegal abortion, incomplete,
                                   complicated by shock.
63652...........................  Illegal abortion, complete,
                                   complicated by shock.
63660...........................  Illegal abortion, unspecified,
                                   complicated by embolism.
63661...........................  Illegal abortion, incomplete,
                                   complicated by embolism.
63662...........................  Illegal abortion, complete,
                                   complicated by embolism.
63730...........................  Legally unspecified type of abortion,
                                   unspecified, complicated by renal
                                   failure.
63731...........................  Legally unspecified abortion,
                                   incomplete, complicated by renal
                                   failure.
63732...........................  Legally unspecified abortion,
                                   complete, complicated by renal
                                   failure.
63750...........................  Legally unspecified type of abortion,
                                   unspecified, complicated by shock.
63751...........................  Legally unspecified abortion,
                                   incomplete, complicated by shock.
63752...........................  Legally unspecified abortion,
                                   complete, complicated by shock.
63760...........................  Legally unspecified type of abortion,
                                   unspecified, complicated by embolism.
63761...........................  Legally unspecified abortion,
                                   incomplete, complicated by embolism.
63762...........................  Legally unspecified abortion,
                                   complete, complicated by embolism.
6383............................  Failed attempted abortion complicated
                                   by renal failure.
6385............................  Failed attempted abortion complicated
                                   by shock.

[[Page 24994]]

 
6386............................  Failed attempted abortion complicated
                                   by embolism.
6393............................  Renal failure following abortion or
                                   ectopic and molar pregnancies.
6395............................  Shock following abortion or ectopic
                                   and molar pregnancies.
6396............................  Embolism following abortion or ectopic
                                   and molar pregnancies.
64111...........................  Hemorrhage from placenta previa, with
                                   delivery.
64113...........................  Hemorrhage from placenta previa,
                                   antepartum.
64121...........................  Premature separation of placenta, with
                                   delivery.
64131...........................  Antepartum hemorrhage associated with
                                   coagulation defects, with delivery.
64133...........................  Antepartum hemorrhage associated with
                                   coagulation defects.
64211...........................  Hypertension secondary to renal
                                   disease, with delivery.
64212...........................  Hypertension secondary to renal
                                   disease, with delivery, with mention
                                   of postpartum complication.
64242...........................  Mild or unspecified pre-eclampsia,
                                   with delivery, with mention of
                                   postpartum complication.
64251...........................  Severe pre-eclampsia, with delivery.
64252...........................  Severe pre-eclampsia, with delivery,
                                   with mention of postpartum
                                   complication.
64253...........................  Severe pre-eclampsia, antepartum.
64254...........................  Severe pre-eclampsia, postpartum.
64261...........................  Eclampsia, with delivery.
64262...........................  Eclampsia, with delivery, with mention
                                   of postpartum complication.
64263...........................  Eclampsia, antepartum.
64264...........................  Eclampsia, postpartum.
64271...........................  Pre-eclampsia or eclampsia
                                   superimposed on pre-existing
                                   hypertension, with delivery.
64272...........................  Pre-eclampsia or eclampsia
                                   superimposed on pre-existing
                                   hypertension, with delivery, with
                                   mention of postpartum complication.
64273...........................  Pre-eclampsia or eclampsia
                                   superimposed on pre-existing
                                   hypertension, antepartum.
64274...........................  Pre-eclampsia or eclampsia
                                   superimposed on pre-existing
                                   hypertension, postpartum.
64403...........................  Threatened premature labor,
                                   antepartum.
64421...........................  Early onset of delivery, delivered,
                                   with or without mention of antepartum
                                   condition.
64801...........................  Diabetes mellitus of mother, with
                                   delivery.
64802...........................  Diabetes mellitus of mother, with
                                   delivery, with mention of postpartum
                                   complication.
65451...........................  Cervical incompetence, with delivery.
65452...........................  Cervical incompetence, delivered, with
                                   mention of postpartum complication.
65453...........................  Cervical incompetence, antepartum
                                   condition or complication.
65454...........................  Cervical incompetence, postpartum
                                   condition or complication.
65841...........................  Infection of amniotic cavity,
                                   delivered.
65843...........................  Infection of amniotic cavity,
                                   antepartum.
65931...........................  Generalized infection during labor,
                                   delivered.
65933...........................  Generalized infection during labor,
                                   antepartum.
66501...........................  Rupture of uterus before onset of
                                   labor, with delivery.
66503...........................  Rupture of uterus before onset of
                                   labor, antepartum.
66511...........................  Rupture of uterus, with delivery.
66911...........................  Obstetric shock, with delivery, with
                                   or without mention of antepartum
                                   condition.
66912...........................  Obstetric shock, with delivery, with
                                   mention of postpartum complication.
66913...........................  Antepartum obstetric shock.
66914...........................  Postpartum obstetric shock.
66921...........................  Maternal hypotension syndrome, with
                                   delivery, with or without mention of
                                   antepartum condition.
66922...........................  Maternal hypotension syndrome, with
                                   delivery, with mention of postpartum
                                   complication.
66932...........................  Acute renal failure with delivery,
                                   with mention of postpartum
                                   complication.
66934...........................  Acute renal failure following labor
                                   and delivery, postpartum condition or
                                   complication.
67002...........................  Major puerperal infection, delivered,
                                   with mention of postpartum
                                   complication.
67004...........................  Major puerperal infection, postpartum.
67131...........................  Deep phlebothrombosis, antepartum,
                                   with delivery.
67133...........................  Deep phlebothrombosis, antepartum.
67142...........................  Deep phlebothrombosis, postpartum,
                                   with delivery.
67144...........................  Deep phlebothrombosis, postpartum.
67301...........................  Obstetrical air embolism, with
                                   delivery, with or without mention of
                                   antepartum condition.
67302...........................  Obstetrical air embolism, with
                                   delivery, with mention of postpartum
                                   complication.
67303...........................  Obstetrical air embolism, antepartum
                                   condition or complication.
67304...........................  Obstetrical air embolism, postpartum
                                   condition or complication.
67311...........................  Amniotic fluid embolism, with
                                   delivery, with or without mention of
                                   antepartum condition.
67312...........................  Amniotic fluid embolism, with
                                   delivery, with mention of postpartum
                                   complication.
67313...........................  Amniotic fluid embolism, antepartum
                                   condition or complication.
67314...........................  Amniotic fluid embolism, postpartum
                                   condition or complication.
67321...........................  Obstetrical blood-clot embolism, with
                                   delivery, with or without mention of
                                   antepartum condition.
67322...........................  Obstetrical blood-clot embolism, with
                                   mention of postpartum complication.
67323...........................  Obstetrical blood-clot embolism,
                                   antepartum.
67324...........................  Obstetrical blood-clot embolism,
                                   postpartum.
67331...........................  Obstetrical pyemic and septic
                                   embolism, with delivery, with or
                                   without mention of antepartum
                                   condition.
67332...........................  Obstetrical pyemic and septic
                                   embolism, with delivery, with mention
                                   of postpartum complicaton.
67333...........................  Obstetrical pyemic and septic
                                   embolism, antepartum.
67334...........................  Obstetrical pyemic and septic
                                   embolism, postpartum.
67381...........................  Other obstetrical pulmonary embolism,
                                   with delivery, with or without
                                   mention of antepartum condition.
67382...........................  Other obstetrical pulmonary embolism,
                                   with delivery, with mention of
                                   postpartum complication.

[[Page 24995]]

 
67383...........................  Other obstetrical pulmonary embolism,
                                   antepartum.
67384...........................  Other obstetrical pulmonary embolism,
                                   postpartum.
67401...........................  Cerebrovascular disorders, with
                                   delivery, with or without mention of
                                   antepartum condition.
67450...........................  Peripartum cardiomyopathy, unspecified
                                   as to episode of care or not
                                   applicable.
67451...........................  Peripartum cardiomyopathy, delivered,
                                   with or without mention of antepartum
                                   condition.
67452...........................  Peripartum cardiomyopathy, delivered,
                                   with mention of postpartum condition.
67453...........................  Peripartum cardiomyopathy, antepartum
                                   condition or complication.
67454...........................  Peripartum cardiomyopathy, postpartum
                                   condition or complication.
70702...........................  Decubitus ulcer, upper back.
70703...........................  Decubitus ulcer, lower back.
70704...........................  Decubitus ulcer, hip.
70705...........................  Decubitus ulcer, buttock.
70706...........................  Decubitus ulcer, ankle.
70707...........................  Decubitus ulcer, heel.
72886...........................  Necrotizing fasciitis.
7400............................  Anencephalus.
7401............................  Craniorachischisis.
7402............................  Iniencephaly.
7422............................  Congenital reduction deformities of
                                   brain.
7450............................  Common truncus.
74510...........................  Complete transposition of great
                                   vessels.
74511...........................  Double outlet right ventricle.
74519...........................  Other transposition of great vessels.
7452............................  Tetralogy of fallot.
7453............................  Common ventricle.
7457............................  Cor biloculare.
74601...........................  Atresia of pulmonary valve,
                                   congenital.
7461............................  Tricuspid atresia and stenosis,
                                   congenital.
7462............................  Ebstein's anomaly.
7467............................  Hypoplastic left heart syndrome.
74681...........................  Subaortic stenosis, congenital.
74682...........................  Cor triatriatum.
74684...........................  Congenital obstructive anomalies of
                                   heart, not elsewhere classified.
74686...........................  Congenital heart block.
74711...........................  Interruption of aortic arch.
7473............................  Congenital anomalies of pulmonary
                                   artery.
74781...........................  Congenital anomalies of
                                   cerebrovascular system.
74783...........................  Persistent fetal circulation.
7485............................  Congenital agenesis, hypoplasia, and
                                   dysplasia of lung.
7503............................  Congenital tracheoesophageal fistula,
                                   esophageal atresia and stenosis.
75161...........................  Biliary atresia, congenital.
75555...........................  Acrocephalosyndactyly.
7566............................  Congenital anomalies of diaphragm.
75670...........................  Anomaly of abdominal wall,
                                   unspecified.
75671...........................  Prune belly syndrome.
75679...........................  Other congenital anomalies of
                                   abdominal wall.
75832...........................  Velo-cardio-facial syndrome.
7594............................  Conjoined twins.
7670............................  Subdural and cerebral hemorrhage due
                                   to birth trauma.
7685............................  Severe birth asphyxia.
7687............................  Hypoxic-ischemic encephalopathy (HIE).
769.............................  Respiratory distress syndrome in
                                   newborn.
7700............................  Congenital pneumonia.
77012...........................  Meconium aspiration with respiratory
                                   symptoms.
77014...........................  Aspiration of clear amniotic fluid
                                   with respiratory symptoms.
77016...........................  Aspiration of blood with respiratory
                                   symptoms.
77018...........................  Other fetal and newborn aspiration
                                   with respiratory symptoms.
7702............................  Interstitial emphysema and related
                                   conditions of newborn.
7703............................  Pulmonary hemorrhage of fetus or
                                   newborn.
7707............................  Chronic respiratory disease arising in
                                   the perinatal period.
77084...........................  Respiratory failure of newborn.
77086...........................  Aspiration of postnatal stomach
                                   contents with respiratory symptoms.
77087...........................  Respiratory arrest of newborn.
7711............................  Congenital cytomegalovirus infection.
7712............................  Other congenital infections specific
                                   to the perinatal period.
7713............................  Tetanus neonatorum.
77181...........................  Septicemia [sepsis] of newborn.
77213...........................  Intraventricular hemorrhage grade iii.
77214...........................  Intraventricular hemorrhage grade iv.
7722............................  Subarachnoid hemorrhage of newborn.
7724............................  Gastrointestinal hemorrhage of fetus
                                   or newborn.
7733............................  Hydrops fetalis due to
                                   isoimmunization.

[[Page 24996]]

 
7734............................  Kernicterus of fetus or newborn due to
                                   isoimmunization.
7744............................  Perinatal jaundice due to
                                   hepatocellular damage.
7747............................  Kernicterus of fetus or newborn not
                                   due to isoimmunization.
7757............................  Late metabolic acidosis of newborn.
7761............................  Transient neonatal thrombocytopenia.
7762............................  Disseminated intravascular coagulation
                                   in newborn.
7767............................  Transient neonatal neutropenia.
7775............................  Necrotizing enterocolitis in fetus or
                                   newborn.
7776............................  Perinatal intestinal perforation.
7780............................  Hydrops fetalis not due to
                                   isoimmunization.
7790............................  Convulsions in newborn.
7792............................  Cerebral depression, coma, and other
                                   abnormal cerebral signs in fetus or
                                   newborn.
7797............................  Preventricular leukomalacia.
77985...........................  Cardiac arrest of newborn.
78551...........................  Cardiogenic shock.
78552...........................  Septic shock.
78559...........................  Other shock without mention of trauma.
7991............................  Respiratory arrest.
80003...........................  Closed fracture of vault of skull
                                   without mention of intracranial
                                   injury, with moderate (1-24 hours)
                                   loss of consciousness.
80004...........................  Closed fracture of vault of skull
                                   without mention of intracranial
                                   injury, with prolonged (more than 24
                                   hours) loss of consciousness and
                                   return to pre-existing conscious
                                   level.
80005...........................  Closed fracture of vault of skull
                                   without mention of intracranial
                                   injury, with prolonged (more than 24
                                   hours) loss of consciousness, without
                                   return to pre-existing conscious
                                   level.
80010...........................  Closed fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with state of consciousness
                                   unspecified.
80011...........................  Closed fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with no loss of consciousness.
80012...........................  Closed fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with brief (less than one hour) loss
                                   of consciousness.
80013...........................  Closed fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with moderate (1-24 hours) loss of
                                   consciousness.
80014...........................  Closed fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness and return to
                                   pre-existing conscious level.
80015...........................  Closed fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness, without return
                                   to pre-existing conscious level.
80016...........................  Closed fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with loss of consciousness of
                                   unspecified duration.
80019...........................  Closed fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with concussion, unspecified.
80020...........................  Closed fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with state of
                                   consciousness unspecified.
80021...........................  Closed fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with no loss
                                   of consciousness.
80022...........................  Closed fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with brief
                                   (less than one hour) loss of
                                   consciousness.
80023...........................  Closed fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with moderate
                                   (1-24 hours) loss of consciousness.
80024...........................  Closed fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
80025...........................  Closed fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
80026...........................  Closed fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with loss of
                                   consciousness of unspecified
                                   duration.
80029...........................  Closed fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with
                                   concussion, unspecified.
80030...........................  Closed fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with state of
                                   consciousness unspecified.
80031...........................  Closed fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with no loss of
                                   consciousness.
80032...........................  Closed fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with brief (less than one
                                   hour) loss of consciousness.
80033...........................  Closed fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with moderate (1-24
                                   hours) loss of consciousness.
80034...........................  Closed fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with prolonged (more than
                                   24 hours) loss of consciousness and
                                   return to pre-existing conscious
                                   level.
80035...........................  Closed fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with prolonged (more than
                                   24 hours) loss of consciousness,
                                   without return to pre-existing
                                   conscious level.
80036...........................  Closed fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with loss of
                                   consciousness of unspecified
                                   duration.
80039...........................  Closed fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with concussion,
                                   unspecified.
80043...........................  Closed fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with moderate (1-
                                   24 hours) loss of consciousness.

[[Page 24997]]

 
80044...........................  Closed fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
80045...........................  Closed fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
80050...........................  Open fracture of vault of skull
                                   without mention of intracranial
                                   injury, with state of consciousness
                                   unspecified.
80051...........................  Open fracture of vault of skull
                                   without mention of intracranial
                                   injury, with no loss of
                                   consciousness.
80052...........................  Open fracture of vault of skull
                                   without mention of intracranial
                                   injury, with brief (less than one
                                   hour) loss of consciousness.
80053...........................  Open fracture of vault of skull
                                   without mention of intracranial
                                   injury, with moderate (1-24 hours)
                                   loss of consciousness.
80054...........................  Open fracture of vault of skull
                                   without mention of intracranial
                                   injury, with prolonged (more than 24
                                   hours) loss of consciousness and
                                   return to pre-existing conscious
                                   level.
80055...........................  Open fracture of vault of skull
                                   without mention of intracranial
                                   injury, with prolonged (more than 24
                                   hours) loss of consciousness, without
                                   return to pre-existing conscious
                                   level.
80056...........................  Open fracture of vault of skull
                                   without mention of intracranial
                                   injury, with loss of consciousness of
                                   unspecified duration.
80059...........................  Open fracture of vault of skull
                                   without mention of intracranial
                                   injury, with concussion, unspecified.
80060...........................  Open fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with state of consciousness
                                   unspecified.
80061...........................  Open fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with no loss of consciousness.
80062...........................  Open fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with brief (less than one hour) loss
                                   of consciousness.
80063...........................  Open fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with moderate (1-24 hours) loss of
                                   consciousness.
80064...........................  Open fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness and return to
                                   pre-existing conscious level.
80065...........................  Open fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness, without return
                                   to pre-existing conscious level.
80066...........................  Open fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with loss of consciousness of
                                   unspecified duration.
80069...........................  Open fracture of vault of skull with
                                   cerebral laceration and contusion,
                                   with concussion, unspecified.
80070...........................  Open fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with state of
                                   consciousness unspecified.
80071...........................  Open fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with no loss
                                   of consciousness.
80072...........................  Open fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with brief
                                   (less than one hour) loss of
                                   consciousness.
80073...........................  Open fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with moderate
                                   (1-24 hours) loss of consciousness.
80074...........................  Open fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
80075...........................  Open fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
80076...........................  Open fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with loss of
                                   consciousness of unspecified
                                   duration.
80079...........................  Open fracture of vault of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with
                                   concussion, unspecified.
80080...........................  Open fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with state of
                                   consciousness unspecified.
80081...........................  Open fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with no loss of
                                   consciousness.
80082...........................  Open fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with brief (less than one
                                   hour) loss of consciousness.
80083...........................  Open fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with moderate (1-24
                                   hours) loss of consciousness.
80084...........................  Open fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with prolonged (more than
                                   24 hours)loss of consciousness and
                                   return to pre-existing conscious
                                   level.
80085...........................  Open fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with prolonged (more than
                                   24 hours)loss of consciousness,
                                   without return to pre-existing
                                   conscious level.
80086...........................  Open fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with loss of
                                   consciousness of unspecified
                                   duration.
80089...........................  Open fracture of vault of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with concussion,
                                   unspecified.
80090...........................  Open fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with state of
                                   consciousness unspecified.
80091...........................  Open fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with no loss of
                                   consciousness.
80092...........................  Open fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with brief (less
                                   than one hour) loss of consciousness.
80093...........................  Open fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with moderate (1-
                                   24 hours) loss of consciousness.
80094...........................  Open fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.

[[Page 24998]]

 
80095...........................  Open fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
80096...........................  Open fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with loss of
                                   consciousness of unspecified
                                   duration.
80099...........................  Open fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with concussion,
                                   unspecified.
80103...........................  Closed fracture of base of skull
                                   without mention of intra cranial
                                   injury, with moderate (1-24 hours)
                                   loss of consciousness.
80104...........................  Closed fracture of base of skull
                                   without mention of intra cranial
                                   injury, with prolonged (more than 24
                                   hours) loss of consciousness and
                                   return to pre-existing conscious
                                   level.
80105...........................  Closed fracture of base of skull
                                   without mention of intra cranial
                                   injury, with prolonged (more than 24
                                   hours) loss of consciousness, without
                                   return to pre-existing conscious
                                   level.
80110...........................  Closed fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with state of consciousness
                                   unspecified.
80111...........................  Closed fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with no loss of consciousness.
80112...........................  Closed fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with brief (less than one hour) loss
                                   of consciousness.
80113...........................  Closed fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with moderate (1-24 hours) loss of
                                   consciousness.
80114...........................  Closed fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness and return to
                                   pre-existing conscious level.
80115...........................  Closed fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness, without return
                                   to pre-existing conscious level.
80116...........................  Closed fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with loss of consciousness of
                                   unspecified duration.
80119...........................  Closed fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with concussion, unspecified.
80120...........................  Closed fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with state of
                                   consciousness unspecified.
80121...........................  Closed fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with no loss
                                   of consciousness.
80122...........................  Closed fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with brief
                                   (less than one hour) loss of
                                   consciousness.
80123...........................  Closed fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with moderate
                                   (1-24 hours) loss of consciousness.
80124...........................  Closed fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
80125...........................  Closed fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
80126...........................  Closed fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with loss of
                                   consciousness of unspecified
                                   duration.
80129...........................  Closed fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with
                                   concussion, unspecified.
80130...........................  Closed fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with state of
                                   consciousness unspecified.
80131...........................  Closed fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with no loss of
                                   consciousness.
80132...........................  Closed fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with brief (less than one
                                   hour) loss of consciousness.
80133...........................  Closed fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with moderate (1-24
                                   hours) loss of consciousness.
80134...........................  Closed fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with prolonged (more than
                                   24 hours) loss of consciousness and
                                   return to pre-existing conscious
                                   level.
80135...........................  Closed fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with prolonged (more than
                                   24 hours) loss of consciousness,
                                   without return to pre-existing
                                   conscious level.
80136...........................  Closed fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with loss of
                                   consciousness of unspecified
                                   duration.
80139...........................  Closed fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with concussion,
                                   unspecified.
80143...........................  Closed fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with moderate (1-
                                   24 hours) loss of consciousness.
80144...........................  Closed fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
80145...........................  Closed fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
80150...........................  Open fracture of base of skull without
                                   mention of intracranial injury, with
                                   state of consciousness unspecified.
80151...........................  Open fracture of base of skull without
                                   mention of intracranial injury, with
                                   no loss of consciousness.
80152...........................  Open fracture of base of skull without
                                   mention of intracranial injury, with
                                   brief (less than one hour) loss of
                                   consciousness.
80153...........................  Open fracture of base of skull without
                                   mention of intracranial injury, with
                                   moderate (1-24 hours) loss of
                                   consciousness.
80154...........................  Open fracture of base of skull without
                                   mention of intracranial injury, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness and return to pre-
                                   existing conscious level.

[[Page 24999]]

 
80155...........................  Open fracture of base of skull without
                                   mention of intracranial injury, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness, without return to
                                   pre-existing conscious level.
80156...........................  Open fracture of base of skull without
                                   mention of intracranial injury, with
                                   loss of consciousness of unspecified
                                   duration.
80159...........................  Open fracture of base of skull without
                                   mention of intracranial injury, with
                                   concussion, unspecified.
80160...........................  Open fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with state of consciousness
                                   unspecified.
80161...........................  Open fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with no loss of consciousness.
80162...........................  Open fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with brief (less than one hour) loss
                                   of consciousness.
80163...........................  Open fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with moderate (1-24 hours) loss of
                                   consciousness.
80164...........................  Open fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness and return to
                                   pre-existing conscious level.
80165...........................  Open fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness, without return
                                   to pre-existing conscious level.
80166...........................  Open fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with loss of consciousness of
                                   unspecified duration.
80169...........................  Open fracture of base of skull with
                                   cerebral laceration and contusion,
                                   with concussion, unspecified.
80170...........................  Open fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with state of
                                   consciousness unspecified.
80171...........................  Open fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with no loss
                                   of consciousness.
80172...........................  Open fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with brief
                                   (less than one hour) loss of
                                   consciousness.
80173...........................  Open fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with moderate
                                   (1-24 hours) loss of consciousness.
80174...........................  Open fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
80175...........................  Open fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
80176...........................  Open fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with loss of
                                   consciousness of unspecified
                                   duration.
80179...........................  Open fracture of base of skull with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with
                                   concussion, unspecified.
80180...........................  Open fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with state of
                                   consciousness unspecified.
80181...........................  Open fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with no loss of
                                   consciousness.
80182...........................  Open fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with brief (less than one
                                   hour) loss of consciousness.
80183...........................  Open fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with moderate (1-24
                                   hours) loss of consciousness.
80184...........................  Open fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with prolonged (more than
                                   24 hours) loss of consciousness and
                                   return to pre-existing conscious
                                   level.
80185...........................  Open fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with prolonged (more than
                                   24 hours) loss of consciousness,
                                   without return to pre-existing
                                   conscious level.
80186...........................  Open fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with loss of
                                   consciousness of unspecified
                                   duration.
80189...........................  Open fracture of base of skull with
                                   other and unspecified intracranial
                                   hemorrhage, with concussion,
                                   unspecified.
80190...........................  Open fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with state of
                                   consciousness unspecified.
80191...........................  Open fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with no loss of
                                   consciousness.
80192...........................  Open fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with brief (less
                                   than one hour) loss of consciousness.
80193...........................  Open fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with moderate (1-
                                   24 hours) loss of consciousness.
80194...........................  Open fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
80195...........................  Open fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
80196...........................  Open fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with loss of
                                   consciousness of unspecified
                                   duration.
80199...........................  Open fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with concussion,
                                   unspecified.
80303...........................  Other closed skull fracture without
                                   mention of intracranial injury, with
                                   moderate (1-24 hours) loss of
                                   consciousness.
80304...........................  Other closed skull fracture without
                                   mention of intracranial injury, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness and return to pre-
                                   existing conscious level.
80305...........................  Other closed skull fracture without
                                   mention of intracranial injury, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness, without return to
                                   pre-existing conscious level.

[[Page 25000]]

 
80310...........................  Other closed skull fracture with
                                   cerebral laceration and contusion,
                                   with state of consciousness
                                   unspecified.
80311...........................  Other closed skull fracture with
                                   cerebral laceration and contusion,
                                   with no loss of consciousness.
80312...........................  Other closed skull fracture with
                                   cerebral laceration and contusion,
                                   with brief (less than one hour) loss
                                   of consciousness.
80313...........................  Other closed skull fracture with
                                   cerebral laceration and contusion,
                                   with moderate (1-24 hours) loss of
                                   consciousness.
80314...........................  Other closed skull fracture with
                                   cerebral laceration and contusion,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness and return to
                                   pre-existing conscious level.
80315...........................  Other closed skull fracture with
                                   cerebral laceration and contusion,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness, without return
                                   to pre-existing conscious level.
80316...........................  Other closed skull fracture with
                                   cerebral laceration and contusion,
                                   with loss of consciousness of
                                   unspecified duration.
80319...........................  Other closed skull fracture with
                                   cerebral laceration and contusion,
                                   with concussion, unspecified.
80320...........................  Other closed skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with state of
                                   consciousness unspecified.
80321...........................  Other closed skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with no loss
                                   of consciousness.
80322...........................  Other closed skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with brief
                                   (less than one hour) loss of
                                   consciousness.
80323...........................  Other closed skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with moderate
                                   (1-24 hours) loss of consciousness.
80324...........................  Other closed skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
80325...........................  Other closed skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
80326...........................  Other closed skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with loss of
                                   consciousness of unspecified
                                   duration.
80329...........................  Other closed skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with
                                   concussion, unspecified.
80330...........................  Other closed skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with state of
                                   unconsciousness unspecified.
80331...........................  Other closed skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with no loss of
                                   consciousness.
80332...........................  Other closed skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with brief (less than one
                                   hour) loss of consciousness.
80333...........................  Other closed skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with moderate (1-24
                                   hours) loss of consciousness.
80334...........................  Other closed skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with prolonged (more than
                                   24 hours) loss of consciousness and
                                   return to pre-existing conscious
                                   level.
80335...........................  Other closed skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with prolonged (more than
                                   24 hours) loss of consciousness,
                                   without return to pre-existing
                                   conscious level.
80336...........................  Other closed skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with loss of
                                   consciousness of unspecified
                                   duration.
80339...........................  Other closed skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with concussion,
                                   unspecified.
80343...........................  Other closed skull fracture with
                                   intracranial injury of other and
                                   unspecified nature, with moderate (1-
                                   24 hours) loss of consciousness.
80344...........................  Other closed skull fracture with
                                   intracranial injury of other and
                                   unspecified nature, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
80345...........................  Other site of closed skull fracture
                                   with intracranial injury of other and
                                   unspecified nature, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
80350...........................  Other open skull fracture without
                                   mention of injury, with state of
                                   consciousness unspecified.
80351...........................  Other open skull fracture without
                                   mention of intracranial injury, with
                                   no loss of consciousness.
80352...........................  Other open skull fracture without
                                   mention of intracranial injury, with
                                   brief (less than one hour) loss of
                                   consciousness.
80353...........................  Other open skull fracture without
                                   mention of intracranial injury, with
                                   moderate (1-24 hours) loss of
                                   consciousness.
80354...........................  Other open skull fracture without
                                   mention of intracranial injury, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness and return to pre-
                                   existing conscious level.
80355...........................  Other open skull fracture without
                                   mention of intracranial injury, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness, without return to
                                   pre-existing conscious level.
80356...........................  Other open skull fracture without
                                   mention of intracranial injury, with
                                   loss of consciousness of unspecified
                                   duration.
80359...........................  Other open skull fracture without
                                   mention of intracranial injury, with
                                   concussion, unspecified.
80360...........................  Other open skull fracture with
                                   cerebral laceration and contusion,
                                   with state of consciousness
                                   unspecified.
80361...........................  Other open skull fracture with
                                   cerebral laceration and contusion,
                                   with no loss of consciousness.
80362...........................  Other open skull fracture with
                                   cerebral laceration and contusion,
                                   with brief (less than one hour) loss
                                   of consciousness.
80363...........................  Other open skull fracture with
                                   cerebral laceration and contusion,
                                   with moderate (1-24 hours) loss of
                                   consciousness.
80364...........................  Other open skull fracture with
                                   cerebral laceration and contusion,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness and return to
                                   pre-existing conscious level.
80365...........................  Other open skull fracture with
                                   cerebral laceration and contusion,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness, without return
                                   to pre-existing conscious level.

[[Page 25001]]

 
80366...........................  Other open skull fracture with
                                   cerebral laceration and contusion,
                                   with loss of consciousness of
                                   unspecified duration.
80369...........................  Other open skull fracture with
                                   cerebral laceration and contusion,
                                   with concussion, unspecified.
80370...........................  Other open skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with state of
                                   consciousness unspecified.
80371...........................  Other open skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with no loss
                                   of consciousness.
80372...........................  Other open skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with brief
                                   (less than one hour) loss of
                                   consciousness.
80373...........................  Other open skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with moderate
                                   (1-24 hours) loss of consciousness.
80374...........................  Other open skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
80375...........................  Other open skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
80376...........................  Other open skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with loss of
                                   consciousness of unspecified
                                   duration.
80379...........................  Other open skull fracture with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with
                                   concussion, unspecified.
80380...........................  Other open skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with state of
                                   consciousness unspecified.
80381...........................  Other open skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with no loss of
                                   consciousness.
80382...........................  Other open skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with brief (less than one
                                   hour) loss of consciousness.
80383...........................  Other open skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with moderate (1-24
                                   hours) loss of consciousness.
80384...........................  Other open skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with prolonged (more than
                                   24 hours) loss of consciousness and
                                   return to pre-existing conscious
                                   level.
80385...........................  Other open skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with prolonged (more than
                                   24 hours) loss of consciousness,
                                   without return to pre-existing
                                   conscious level.
80386...........................  Other open skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with loss of
                                   consciousness of unspecified
                                   duration.
80389...........................  Other open skull fracture with other
                                   and unspecified intracranial
                                   hemorrhage, with concussion,
                                   unspecified.
80390...........................  Other open skull fracture with
                                   intracranial injury of other and
                                   unspecified nature, with state of
                                   consciousness unspecified.
80391...........................  Other open skull fracture with
                                   intracranial injury of other and
                                   unspecified nature, with no loss of
                                   consciousness.
80392...........................  Other open skull fracture with
                                   intracranial injury of other and
                                   unspecified nature, with brief (less
                                   than one hour) loss of consciousness.
80393...........................  Other open skull fracture with
                                   intracranial injury of other and
                                   unspecified nature, with moderate (1-
                                   24 hours) loss of consciousness.
80394...........................  Other open skull fracture with
                                   intracranial injury of other and
                                   unspecified nature, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
80395...........................  Other open skull fracture with
                                   intracranial injury of other and
                                   unspecified nature, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
80396...........................  Other open skull fracture with
                                   intracranial injury of other and
                                   unspecified nature, with loss of
                                   consciousness of unspecified
                                   duration.
80399...........................  Other open skull fracture with
                                   intracranial injury of other and
                                   unspecified nature, with concussion,
                                   unspecified.
80403...........................  Closed fractures involving skull or
                                   face with other bones, without
                                   mention of intracranial injury, with
                                   moderate (1-24 hours) loss of
                                   consciousness.
80404...........................  Closed fractures involving skull or
                                   face with other bones, without
                                   mention or intracranial injury, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness and return to pre-
                                   existing conscious level.
80405...........................  Closed fractures involving skull of
                                   face with other bones, without
                                   mention of intracranial injury, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness, without return to
                                   pre-existing conscious level.
80410...........................  Closed fractures involving skull or
                                   face with other bones, with cerebral
                                   laceration and contusion, with state
                                   of consciousness unspecified.
80411...........................  Closed fractures involving skull or
                                   face with other bones, with cerebral
                                   laceration and contusion, with no
                                   loss of consciousness.
80412...........................  Closed fractures involving skull or
                                   face with other bones, with cerebral
                                   laceration and contusion, with brief
                                   (less than one hour) loss of
                                   consciousness.
80413...........................  Closed fractures involving skull or
                                   face with other bones, with cerebral
                                   laceration and contusion, with
                                   moderate (1-24 hours) loss of
                                   consciousness.
80414...........................  Closed fractures involving skull or
                                   face with other bones, with cerebral
                                   laceration and contusion, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness and return to pre-
                                   existing conscious level.
80415...........................  Closed fractures involving skull or
                                   face with other bones, with cerebral
                                   laceration and contusion, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness, without return to
                                   pre-existing conscious level.
80416...........................  Closed fractures involving skull or
                                   face with other bones, with cerebral
                                   laceration and contusion, with loss
                                   of consciousness of unspecified
                                   duration.
80419...........................  Closed fractures involving skull or
                                   face with other bones, with cerebral
                                   laceration and contusion, with
                                   concussion, unspecified.
80420...........................  Closed fractures involving skull or
                                   face with other bones with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with state of
                                   consciousness unspecified.

[[Page 25002]]

 
80421...........................  Closed fractures involving skull or
                                   face with other bones with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with no loss
                                   of consciousness.
80422...........................  Closed fractures involving skull or
                                   face with other bones with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with brief
                                   (less than one hour) loss of
                                   consciousness.
80423...........................  Closed fractures involving skull or
                                   face with other bones with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with moderate
                                   (1-24 hours) loss of consciousness.
80424...........................  Closed fractures involving skull or
                                   face with other bones with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
80425...........................  Closed fractures involving skull or
                                   face with other bones with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
80426...........................  Closed fractures involving skull or
                                   face with other bones with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with loss of
                                   consciousness of unspecified
                                   duration.
80429...........................  Closed fractures involving skull or
                                   face with other bones with
                                   subarachnoid, subdural, and
                                   extradural hemorrhage, with
                                   concussion, unspecified.
80430...........................  Closed fractures involving skull or
                                   face with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with state of consciousness
                                   unspecified.
80431...........................  Closed fractures involving skull or
                                   face with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with no loss of consciousness.
80432...........................  Closed fractures involving skull or
                                   face with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with brief (less than one hour) loss
                                   of consciousness.
80433...........................  Closed fractures involving skull or
                                   face with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with moderate (1-24 hours) loss of
                                   consciousness.
80434...........................  Closed fractures involving skull or
                                   face with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness and return to
                                   pre-existing conscious level.
80435...........................  Closed fractures involving skull or
                                   face with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness, without return
                                   to pre-existing conscious level.
80436...........................  Closed fractures involving skull or
                                   face with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with loss of consciousness of
                                   unspecified duration.
80439...........................  Closed fractures involving skull or
                                   face with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with concussion, unspecified.
80443...........................  Closed fractures involving skull or
                                   face with other bones, with
                                   intracranial injury of other and
                                   unspecified nature, with moderate (1-
                                   24 hours) loss of consciousness.
80444...........................  Closed fractures involving skull or
                                   face with other bones, with
                                   intracranial injury of other and
                                   unspecified nature, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
80445...........................  Closed fractures involving skull or
                                   face with other bones, with
                                   intracranial injury of other and
                                   unspecified nature, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
80453...........................  Open fractures involving skull or face
                                   with other bones, without mention of
                                   intracranial injury, with moderate (1-
                                   24 hours) loss of consciousness.
80454...........................  Open fractures involving skull or face
                                   with other bones, without mention of
                                   intracranial injury, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
80455...........................  Open fractures involving skull or face
                                   with other bones, without mention of
                                   intracranial injury, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
80460...........................  Open fractures involving skull or face
                                   with other bones, with cerebral
                                   laceration and contusion, with state
                                   of consciousness unspecified.
80461...........................  Open fractures involving skull or face
                                   with other bones, with cerebral
                                   laceration and contusion, with no
                                   loss of consciousness.
80462...........................  Open fractures involving skull or face
                                   with other bones, with cerebral
                                   laceration and contusion, with brief
                                   (less than one hour) loss of
                                   consciousness.
80463...........................  Open fractures involving skull or face
                                   with other bones, with cerebral
                                   laceration and contusion, with
                                   moderate (1-24 hours) loss of
                                   consciousness.
80464...........................  Open fractures involving skull or face
                                   with other bones, with cerebral
                                   laceration and contusion, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness and return to pre-
                                   existing conscious level.
80465...........................  Open fractures involving skull or face
                                   with other bones, with cerebral
                                   laceration and contusion, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness, without return to
                                   pre-existing conscious level.
80466...........................  Open fractures involving skull or face
                                   with other bones, with cerebral
                                   laceration and contusion, with loss
                                   of consciousness of unspecified
                                   duration.
80469...........................  Open fractures involving skull or face
                                   with other bones, with cerebral
                                   laceration and contusion, with
                                   concussion, unspecified.
80470...........................  Open fractures involving skull or face
                                   with other bones with subarachnoid,
                                   subdural, and extradural hemorrhage,
                                   with state of consciousness
                                   unspecified.
80471...........................  Open fractures involving skull or face
                                   with other bones with subarachnoid,
                                   subdural, and extradural hemorrhage,
                                   with no loss of consciousness.
80472...........................  Open fractures involving skull or face
                                   with other bones with subarachnoid,
                                   subdural, and extradural hemorrhage,
                                   with brief (less than one hour) loss
                                   of consciousness.
80473...........................  Open fractures involving skull or face
                                   with other bones with subarachnoid,
                                   subdural, and extradural hemorrhage,
                                   with moderate (1-24 hours) loss of
                                   consciousness.
80474...........................  Open fractures involving skull or face
                                   with other bones with subarachnoid,
                                   subdural, and extradural hemorrhage,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness and return to
                                   pre-existing conscious level.

[[Page 25003]]

 
80475...........................  Open fractures involving skull or face
                                   with other bones with subarachnoid,
                                   subdural, and extradural hemorrhage,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness, without return
                                   to pre-existing conscious level.
80476...........................  Open fractures involving skull or face
                                   with other bones with subarachnoid,
                                   subdural, and extradural hemorrhage,
                                   with loss of consciousness of
                                   unspecified duration.
80479...........................  Open fractures involving skull or face
                                   with other bones with subarachnoid,
                                   subdural, and extradural hemorrhage,
                                   with concussion, unspecified.
80480...........................  Open fractures involving skull or face
                                   with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with state of consciousness
                                   unspecified.
80481...........................  Open fractures involving skull or face
                                   with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with no loss of consciousness.
80482...........................  Open fractures involving skull or face
                                   with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with brief (less than one hour) loss
                                   of consciousness.
80483...........................  Open fractures involving skull or face
                                   with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with moderate (1-24 hours) loss of
                                   consciousness.
80484...........................  Open fractures involving skull or face
                                   with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness and return to
                                   pre-existing conscious level.
80485...........................  Open fractures involving skull or face
                                   with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with prolonged (more than 24 hours)
                                   loss consciousness, without return to
                                   pre-existing conscious level.
80486...........................  Open fractures involving skull or face
                                   with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with loss of consciousness of
                                   unspecified duration.
80489...........................  Open fractures involving skull or face
                                   with other bones, with other and
                                   unspecified intracranial hemorrhage,
                                   with concussion, unspecified.
80493...........................  Open fractures involving skull or face
                                   with other bones, with intracranial
                                   injury of other and unspecified
                                   nature, with moderate (1-24 hours)
                                   loss of consciousness.
80494...........................  Open fractures involving skull or face
                                   with other bones, with intracranial
                                   injury of other and unspecified
                                   nature, with prolonged (more than 24
                                   hours) loss of consciousness and
                                   return to pre-existing conscious
                                   level.
80495...........................  Open fractures involving skull or face
                                   with other bones, with intracranial
                                   injury of other and unspecified
                                   nature, with prolonged (more than 24
                                   hours) loss of consciousness without
                                   return to pre-existing conscious
                                   level.
80510...........................  Open fracture of cervical vertebra,
                                   unspecified level.
80511...........................  Open fracture of first cervical
                                   vertebra.
80512...........................  Open fracture of second cervical
                                   vertebra.
80513...........................  Open fracture of third cervical
                                   vertebra.
80514...........................  Open fracture of fourth cervical
                                   vertebra.
80515...........................  Open fracture of fifth cervical
                                   vertebra.
80516...........................  Open fracture of sixth cervical
                                   vertebra.
80517...........................  Open fracture of seventh cervical
                                   vertebra.
80518...........................  Open fracture of multiple cervical
                                   vertebrae.
8053............................  Open fracture of dorsal (thoracic)
                                   vertebra without mention of spinal
                                   cord injury.
8055............................  Open fracture of lumbar vertebra
                                   without mention of spinal cord
                                   injury.
8057............................  Open fracture of sacrum and coccyx
                                   without mention of spinal cord
                                   injury.
8059............................  Open fracture of unspecified part of
                                   vertebral column without mention of
                                   spinal cord injury.
80600...........................  Closed fracture of C1-C4 level with
                                   unspecified spinal cord injury.
80601...........................  Closed fracture of C1-C4 level with
                                   complete lesion of cord.
80602...........................  Closed fracture of C1-C4 level with
                                   anterior cord syndrome.
80603...........................  Closed fracture of C1-C4 level with
                                   central cord syndrome.
80604...........................  Closed fracture of C1-C4 level with
                                   other specified spinal cord injury.
80605...........................  Closed fracture of C5-C7 level with
                                   unspecified spinal cord injury.
80606...........................  Closed fracture of C5-C7 level with
                                   complete lesion of cord.
80607...........................  Closed fracture of C5-C7 level with
                                   anterior cord syndrome.
80608...........................  Closed fracture of C5-C7 level with
                                   central cord syndrome.
80609...........................  Closed fracture of C5-C7 level with
                                   other specified spinal cord injury.
80610...........................  Open fracture of C1-C4 level with
                                   unspecified spinal cord injury.
80611...........................  Open fracture of C1-C4 level with
                                   complete lesion of cord.
80612...........................  Open fracture of C1-C4 level with
                                   anterior cord syndrome.
80613...........................  Open fracture of C1-C4 level with
                                   central cord syndrome.
80614...........................  Open fracture of C1-C4 level with
                                   other specified spinal cord injury.
80615...........................  Open fracture of C5-C7 level with
                                   unspecified spinal cord injury.
80616...........................  Open fracture of C5-C7 level with
                                   complete lesion of cord.
80617...........................  Open fracture of C5-C7 level with
                                   anterior cord syndrome.
80618...........................  Open fracture of C5-C7 level with
                                   central cord syndrome.
80619...........................  Open fracture of C5-C7 level with
                                   other specified spinal cord injury.
80620...........................  Closed fracture of T1-T6 level with
                                   unspecified spinal cord injury.
80621...........................  Closed fracture of T1-T6 level with
                                   complete lesion of cord.
80622...........................  Closed fracture of T1-T6 level with
                                   anterior cord syndrome.
80623...........................  Closed fracture of T1-T6 level with
                                   central cord syndrome.
80624...........................  Closed fracture of T1-T6 level with
                                   other specified spinal cord injury.
80625...........................  Closed fracture of T7-T12 level with
                                   unspecified spinal cord injury.
80626...........................  Closed fracture of T7-T12 level with
                                   complete lesion of cord.
80627...........................  Closed fracture of T7-T12 level with
                                   anterior cord syndrome.
80628...........................  Closed fracture of T7-T12 level with
                                   central cord syndrome.
80629...........................  Closed fracture of T7-T12 level with
                                   other specified spinal cord injury.

[[Page 25004]]

 
80630...........................  Open fracture of T1-T6 level with
                                   unspecified spinal cord injury.
80631...........................  Open fracture of T1-T6 level with
                                   complete lesion of cord.
80632...........................  Open fracture of T1-T6 level with
                                   anterior cord syndrome.
80633...........................  Open fracture of T1-T6 level with
                                   central cord syndrome.
80634...........................  Open fracture of T1-T6 level with
                                   other specified spinal cord injury.
80635...........................  Open fracture of T7-T12 level with
                                   unspecified spinal cord injury.
80636...........................  Open fracture of T7-T12 level with
                                   complete lesion of cord.
80637...........................  Open fracture of T7-T12 level with
                                   anterior cord syndrome.
80638...........................  Open fracture of T7-T12 level with
                                   central cord syndrome.
80639...........................  Open fracture of T7-T-12 level with
                                   other specified spinal cord injury.
8064............................  Closed fracture of lumbar spine with
                                   spinal cord injury.
8065............................  Open fracture of lumbar spine with
                                   spinal cord injury.
80660...........................  Closed fracture of sacrum and coccyx
                                   with unspecified spinal cord injury.
80661...........................  Closed fracture of sacrum and coccyx
                                   with complete cauda equina lesion.
80662...........................  Closed fracture of sacrum and coccyx
                                   with other cauda equina injury.
80669...........................  Closed fracture of sacrum and coccyx
                                   with other spinal cord injury.
80670...........................  Open fracture of sacrum and coccyx
                                   with unspecified spinal cord injury.
80671...........................  Open fracture of sacrum and coccyx
                                   with complete cauda equina lesion.
80672...........................  Open fracture of sacrum and coccyx
                                   with other cauda equina injury.
80679...........................  Open fracture of sacrum and coccyx
                                   with other spinal cord injury.
8068............................  Closed fracture of unspecified
                                   vertebra with spinal cord injury.
8069............................  Open fracture of unspecified vertebra
                                   with spinal cord injury.
80710...........................  Open fracture of rib(s), unspecified.
80711...........................  Open fracture of one rib.
80712...........................  Open fracture of two ribs.
80713...........................  Open fracture of three ribs.
80714...........................  Open fracture of four ribs.
80715...........................  Open fracture of five ribs.
80716...........................  Open fracture of six ribs.
80717...........................  Open fracture of seven ribs.
80718...........................  Open fracture of eight or more ribs.
80719...........................  Open fracture of multiple ribs,
                                   unspecified.
8073............................  Open fracture of sternum.
8074............................  Flail chest.
8075............................  Closed fracture of larynx and trachea.
8076............................  Open fracture of larynx and trachea.
8080............................  Closed fracture of acetabulum.
8081............................  Open fracture of acetabulum.
8083............................  Open fracture of pubis.
80851...........................  Open fracture of ilium.
80852...........................  Open fracture of ischium.
80853...........................  Multiple open pelvic fractures with
                                   disruption of pelvic circle.
80859...........................  Open fracture of other specified part
                                   of pelvis.
8089............................  Unspecified open fracture of pelvis.
8091............................  Fracture of bones of trunk, open.
81210...........................  Fracture of unspecified part of upper
                                   end of humerus, open.
81211...........................  Fracture of surgical neck of humerus,
                                   open.
81212...........................  Fracture of anatomical neck of
                                   humerus, open.
81213...........................  Fracture of greater tuberosity of
                                   humerus, open.
81219...........................  Other open fracture of upper end of
                                   humerus.
81230...........................  Fracture of unspecified part of
                                   humerus, open.
81231...........................  Fracture of shaft of humerus, open.
81250...........................  Fracture of unspecified part of lower
                                   end of humerus, open.
81251...........................  Supracondylar fracture of humerus,
                                   open.
81252...........................  Fracture of lateral condyle of
                                   humerus, open.
81253...........................  Fracture of medial condyle of humerus,
                                   open.
81254...........................  Fracture of unspecified condyle(s) of
                                   humerus, open.
81259...........................  Other fracture of lower end of
                                   humerus, open.
81310...........................  Open fracture of upper end of forearm,
                                   unspecified.
81311...........................  Fracture of olecranon process of ulna,
                                   open.
81312...........................  Fracture of coronoid process of ulna,
                                   open.
81313...........................  Monteggia's fracture, open.
81314...........................  Other and unspecified open fractures
                                   of proximal end of ulna (alone).
81315...........................  Fracture of head of radius, open.
81316...........................  Fracture of neck of radius, open.
81317...........................  Other and unspecified open fractures
                                   of proximal end of radius (alone).
81318...........................  Fracture of radius with ulna, upper
                                   end (any part), open.
81330...........................  Fracture of shaft of radius or ulna,
                                   unspecified, open.
81331...........................  Fracture of shaft of radius (alone),
                                   open.
81332...........................  Fracture of shaft of ulna (alone),
                                   open.
81333...........................  Fracture of shaft of radius with ulna,
                                   open.
81350...........................  Open fracture of lower end of forearm,
                                   unspecified.

[[Page 25005]]

 
81351...........................  Colles' fracture, open.
81352...........................  Other open fractures of distal end of
                                   radius (alone).
81353...........................  Fracture of distal end of ulna
                                   (alone), open.
81354...........................  Fracture of lower end of radius with
                                   ulna, open.
81390...........................  Fracture of unspecified part of
                                   forearm, open.
81391...........................  Fracture of unspecified part of radius
                                   (alone), open.
81392...........................  Fracture of unspecified part of ulna
                                   (alone), open.
81393...........................  Fracture of unspecified part of radius
                                   with ulna, open.
82000...........................  Fracture of unspecified intracapsular
                                   section of neck of femur, closed.
82001...........................  Fracture of epiphysis (separation)
                                   (upper) of neck of femur, closed.
82002...........................  Fracture of midcervical section of
                                   femur, closed.
82003...........................  Fracture of base of neck of femur,
                                   closed.
82009...........................  Other transcervical fracture of femur,
                                   closed.
82010...........................  Fracture of unspecified intracapsular
                                   section of neck of femur, open.
82011...........................  Fracture of epiphysis (separation)
                                   (upper) of neck of femur, open.
82012...........................  Fracture of midcervical section of
                                   femur, open.
82013...........................  Fracture of base of neck of femur,
                                   open.
82019...........................  Other transcervical fracture of femur,
                                   open.
82020...........................  Fracture of unspecified trochanteric
                                   section of femur, closed.
82021...........................  Fracture of intertrochanteric section
                                   of femur, closed.
82022...........................  Fracture of subtrochanteric section of
                                   femur, closed.
82030...........................  Fracture of unspecified trochanteric
                                   section of femur, open.
82031...........................  Fracture of intertrochanteric section
                                   of femur, open.
82032...........................  Fracture of subtrochanteric section of
                                   femur, open.
8208............................  Fracture of unspecified part of neck
                                   of femur, closed.
8209............................  Fracture of unspecified part of neck
                                   of femur, open.
82100...........................  Fracture of unspecified part of femur,
                                   closed.
82101...........................  Fracture of shaft of femur, closed.
82110...........................  Fracture of unspecified part of femur,
                                   open.
82111...........................  Fracture of shaft of femur, open.
82130...........................  Fracture of lower end of femur,
                                   unspecified part, open.
82131...........................  Fracture of femoral condyle, open.
82132...........................  Fracture of lower epiphysis of femur,
                                   open.
82133...........................  Supracondylar fracture of femur, open.
82139...........................  Other fracture of lower end of femur,
                                   open.
82310...........................  Open fracture of upper end of tibia.
82311...........................  Open fracture of upper end of fibula.
82312...........................  Open fracture of upper end of fibula
                                   with tibia.
82330...........................  Open fracture of shaft of tibia.
82331...........................  Open fracture of shaft of fibula.
82332...........................  Open fracture of shaft of fibula with
                                   tibia.
82390...........................  Open fracture of unspecified part of
                                   tibia.
82391...........................  Open fracture of unspecified part of
                                   fibula.
82392...........................  Open fracture of unspecified part of
                                   fibula with tibia.
8280............................  Multiple fractures involving both
                                   lower limbs, lower with upper limb,
                                   and lower limb(s) with rib(s) and
                                   sternum, closed.
8281............................  Multiple fractures involving both
                                   lower limbs, lower with upper limb,
                                   and lower limb(s) with rib(s) and
                                   sternum, open.
83510...........................  Open dislocation of hip, unspecified
                                   site.
83511...........................  Open posterior dislocation of hip.
83512...........................  Open obturator dislocation of hip.
83513...........................  Other open anterior dislocation of
                                   hip.
83910...........................  Open dislocation, cervical vertebra,
                                   unspecified.
83911...........................  Open dislocation, first cervical
                                   vertebra.
83912...........................  Open dislocation, second cervical
                                   vertebra.
83913...........................  Open dislocation, third cervical
                                   vertebra.
83914...........................  Open dislocation, fourth cervical
                                   vertebra.
83915...........................  Open dislocation, fifth cervical
                                   vertebra.
83916...........................  Open dislocation, sixth cervical
                                   vertebra.
83917...........................  Open dislocation, seventh cervical
                                   vertebra.
83918...........................  Open dislocation, multiple cervical
                                   vertebrae.
83930...........................  Open dislocation, lumbar vertebra.
83931...........................  Open dislocation, thoracic vertebra.
83950...........................  Open dislocation, vertebra,
                                   unspecified site.
83959...........................  Open dislocation, other vertebra.
83971...........................  Open dislocation, sternum.
8504............................  Concussion with prolonged loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
85105...........................  Cortex (cerebral) contusion without
                                   mention of open intracranial wound,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness, without return
                                   to pre-existing conscious level.
85110...........................  Cortex (cerebral) contusion with open
                                   intracranial wound, without mention
                                   of specific state of consciousness.
85111...........................  Cortex (cerebral) contusion with open
                                   intracranial wound, with no loss of
                                   consciousness.
85112...........................  Cortex (cerebral) contusion with open
                                   intracranial wound, with brief (less
                                   than one hour) loss of consciousness.

[[Page 25006]]

 
85113...........................  Cortex (cerebral) contusion with open
                                   intracranial wound, with moderate (1-
                                   24 hours) loss of consciousness.
85114...........................  Cortex (cerebral) contusion with open
                                   intracranial wound, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
85115...........................  Cortex (cerebral) contusion with open
                                   intracranial wound, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
85116...........................  Cortex (cerebral) contusion with open
                                   intracranial wound, with loss of
                                   consciousness of unspecified
                                   duration.
85119...........................  Cortex (cerebral) contusion with open
                                   intracranial wound, with concussion,
                                   unspecified.
85120...........................  Cortex (cerebral) laceration without
                                   mention of open intracranial wound,
                                   with state of consciousness
                                   unspecified.
85121...........................  Cortex (cerebral) laceration without
                                   mention of open intracranial wound,
                                   with no loss of consciousness.
85122...........................  Cortex (cerebral) laceration without
                                   mention of open intracranial wound,
                                   with brief (less than one hour) loss
                                   of consciousness.
85123...........................  Cortex (cerebral) laceration without
                                   mention of open intracranial wound,
                                   with moderate (1-24 hours) loss of
                                   consciousness.
85124...........................  Cortex (cerebral) laceration without
                                   mention of open intracranial wound,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness and return to
                                   pre-existing conscious level.
85125...........................  Cortex (cerebral) laceration without
                                   mention of open intracranial wound,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness, without return
                                   to pre-existing conscious level.
85126...........................  Cortex (cerebral) laceration without
                                   mention of open intracranial wound,
                                   with loss of consciousness of
                                   unspecified duration.
85129...........................  Cortex (cerebral) laceration without
                                   mention of open intracranial wound,
                                   with concussion, unspecified.
85130...........................  Cortex (cerebral) laceration with open
                                   intracranial wound, with state of
                                   consciousness unspecified.
85131...........................  Cortex (cerebral) laceration with open
                                   intracranial wound, with no loss of
                                   consciousness.
85132...........................  Cortex (cerebral) laceration with open
                                   intracranial wound, with brief (less
                                   than one hour) loss of consciousness.
85133...........................  Cortex (cerebral) laceration with open
                                   intracranial wound, with moderate (1-
                                   24 hours) loss of consciousness.
85134...........................  Cortex (cerebral) laceration with open
                                   intracranial wound, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
85135...........................  Cortex (cerebral) laceration with open
                                   intracranial wound, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
85136...........................  Cortex (cerebral) laceration with open
                                   intracranial wound, with loss of
                                   consciousness of unspecified
                                   duration.
85139...........................  Cortex (cerebral) laceration with open
                                   intracranial wound, with concussion,
                                   unspecified.
85145...........................  Cerebellar or brain stem contusion
                                   without mention of open intracranial
                                   wound, with prolonged (more than 24
                                   hours) loss of consciousness, without
                                   return to pre-existing conscious
                                   level.
85150...........................  Cerebellar or brain stem contusion
                                   with open intracranial wound, with
                                   state of consciousness unspecified.
85151...........................  Cerebellar or brain stem contusion
                                   with open intracranial wound, with no
                                   loss of consciousness.
85152...........................  Cerebellar or brain stem contusion
                                   with open intracranial wound, with
                                   brief (less than one hour) loss of
                                   consciousness.
85153...........................  Cerebellar or brain stem contusion
                                   with open intracranial wound, with
                                   moderate (1-24 hours) loss of
                                   consciousness.
85154...........................  Cerebellar or brain stem contusion
                                   with open intracranial wound, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness and return to pre-
                                   existing conscious level.
85155...........................  Cerebellar or brain stem contusion
                                   with open intracranial wound, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness, without return to
                                   pre-existing conscious level.
85156...........................  Cerebellar or brain stem contusion
                                   with open intracranial wound, with
                                   loss of consciousness of unspecified
                                   duration.
85159...........................  Cerebellar or brain stem contusion
                                   with open intracranial wound, with
                                   concussion, unspecified.
85160...........................  Cerebellar or brain stem laceration
                                   without mention of open intracranial
                                   wound, with state of consciousness
                                   unspecified.
85161...........................  Cerebellar or brain stem laceration
                                   without mention of open intracranial
                                   wound, with no loss of consciousness.
85162...........................  Cerebellar or brain stem laceration
                                   without mention of open intracranial
                                   wound, with brief (less than 1 hour)
                                   loss of consciousness.
85163...........................  Cerebellar or brain stem laceration
                                   without mention of open intracranial
                                   wound, with moderate (1-24 hours)
                                   loss of consciousness.
85164...........................  Cerebellar or brain stem laceration
                                   without mention of open intracranial
                                   wound, with prolonged (more than 24
                                   hours) loss of consciousness and
                                   return to pre-existing conscious
                                   level.
85165...........................  Cerebellar or brain stem laceration
                                   without mention of open intracranial
                                   wound, with prolonged (more than 24
                                   hours) loss of consciousness, without
                                   return to pre-existing conscious
                                   level.
85166...........................  Cerebellar or brain stem laceration
                                   without mention of open intracranial
                                   wound, with loss of consciousness of
                                   unspecified duration.
85169...........................  Cerebellar or brain stem laceration
                                   without mention of open intracranial
                                   wound, with concussion, unspecified.
85170...........................  Cerebellar or brain stem laceration
                                   with open intracranial wound, with
                                   state of consciousness unspecified.
85171...........................  Cerebellar or brain stem laceration
                                   with open intracranial wound, with no
                                   loss of consciousness.
85172...........................  Cerebellar or brain stem laceration
                                   with open intracranial wound, with
                                   brief (less than one hour) loss of
                                   consciousness.
85173...........................  Cerebellar or brain stem laceration
                                   with open intracranial wound, with
                                   moderate (1-24 hours) loss of
                                   consciousness.
85174...........................  Cerebellar or brain stem laceration
                                   with open intracranial wound, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness and return to pre-
                                   existing conscious level.
85175...........................  Cerebellar or brain stem laceration
                                   with open intracranial wound, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness, without return to
                                   pre-existing conscious level.

[[Page 25007]]

 
85176...........................  Cerebellar or brain stem laceration
                                   with open intracranial wound, with
                                   loss of consciousness of unspecified
                                   duration.
85179...........................  Cerebellar or brain stem laceration
                                   with open intracranial wound, with
                                   concussion, unspecified.
85180...........................  Other and unspecified cerebral
                                   laceration and contusion, without
                                   mention of open intracranial wound,
                                   with state of consciousness
                                   unspecified.
85181...........................  Other and unspecified cerebral
                                   laceration and contusion, without
                                   mention of open intracranial wound,
                                   with no loss of consciousness.
85182...........................  Other and unspecified cerebral
                                   laceration and contusion, without
                                   mention of open intracranial wound,
                                   with brief (less than one hour) loss
                                   of consciousness.
85183...........................  Other and unspecified cerebral
                                   laceration and contusion, without
                                   mention of open intracranial wound,
                                   with moderate (1-24 hours) loss of
                                   consciousness.
85184...........................  Other and unspecified cerebral
                                   laceration and contusion, without
                                   mention of open intracranial wound,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness and return to
                                   pre-existing conscious level.
85185...........................  Other and unspecified cerebral
                                   laceration and contusion, without
                                   mention of open intracranial wound,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness, without return
                                   to pre-existing conscious level.
85186...........................  Other and unspecified cerebral
                                   laceration and contusion, without
                                   mention of open intracranial wound,
                                   with loss of consciousness of
                                   unspecified duration.
85189...........................  Other and unspecified cerebral
                                   laceration and contusion, without
                                   mention of open intracranial wound,
                                   with concussion, unspecified.
85190...........................  Other and unspecified cerebral
                                   laceration and contusion, with open
                                   intracranial wound, with state of
                                   consciousness unspecified.
85191...........................  Other and unspecified cerebral
                                   laceration and contusion, with open
                                   intracranial wound, with no loss of
                                   consciousness.
85192...........................  Other and unspecified cerebral
                                   laceration and contusion, with open
                                   intracranial wound, with brief (less
                                   than one hour) loss of consciousness.
85193...........................  Other and unspecified cerebral
                                   laceration and contusion, with open
                                   intracranial wound, with moderate (1-
                                   24 hours) loss of consciousness.
85194...........................  Other and unspecified cerebral
                                   laceration and contusion, with open
                                   intracranial wound, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
85195...........................  Other and unspecified cerebral
                                   laceration and contusion, with open
                                   intracranial wound, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
85196...........................  Other and unspecified cerebral
                                   laceration and contusion, with open
                                   intracranial wound, with loss of
                                   consciousness of unspecified
                                   duration.
85199...........................  Other and unspecified cerebral
                                   laceration and contusion, with open
                                   intracranial wound, with concussion,
                                   unspecified.
85200...........................  Subarachnoid hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with state of
                                   consciousness unspecified.
85201...........................  Subarachnoid hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with no loss of
                                   consciousness.
85202...........................  Subarachnoid hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with brief (less
                                   than one hour) loss of consciousness.
85203...........................  Subarachnoid hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with moderate (1-
                                   24 hours) loss of consciousness.
85204...........................  Subarachnoid hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
85205...........................  Subarachnoid hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
85206...........................  Subarachnoid hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with loss of
                                   consciousness of unspecified
                                   duration.
85209...........................  Subarachnoid hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with concussion,
                                   unspecified.
85210...........................  Subarachnoid hemorrhage following
                                   injury, with open intracranial wound,
                                   with state of consciousness
                                   unspecified.
85211...........................  Subarachnoid hemorrhage following
                                   injury, with open intracranial wound,
                                   with no loss of consciousness.
85212...........................  Subarachnoid hemorrhage following
                                   injury, with open intracranial wound,
                                   with brief (less than one hour) loss
                                   of consciousness.
85213...........................  Subarachnoid hemorrhage following
                                   injury, with open intracranial wound,
                                   with moderate (1-24 hours) loss of
                                   consciousness.
85214...........................  Subarachnoid hemorrhage following
                                   injury, with open intracranial wound,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness and return to
                                   pre-existing conscious level.
85215...........................  Subarachnoid hemorrhage following
                                   injury, with open intracranial wound,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness, without return
                                   to pre-existing conscious level.
85216...........................  Subarachnoid hemorrhage following
                                   injury, with open intracranial wound,
                                   with loss of consciousness of
                                   unspecified duration.
85219...........................  Subarachnoid hemorrhage following
                                   injury, with open intracranial wound,
                                   with concussion, unspecified.
85220...........................  Subdural hemorrhage following injury,
                                   without mention of open intracranial
                                   wound, with state of consciousness
                                   unspecified.
85221...........................  Subdural hemorrhage following injury,
                                   without mention of open intracranial
                                   wound, with no loss of consciousness.
85222...........................  Subdural hemorrhage following injury,
                                   without mention of open intracranial
                                   wound, with brief (less than one
                                   hour) loss of consciousness.

[[Page 25008]]

 
85223...........................  Subdural hemorrhage following injury,
                                   without mention of open intracranial
                                   wound, with moderate (1-24 hours)
                                   loss of consciousness.
85224...........................  Subdural hemorrhage following injury,
                                   without mention of open intracranial
                                   wound, with prolonged (more than 24
                                   hours) loss of consciousness and
                                   return to pre-existing conscious
                                   level.
85225...........................  Subdural hemorrhage following injury,
                                   without mention of open intracranial
                                   wound, with prolonged (more than 24
                                   hours) loss of consciousness, without
                                   return to pre-existing conscious
                                   level.
85226...........................  Subdural hemorrhage following injury,
                                   without mention of open intracranial
                                   wound, with loss of consciousness of
                                   unspecified duration.
85229...........................  Subdural hemorrhage following injury,
                                   without mention of open intracranial
                                   wound, with concussion, unspecified.
85230...........................  Subdural hemorrhage following injury,
                                   with open intracranial wound, with
                                   state of consciousness unspecified.
85231...........................  Subdural hemorrhage following injury,
                                   with open intracranial wound, with no
                                   loss of consciousness.
85232...........................  Subdural hemorrhage following injury,
                                   with open intracranial wound, with
                                   brief (less than one hour) loss of
                                   consciousness.
85233...........................  Subdural hemorrhage following injury,
                                   with open intracranial wound, with
                                   moderate (1-24 hours) loss of
                                   consciousness.
85234...........................  Subdural hemorrhage following injury,
                                   with open intracranial wound, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness and return to pre-
                                   existing conscious level.
85235...........................  Subdural hemorrhage following injury,
                                   with open intracranial wound, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness, without return to
                                   pre-existing conscious level.
85236...........................  Subdural hemorrhage following injury,
                                   with open intracranial wound, with
                                   loss of consciousness of unspecified
                                   duration.
85239...........................  Subdural hemorrhage following injury,
                                   with open intracranial wound, with
                                   concussion, unspecified.
85240...........................  Extradural hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with state of
                                   consciousness unspecified.
85241...........................  Extradural hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with no loss of
                                   consciousness.
85242...........................  Extradural hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with brief (less
                                   than 1 hour) loss of consciousness.
85243...........................  Extradural hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with moderate (1-
                                   24 hours) loss of consciousness.
85244...........................  Extradural hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
85245...........................  Extradural hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
85246...........................  Extradural hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with loss of
                                   consciousness of unspecified
                                   duration.
85249...........................  Extradural hemorrhage following
                                   injury, without mention of open
                                   intracranial wound, with concussion,
                                   unspecified.
85250...........................  Extradural hemorrhage following
                                   injury, with open intracranial wound,
                                   with state of consciousness
                                   unspecified.
85251...........................  Extradural hemorrhage following
                                   injury, with open intracranial wound,
                                   with no loss of consciousness.
85252...........................  Extradural hemorrhage following
                                   injury, with open intracranial wound,
                                   with brief (less than one hour) loss
                                   of consciousness.
85253...........................  Extradural hemorrhage following
                                   injury, with open intracranial wound,
                                   with moderate (1-24 hours) loss of
                                   consciousness.
85254...........................  Extradural hemorrhage following
                                   injury, with open intracranial wound,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness and return to
                                   pre-existing conscious level.
85255...........................  Extradural hemorrhage following
                                   injury, with open intracranial wound,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness, without return
                                   to pre-existing conscious level.
85256...........................  Extradural hemorrhage following
                                   injury, with open intracranial wound,
                                   with loss of consciousness of
                                   unspecified duration.
85259...........................  Extradural hemorrhage following
                                   injury, with open intracranial wound,
                                   with concussion, unspecified.
85300...........................  Other and unspecified intracranial
                                   hemorrhage following injury, without
                                   mention of open intracranial wound,
                                   with state of consciousness
                                   unspecified.
85301...........................  Other and unspecified intracranial
                                   hemorrhage following injury, without
                                   mention of open intracranial wound,
                                   with no loss of consciousness.
85302...........................  Other and unspecified intracranial
                                   hemorrhage following injury, without
                                   mention of open intracranial wound,
                                   with brief (less than one hour) loss
                                   of consciousness.
85303...........................  Other and unspecified intracranial
                                   hemorrhage following injury, without
                                   mention of open intracranial wound,
                                   with moderate (1-24 hours) loss of
                                   consciousness.
85304...........................  Other and unspecified intracranial
                                   hemorrhage following injury, without
                                   mention of open intracranial wound,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness and return to
                                   pre-existing conscious level.
85305...........................  Other and unspecified intracranial
                                   hemorrhage following injury. without
                                   mention of open intracranial wound,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness, without return
                                   to pre-existing conscious level.
85306...........................  Other and unspecified intracranial
                                   hemorrhage following injury, without
                                   mention of open intracranial wound,
                                   with loss of consciousness of
                                   unspecified duration.
85309...........................  Other and unspecified intracranial
                                   hemorrhage following injury, without
                                   mention of open intracranial wound,
                                   with concussion, unspecified.
85310...........................  Other and unspecified intracranial
                                   hemorrhage following injury, with
                                   open intracranial wound, with state
                                   of consciousness unspecified.
85311...........................  Other and unspecified intracranial
                                   hemorrhage following injury, with
                                   open intracranial wound, with no loss
                                   of consciousness.

[[Page 25009]]

 
85312...........................  Other and unspecified intracranial
                                   hemorrhage following injury, with
                                   open intracranial wound, with brief
                                   (less than one hour) loss of
                                   consciousness.
85313...........................  Other and unspecified intracranial
                                   hemorrhage following injury, with
                                   open intracranial wound, with
                                   moderate (1-24 hours) loss of
                                   consciousness.
85314...........................  Other and unspecified intracranial
                                   hemorrhage following injury, with
                                   open intracranial wound, with
                                   prolonged( more than 24 hours) loss
                                   of consciousness and return to pre-
                                   existing conscious level.
85315...........................  Other and unspecified intracranial
                                   hemorrhage following injury, with
                                   open intracranial wound, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness, without return to
                                   pre-existing conscious level.
85316...........................  Other and unspecified intracranial
                                   hemorrhage following injury, with
                                   open intracranial wound, with loss of
                                   consciousness of unspecified
                                   duration.
85319...........................  Other and unspecified intracranial
                                   hemorrhage following injury, with
                                   open intracranial wound, with
                                   concussion, unspecified.
85405...........................  Intracranial injury of other and
                                   unspecified nature, without mention
                                   of open intracranial wound, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness, without return to
                                   pre-existing conscious level.
85410...........................  Intracranial injury of other and
                                   unspecified nature, with open
                                   intracranial wound, with state of
                                   consciousness unspecified.
85411...........................  Intracranial injury of other and
                                   unspecified nature, with open
                                   intracranial wound, with no loss of
                                   consciousness.
85412...........................  Intracranial injury of other and
                                   unspecified nature, with open
                                   intracranial wound, with brief (less
                                   than one hour) loss of consciousness.
85413...........................  Intracranial injury of other and
                                   unspecified nature, with open
                                   intracranial wound, with moderate (1-
                                   24 hours) loss of consciousness.
85414...........................  Intracranial injury of other and
                                   unspecified nature, with open
                                   intracranial wound, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness and return to pre-
                                   existing conscious level.
85415...........................  Intracranial injury of other and
                                   unspecified nature, with open
                                   intracranial wound, with prolonged
                                   (more than 24 hours) loss of
                                   consciousness, without return to pre-
                                   existing conscious level.
85416...........................  Intracranial injury of other and
                                   unspecified nature, with open
                                   intracranial wound, with loss of
                                   consciousness of unspecified
                                   duration.
85419...........................  Intracranial injury of other and
                                   unspecified nature, with open
                                   intracranial wound, with concussion,
                                   unspecified.
8601............................  Traumatic pneumothorax with open wound
                                   into thorax.
8602............................  Traumatic hemothorax without mention
                                   of open wound into thorax.
8603............................  Traumatic hemothorax with open wound
                                   into thorax.
8604............................  Traumatic pneumohemothorax without
                                   mention of open wound into thorax.
8605............................  Traumatic pneumohemothorax with open
                                   wound into thorax.
86102...........................  Laceration of heart without
                                   penetration of heart chambers or open
                                   wound into thorax.
86103...........................  Laceration of heart with penetration
                                   of heart chambers, without mention of
                                   open wound into thorax.
86110...........................  Unspecified injury of heart with open
                                   wound into thorax.
86111...........................  Contusion of heart with open wound
                                   into thorax.
86112...........................  Laceration of heart without
                                   penetration of heart chambers, with
                                   open wound into thorax.
86113...........................  Laceration of heart with penetration
                                   of heart chambers and open wound into
                                   thorax.
86122...........................  Laceration of lung without open wound
                                   into thorax.
86130...........................  Unspecified injury of lung with open
                                   wound into thorax.
86131...........................  Contusion of lung with open wound into
                                   thorax.
86132...........................  Laceration of lung with open wound
                                   into thorax.
8621............................  Injury to diaphragm with open wound
                                   into cavity.
86221...........................  Injury to bronchus without open wound
                                   into cavity.
86222...........................  Injury to esophagus without mention of
                                   open wound into cavity.
86231...........................  Injury to bronchus with open wound
                                   into cavity.
86232...........................  Injury to esophagus with open wound
                                   into cavity.
86239...........................  Injury to other specified
                                   intrathoracic organs with open wound
                                   into cavity.
8629............................  Injury to multiple and unspecified
                                   intrathoracic organs with open wound
                                   into cavity.
8631............................  Injury to stomach with open wound into
                                   cavity.
86330...........................  Injury to small intestine, unspecified
                                   site, with open wound into cavity.
86331...........................  Injury to duodenum with open wound
                                   into cavity.
86339...........................  Other injury to small intestine with
                                   open wound into cavity.
86350...........................  Injury to colon, unspecified site,
                                   with open wound into cavity.
86351...........................  Injury to ascending (right) colon with
                                   open wound into cavity.
86352...........................  Injury to transverse colon with open
                                   wound into cavity.
86353...........................  Injury to descending (left) colon with
                                   open wound into cavity.
86354...........................  Injury to sigmoid colon with open
                                   wound into cavity.
86355...........................  Injury to rectum with open wound into
                                   cavity.
86356...........................  Injury to multiple sites in colon and
                                   rectum with open wound into cavity.
86359...........................  Other injury to colon and rectum with
                                   open wound into cavity.
86390...........................  Injury to gastrointestinal tract,
                                   unspecified site, with open wound
                                   into cavity.
86391...........................  Injury to pancreas head with open
                                   wound into cavity.
86392...........................  Injury to pancreas body with open
                                   wound into cavity.
86393...........................  Injury to pancreas tail with open
                                   wound into cavity.
86394...........................  Injury to pancreas, multiple and
                                   unspecified sites, with open wound
                                   into cavity.
86395...........................  Injury to appendix with open wound
                                   into cavity.
86399...........................  Injury to other and unspecified
                                   gastrointestinal sites with open
                                   wound into cavity.
86403...........................  Laceration of liver, moderate, without
                                   mention of open wound into cavity.
86404...........................  Laceration of liver, major, without
                                   mention of open wound into cavity.

[[Page 25010]]

 
86410...........................  Unspecified injury to liver with open
                                   wound into cavity.
86411...........................  Hematoma and contusion of liver with
                                   open wound into cavity.
86412...........................  Laceration of liver, minor, with open
                                   wound into cavity.
86413...........................  Laceration of liver, moderate, with
                                   open wound into cavity.
86414...........................  Laceration of liver, major, with open
                                   wound into cavity.
86415...........................  Laceration of liver, unspecified, with
                                   open wound into cavity.
86419...........................  Other injury to liver with open wound
                                   into cavity.
86503...........................  Laceration of spleen extending into
                                   parenchyma without mention of open
                                   wound into cavity.
86504...........................  Massive parenchymal disruption of
                                   spleen without mention of open wound
                                   into cavity.
86510...........................  Unspecified injury to spleen with open
                                   wound into cavity.
86511...........................  Hematoma of spleen, without rupture of
                                   capsule, with open wound into cavity.
86512...........................  Capsular tears to spleen, without
                                   major disruption of parenchyma, with
                                   open wound into cavity.
86513...........................  Laceration of spleen extending into
                                   parenchyma, with open wound into
                                   cavity.
86514...........................  Massive parenchyma disruption of
                                   spleen with open wound into cavity.
86519...........................  Other injury to spleen with open wound
                                   into cavity.
86603...........................  Complete disruption of kidney
                                   parenchyma, without mention of open
                                   wound into cavity.
86610...........................  Unspecified injury to kidney with open
                                   wound into cavity.
86611...........................  Hematoma of kidney, without rupture of
                                   capsule, with open wound into cavity.
86612...........................  Laceration of kidney with open wound
                                   into cavity.
86613...........................  Complete disruption of kidney
                                   parenchyma, with open wound into
                                   cavity.
8671............................  Injury to bladder and urethra with
                                   open wound into cavity.
8673............................  Injury to ureter with open wound into
                                   cavity.
8675............................  Injury to uterus with open wound into
                                   cavity.
8677............................  Injury to other specified pelvic
                                   organs with open wound into cavity.
8679............................  Injury to unspecified pelvic organ
                                   with open wound into cavity.
86810...........................  Injury to unspecified intra-abdominal
                                   organ, with open wound into cavity.
86811...........................  Injury to adrenal gland, with open
                                   wound into cavity.
86812...........................  Injury to bile duct and gallbladder,
                                   with open wound into cavity.
86813...........................  Injury to peritoneum with open wound
                                   into cavity.
86814...........................  Injury to retroperitoneum with open
                                   wound into cavity.
86819...........................  Injury to other and multiple intra-
                                   abdominal organs, with open wound
                                   into cavity.
8691............................  Internal injury to unspecified or ill-
                                   defined organs with open wound into
                                   cavity.
87400...........................  Open wound of larynx with trachea,
                                   uncomplicated.
87401...........................  Open wound of larynx, uncomplicated.
87402...........................  Open wound of trachea, uncomplicated.
87410...........................  Open wound of larynx with trachea,
                                   complicated.
87411...........................  Open wound of larynx, complicated.
87412...........................  Open wound of trachea, complicated.
8876............................  Traumatic amputation of arm and hand
                                   (complete) (partial), bilateral (any
                                   level), without mention of
                                   complication.
8877............................  Traumatic amputation of arm and hand
                                   (complete) (partial), bilateral (any
                                   level), complicated.
8962............................  Traumatic amputation of foot
                                   (complete) (partial), bilateral,
                                   without mention of complication.
8963............................  Traumatic amputation of foot
                                   (complete) (partial), bilateral,
                                   complicated.
8976............................  Traumatic amputation of leg(s)
                                   (complete) (partial), bilateral (any
                                   level), without mention of
                                   complication.
8977............................  Traumatic amputation of leg(s)
                                   (complete) (partial), bilateral (any
                                   level), complicated.
9010............................  Injury to thoracic aorta.
9011............................  Injury to innominate and subclavian
                                   arteries.
9012............................  Injury to superior vena cava.
9013............................  Injury to innominate and subclavian
                                   veins.
90140...........................  Injury to pulmonary vessel(s),
                                   unspecified.
90141...........................  Injury to pulmonary artery.
90142...........................  Injury to pulmonary vein.
90183...........................  Injury to multiple blood vessels of
                                   thorax.
9020............................  Injury to abdominal aorta.
90210...........................  Injury to inferior vena cava,
                                   unspecified.
90211...........................  Injury to hepatic veins.
90219...........................  Injury to other specified branches of
                                   inferior vena cava.
90220...........................  Injury to celiac and mesenteric
                                   arteries, unspecified.
90221...........................  Injury to gastric artery.
90222...........................  Injury to hepatic artery.
90223...........................  Injury to splenic artery.
90224...........................  Injury to other specified branches of
                                   celiac axis.
90225...........................  Injury to superior mesenteric artery
                                   (trunk).
90226...........................  Injury to primary branches of superior
                                   mesenteric artery.
90227...........................  Injury to inferior mesenteric artery.
90229...........................  Injury to other celiac and mesenteric
                                   arteries.
90231...........................  Injury to superior mesenteric vein and
                                   primary subdivisions.
90232...........................  Injury to inferior mesenteric vein.
90233...........................  Injury to portal vein.
90234...........................  Injury to splenic vein.
90239...........................  Injury to other portal and splenic
                                   veins.
90240...........................  Injury to renal vessel(s),
                                   unspecified.

[[Page 25011]]

 
90241...........................  Injury to renal artery.
90242...........................  Injury to renal vein.
90249...........................  Injury to other renal blood vessels.
90250...........................  Injury to iliac vessel(s),
                                   unspecified.
90251...........................  Injury to hypogastric artery.
90252...........................  Injury to hypogastric vein.
90253...........................  Injury to iliac artery.
90254...........................  Injury to iliac vein.
90259...........................  Injury to other iliac blood vessels.
90287...........................  Injury to multiple blood vessels of
                                   abdomen and pelvis.
90300...........................  Injury to axillary vessel(s),
                                   unspecified.
90301...........................  Injury to axillary artery.
90302...........................  Injury to axillary vein.
9040............................  Injury to common femoral artery.
9041............................  Injury to superficial femoral artery.
9042............................  Injury to femoral veins.
90440...........................  Injury to popliteal vessel(s),
                                   unspecified.
90441...........................  Injury to popliteal artery.
90442...........................  Injury to popliteal vein.
94821...........................  Burn (any degree) involving 20-29
                                   percent of body surface with third
                                   degree burn of 10-19%.
94822...........................  Burn (any degree) involving 20-29
                                   percent of body surface with third
                                   degree burn of 20-29%.
94831...........................  Burn (any degree) involving 30-39
                                   percent of body surface with third
                                   degree burn of 10-19%.
94832...........................  Burn (any degree) involving 30-39
                                   percent of body surface with third
                                   degree burn of 20-29%.
94833...........................  Burn (any degree) involving 30-39
                                   percent of body surface with third
                                   degree burn of 30-39%.
94841...........................  Burn (any degree) involving 40-49
                                   percent of body surface with third
                                   degree burn of 10-19%.
94842...........................  Burn (any degree) involving 40-49
                                   percent of body surface with third
                                   degree burn of 20-29%.
94843...........................  Burn (any degree) involving 40-49
                                   percent of body surface with third
                                   degree burn of 30-39%.
94844...........................  Burn (any degree) involving 40-49
                                   percent of body surface with third
                                   degree burn of 40-49%.
94851...........................  Burn (any degree) involving 50-59
                                   percent of body surface with third
                                   degree burn of 10-19%.
94852...........................  Burn (any degree) involving 50-59
                                   percent of body surface with third
                                   degree burn of 20-29%.
94853...........................  Burn (any degree) involving 50-59
                                   percent of body surface with third
                                   degree burn of 30-39%.
94854...........................  Burn (any degree) involving 50-59
                                   percent of body surface with third
                                   degree burn of 40-49%.
94855...........................  Burn (any degree) involving 50-59
                                   percent of body surface with third
                                   degree burn of 50-59%.
94861...........................  Burn (any degree) involving 60-69
                                   percent of body surface with third
                                   degree burn of 10-19%.
94862...........................  Burn (any degree) involving 60-69
                                   percent of body surface with third
                                   degree burn of 20-29%.
94863...........................  Burn (any degree) involving 60-69
                                   percent of body surface with third
                                   degree burn of 30-39%.
94864...........................  Burn (any degree) involving 60-69
                                   percent of body surface with third
                                   degree burn of 40-49%.
94865...........................  Burn (any degree) involving 60-69
                                   percent of body surface with third
                                   degree burn of 50-59%.
94866...........................  Burn (any degree) involving 60-69
                                   percent of body surface with third
                                   degree burn of 60-69%.
94871...........................  Burn (any degree) involving 70-79
                                   percent of body surface with third
                                   degree burn of 10-19%.
94872...........................  Burn (any degree) involving 70-79
                                   percent of body surface with third
                                   degree burn of 20-29%.
94873...........................  Burn (any degree) involving 70-79
                                   percent of body surface with third
                                   degree burn of 30-39%.
94874...........................  Burn (any degree) involving 70-79
                                   percent of body surface with third
                                   degree burn of 40-49%.
94875...........................  Burn (any degree) involving 70-79
                                   percent of body surface with third
                                   degree burn of 50-59%.
94876...........................  Burn (any degree) involving 70-79
                                   percent of body surface with third
                                   degree burn of 60-69%.
94877...........................  Burn (any degree) involving 70-79
                                   percent of body surface with third
                                   degree burn of 70-79%.
94881...........................  Burn (any degree) involving 80-89
                                   percent of body surface with third
                                   degree burn of 10-19%.
94882...........................  Burn (any degree) involving 80-89
                                   percent of body surface with third
                                   degree burn of 20-29%.
94883...........................  Burn (any degree) involving 80-89
                                   percent of body surface with third
                                   degree burn of 30-39%.
94884...........................  Burn (any degree) involving 80-89
                                   percent of body surface with third
                                   degree burn of 40-49%.
94885...........................  Burn (any degree) involving 80-89
                                   percent of body surface with third
                                   degree burn of 50-59%.
94886...........................  Burn (any degree) involving 80-89
                                   percent of body surface with third
                                   degree burn of 60-69%.
94887...........................  Burn (any degree) involving 80-89
                                   percent of body surface with third
                                   degree burn of 70-79%.
94888...........................  Burn (any degree) involving 80-89
                                   percent of body surface with third
                                   degree burn of 80-89%.
94891...........................  Burn (any degree) involving 90 percent
                                   or more of body surface with third
                                   degree burn of 10-19%.
94892...........................  Burn (any degree) involving 90 percent
                                   or more of body surface with third
                                   degree burn of 20-29%.
94893...........................  Burn (any degree) involving 90 percent
                                   or more of body surface with third
                                   degree burn of 30-39%.
94894...........................  Burn (any degree) involving 90 percent
                                   or more of body surface with third
                                   degree burn of 40-49%.
94895...........................  Burn (any degree) involving 90 percent
                                   or more of body surface with third
                                   degree burn of 50-59%.
94896...........................  Burn (any degree) involving 90 percent
                                   or more of body surface with third
                                   degree burn of 60-69%.
94897...........................  Burn (any degree) involving 90 percent
                                   or more of body surface with third
                                   degree burn of 70-79%.
94898...........................  Burn (any degree) involving 90 percent
                                   or more of body surface with third
                                   degree burn of 80-89%.
94899...........................  Burn (any degree) involving 90 percent
                                   or more of body surface with third
                                   degree burn of 90% or more of body
                                   surface.
95200...........................  C1-C4 level spinal cord injury,
                                   unspecified.
95201...........................  C1-C4 level with complete lesion of
                                   spinal cord.
95202...........................  C1-C4 level with anterior cord
                                   syndrome.
95203...........................  C1-C4 level with central cord
                                   syndrome.
95204...........................  C1-C4 level with other specified
                                   spinal cord injury.
95205...........................  C5-C7 level spinal cord injury,
                                   unspecified.
95206...........................  C5-C7 level with complete lesion of
                                   spinal cord.
95207...........................  C5-C7 level with anterior cord
                                   syndrome.

[[Page 25012]]

 
95208...........................  C5-C7 level with central cord
                                   syndrome.
95209...........................  C5-C7 level with other specified
                                   spinal cord injury.
95210...........................  T1-T6 level spinal cord injury,
                                   unspecified.
95211...........................  T1-T6 level with complete lesion of
                                   spinal cord.
95212...........................  T1-T6 level with anterior cord
                                   syndrome.
95213...........................  T1-T6 level with central cord
                                   syndrome.
95214...........................  T1-T6 level with other specified
                                   spinal cord injury.
95215...........................  T7-T12 level spinal cord injury,
                                   unspecified.
95216...........................  T7-T12 level with complete lesion of
                                   spinal cord.
95217...........................  T7-T12 level with anterior cord
                                   syndrome.
95218...........................  T7-T12 level with central cord
                                   syndrome.
95219...........................  T7-T12 level with other specified
                                   spinal cord injury.
9522............................  Lumbar spinal cord injury without
                                   spinal bone injury.
9523............................  Sacral spinal cord injury without
                                   spinal bone injury.
9524............................  Cauda equina spinal cord injury
                                   without spinal bone injury.
9528............................  Multiple sites of spinal cord injury
                                   without spinal bone injury.
9580............................  Air embolism as an early complication
                                   of trauma.
9581............................  Fat embolism as an early complication
                                   of trauma.
9584............................  Traumatic shock.
9585............................  Traumatic anuria.
99591...........................  Sepsis.
99592...........................  Severe sepsis.
99594...........................  Systemic inflammatory response
                                   syndrome due to noninfectious process
                                   with acute organ dysfunction.
9991............................  Air embolism as a complication of
                                   medical care, not elsewhere
                                   classified.
------------------------------------------------------------------------


              Table 6K.--Complication and Comorbidity List
------------------------------------------------------------------------
         Diagnosis code                         Code title
------------------------------------------------------------------------
0010............................  Cholera due to vibrio cholerae.
0011............................  Cholera due to vibrio cholerae el tor.
0019............................  Cholera, unspecified.
0020............................  Typhoid fever.
0021............................  Paratyphoid fever A.
0022............................  Paratyphoid fever B.
0023............................  Paratyphoid fever C.
0029............................  Paratyphoid fever, unspecified.
0030............................  Salmonella gastroenteritis.
00323...........................  Salmonella arthritis.
00324...........................  Salmonella osteomyelitis.
00329...........................  Other localized salmonella infections.
0038............................  Other specified salmonella infections.
0039............................  Salmonella infection, unspecified.
0040............................  Shigella dysenteriae.
0050............................  Staphylococcal food poisoning.
0051............................  Botulism food poisoning.
0052............................  Food poisoning due to clostridium
                                   perfringens (c. welchii).
0053............................  Food poisoning due to other
                                   clostridia.
0054............................  Food poisoning due to vibrio
                                   parahaemolyticus.
00581...........................  Food poisoning due to vibrio
                                   vulnificus.
00589...........................  Other bacterial food poisoning.
0060............................  Acute amebic dysentery without mention
                                   of abscess.
0061............................  Chronic intestinal amebiasis without
                                   mention of abscess.
0062............................  Amebic nondysenteric colitis.
0068............................  Amebic infection of other sites.
0071............................  Giardiasis.
0072............................  Coccidiosis.
0074............................  Cryptosporidiosis.
0075............................  Cyclosporiasis.
0078............................  Other specified protozoal intestinal
                                   diseases.
0079............................  Unspecified protozoal intestinal
                                   disease.
00800...........................  Intestinal infection due to e. coli,
                                   unspecified.
00801...........................  Intestinal infection due to
                                   enteropathogenic e. coli.
00802...........................  Intestinal infection due to
                                   enterotoxigenic e. coli.
00803...........................  Intestinal infection due to
                                   enteroinvasive e. coli.
00804...........................  Intestinal infection due to
                                   enterohemorrhagic e. coli.
00809...........................  Intestinal infection due to other
                                   intestinal e. coli infections.
0081............................  Intestinal infection due to arizona
                                   group of paracolon bacilli.
0082............................  Intestinal infection due to aerobacter
                                   aerogenes.
0083............................  Intestinal infection due to proteus
                                   (mirabilis) (morganii).
00841...........................  Intestinal infection due to
                                   staphylococcus.

[[Page 25013]]

 
00842...........................  Intestinal infection due to
                                   pseudomonas.
00843...........................  Intestinal infection due to
                                   campylobacter.
00844...........................  Intestinal infection due to yersinia
                                   enterocolitica.
00845...........................  Intestinal infection due to
                                   clostridium difficile.
00846...........................  Intestinal infection due to other
                                   anaerobes.
00847...........................  Intestinal infection due to other gram-
                                   negative bacteria.
00849...........................  Intestinal infection due to other
                                   organisms.
0085............................  Bacterial enteritis, unspecified.
00861...........................  Enteritis due to rotavirus.
00862...........................  Enteritis due to adenovirus.
00863...........................  Enteritis due to norwalk virus.
00864...........................  Enteritis due to other small round
                                   viruses [srv's].
00865...........................  Enteritis due to calcivirus.
00866...........................  Enteritis due to astrovirus.
00867...........................  Enteritis due to enterovirus nec.
00869...........................  Enteritis due to other viral
                                   enteritis.
0090............................  Infectious colitis, enteritis, and
                                   gastroenteritis.
0091............................  Colitis, enteritis, and
                                   gastroenteritis of presumed
                                   infectious origin.
0092............................  Infectious diarrhea.
0093............................  Diarrhea of presumed infectious
                                   origin.
01000...........................  Primary tuberculous complex,
                                   unspecified examination.
01001...........................  Primary tuberculous complex,
                                   bacteriological or histological
                                   examination not done.
01002...........................  Primary tuberculous complex,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01003...........................  Primary tuberculous complex, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01004...........................  Primary tuberculous complex, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01005...........................  Primary tuberculous complex, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01006...........................  Primary tuberculous complex, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01010...........................  Tuberculous pleurisy in primary
                                   progressive tuberculosis,
                                   confirmation unspecified.
01011...........................  Tuberculous pleurisy in primary
                                   progressive tuberculosis,
                                   bacteriological or histological
                                   examination not done.
01012...........................  Tuberculous pleurisy in primary
                                   progressive tuberculosis,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01013...........................  Tuberculous pleurisy in primary
                                   progressive tuberculosis, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01014...........................  Tuberculous pleurisy in primary
                                   progressive tuberculosis, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01015...........................  Tuberculous pleurisy in primary
                                   progressive tuberculosis, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01016...........................  Tuberculous pleurisy in primary
                                   progressive tuberculosis, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01080...........................  Other primary progressive
                                   tuberculosis, confirmation
                                   unspecified.
01081...........................  Other primary progressive
                                   tuberculosis, bacteriological or
                                   histological examination not done.
01082...........................  Other primary progressive
                                   tuberculosis, bacteriological or
                                   histological examination results
                                   unknown (at present).
01083...........................  Other primary progressive
                                   tuberculosis, tubercle bacilli found
                                   (in sputum) by microscopy.
01084...........................  Other primary progressive
                                   tuberculosis, tubercle bacilli not
                                   found (in sputum) by microscopy, but
                                   found by bacterial culture.
01085...........................  Other primary progressive
                                   tuberculosis, tubercle bacilli not
                                   found by bacteriological examination,
                                   but tuberculosis confirmed
                                   histologically.
01086...........................  Other primary progressive
                                   tuberculosis, tubercle bacilli not
                                   found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01090...........................  Primary tuberculous infection,
                                   unspecified type, confirmation
                                   unspecified.
01091...........................  Primary tuberculous infection,
                                   unspecified type, bacteriological or
                                   histological examination not done.
01092...........................  Primary tuberculous infection,
                                   unspecified type, bacteriological or
                                   histological examination results
                                   unknown (at present).
01093...........................  Primary tuberculous infection,
                                   unspecified type, tubercle bacilli
                                   found (in sputum) by microscopy.
01094...........................  Primary tuberculous infection,
                                   unspecified type, tubercle bacilli
                                   not found (in sputum) by microscopy,
                                   but found by bacterial culture.
01095...........................  Primary tuberculous infection,
                                   unspecified type, tubercle bacilli
                                   not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01096...........................  Primary tuberculous infection,
                                   unspecified type, tubercle bacilli
                                   not found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01100...........................  Tuberculosis of lung, infiltrative,
                                   confirmation unspecified.
01101...........................  Tuberculosis of lung, infiltrative,
                                   bacteriological or histological
                                   examination not done.
01102...........................  Tuberculosis of lung, infiltrative,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01103...........................  Tuberculosis of lung, infiltrative,
                                   tubercle bacilli found (in sputum) by
                                   microscopy.
01104...........................  Tuberculosis of lung, infiltrative,
                                   tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01105...........................  Tuberculosis of lung, infiltrative,
                                   tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.

[[Page 25014]]

 
01106...........................  Tuberculosis of lung, infiltrative,
                                   tubercle bacilli not found
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01110...........................  Tuberculosis of lung, nodular,
                                   unspecified examination.
01111...........................  Tuberculosis of lung, nodular,
                                   bacteriological or histological
                                   examination not done.
01112...........................  Tuberculosis of lung, nodular,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01113...........................  Tuberculosis of lung, nodular,
                                   tubercle bacilli found (in sputum) by
                                   microscopy.
01114...........................  Tuberculosis of lung, nodular,
                                   tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01115...........................  Tuberculosis of lung, nodular,
                                   tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01116...........................  Tuberculosis of lung, nodular,
                                   tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01120...........................  Tuberculosis of lung with cavitation,
                                   unspecified examination.
01121...........................  Tuberculosis of lung with cavitation,
                                   bacteriological or histological
                                   examination not done.
01122...........................  Tuberculosis of lung with cavitation,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01123...........................  Tuberculosis of lung with cavitation,
                                   tubercle bacilli found (in sputum) by
                                   microscopy.
01124...........................  Tuberculosis of lung with cavitation,
                                   tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01125...........................  Tuberculosis of lung with cavitation,
                                   tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01126...........................  Tuberculosis of lung with cavitation,
                                   tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01130...........................  Tuberculosis of bronchus, unspecified
                                   examination.
01131...........................  Tuberculosis of bronchus,
                                   bacteriological or histological
                                   examination not done.
01132...........................  Tuberculosis of bronchus,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01133...........................  Tuberculosis of bronchus, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01134...........................  Tuberculosis of bronchus, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found in bacterial
                                   culture.
01135...........................  Tuberculosis of bronchus, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01136...........................  Tuberculosis of bronchus, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01140...........................  Tuberculous fibrosis of lung,
                                   unspecified examination.
01141...........................  Tuberculous fibrosis of lung,
                                   bacteriological or histological
                                   examination not done.
01142...........................  Tuberculous fibrosis of lung,
                                   bacteriological or histological
                                   examination unknown (at present).
01143...........................  Tuberculous fibrosis of lung, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01144...........................  Tuberculous fibrosis of lung, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01145...........................  Tuberculous fibrosis of lung, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01146...........................  Tuberculous fibrosis of lung, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01150...........................  Tuberculous bronchiectasis,
                                   unspecified examination.
01151...........................  Tuberculous bronchiectasis,
                                   bacteriological or histological
                                   examination not done.
01152...........................  Tuberculous bronchiectasis,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01153...........................  Tuberculous bronchiectasis, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01154...........................  Tuberculous bronchiectasis, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01155...........................  Tuberculous bronchiectasis, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01156...........................  Tuberculous bronchiectasis, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01170...........................  Tuberculous pneumothorax, unspecified
                                   examination.
01171...........................  Tuberculous pneumothorax,
                                   bacteriological or histological
                                   examination not done.
01172...........................  Tuberculous pneumothorax,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01173...........................  Tuberculous pneumothorax, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01174...........................  Tuberculous pneumothorax, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01175...........................  Tuberculous pneumothorax, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01176...........................  Tuberculous pneumothorax, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01180...........................  Other specified pulmonary
                                   tuberculosis, unspecified
                                   confirmation.
01181...........................  Other specified pulmonary
                                   tuberculosis, bacteriological or
                                   histological examination not done.
01182...........................  Other specified pulmonary
                                   tuberculosis, bacteriological or
                                   histological examination results
                                   unknown (at present).
01183...........................  Other specified pulmonary
                                   tuberculosis, tubercle bacilli found
                                   (in sputum) by microscopy.
01184...........................  Other specified pulmonary
                                   tuberculosis, tubercle bacilli not
                                   found (in sputum) by microscopy, but
                                   found by bacterial culture.
01185...........................  Other specified pulmonary
                                   tuberculosis, tubercle bacilli not
                                   found by bacteriological examination,
                                   but tuberculosis confirmed
                                   histologically.
01186...........................  Other specified pulmonary
                                   tuberculosis, tubercle bacilli not
                                   found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).

[[Page 25015]]

 
01190...........................  Unspecified pulmonary tuberculosis,
                                   confirmation unspecified.
01191...........................  Unspecified pulmonary tuberculosis,
                                   bacteriological or histological
                                   examination not done.
01192...........................  Unspecified pulmonary tuberculosis,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01193...........................  Unspecified pulmonary tuberculosis,
                                   tubercle bacilli found (in sputum) by
                                   microscopy.
01194...........................  Unspecified pulmonary tuberculosis,
                                   tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01195...........................  Unspecified pulmonary tuberculosis,
                                   tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01196...........................  Unspecified pulmonary tuberculosis,
                                   tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01200...........................  Tuberculous pleurisy, confirmation
                                   unspecified.
01201...........................  Tuberculous pleurisy, bacteriological
                                   or histological examination not done.
01202...........................  Tuberculous pleurisy, bacteriological
                                   or histological examination results
                                   unknown (at present).
01203...........................  Tuberculous pleurisy, tubercle bacilli
                                   found (in sputum) by microscopy.
01204...........................  Tuberculous pleurisy, tubercle bacilli
                                   not found (in sputum) by microscopy,
                                   but found by bacterial culture.
01205...........................  Tuberculous pleurisy, tubercle bacilli
                                   not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01206...........................  Tuberculous pleurisy, tubercle bacilli
                                   not found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01210...........................  Tuberculosis of intrathoracic lymph
                                   nodes, confirmation unspecified.
01211...........................  Tuberculosis of intrathoracic lymph
                                   nodes, bacteriological or
                                   histological examination not done.
01212...........................  Tuberculosis of intrathoracic lymph
                                   nodes, bacteriological or
                                   histological examination results
                                   unknown (at present).
01213...........................  Tuberculosis of intrathoracic lymph
                                   nodes, tubercle bacilli found (in
                                   sputum) by microscopy.
01214...........................  Tuberculosis of intrathoracic lymph
                                   nodes, tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01215...........................  Tuberculosis of intrathoracic lymph
                                   nodes, tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01216...........................  Tuberculosis of intrathoracic lymph
                                   nodes, tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01220...........................  Isolated tracheal or bronchial
                                   tuberculosis, unspecified
                                   examination.
01221...........................  Isolated tracheal or bronchial
                                   tuberculosis, bacteriological or
                                   histological examination not done.
01222...........................  Isolated tracheal or bronchial
                                   tuberculosis, bacteriological or
                                   histological examination results
                                   unknown (at present).
01223...........................  Isolated tracheal or bronchial
                                   tuberculosis, tubercle bacilli found
                                   (in sputum) by microscopy.
01224...........................  Isolated tracheal or bronchial
                                   tuberculosis, tubercle bacilli not
                                   found (in sputum) by microscopy, but
                                   found by bacterial culture.
01225...........................  Isolated tracheal or bronchial
                                   tuberculosis, tubercle bacilli not
                                   found by bacteriological examination,
                                   but tuberculosis confirmed
                                   histologically.
01226...........................  Isolated tracheal or bronchial
                                   tuberculosis, tubercle bacilli not
                                   found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01230...........................  Tuberculous laryngitis, unspecified
                                   examination.
01231...........................  Tuberculous laryngitis,
                                   bacteriological or histological
                                   examination not done.
01232...........................  Tuberculous laryngitis,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01233...........................  Tuberculous laryngitis, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01234...........................  Tuberculous laryngitis, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01235...........................  Tuberculous laryngitis, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01236...........................  Tuberculous laryngitis, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01280...........................  Other specified respiratory
                                   tuberculosis, unspecified
                                   examination.
01281...........................  Other specified respiratory
                                   tuberculosis, bacteriological or
                                   histological examination not done.
01282...........................  Other specified respiratory
                                   tuberculosis, bacteriological or
                                   histological examination results
                                   unknown (at present).
01283...........................  Other specified respiratory
                                   tuberculosis, tubercle bacilli found
                                   (in sputum) by microscopy.
01284...........................  Other specified respiratory
                                   tuberculosis, tubercle bacilli not
                                   found (in sputum) by microscopy, but
                                   found by bacterial culture.
01285...........................  Other specified respiratory
                                   tuberculosis, tubercle bacilli not
                                   found by bacteriological examination,
                                   but tuberculosis confirmed
                                   histologically.
01286...........................  Other specified respiratory
                                   tuberculosis, tubercle bacilli not
                                   found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01480...........................  Other tuberculosis of intestines and
                                   mesenteric glands, unspecified
                                   examination.
01481...........................  Other tuberculosis of intestines and
                                   mesenteric glands, bacteriological or
                                   histological examination not done.
01482...........................  Other tuberculosis of intestines and
                                   mesenteric glands, bacteriological or
                                   histological examination results
                                   unknown (at present).
01483...........................  Other tuberculosis of intestines and
                                   mesenteric glands, tubercle bacilli
                                   found (in sputum) by microscopy.
01484...........................  Other tuberculosis of intestines and
                                   mesenteric glands, tubercle bacilli
                                   not found (in sputum) by microscopy,
                                   but found by bacterial culture.
01485...........................  Other tuberculosis of intestines and
                                   mesenteric glands, tubercle bacilli
                                   not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01486...........................  Other tuberculosis of intestines and
                                   mesenteric glands, tubercle bacilli
                                   not found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).

[[Page 25016]]

 
01500...........................  Tuberculosis of vertebral column,
                                   unspecified examination.
01501...........................  Tuberculosis of vertebral column,
                                   bacteriological or histological
                                   examination not done.
01502...........................  Tuberculosis of vertebral column,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01503...........................  Tuberculosis of vertebral column,
                                   tubercle bacilli found (in sputum) by
                                   microscopy.
01504...........................  Tuberculosis of vertebral column,
                                   tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01505...........................  Tuberculosis of vertebral column,
                                   tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01506...........................  Tuberculosis of vertebral column,
                                   tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01510...........................  Tuberculosis of hip, unspecified
                                   examination.
01511...........................  Tuberculosis of hip, bacteriological
                                   or histological examination not done.
01512...........................  Tuberculosis of hip, bacteriological
                                   or histological examination results
                                   unknown (at present).
01513...........................  Tuberculosis of hip, tubercle bacilli
                                   found (in sputum) by microscopy.
01514...........................  Tuberculosis of hip, tubercle bacilli
                                   not found (in sputum) by microscopy,
                                   but found by bacterial culture.
01515...........................  Tuberculosis of hip, tubercle bacilli
                                   not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01516...........................  Tuberculosis of hip, tubercle bacilli
                                   not found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01520...........................  Tuberculosis of knee, unspecified
                                   examination.
01521...........................  Tuberculosis of knee, bacteriological
                                   or histological examination not done.
01522...........................  Tuberculosis of knee, bacteriological
                                   or histological examination results
                                   unknown (at present).
01523...........................  Tuberculosis of knee, tubercle bacilli
                                   found (in sputum) by microscopy.
01524...........................  Tuberculosis of knee, tubercle bacilli
                                   not found (in sputum) by microscopy,
                                   but found by bacterial culture.
01525...........................  Tuberculosis of knee, tubercle bacilli
                                   not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01526...........................  Tuberculosis of knee, tubercle bacilli
                                   not found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01550...........................  Tuberculosis of limb bones,
                                   unspecified examination.
01551...........................  Tuberculosis of limb bones,
                                   bacteriological or histological
                                   examination not done.
01552...........................  Tuberculosis of limb bones,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01553...........................  Tuberculosis of limb bones, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01554...........................  Tuberculosis of limb bones, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01555...........................  Tuberculosis of limb bones, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01556...........................  Tuberculosis of limb bones, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01560...........................  Tuberculosis of mastoid, unspecified
                                   examination.
01561...........................  Tuberculosis of mastoid,
                                   bacteriological or histological
                                   examination not done.
01562...........................  Tuberculosis of mastoid,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01563...........................  Tuberculosis of mastoid, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01564...........................  Tuberculosis of mastoid, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01565...........................  Tuberculosis of mastoid, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01566...........................  Tuberculosis of mastoid, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01570...........................  Tuberculosis of other specified bone,
                                   unspecified examination.
01571...........................  Tuberculosis of other specified bone,
                                   bacteriological or histological
                                   examination not done.
01572...........................  Tuberculosis of other specified bone,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01573...........................  Tuberculosis of other specified bone,
                                   tubercle bacilli found (in sputum) by
                                   microscopy.
01574...........................  Tuberculosis of other specified bone,
                                   tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01575...........................  Tuberculosis of other specified bone,
                                   tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01576...........................  Tuberculosis of other specified bone,
                                   tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01580...........................  Tuberculosis of other specified joint,
                                   unspecified examination.
01581...........................  Tuberculosis of other specified joint,
                                   bacteriological or histological
                                   examination not done.
01582...........................  Tuberculosis of other specified joint,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01583...........................  Tuberculosis of other specified joint,
                                   tubercle bacilli found (in sputum) by
                                   microscopy.
01584...........................  Tuberculosis of other specified joint,
                                   tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01585...........................  Tuberculosis of other specified joint,
                                   tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01586...........................  Tuberculosis of other specified joint,
                                   tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01590...........................  Tuberculosis of unspecified bones and
                                   joints, unspecified examination.
01591...........................  Tuberculosis of unspecified bones and
                                   joints, bacteriological or
                                   histological examination not done.
01592...........................  Tuberculosis of unspecified bones and
                                   joints, bacteriological or
                                   histological examination results
                                   unknown (at present).
01593...........................  Tuberculosis of unspecified bones and
                                   joints, tubercle bacilli found (in
                                   sputum) by microscopy.

[[Page 25017]]

 
01594...........................  Tuberculosis of unspecified bones and
                                   joints, tubercle bacilli not found
                                   (in sputum) by microscopy, but found
                                   by bacterial culture.
01595...........................  Tuberculosis of unspecified bones and
                                   joints, tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01596...........................  Tuberculosis of unspecified bones and
                                   joints, tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01600...........................  Tuberculosis of kidney, unspecified
                                   examination.
01601...........................  Tuberculosis of kidney,
                                   bacteriological or histological
                                   examination not done.
01602...........................  Tuberculosis of kidney,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01603...........................  Tuberculosis of kidney, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01604...........................  Tuberculosis of kidney, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01605...........................  Tuberculosis of kidney, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01606...........................  Tuberculosis of kidney, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01610...........................  Tuberculosis of bladder, unspecified
                                   examination.
01611...........................  Tuberculosis of bladder,
                                   bacteriological or histological
                                   examination not done.
01612...........................  Tuberculosis of bladder,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01613...........................  Tuberculosis of bladder, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01614...........................  Tuberculosis of bladder, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01615...........................  Tuberculosis of bladder, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01616...........................  Tuberculosis of bladder, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01620...........................  Tuberculosis of ureter, unspecified
                                   examination.
01621...........................  Tuberculosis of ureter,
                                   bacteriological or histological
                                   examination not done.
01622...........................  Tuberculosis of ureter,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01623...........................  Tuberculosis of ureter, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01624...........................  Tuberculosis of ureter, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01625...........................  Tuberculosis of ureter, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01626...........................  Tuberculosis of ureter, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01630...........................  Tuberculosis of other urinary organs,
                                   unspecified examination.
01631...........................  Tuberculosis of other urinary organs,
                                   bacteriological or histological
                                   examination not done.
01632...........................  Tuberculosis of other urinary organs,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01633...........................  Tuberculosis of other urinary organs,
                                   tubercle bacilli found (in sputum) by
                                   microscopy.
01634...........................  Tuberculosis of other urinary organs,
                                   tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01635...........................  Tuberculosis of other urinary organs,
                                   tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01636...........................  Tuberculosis of other urinary organs,
                                   tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01640...........................  Tuberculosis of epididymis,
                                   unspecified examination.
01641...........................  Tuberculosis of epididymis,
                                   bacteriological or histological
                                   examination not done.
01642...........................  Tuberculosis of epididymis,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01643...........................  Tuberculosis of epididymis, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01644...........................  Tuberculosis of epididymis, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01645...........................  Tuberculosis of epididymis, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01646...........................  Tuberculosis of epididymis, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01650...........................  Tuberculosis of other male genital
                                   organs, unspecified examination.
01651...........................  Tuberculosis of other male genital
                                   organs, bacteriological or
                                   histological examination not done.
01652...........................  Tuberculosis of other male genital
                                   organs, bacteriological or
                                   histological examination results
                                   unknown (at present).
01653...........................  Tuberculosis of other male genital
                                   organs, tubercle bacilli found (in
                                   sputum) by microscopy.
01654...........................  Tuberculosis of other male genital
                                   organs, tubercle bacilli not found
                                   (in sputum) by microscopy, but found
                                   by bacterial culture.
01655...........................  Tuberculosis of other male genital
                                   organs, tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01656...........................  Tuberculosis of other male genital
                                   organs, tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01660...........................  Tuberculous oophoritis and
                                   salpingitis, unspecified examination.
01661...........................  Tuberculous oophoritis and
                                   salpingitis, bacteriological or
                                   histological examination not done.
01662...........................  Tuberculous oophoritis and
                                   salpingitis, bacteriological or
                                   histological examination results
                                   unknown (at present).
01663...........................  Tuberculous oophoritis and
                                   salpingitis, tubercle bacilli found
                                   (in sputum) by microscopy.
01664...........................  Tuberculous oophoritis and
                                   salpingitis, tubercle bacilli not
                                   found (in sputum) by microscopy, but
                                   found by bacterial culture.
01665...........................  Tuberculous oophoritis and
                                   salpingitis, tubercle bacilli not
                                   found by bacteriological examination,
                                   but tuberculosis confirmed
                                   histologically.

[[Page 25018]]

 
01666...........................  Tuberculous oophoritis and
                                   salpingitis, tubercle bacilli not
                                   found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01670...........................  Tuberculosis of other female genital
                                   organs, unspecified examination.
01671...........................  Tuberculosis of other female genital
                                   organs, bacteriological or
                                   histological examination not done.
01672...........................  Tuberculosis of other female genital
                                   organs, bacteriological or
                                   histological examination results
                                   unknown (at present).
01673...........................  Tuberculosis of other female genital
                                   organs, tubercle bacilli found (in
                                   sputum) by microscopy.
01674...........................  Tuberculosis of other female genital
                                   organs, tubercle bacilli not found
                                   (in sputum) by microscopy, but found
                                   by bacterial culture.
01675...........................  Tuberculosis of other female genital
                                   organs, tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01676...........................  Tuberculosis of other female genital
                                   organs, tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01690...........................  Unspecified genitourinary
                                   tuberculosis, unspecified
                                   examination.
01691...........................  Unspecified genitourinary
                                   tuberculosis, bacteriological or
                                   histological examination not done.
01692...........................  Unspecified genitourinary
                                   tuberculosis, bacteriological or
                                   histological examination results
                                   unknown (at present).
01693...........................  Unspecified genitourinary
                                   tuberculosis, tubercle bacilli found
                                   (in sputum) by microscopy.
01694...........................  Unspecified genitourinary
                                   tuberculosis, tubercle ba cilli not
                                   found (in sputum) by microscopy, but
                                   found by bacterial culture.
01695...........................  Unspecified genitourinary
                                   tuberculosis, tubercle bacilli not
                                   found by bacteriological examination,
                                   but tuberculosis confirmed
                                   histologically.
01696...........................  Unspecified genitourinary
                                   tuberculosis, tubercle bacilli not
                                   found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01700...........................  Tuberculosis of skin and subcutaneous
                                   cellular tissue, unspecified
                                   examination.
01701...........................  Tuberculosis of skin and subcutaneous
                                   cellular tissue, bacteriological or
                                   histological examination not done.
01702...........................  Tuberculosis of skin and subcutaneous
                                   cellular tissue, bacteriological or
                                   histological examination results
                                   unknown (at present).
01703...........................  Tuberculosis of skin and subcutaneous
                                   cellular tissue, tubercle bacilli
                                   found (in sputum) by microscopy.
01704...........................  Tuberculosis of skin and subcutaneous
                                   cellular tissue, tubercle bacilli not
                                   found (in sputum) by microscopy, but
                                   found by bacterial culture.
01705...........................  Tuberculosis of skin and subcutaneous
                                   cellular tissue, tubercle bacilli not
                                   found by bacteriological examination,
                                   but tuberculosis confirmed
                                   histologically.
01706...........................  Tuberculosis of skin and subcutaneous
                                   cellular tissue, tubercle bacilli not
                                   found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01720...........................  Tuberculosis of peripheral lymph
                                   nodes, unspecified examination.
01721...........................  Tuberculosis of peripheral lymph
                                   nodes, bacteriological or
                                   histological examination not done.
01722...........................  Tuberculosis of peripheral lymph
                                   nodes, bacteriological or
                                   histological examination results
                                   unknown (at present).
01723...........................  Tuberculosis of peripheral lymph
                                   nodes, tubercle bacilli found (in
                                   sputum) by microscopy.
01724...........................  Tuberculosis of peripheral lymph
                                   nodes, tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01725...........................  Tuberculosis of peripheral lymph
                                   nodes, tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01726...........................  Tuberculosis of peripheral lymph
                                   nodes, tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01730...........................  Tuberculosis of eye, unspecified
                                   examination.
01731...........................  Tuberculosis of eye, bacteriological
                                   or histological examination not done.
01732...........................  Tuberculosis of eye, bacteriological
                                   or histological examination results
                                   unknown (at present).
01733...........................  Tuberculosis of eye, tubercle bacilli
                                   found (in sputum) by microscopy.
01734...........................  Tuberculosis of eye, tubercle bacilli
                                   not found (in sputum) by microscopy,
                                   but found by bacterial culture.
01735...........................  Tuberculosis of eye, tubercle bacilli
                                   not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01736...........................  Tuberculosis of eye, tubercle bacilli
                                   not found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01740...........................  Tuberculosis of ear, unspecified
                                   examination.
01741...........................  Tuberculosis of ear, bacteriological
                                   or histological examination not done.
01742...........................  Tuberculosis of ear, bacteriological
                                   or histological examination results
                                   unknown (at present).
01743...........................  Tuberculosis of ear, tubercle bacilli
                                   found (in sputum) by microscopy.
01744...........................  Tuberculosis of ear, tubercle bacilli
                                   not found (in sputum) by microscopy,
                                   but found by bacterial culture.
01745...........................  Tuberculosis of ear, tubercle bacilli
                                   not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01746...........................  Tuberculosis of ear, tubercle bacilli
                                   not found by bacteriological or
                                   histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01750...........................  Tuberculosis of thyroid gland,
                                   unspecified origin.
01751...........................  Tuberculosis of thyroid gland,
                                   bacteriological or histological
                                   examination not done.
01752...........................  Tuberculosis of thyroid gland,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01753...........................  Tuberculosis of thyroid gland,
                                   tubercle bacilli found (in sputum) by
                                   microscopy.
01754...........................  Tuberculosis of thyroid gland,
                                   tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01755...........................  Tuberculosis of thyroid gland,
                                   tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.

[[Page 25019]]

 
01756...........................  Tuberculosis of thyroid gland,
                                   tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01760...........................  Tuberculosis of adrenal glands,
                                   unspecified examination.
01761...........................  Tuberculosis of adrenal glands,
                                   bacteriological or histological
                                   examination not done.
01762...........................  Tuberculosis of adrenal glands,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01763...........................  Tuberculosis of adrenal glands,
                                   tubercle bacilli found (in sputum) by
                                   microscopy.
01764...........................  Tuberculosis of adrenal glands,
                                   tubercle bacilli not found (in
                                   sputum) by microscopy, but found by
                                   bacterial culture.
01765...........................  Tuberculosis of adrenal glands,
                                   tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01766...........................  Tuberculosis of adrenal glands,
                                   tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
01770...........................  Tuberculosis of spleen, unspecified
                                   examination.
01771...........................  Tuberculosis of spleen,
                                   bacteriological or histological
                                   examination not done.
01772...........................  Tuberculosis of spleen,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01773...........................  Tuberculosis of spleen, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01774...........................  Tuberculosis of spleen, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01775...........................  Tuberculosis of spleen, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01776...........................  Tuberculosis of spleen, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01780...........................  Tuberculosis of esophagus, unspecified
                                   examination.
01781...........................  Tuberculosis of esophagus,
                                   bacteriological or histological
                                   examination not done.
01782...........................  Tuberculosis of esophagus,
                                   bacteriological or histological
                                   examination results unknown (at
                                   present).
01783...........................  Tuberculosis of esophagus, tubercle
                                   bacilli found (in sputum) by
                                   microscopy.
01784...........................  Tuberculosis of esophagus, tubercle
                                   bacilli not found (in sputum) by
                                   microscopy, but found by bacterial
                                   culture.
01785...........................  Tuberculosis of esophagus, tubercle
                                   bacilli not found by bacteriological
                                   examination, but tuberculosis
                                   confirmed histologically.
01786...........................  Tuberculosis of esophagus, tubercle
                                   bacilli not found by bacteriological
                                   or histological examination, but
                                   tuberculosis confirmed by other
                                   methods (inoculation of animals).
01790...........................  Tuberculosis of other specified
                                   organs, unspecified examination.
01791...........................  Tuberculosis of other specified
                                   organs, bacteriological or
                                   histological examination not done.
01792...........................  Tuberculosis of other specified
                                   organs, bacteriological or
                                   histological examination results
                                   unknown (at present).
01793...........................  Tuberculosis of other specified
                                   organs, tubercle bacilli found (in
                                   sputum) by microscopy.
01794...........................  Tuberculosis of other specified
                                   organs, tubercle bacilli not found
                                   (in sputum) by microscopy, but found
                                   by bacterial culture.
01795...........................  Tuberculosis of other specified
                                   organs, tubercle bacilli not found by
                                   bacteriological examination, but
                                   tuberculosis confirmed
                                   histologically.
01796...........................  Tuberculosis of other specified
                                   organs, tubercle bacilli not found by
                                   bacteriological or histological
                                   examination, but tuberculosis
                                   confirmed by other methods
                                   (inoculation of animals).
0210............................  Ulceroglandular tularemia.
0211............................  Enteric tularemia.
0212............................  Pulmonary tularemia.
0213............................  Oculoglandular tularemia.
0218............................  Other specified tularemia.
0219............................  Unspecified tularemia.
0220............................  Cutaneous anthrax.
0222............................  Gastrointestinal anthrax.
0228............................  Other specified manifestations of
                                   anthrax.
0229............................  Anthrax, unspecified.
0238............................  Other brucellosis.
0239............................  Brucellosis, unspecified.
024.............................  Glanders.
025.............................  Melioidosis.
0260............................  Spirillary fever.
0261............................  Streptobacillary fever.
0269............................  Unspecified rat-bite fever.
0270............................  Listeriosis.
0272............................  Pasteurellosis.
0278............................  Other specified zoonotic bacterial
                                   diseases.
0279............................  Unspecified zoonotic bacterial
                                   disease.
0300............................  Lepromatous leprosy (type L).
0301............................  Tuberculoid leprosy (type T).
0302............................  Indeterminate leprosy (group I).
0303............................  Borderline leprosy (group B).
0308............................  Other specified leprosy.
0309............................  Leprosy, unspecified.
0310............................  Pulmonary diseases due to other
                                   mycobacteria.
0311............................  Cutaneous diseases due to other
                                   mycobacteria.
0312............................  Disseminated mycobacterium.

[[Page 25020]]

 
0318............................  Other specified mycobacterial
                                   diseases.
0319............................  Unspecified diseases due to
                                   mycobacteria.
0320............................  Faucial diphtheria.
0321............................  Nasopharyngeal diphtheria.
0322............................  Anterior nasal diphtheria.
0323............................  Laryngeal diphtheria.
03281...........................  Conjunctival diphtheria.
03282...........................  Diphtheritic myocarditis.
03283...........................  Diphtheritic peritonitis.
03284...........................  Diphtheritic cystitis.
03285...........................  Cutaneous diphtheria.
03289...........................  Other specified diphtheria.
0329............................  Diphtheria, unspecified.
0330............................  Whooping cough due to bordetella
                                   pertussis (b. pertussis).
0331............................  Whooping cough due to bordetella
                                   parapertussis (b. parapertussis).
0338............................  Whooping cough due to other specified
                                   organism.
0339............................  Whooping cough, unspecified organism.
0341............................  Scarlet fever.
03681...........................  Meningococcal optic neuritis.
03682...........................  Meningococcal arthropathy.
03689...........................  Other specified meningococcal
                                   infections.
0369............................  Meningococcal infection, unspecified.
0390............................  Cutaneous actinomycotic infection.
0391............................  Pulmonary actinomycotic infection.
0392............................  Abdominal actinomycotic infection.
0393............................  Cervicofacial actinomycotic infection.
0394............................  Madura foot.
0398............................  Actinomycotic infection of other
                                   specified sites.
0399............................  Actinomycotic infection of unspecified
                                   site.
0402............................  Whipple's disease.
0403............................  Necrobacillosis.
04041...........................  Infant botulism.
04042...........................  Wound botulism.
04081...........................  Tropical pyomyositis.
0460............................  Kuru.
0461............................  Jakob-creutzfeldt disease.
0462............................  Subacute sclerosing panencephalitis.
0463............................  Progressive multifocal
                                   leukoencephalopathy.
0468............................  Other specified slow virus infection
                                   of central nervous system.
0469............................  Unspecified slow virus infection of
                                   central nervous system.
0470............................  Meningitis due to coxsackie virus.
0471............................  Meningitis due to echo virus.
0478............................  Other specified viral meningitis.
0479............................  Unspecified viral meningitis.
048.............................  Other enterovirus diseases of central
                                   nervous system.
0490............................  Non-arthopod borne lymphocytic
                                   choriomeningitis.
0491............................  Non-arthopod borne meningitis due to
                                   adenovirus.
0498............................  Other specified non-arthropod-borne
                                   viral diseases of central nervous
                                   system.
0499............................  Unspecified non-arthropod-borne viral
                                   diseases of central nervous system.
0500............................  Variola major.
0501............................  Alastrim.
0502............................  Modified smallpox.
0509............................  Smallpox, unspecified.
0527............................  Chickenpox with other specified
                                   complications.
0528............................  Chickenpox with unspecified
                                   complication.
0529............................  Varicella without mention of
                                   complication.
05310...........................  Herpes zoster with unspecified nervous
                                   system complication.
05311...........................  Geniculate herpes zoster.
05312...........................  Postherpetic trigeminal neuralgia.
05313...........................  Postherpetic polyneuropathy.
05319...........................  Herpes zoster with other nervous
                                   system complications.
05320...........................  Herpes zoster dermatitis of eyelid.
05321...........................  Herpes zoster keratoconjunctivitis.
05322...........................  Herpes zoster iridocyclitis.
05329...........................  Herpes zoster with other ophthalmic
                                   complications.
05371...........................  Otitis externa due to herpes zoster.
05379...........................  Herpes zoster with other specified
                                   complications.
0538............................  Herpes zoster with unspecified
                                   complication.
0542............................  Herpetic gingivostomatitis.
05440...........................  Herpes simplex with unspecified
                                   ophthalmic complication.
05441...........................  Herpes simplex dermatitis of eyelid.
05442...........................  Dendritic keratitis.

[[Page 25021]]

 
05443...........................  Herpes simplex disciform keratitis.
05444...........................  Herpes simplex iridocyclitis.
05449...........................  Herpes simplex with other ophthalmic
                                   complications.
05471...........................  Visceral herpes simplex.
05479...........................  Herpes simplex with other specified
                                   complications.
05571...........................  Measles keratoconjunctivitis.
05579...........................  Measles with other specified
                                   complications.
05600...........................  Rubella with unspecified neurological
                                   complication.
05609...........................  Rubella with other neurological
                                   complications.
05671...........................  Arthritis due to rubella.
05679...........................  Rubella with other specified
                                   complications.
0570............................  Erythema infectiosum (fifth disease).
0600............................  Sylvatic yellow fever.
0601............................  Urban yellow fever.
0609............................  Yellow fever, unspecified.
061.............................  Dengue.
0650............................  Crimean hemorrhagic fever (chf congo
                                   virus).
0651............................  Omsk hemorrhagic fever.
0652............................  Kyasanur forest disease.
0653............................  Other tick-borne hemorrhagic fever.
0654............................  Mosquito-borne hemorrhagic fever.
0658............................  Other specified arthropod-borne
                                   hemorrhagic fever.
0659............................  Arthropod-borne hemorrhagic fever,
                                   unspecified.
0660............................  Phlebotomus fever.
0661............................  Tick-borne fever.
0662............................  Venezuelan equine fever.
0663............................  Other mosquito-borne fever.
0668............................  Other specified arthropod-borne viral
                                   diseases.
0669............................  Arthropod-borne viral disease,
                                   unspecified.
0701............................  Viral hepatitis a without mention of
                                   hepatic coma.
07030...........................  Viral hepatitis b without mention of
                                   hepatic coma, acute or unspecified,
                                   without mention of hepatitis delta.
07031...........................  Viral hepatitis b without mention of
                                   hepatic coma, acute or unspecified,
                                   with hepatitis delta.
07032...........................  Chronic viral hepatitis b without
                                   mention of hepatic coma without
                                   mention of hepatitis delta.
07033...........................  Chronic viral hepatitis b without
                                   mention of hepatic coma with
                                   hepatitis delta.
07051...........................  Acute hepatitis C without mention of
                                   hepatic coma.
07052...........................  Hepatitis delta without mention of
                                   active hepatitis B disease or hepatic
                                   coma.
07053...........................  Hepatitis E without mention of hepatic
                                   coma.
07059...........................  Other specified viral hepatitis
                                   without mention of hepatic coma.
0709............................  Unspecified viral hepatitis without
                                   mention of hepatic coma.
071.............................  Rabies.
0720............................  Mumps orchitis.
0723............................  Mumps pancreatitis.
07271...........................  Mumps hepatitis.
07272...........................  Mumps polyneuropathy.
07279...........................  Mumps with other specified
                                   complications.
0728............................  Mumps with unspecified complication.
0737............................  Ornithosis with other specified
                                   complications.
0738............................  Ornithosis with unspecified
                                   complication.
0739............................  Ornithosis, unspecified.
07420...........................  Coxsackie carditis, unspecified.
07421...........................  Coxsackie pericarditis.
07422...........................  Coxsackie endocarditis.
07423...........................  Coxsackie myocarditis.
0783............................  Cat-scratch disease.
0785............................  Cytomegaloviral disease.
0786............................  Hemorrhagic nephrosonephritis.
0787............................  Arenaviral hemorrhagic fever.
07951...........................  Human t-cell lymphotrophic virus, type
                                   i [HTLV-I].
07952...........................  Human t-cell lymphotrophic virus, type
                                   ii [HTLV-II].
07953...........................  Human immunodeficiency virus, type 2
                                   [HIV-2].
07981...........................  Hantaviris infection.
07982...........................  Sars-assoc coronavirus.
07983...........................  Parvovirus B19.
080.............................  Louse-borne (epidemic) typhus.
0810............................  Murine (endemic) typhus.
0811............................  Brill's disease.
0812............................  Scrub typhus.
0819............................  Typhus, unspecified.
0820............................  Spotted fevers.
0821............................  Boutonneuse fever.
0822............................  North asian tick fever.
0823............................  Queensland tick typhus.

[[Page 25022]]

 
08240...........................  Unspecified ehrlichiosis.
08241...........................  Ehrlichiosis chafeensis (e
                                   chafeensis).
08249...........................  Other ehrlichiosis.
0828............................  Other specified tick-borne
                                   rickettsioses.
0829............................  Tick-borne rickettsiosis, unspecified.
0830............................  Q fever.
0831............................  Trench fever.
0832............................  Rickettsialpox.
0838............................  Other specified rickettsioses.
0839............................  Rickettsiosis, unspecified.
0841............................  Vivax malaria (benign tertian).
0842............................  Quartan malaria.
0843............................  Ovale malaria.
0844............................  Other malaria.
0845............................  Mixed malaria.
0846............................  Malaria, unspecified.
0847............................  Induced malaria.
0848............................  Blackwater fever.
0849............................  Other pernicious complications of
                                   malaria.
0850............................  Leishmaniasis visceral (kala-azar).
0851............................  Cutaneous leishmaniasis, urban.
0852............................  Cutaneous leishmaniasis, asian desert.
0853............................  Cutaneous leishmaniasis, ethiopian.
0854............................  Cutaneous leishmaniasis, american.
0855............................  Mucocutaneous leishmaniasis,
                                   (american).
0859............................  Leishmaniasis, unspecified.
0860............................  Chagas' disease with heart
                                   involvement.
0861............................  Chagas' disease with other organ
                                   involvement.
0862............................  Chagas' disease without mention of
                                   organ involvement.
0863............................  Gambian trypanosomiasis.
0864............................  Rhodesian trypanosomiasis.
0865............................  African trypanosomiasis, unspecified.
0869............................  Trypanosomiasis, unspecified.
0870............................  Relapsing fever, louse-borne.
0871............................  Relapsing fever, tick-borne.
0879............................  Relapsing fever, unspecified.
0880............................  Bartonellosis.
08881...........................  Lyme disease.
08882...........................  Babesiosis.
0900............................  Early congenital syphilis,
                                   symptomatic.
0902............................  Early congenital syphilis,
                                   unspecified.
0903............................  Syphilitic interstitial keratitis.
09040...........................  Juvenile neurosyphilis, unspecified.
09049...........................  Other juvenile neurosyphilis.
0905............................  Other late congenital syphilis,
                                   symptomatic.
0913............................  Secondary syphilis of skin or mucous
                                   membranes.
0914............................  Adenopathy due to secondary syphilis.
09150...........................  Syphilitic uveitis, unspecified.
09151...........................  Syphilitic chorioretinitis
                                   (secondary).
09152...........................  Syphilitic iridocyclitis (secondary).
09161...........................  Secondary syphilitic periostitis.
09162...........................  Secondary syphilitic hepatitis.
09169...........................  Secondary syphilis of other viscera.
0917............................  Secondary syphilis, relapse.
09182...........................  Syphilitic alopecia.
09189...........................  Other forms of secondary syphilis.
0919............................  Unspecified secondary syphilis.
0930............................  Aneurysm of aorta, specified as
                                   syphilitic.
0931............................  Syphilitic aortitis.
09320...........................  Syphilitic endocarditis of valve,
                                   unspecified.
09321...........................  Syphilitic endocarditis of mitral
                                   valve.
09322...........................  Syphilitic endocarditis of aortic
                                   valve.
09323...........................  Syphilitic endocarditis of tricuspid
                                   valve.
09324...........................  Syphilitic endocarditis of pulmonary
                                   valve.
09381...........................  Syphilitic pericarditis.
09382...........................  Syphilitic myocarditis.
09389...........................  Other specified cardiovascular
                                   syphilis.
0939............................  Cardiovascular syphilis, unspecified.
0940............................  Tabes dorsalis.
0941............................  General paresis.
0943............................  Asymptomatic neurosyphilis.
09482...........................  Syphilitic parkinsonism.

[[Page 25023]]

 
09483...........................  Syphilitic disseminated
                                   retinochoroiditis.
09484...........................  Syphilitic optic atrophy.
09485...........................  Syphilitic retrobulbar neuritis.
09486...........................  Syphilitic acoustic neuritis.
09489...........................  Other specified neurosyphilis.
0949............................  Neurosyphilis, unspecified.
0950............................  Syphilitic episcleritis.
0951............................  Syphilis of lung.
0952............................  Syphilitic peritonitis.
0953............................  Syphilis of liver.
0954............................  Syphilis of kidney.
0955............................  Syphilis of bone.
0956............................  Syphilis of muscle.
0957............................  Syphilis of synovium, tendon, and
                                   bursa.
0958............................  Other specified forms of late
                                   symptomatic syphilis.
0959............................  Late symptomatic syphilis,
                                   unspecified.
0980............................  Gonococcal infection (acute) of lower
                                   genitourinary tract.
09810...........................  Gonococcal infection (acute) of upper
                                   genitourinary tract, site
                                   unspecified.
09811...........................  Gonococcal cystitis (acute).
09812...........................  Gonococcal prostatitis (acute).
09813...........................  Gonococcal epididymo-orchitis (acute).
09814...........................  Gonococcal seminal vesiculitis
                                   (acute).
09815...........................  Gonococcal cervicitis (acute).
09816...........................  Gonococcal endometritis (acute).
09817...........................  Gonococcal salpingitis, specified as
                                   acute.
09819...........................  Other gonococcal infection (acute) of
                                   upper genitourinary tract.
09840...........................  Gonococcal conjunctivitis
                                   (neonatorum).
09841...........................  Gonococcal iridocyclitis.
09842...........................  Gonococcal endophthalmia.
09843...........................  Gonococcal keratitis.
09849...........................  Other gonococcal infection of eye.
09850...........................  Gonococcal arthritis.
09851...........................  Gonococcal synovitis and
                                   tenosynovitis.
09852...........................  Gonococcal bursitis.
09853...........................  Gonococcal spondylitis.
09859...........................  Other gonococcal infection of joint.
09881...........................  Gonococcal keratosis (blennorrhagica).
09885...........................  Other gonococcal heart disease.
09886...........................  Gonococcal peritonitis.
09889...........................  Gonococcal infection of other
                                   specified sites.
09956...........................  Other venereal diseases due to
                                   chlamydia trachomatis, peritoneum.
1000............................  Leptospirosis icterohemorrhagica.
10089...........................  Other specified leptospiral
                                   infections.
1009............................  Leptospirosis, unspecified.
101.............................  Vincent's angina.
1120............................  Candidiasis of mouth.
1122............................  Candidiasis of other urogenital sites.
11282...........................  Candidal otitis externa.
11284...........................  Candidal esophagitis.
11285...........................  Candidal enteritis.
11289...........................  Other candidiasis of other specified
                                   sites.
1140............................  Primary coccidioidomycosis
                                   (pulmonary).
1141............................  Primary extrapulmonary
                                   coccidioidomycosis.
1143............................  Other forms of progressive
                                   coccidioidomycosis.
1144............................  Chronic pulmonary coccidioidomycosis.
1145............................  Pulmonary coccidioidomycosis,
                                   unspecified.
1149............................  Coccidioidomycosis, unspecified.
11502...........................  Histoplasma capsulatum retinitis.
11509...........................  Infection by histoplasma capsulatum,
                                   with mention of other manifestation.
11512...........................  Histoplasma duboisii retinitis.
11519...........................  Infection by histoplasma duboisii with
                                   mention of other manifestation.
11592...........................  Histoplasmosis retinitis, unspecified.
1160............................  Blastomycosis.
1161............................  Paracoccidioidomycosis.
1173............................  Aspergillosis.
1174............................  Mycotic mycetomas.
1175............................  Cryptococcosis.
1176............................  Allescheriosis (petriellidosis).
1178............................  Infection by dematiacious fungi,
                                   (phaehyphomycosis).
1179............................  Other and unspecified mycoses.
118.............................  Opportunistic mycoses.
1200............................  Schistosomiasis due to schistosoma
                                   haematobium.

[[Page 25024]]

 
1201............................  Schistosomiasis due to schistosoma
                                   mansoni.
1202............................  Schistosomiasis due to schistosoma
                                   japonicum.
1203............................  Cutaneous schistosomiasis.
1208............................  Other specified schistosomiasis.
1209............................  Schistosomiasis, unspecified.
1210............................  Opisthorchiasis.
1211............................  Clonorchiasis.
1212............................  Paragonimiasis.
1213............................  Fascioliasis.
1214............................  Fasciolopsiasis.
1215............................  Metagonimiasis.
1216............................  Heterophyiasis.
1218............................  Other specified trematode infections.
1220............................  Echinococcus granulosus infection of
                                   liver.
1221............................  Echinococcus granulosus infection of
                                   lung.
1222............................  Echinococcus granulosus infection of
                                   thyroid.
1223............................  Echinococcus granulosus infection,
                                   other.
1224............................  Echinococcus granulosus infection,
                                   unspecified.
1225............................  Echinococcus multilocularis infection
                                   of liver.
1226............................  Echinococcus multilocularis infection,
                                   other.
1227............................  Echinococcus multilocularis infection,
                                   unspecified.
1228............................  Echinococcosis, unspecified, of liver.
1229............................  Echinococcosis, other and unspecified.
1230............................  Taenia solium infection, intestinal
                                   form.
1231............................  Cysticercosis.
1232............................  Taenia saginata infection.
1233............................  Taeniasis, unspecified.
1234............................  Diphyllobothriasis, intestinal.
1235............................  Sparganosis (larval
                                   diphyllobothriasis).
1236............................  Hymenolepiasis.
1238............................  Other specified cestode infection.
124.............................  Trichinosis.
1250............................  Bancroftian filariasis.
1251............................  Malayan filariasis.
1252............................  Loiasis.
1253............................  Onchocerciasis.
1254............................  Dipetalonemiasis.
1255............................  Mansonella ozzardi infection.
1256............................  Other specified filariasis.
1257............................  Dracontiasis.
1259............................  Unspecified filariasis.
1260............................  Ancylostomiasis due to ancylostoma
                                   duodenale.
1261............................  Necatoriasis due to necator
                                   americanus.
1262............................  Ancylostomiasis due to ancylostoma
                                   braziliense.
1263............................  Ancylostomiasis due to ancylostoma
                                   ceylanicum.
1268............................  Other specified ancylostoma.
1269............................  Ancylostomiasis and necatoriasis,
                                   unspecified.
1270............................  Ascariasis.
1271............................  Anisakiasis.
1272............................  Strongyloidiasis.
1273............................  Trichuriasis.
1274............................  Enterobiasis.
1275............................  Capillariasis.
1276............................  Trichostrongyliasis.
1277............................  Other specified intestinal
                                   helminthiasis.
1278............................  Mixed intestinal helminthiasis.
1279............................  Intestinal helminthiasis, unspecified.
1301............................  Conjunctivitis due to toxoplasmosis.
1302............................  Chorioretinitis due to toxoplasmosis.
1305............................  Hepatitis due to toxoplasmosis.
1307............................  Toxoplasmosis of other specified
                                   sites.
1309............................  Toxoplasmosis, unspecified.
1364............................  Psorospermiasis.
1365............................  Sarcosporidiosis.
1500............................  Malignant neoplasm of cervical
                                   esophagus.
1501............................  Malignant neoplasm of thoracic
                                   esophagus.
1502............................  Malignant neoplasm of abdominal
                                   esophagus.
1503............................  Malignant neoplasm of upper third of
                                   esophagus.
1504............................  Malignant neoplasm of middle third of
                                   esophagus.
1505............................  Malignant neoplasm of lower third of
                                   esophagus.
1508............................  Malignant neoplasm of other specified
                                   part of esophagus.
1509............................  Malignant neoplasm of esophagus,
                                   unspecified site.

[[Page 25025]]

 
1510............................  Malignant neoplasm of cardia.
1511............................  Malignant neoplasm of pylorus.
1512............................  Malignant neoplasm of pyloric antrum.
1513............................  Malignant neoplasm of fundus of
                                   stomach.
1514............................  Malignant neoplasm of body of stomach.
1515............................  Malignant neoplasm of lesser curvature
                                   of stomach, unspecified.
1516............................  Malignant neoplasm of greater
                                   curvature of stomach, unspecified.
1518............................  Malignant neoplasm of other specified
                                   sites of stomach.
1519............................  Malignant neoplasm of stomach,
                                   unspecified site.
1520............................  Malignant neoplasm of duodenum.
1521............................  Malignant neoplasm of jejunum.
1522............................  Malignant neoplasm of ileum.
1523............................  Malignant neoplasm of meckel's
                                   diverticulum.
1528............................  Malignant neoplasm of other specified
                                   sites of small intestine.
1529............................  Malignant neoplasm of small intestine,
                                   unspecified site.
1530............................  Malignant neoplasm of hepatic flexure.
1531............................  Malignant neoplasm of transverse
                                   colon.
1532............................  Malignant neoplasm of descending
                                   colon.
1533............................  Malignant neoplasm of sigmoid colon.
1534............................  Malignant neoplasm of cecum.
1535............................  Malignant neoplasm of appendix
                                   vermiformis.
1536............................  Malignant neoplasm of ascending colon.
1537............................  Malignant neoplasm of splenic flexure.
1538............................  Malignant neoplasm of other specified
                                   sites of large intestine.
1539............................  Malignant neoplasm of colon,
                                   unspecified site.
1540............................  Malignant neoplasm of rectosigmoid
                                   junction.
1541............................  Malignant neoplasm of rectum.
1542............................  Malignant neoplasm of anal canal.
1543............................  Malignant neoplasm of anus,
                                   unspecified site.
1548............................  Malignant neoplasm of other sites of
                                   rectum, rectosigmoid junction, and
                                   anus.
1550............................  Malignant neoplasm of liver, primary.
1551............................  Malignant neoplasm of intrahepatic
                                   bile ducts.
1552............................  Malignant neoplasm of liver, not
                                   specified as primary or secondary.
1560............................  Malignant neoplasm of gallbladder.
1561............................  Malignant neoplasm of extrahepatic
                                   bile ducts.
1562............................  Malignant neoplasm of ampulla of
                                   vater.
1568............................  Malignant neoplasm of other specified
                                   sites of gallbladder and extrahepatic
                                   bile ducts.
1569............................  Malignant neoplasm of biliary tract,
                                   part unspecified site.
1570............................  Malignant neoplasm of head of
                                   pancreas.
1571............................  Malignant neoplasm of body of
                                   pancreas.
1572............................  Malignant neoplasm of tail of
                                   pancreas.
1573............................  Malignant neoplasm of pancreatic duct.
1574............................  Malignant neoplasm of islets of
                                   langerhans.
1578............................  Malignant neoplasm of other specified
                                   sites of pancreas.
1579............................  Malignant neoplasm of pancreas, part
                                   unspecified.
1580............................  Malignant neoplasm of retroperitoneum.
1588............................  Malignant neoplasm of specified parts
                                   of peritoneum.
1589............................  Malignant neoplasm of peritoneum,
                                   unspecified.
1620............................  Malignant neoplasm of trachea.
1622............................  Malignant neoplasm of main bronchus.
1623............................  Malignant neoplasm of upper lobe,
                                   bronchus or lung.
1624............................  Malignant neoplasm of middle lobe,
                                   bronchus or lung.
1625............................  Malignant neoplasm of lower lobe,
                                   bronchus or lung.
1628............................  Malignant neoplasm of other parts of
                                   bronchus or lung.
1629............................  Malignant neoplasm of bronchus and
                                   lung, unspecified.
1630............................  Malignant neoplasm of parietal pleura.
1631............................  Malignant neoplasm of visceral pleura.
1638............................  Malignant neoplasm of other specified
                                   sites of pleura.
1639............................  Malignant neoplasm of pleura,
                                   unspecified.
1640............................  Malignant neoplasm of thymus.
1641............................  Malignant neoplasm of heart.
1642............................  Malignant neoplasm of anterior
                                   mediastinum.
1643............................  Malignant neoplasm of posterior
                                   mediastinum.
1648............................  Malignant neoplasm of other parts of
                                   mediastinum.
1649............................  Malignant neoplasm of mediastinum,
                                   part unspecified.
1700............................  Malignant neoplasm of bones of skull
                                   and face, except mandible.
1701............................  Malignant neoplasm of mandible.
1702............................  Malignant neoplasm of vertebral
                                   column, excluding sacrum and coccyx.
1703............................  Malignant neoplasm of ribs, sternum,
                                   and clavicle.
1704............................  Malignant neoplasm of scapula and long
                                   bones of upper limb.
1705............................  Malignant neoplasm of short bones of
                                   upper limb.
1706............................  Malignant neoplasm of pelvic bones,
                                   sacrum, and coccyx.

[[Page 25026]]

 
1707............................  Malignant neoplasm of long bones of
                                   lower limb.
1708............................  Malignant neoplasm of short bones of
                                   lower limb.
1709............................  Malignant neoplasm of bone and
                                   articular cartilage, site
                                   unspecified.
1710............................  Malignant neoplasm of connective and
                                   other soft tissue of head, face, and
                                   neck.
1712............................  Malignant neoplasm of connective and
                                   other soft tissue of upper limb,
                                   including shoulder.
1713............................  Malignant neoplasm of connective and
                                   other soft tissue of lower limb,
                                   including hip.
1714............................  Malignant neoplasm of connective and
                                   other soft tissue of thorax.
1715............................  Malignant neoplasm of connective and
                                   other soft tissue of abdomen.
1716............................  Malignant neoplasm of connective and
                                   other soft tissue of pelvis.
1717............................  Malignant neoplasm of connective and
                                   other soft tissue of trunk,
                                   unspecified.
1718............................  Malignant neoplasm of other specified
                                   sites of connective and other soft
                                   tissue.
1719............................  Malignant neoplasm of connective and
                                   other soft tissue, site unspecified.
1760............................  Kaposi's sarcoma, skin.
1761............................  Kaposi's sarcoma, soft tissue.
1762............................  Kaposi's sarcoma, palate.
1763............................  Kaposi's sarcoma, gastrointestinal
                                   sites.
1764............................  Kaposi's sarcoma, lung.
1765............................  Kaposi's sarcoma, lymph nodes.
1768............................  Kaposi's sarcoma, other specified
                                   sites.
1769............................  Kaposi's sarcoma, unspecified site.
1830............................  Malignant neoplasm of ovary.
1890............................  Malignant neoplasm of kidney, except
                                   pelvis.
1891............................  Malignant neoplasm of renal pelvis.
1892............................  Malignant neoplasm of ureter.
1893............................  Malignant neoplasm of urethra.
1894............................  Malignant neoplasm of paraurethral
                                   glands.
1898............................  Malignant neoplasm of other specified
                                   sites of urinary organs.
1899............................  Malignant neoplasm of urinary organ,
                                   site unspecified.
1910............................  Malignant neoplasm of cerebrum, except
                                   lobes and ventricles.
1911............................  Malignant neoplasm of frontal lobe.
1912............................  Malignant neoplasm of temporal lobe.
1913............................  Malignant neoplasm of parietal lobe.
1914............................  Malignant neoplasm of occipital lobe.
1915............................  Malignant neoplasm of ventricles.
1916............................  Malignant neoplasm of cerebellum nos.
1917............................  Malignant neoplasm of brain stem.
1918............................  Malignant neoplasm of other parts of
                                   brain.
1919............................  Malignant neoplasm of brain,
                                   unspecified site.
1920............................  Malignant neoplasm of cranial nerves.
1921............................  Malignant neoplasm of cerebral
                                   meninges.
1922............................  Malignant neoplasm of spinal cord.
1923............................  Malignant neoplasm of spinal meninges.
1928............................  Malignant neoplasm of other specified
                                   sites of nervous system.
1929............................  Malignant neoplasm of nervous system,
                                   part unspecified.
1940............................  Malignant neoplasm of adrenal gland.
1941............................  Malignant neoplasm of parathyroid
                                   gland.
1943............................  Malignant neoplasm of pituitary gland
                                   and craniopharyngeal duct.
1944............................  Malignant neoplasm of pineal gland.
1945............................  Malignant neoplasm of carotid body.
1946............................  Malignant neoplasm of aortic body and
                                   other paraganglia.
1948............................  Malignant neoplasm of other endocrine
                                   glands and related structures.
1949............................  Malignant neoplasm of endocrine gland,
                                   site unspecified.
1960............................  Secondary and unspecified malignant
                                   neoplasm of lymph nodes of head,
                                   face, and neck.
1961............................  Secondary and unspecified malignant
                                   neoplasm of intrathoracic lymph
                                   nodes.
1962............................  Secondary and unspecified malignant
                                   neoplasm of intra-abdominal lymph
                                   nodes.
1963............................  Secondary and unspecified malignant
                                   neoplasm of lymph nodes of axilla and
                                   upper limb.
1965............................  Secondary and unspecified malignant
                                   neoplasm of lymph nodes of inguinal
                                   region and lower limb.
1966............................  Secondary and unspecified malignant
                                   neoplasm of intrapelvic lymph nodes.
1968............................  Secondary and unspecified malignant
                                   neoplasm of lymph nodes of multiple
                                   sites.
1969............................  Secondary and unspecified malignant
                                   neoplasm of lymph nodes, site
                                   unspecified.
1970............................  Secondary malignant neoplasm of lung.
1971............................  Secondary malignant neoplasm of
                                   mediastinum.
1972............................  Secondary malignant neoplasm of
                                   pleura.
1973............................  Secondary malignant neoplasm of other
                                   respiratory organs.
1974............................  Secondary malignant neoplasm of small
                                   intestine including duodenum.
1975............................  Secondary malignant neoplasm of large
                                   intestine and rectum.
1976............................  Secondary malignant neoplasm of
                                   retroperitoneum and peritoneum.
1977............................  Malignant neoplasm of liver,
                                   secondary.
1978............................  Secondary malignant neoplasm of other
                                   digestive organs and spleen.
1980............................  Secondary malignant neoplasm of
                                   kidney.
1981............................  Secondary malignant neoplasm of other
                                   urinary organs.
1982............................  Secondary malignant neoplasm of skin.

[[Page 25027]]

 
1983............................  Secondary malignant neoplasm of brain
                                   and spinal cord.
1984............................  Secondary malignant neoplasm of other
                                   parts of nervous system.
1985............................  Secondary malignant neoplasm of bone
                                   and bone marrow.
1986............................  Secondary malignant neoplasm of ovary.
1987............................  Secondary malignant neoplasm of
                                   adrenal gland.
19881...........................  Secondary malignant neoplasm of
                                   breast.
19882...........................  Secondary malignant neoplasm of
                                   genital organs.
19889...........................  Secondary malignant neoplasm of other
                                   specified sites.
1990............................  Disseminated malignant neoplasm.
20000...........................  Reticulosarcoma, unspecified site.
20001...........................  Reticulosarcoma involving lymph nodes
                                   of head, face, and neck.
20002...........................  Reticulosarcoma involving
                                   intrathoracic lymph nodes.
20003...........................  Reticulosarcoma involving intra-
                                   abdominal lymph nodes.
20004...........................  Reticulosarcoma involving lymph nodes
                                   of axilla and upper limb.
20005...........................  Reticulosarcoma involving lymph nodes
                                   of inguinal region and lower limb.
20006...........................  Reticulosarcoma involving intrapelvic
                                   lymph nodes.
20007...........................  Reticulosarcoma involving spleen.
20008...........................  Reticulosarcoma involving lymph nodes
                                   of multiple sites.
20010...........................  Lymphosarcoma, unspecified site.
20011...........................  Lymphosarcoma involving lymph nodes of
                                   head, face, and neck.
20012...........................  Lymphosarcoma involving intrathoracic
                                   lymph nodes.
20013...........................  Lymphosarcoma involving intra-
                                   abdominal lymph nodes.
20014...........................  Lymphosarcoma involving lymph nodes of
                                   axilla and upper limb.
20015...........................  Lymphosarcoma involving lymph nodes of
                                   inguinal region and lower limb.
20016...........................  Lymphosarcoma involving intrapelvic
                                   lymph nodes.
20017...........................  Lymphosarcoma involving spleen.
20018...........................  Lymphosarcoma involving lymph nodes of
                                   multiple sites.
20020...........................  Burkitt's tumor or lymphoma,
                                   unspecified site.
20021...........................  Burkitt's tumor or lymphoma involving
                                   lymph nodes of head, face, and neck.
20022...........................  Burkitt's tumor or lymphoma involving
                                   intrathoracic lymph nodes.
20023...........................  Burkitt's tumor or lymphoma involving
                                   intra-abdominal lymph nodes.
20024...........................  Burkitt's tumor or lymphoma involving
                                   lymph nodes of axilla and upper limb.
20025...........................  Burkitt's tumor or lymphoma involving
                                   lymph nodes of inguinal region and
                                   lower limb.
20026...........................  Burkitt's tumor or lymphoma involving
                                   intrapelvic lymph nodes.
20027...........................  Burkitt's tumor or lymphoma involving
                                   spleen.
20028...........................  Burkitt's tumor or lymphoma involving
                                   lymph nodes of multiple sites.
20030...........................  Marginal zone lymphoma, unspecified
                                   site, extranodal and solid organ
                                   sites.
20031...........................  Marginal zone lymphoma, lymph nodes of
                                   head, face, and neck.
20032...........................  Marginal zone lymphoma, intrathoracic
                                   lymph nodes.
20033...........................  Marginal zone lymphoma, intraabdominal
                                   lymph nodes.
20034...........................  Marginal zone lymphoma, lymph nodes of
                                   axilla and upper limb.
20035...........................  Marginal zone lymphoma, lymph nodes of
                                   inguinal region and lower limb.
20036...........................  Marginal zone lymphoma, intrapelvic
                                   lymph nodes.
20037...........................  Marginal zone lymphoma, spleen.
20038...........................  Marginal zone lymphoma, lymph nodes of
                                   multiple sites.
20040...........................  Mantle cell lymphoma, unspecified
                                   site, extranodal and solid organ
                                   sites.
20041...........................  Mantle cell lymphoma, lymph nodes of
                                   head, face, and neck.
20042...........................  Mantle cell lymphoma, intrathoracic
                                   lymph nodes.
20043...........................  Mantle cell lymphoma, intra-abdominal
                                   lymph nodes.
20044...........................  Mantle cell lymphoma, lymph nodes of
                                   axilla and upper limb.
20045...........................  Mantle cell lymphoma,lymph nodes of
                                   inguinal region and lower limb.
20046...........................  Mantle cell lymphoma, intrapelvic
                                   lymph nodes.
20047...........................  Mantle cell lymphoma, spleen.
20048...........................  Mantle cell lymphoma, lymph nodes of
                                   multiple sites.
20050...........................  Primary central nervous system
                                   lymphoma, unspecified site,
                                   extranodal and solid organ sites.
20051...........................  Primary central nervous system
                                   lymphoma, lymph nodes of head, face,
                                   and neck.
20052...........................  Primary central nervous system
                                   lymphoma, intrathoracic lymph nodes.
20053...........................  Primary central nervous system
                                   lymphoma, intra-abdominal lymph
                                   nodes.
20054...........................  Primary central nervous system
                                   lymphoma, lymph nodes of axilla and
                                   upper limb.
20055...........................  Primary central nervous system
                                   lymphoma, lymph nodes of inguinal
                                   region and lower limb.
20056...........................  Primary central nervous system
                                   lymphoma, intrapelvic lymph nodes.
20057...........................  Primary central nervous system
                                   lymphoma, spleen.
20058...........................  Primary central nervous system
                                   lymphoma, lymph nodes of multiple
                                   sites.
20060...........................  Anaplastic large cell lymphoma,
                                   unspecified site, extranodal and
                                   solid organ sites.
20061...........................  Anaplastic large cell lymphoma, lymph
                                   nodes of head, face, and neck.
20062...........................  Anaplastic large cell lymphoma,
                                   intrathoracic lymph nodes.
20063...........................  Anaplastic large cell lymphoma, intra-
                                   abdominal lymph nodes.
20064...........................  Anaplastic large cell lymphoma, lymph
                                   nodes of axilla and upper limb.
20065...........................  Anaplastic large cell lymphoma, lymph
                                   nodes of inguinal region and lower
                                   limb.
20066...........................  Anaplastic large cell lymphoma,
                                   intrapelvic lymph nodes.
20067...........................  Anaplastic large cell lymphoma,
                                   spleen.
20068...........................  Anaplastic large cell lymphoma, lymph
                                   nodes of multiple sites.

[[Page 25028]]

 
20070...........................  Large cell lymphoma, unspecified site,
                                   extranodal and solid organ sites.
20071...........................  Large cell lymphoma, lymph nodes of
                                   head, face, and neck.
20072...........................  Large cell lymphoma, intrathoracic
                                   lymph nodes.
20073...........................  Large cell lymphoma, intra-abdominal
                                   lymph nodes.
20074...........................  Large cell lymphoma, lymph nodes of
                                   axilla and upper limb.
20075...........................  Large cell lymphoma, lymph nodes of
                                   inguinal region and lower limb.
20076...........................  Large cell lymphoma, intrapelvic lymph
                                   nodes.
20077...........................  Large cell lymphoma, spleen.
20078...........................  Large cell lymphoma, lymph nodes of
                                   multiple sites.
20080...........................  Other named variants of lymphosarcoma
                                   and reticulosarcoma, unspecified
                                   site.
20081...........................  Other named variants of lymphosarcoma
                                   and reticulosarcoma involving lymph
                                   nodes of head, face, and neck.
20082...........................  Other named variants of lymphosarcoma
                                   and reticulosarcoma involving
                                   intrathoracic lymph nodes.
20083...........................  Other named variants of lymphosarcoma
                                   and reticulosarcoma involving intra-
                                   abdominal lymph nodes.
20084...........................  Other named variants of lymphosarcoma
                                   and reticulosarcoma involving lymph
                                   nodes of axilla and upper limb.
20085...........................  Other named variants of lymphosarcoma
                                   and reticulosarcoma involving lymph
                                   nodes of inguinal region and lower
                                   limb.
20086...........................  Other named variants of lymphosarcoma
                                   and reticulosarcoma involving
                                   intrapelvic lymph nodes.
20087...........................  Other named variants of lymphosarcoma
                                   and reticulosarcoma involving spleen.
20088...........................  Other named variants of lymphosarcoma
                                   and reticulosarcoma involving lymph
                                   nodes of multiple sites.
20100...........................  Hodgkin's paragranuloma, unspecified
                                   site.
20101...........................  Hodgkin's paragranuloma involving
                                   lymph nodes of head, face, and neck.
20102...........................  Hodgkin's paragranuloma involving
                                   intrathoracic lymph nodes.
20103...........................  Hodgkin's paragranuloma involving
                                   intra-abdominal lymph nodes.
20104...........................  Hodgkin's paragranuloma involving
                                   lymph nodes of axilla and upper limb.
20105...........................  Hodgkin's paragranuloma involving
                                   lymph nodes of inguinal region and
                                   lower limb.
20106...........................  Hodgkin's paragranuloma involving
                                   intrapelvic lymph nodes.
20107...........................  Hodgkin's paragranuloma involving
                                   spleen.
20108...........................  Hodgkin's paragranuloma involving
                                   lymph nodes of multiple sites.
20110...........................  Hodgkin's granuloma, unspecified site.
20111...........................  Hodgkin's granuloma involving lymph
                                   nodes of head, face, and neck.
20112...........................  Hodgkin's granuloma involving
                                   intrathoracic lymph nodes.
20113...........................  Hodgkin's granuloma involving intra-
                                   abdominal lymph nodes.
20114...........................  Hodgkin's granuloma involving lymph
                                   nodes of axilla and upper limb.
20115...........................  Hodgkin's granuloma involving lymph
                                   nodes of inguinal region and lower
                                   limb.
20116...........................  Hodgkin's granuloma involving
                                   intrapelvic lymph nodes.
20117...........................  Hodgkin's granuloma involving spleen.
20118...........................  Hodgkin's granuloma involving lymph
                                   nodes of multiple sites.
20120...........................  Hodgkin's sarcoma, unspecified site.
20121...........................  Hodgkin's sarcoma involving lymph
                                   nodes of head, face, and neck.
20122...........................  Hodgkin's sarcoma involving
                                   intrathoracic lymph nodes.
20123...........................  Hodgkin's sarcoma involving intra-
                                   abdominal lymph nodes.
20124...........................  Hodgkin's sarcoma involving lymph
                                   nodes of axilla and upper limb.
20125...........................  Hodgkin's sarcoma involving lymph
                                   nodes of inguinal region and lower
                                   limb.
20126...........................  Hodgkin's sarcoma involving
                                   intrapelvic lymph nodes.
20127...........................  Hodgkin's sarcoma involving spleen.
20128...........................  Hodgkin's sarcoma involving lymph
                                   nodes of multiple sites.
20140...........................  Hodgkin's disease, lymphocytic-
                                   histiocytic predominance, unspecified
                                   site.
20141...........................  Hodgkin's disease, lymphocytic-
                                   histiocytic predominance involving
                                   lymph nodes of head, face, and neck.
20142...........................  Hodgkin's disease, lymphocytic-
                                   histiocytic predominance involving
                                   intrathoracic lymph nodes.
20143...........................  Hodgkin's disease, lymphocytic-
                                   histiocytic predominance involving
                                   intra-abdominal lymph nodes.
20144...........................  Hodgkin's disease, lymphocytic-
                                   histiocytic predominance involving
                                   lymph nodes of axilla and upper limb.
20145...........................  Hodgkin's disease, lymphocytic-
                                   histiocytic predominance involving
                                   lymph nodes of inguinal region and
                                   lower limb.
20146...........................  Hodgkin's disease, lymphocytic-
                                   histiocytic predominance involving
                                   intrapelvic lymph nodes.
20147...........................  Hodgkin's disease, lymphocytic-
                                   histiocytic predominance involving
                                   spleen.
20148...........................  Hodgkin's disease, lymphocytic-
                                   histiocytic predominance involving
                                   lymph nodes of multiple sites.
20150...........................  Hodgkin's disease, nodular sclerosis,
                                   unspecified site.
20151...........................  Hodgkin's disease, nodular sclerosis,
                                   involving lymph nodes of head, face,
                                   and neck.
20152...........................  Hodgkin's disease, nodular sclerosis,
                                   involving intrathoracic lymph nodes.
20153...........................  Hodgkin's disease, nodular sclerosis,
                                   involving intra-abdominal lymph
                                   nodes.
20154...........................  Hodgkin's disease, nodular sclerosis,
                                   involving lymph nodes of axilla and
                                   upper limb.
20155...........................  Hodgkin's disease, nodular sclerosis,
                                   involving lymph nodes of inguinal
                                   region and lower limb.
20156...........................  Hodgkin's disease, nodular sclerosis,
                                   involving intrapelvic lymph nodes.
20157...........................  Hodgkin's disease, nodular sclerosis,
                                   involving spleen.
20158...........................  Hodgkin's disease, nodular sclerosis,
                                   involving lymph nodes of multiple
                                   sites.
20160...........................  Hodgkin's disease, mixed cellularity,
                                   unspecified site.
20161...........................  Hodgkin's disease, mixed cellularity,
                                   involving lymph nodes of head, face,
                                   and neck.
20162...........................  Hodgkin's disease, mixed cellularity,
                                   involving intrathoracic lymph nodes.
20163...........................  Hodgkin's disease, mixed cellularity,
                                   involving intra-abdominal lymph
                                   nodes.
20164...........................  Hodgkin's disease, mixed cellularity,
                                   involving lymph nodes of axilla and
                                   upper limb.
20165...........................  Hodgkin's disease, mixed cellularity,
                                   involving lymph nodes of inguinal
                                   region and lower limb.
20166...........................  Hodgkin's disease, mixed cellularity,
                                   involving intrapelvic lymph nodes.

[[Page 25029]]

 
20167...........................  Hodgkin's disease, mixed cellularity,
                                   involving spleen.
20168...........................  Hodgkin's disease, mixed cellularity,
                                   involving lymph nodes of multiple
                                   sites.
20170...........................  Hodgkin's disease, lymphocytic
                                   depletion, unspecified site.
20171...........................  Hodgkin's disease, lymphocytic
                                   depletion, involving lymph nodes of
                                   head, face, and neck.
20172...........................  Hodgkin's disease, lymphocytic
                                   depletion, involving intrathoracic
                                   lymph nodes.
20173...........................  Hodgkin's disease, lymphocytic
                                   depletion, involving intra-abdominal
                                   lymph nodes.
20174...........................  Hodgkin's disease, lymphocytic
                                   depletion, involving lymph nodes of
                                   axilla and upper limb.
20175...........................  Hodgkin's disease, lymphocytic
                                   depletion, involving lymph nodes of
                                   inguinal region and lower limb.
20176...........................  Hodgkin's disease, lymphocytic
                                   depletion, involving intrapelvic
                                   lymph nodes.
20177...........................  Hodgkin's disease, lymphocytic
                                   depletion, involving spleen.
20178...........................  Hodgkin's disease, lymphocytic
                                   depletion, involving lymph nodes of
                                   multiple sites.
20190...........................  Hodgkin's disease, unspecified type,
                                   unspecified site.
20191...........................  Hodgkin's disease, unspecified type,
                                   involving lymph nodes of head, face,
                                   and neck.
20192...........................  Hodgkin's disease, unspecified type,
                                   involving intrathoracic lymph nodes.
20193...........................  Hodgkin's disease, unspecified type,
                                   involving intra-abdominal lymph
                                   nodes.
20194...........................  Hodgkin's disease, unspecified type,
                                   involving lymph nodes of axilla and
                                   upper limb.
20195...........................  Hodgkin's disease, unspecified type,
                                   involving lymph nodes of inguinal
                                   region and lower limb.
20196...........................  Hodgkin's disease, unspecified type,
                                   involving intrapelvic lymph nodes.
20197...........................  Hodgkin's disease, unspecified type,
                                   involving spleen.
20198...........................  Hodgkin's disease, unspecified type,
                                   involving lymph nodes of multiple
                                   sites.
20200...........................  Nodular lymphoma, unspecified site.
20201...........................  Nodular lymphoma involving lymph nodes
                                   of head, face, and neck.
20202...........................  Nodular lymphoma involving
                                   intrathoracic lymph nodes.
20203...........................  Nodular lymphoma involving intra-
                                   abdominal lymph nodes.
20204...........................  Nodular lymphoma involving lymph nodes
                                   of axilla and upper limb.
20205...........................  Nodular lymphoma involving lymph nodes
                                   of inguinal region and lower limb.
20206...........................  Nodular lymphoma involving intrapelvic
                                   lymph nodes.
20207...........................  Nodular lymphoma involving spleen.
20208...........................  Nodular lymphoma involving lymph nodes
                                   of multiple sites.
20210...........................  Mycosis fungoides, unspecified site.
20211...........................  Mycosis fungoides involving lymph
                                   nodes of head, face, and neck.
20212...........................  Mycosis fungoides involving
                                   intrathoracic lymph nodes.
20213...........................  Mycosis fungoides involving intra-
                                   abdominal lymph nodes.
20214...........................  Mycosis fungoides involving lymph
                                   nodes of axilla and upper limb.
20215...........................  Mycosis fungoides involving lymph
                                   nodes of inguinal region and lower
                                   limb.
20216...........................  Mycosis fungoides involving
                                   intrapelvic lymph nodes.
20217...........................  Mycosis fungoides involving spleen.
20218...........................  Mycosis fungoides involving lymph
                                   nodes of multiple sites.
20220...........................  Sezary's disease, unspecified site.
20221...........................  Sezary's disease involving lymph nodes
                                   of head, face, and neck.
20222...........................  Sezary's disease involving
                                   intrathoracic lymph nodes.
20223...........................  Sezary's disease involving intra-
                                   abdominal lymph nodes.
20224...........................  Sezary's disease involving lymph nodes
                                   of axilla and upper limb.
20225...........................  Sezary's disease involving lymph nodes
                                   of inguinal region and lower limb.
20226...........................  Sezary's disease involving intrapelvic
                                   lymph nodes.
20227...........................  Sezary's disease involving spleen.
20228...........................  Sezary's disease involving lymph nodes
                                   of multiple sites.
20230...........................  Malignant histiocytosis, unspecified
                                   site.
20231...........................  Malignant histiocytosis involving
                                   lymph nodes of head, face, and neck.
20232...........................  Malignant histiocytosis involving
                                   intrathoracic lymph nodes.
20233...........................  Malignant histiocytosis involving
                                   intra-abdominal lymph nodes.
20234...........................  Malignant histiocytosis involving
                                   lymph nodes of axilla and upper limb.
20235...........................  Malignant histiocytosis involving
                                   lymph nodes of inguinal region and
                                   lower limb.
20236...........................  Malignant histiocytosis involving
                                   intrapelvic lymph nodes.
20237...........................  Malignant histiocytosis involving
                                   spleen.
20238...........................  Malignant histiocytosis involving
                                   lymph nodes of multiple sites.
20240...........................  Leukemic reticuloendotheliosis,
                                   unspecified site.
20241...........................  Leukemic reticuloendotheliosis
                                   involving lymph nodes of head, face,
                                   and neck.
20242...........................  Leukemic reticuloendotheliosis
                                   involving intrathoracic lymph nodes.
20243...........................  Leukemic reticuloendotheliosis
                                   involving intra-abdominal lymph
                                   nodes.
20244...........................  Leukemic reticuloendotheliosis
                                   involving lymph nodes of axilla and
                                   upper arm.
20245...........................  Leukemic reticuloendotheliosis
                                   involving lymph nodes of inguinal
                                   region and lower limb.
20246...........................  Leukemic reticuloendotheliosis
                                   involving intrapelvic lymph nodes.
20247...........................  Leukemic reticuloendotheliosis
                                   involving spleen.
20248...........................  Leukemic reticuloendotheliosis
                                   involving lymph nodes of multipes
                                   sites.
20250...........................  Letterer-siwe disease, unspecified
                                   site.
20251...........................  Letterer-siwe disease involving lymph
                                   nodes of head, face, and neck.
20252...........................  Letterer-siwe disease involving
                                   intrathoracic lymph nodes.
20253...........................  Letterer-siwe disease involving intra-
                                   abdominal lymph nodes.
20254...........................  Letterer-siwe disease involving lymph
                                   nodes of axilla and upper limb.
20255...........................  Letterer-siwe disease involving lymph
                                   nodes of inguinal region and lower
                                   limb.
20256...........................  Letterer-siwe disease involving
                                   intrapelvic lymph nodes.

[[Page 25030]]

 
20257...........................  Letterer-siwe disease involving
                                   spleen.
20258...........................  Letterer-siwe disease involving lymph
                                   nodes of multiple sites.
20260...........................  Malignant mast cell tumors,
                                   unspecified site.
20261...........................  Malignant mast cell tumors involving
                                   lymph nodes of head, face, and neck.
20262...........................  Malignant mast cell tumors involving
                                   intrathoracic lymph nodes.
20263...........................  Malignant mast cell tumors involving
                                   intra-abdominal lymph nodes.
20264...........................  Malignant mast cell tumors involving
                                   lymph nodes of axilla and upper limb.
20265...........................  Malignant mast cell tumors involving
                                   lymph nodes of inguinal region and
                                   lower limb.
20266...........................  Malignant mast cell tumors involving
                                   intrapelvic lymph nodes.
20267...........................  Malignant mast cell tumors involving
                                   spleen.
20268...........................  Malignant mast cell tumors involving
                                   lymph nodes of multiple sites.
20270...........................  Peripheral T cell lymphoma,
                                   unspecified site, extranodal and
                                   solid organ sites.
20271...........................  Peripheral T cell lymphoma, lymph
                                   nodes of head, face, and neck.
20272...........................  Peripheral T cell lymphoma,
                                   intrathoracic lymph nodes.
20273...........................  Peripheral T cell lymphoma, intra-
                                   abdominal lymph nodes.
20274...........................  Peripheral T cell lymphoma, lymph
                                   nodes of axilla and upper limb.
20275...........................  Peripheral T cell lymphoma, lymph
                                   nodes of inguinal region and lower
                                   limb.
20276...........................  Peripheral T cell lymphoma,
                                   intrapelvic lymph nodes.
20277...........................  Peripheral T cell lymphoma, spleen.
20278...........................  Peripheral T cell lymphoma, lymph
                                   nodes of multiple sites.
20280...........................  Other malignant lymphomas, unspecified
                                   site.
20281...........................  Other malignant lymphomas involving
                                   lymph nodes of head, face, and neck.
20282...........................  Other malignant lymphomas involving
                                   intrathoracic lymph nodes.
20283...........................  Other malignant lymphomas involving
                                   intra-abdominal lymph nodes.
20284...........................  Other malignant lymphomas involving
                                   lymph nodes of axilla and upper limb.
20285...........................  Other malignant lymphomas involving
                                   lymph nodes of inguinal region and
                                   lower limb.
20286...........................  Other malignant lymphomas involving
                                   intrapelvic lymph nodes.
20287...........................  Other malignant lymphomas involving
                                   spleen.
20288...........................  Other malignant lymphomas involving
                                   lymph nodes of multiple sites.
290.............................  Other and unspecified malignant
                                   neoplasms of lymphoid and histiocytic
                                   tissue, unspecified site.
20291...........................  Other and unspecified malignant
                                   neoplasms of lymphoid and histiocytic
                                   tissue involving lymph nodes of head,
                                   face, and neck.
20292...........................  Other and unspecified malignant
                                   neoplasms of lymphoid and histiocytic
                                   tissue involving intrathoracic lymph
                                   nodes.
20293...........................  Other and unspecified malignant
                                   neoplasms of lymphoid and histiocytic
                                   tissue involving intra-abdominal
                                   lymph nodes.
20294...........................  Other and unspecified malignant
                                   neoplasms of lymphoid and histiocytic
                                   tissue involving lymph nodes of
                                   axilla and upper limb.
20295...........................  Other and unspecified malignant
                                   neoplasms of lymphoid and histiocytic
                                   tissue involving lymph nodes of
                                   inguinal region and lower limb.
20296...........................  Other and unspecified malignant
                                   neoplasms of lymphoid and histiocytic
                                   tissue involving intrapelvic lymph
                                   nodes.
20297...........................  Other and unspecified malignant
                                   neoplasms of lymphoid and histiocytic
                                   tissue involving spleen.
20298...........................  Other and unspecified malignant
                                   neoplasms of lymphoid and histiocytic
                                   tissue involving lymph nodes of
                                   multiple sites.
20300...........................  Multiple myeloma, without mention of
                                   remission.
20301...........................  Multiple myeloma, in remission.
20310...........................  Plasma cell leukemia, without mention
                                   of remission.
20311...........................  Plasma cell leukemia, in remission.
20380...........................  Other immunoproliferative neoplasms,
                                   without mention of remission.
20381...........................  Other immunoproliferative neoplasms,
                                   in remission.
20400...........................  Lymphoid leukemia, acute, without
                                   mention of remission.
20401...........................  Lymphoid leukemia, acute, in
                                   remission.
20410...........................  Lymphoid leukemia, chronic, without
                                   mention of remission.
20411...........................  Lymphoid leukemia, chronic, in
                                   remission.
20420...........................  Lymphoid leukemia, subacute, without
                                   mention of remission.
20421...........................  Lymphoid leukemia, subacute, in
                                   remission.
20480...........................  Other lymphoid leukemia, without
                                   mention of remission.
20481...........................  Other lymphoid leukemia, in remission.
20490...........................  Unspecified lymphoid leukemia, without
                                   mention of remission.
20491...........................  Unspecified lymphoid leukemia, in
                                   remission.
20500...........................  Myeloid leukemia, acute, without
                                   mention of remission.
20501...........................  Myeloid leukemia, acute, in remission.
20510...........................  Myeloid leukemia, chronic, without
                                   mention of remission.
20511...........................  Myeloid leukemia, chronic, in
                                   remission.
20520...........................  Myeloid leukemia, subacute, without
                                   mention of remission.
20521...........................  Myeloid leukemia, subacute, in
                                   remission.
20530...........................  Myeloid sarcoma, without mention of
                                   remission.
20531...........................  Myeloid sarcoma, in remission.
20580...........................  Other myeloid leukemia, without
                                   mention of remission.
20581...........................  Other myeloid leukemia, in remission.
20590...........................  Unspecified myeloid leukemia, without
                                   mention of remission.

[[Page 25031]]

 
20591...........................  Unspecified myeloid leukemia, in
                                   remission.
20600...........................  Monocytic leukemia, acute, without
                                   mention of remission.
20601...........................  Monocytic leukemia, acute, in
                                   remission.
20610...........................  Monocytic leukemia, chronic without
                                   mention of remission.
20611...........................  Monocytic leukemia, chronic, in
                                   remission.
20620...........................  Monocytic leukemia, subacute, without
                                   mention of remission.
20621...........................  Monocytic leukemia, subacute, in
                                   remission.
20680...........................  Other monocytic leukemia, without
                                   mention of remission.
20681...........................  Other monocytic leukemia, in
                                   remission.
20690...........................  Unspecified monocytic leukemia,
                                   without mention of remission.
20691...........................  Unspecified monocytic leukemia, in
                                   remission.
20700...........................  Acute erythremia and erythroleukemia,
                                   without mention of remission.
20701...........................  Acute erythremia and erythroleukemia,
                                   in remission.
20710...........................  Chronic erythremia, without mention of
                                   remission.
20711...........................  Chronic erythremia, in remission.
20720...........................  Megakaryocytic leukemia, without
                                   mention of remission.
20721...........................  Megakaryocytic leukemia, in remission.
20780...........................  Other specified leukemia, without
                                   mention of remission.
20781...........................  Other specified leukemia, in
                                   remission.
20800...........................  Leukemia of unspecified cell type,
                                   acute, without mention of remission.
20801...........................  Leukemia of unspecified cell type,
                                   acute, in remission.
20810...........................  Leukemia of unspecified cell type,
                                   chronic, without mention of
                                   remission.
20811...........................  Leukemia of unspecified cell type,
                                   chronic, in remission.
20820...........................  Leukemia of unspecified cell type,
                                   subacute, without mention of
                                   remission.
20821...........................  Leukemia of unspecified cell type,
                                   subacute, in remission.
20880...........................  Other leukemia of unspecified cell
                                   type, without mention of remission.
20881...........................  Other leukemia of unspecified cell
                                   type, in remission.
20890...........................  Unspecified leukemia, without mention
                                   of remission.
20891...........................  Unspecified leukemia, in remission.
2385............................  Neoplasm of uncertain behavior of
                                   histiocytic and mast cells.
2386............................  Neoplasm of uncertain behavior of
                                   plasma cells.
23873...........................  High grade myelodysplastic syndrome
                                   lesions.
23874...........................  Myelodysplastic syndrome with 5q
                                   deletion.
23876...........................  Myelofibrosis with myeloid metaplasia.
23879...........................  Other lymphatic and hematopoietic
                                   tissues.
2450............................  Acute thyroiditis.
2463............................  Hemorrhage and infarction of thyroid.
2510............................  Hypoglycemic coma.
2513............................  Postsurgical hypoinsulinemia.
2531............................  Other and unspecified anterior
                                   pituitary hyperfunction.
2532............................  Panhypopituitarism.
2535............................  Diabetes insipidus.
2536............................  Other disorders of neurohypophysis.
2541............................  Abscess of thymus.
2550............................  Cushing's syndrome.
2553............................  Other corticoadrenal overactivity.
25541...........................  Glucocorticoid deficiency.
25542...........................  Mineralocorticoid deficiency.
2555............................  Other adrenal hypofunction.
2556............................  Medulloadrenal hyperfunction.
2592............................  Carcinoid syndrome.
2632............................  Arrested development following protein-
                                   calorie malnutrition.
2638............................  Other protein-calorie malnutrition.
2639............................  Unspecified protein-calorie
                                   malnutrition.
2650............................  Beriberi.
2651............................  Other and unspecified manifestations
                                   of thiamine deficiency.
2660............................  Ariboflavinosis.
2680............................  Rickets, active.
2700............................  Disturbances of amino-acid transport.
2701............................  Phenylketonuria (PKU).
2702............................  Other disturbances of aromatic amino-
                                   acid metabolism.
2703............................  Disturbances of branched-chain amino-
                                   acid metabolism.
2704............................  Disturbances of sulphur-bearing amino-
                                   acid metabolism.
2705............................  Disturbances of histidine metabolism.
2706............................  Disorders of urea cycle metabolism.
2707............................  Other disturbances of straight-chain
                                   amino-acid metabolism.
2708............................  Other specified disorders of amino-
                                   acid metabolism.
2709............................  Unspecified disorder of amino-acid
                                   metabolism.
2710............................  Glycogenosis.
2711............................  Galactosemia.
2718............................  Other specified disorders of
                                   carbohydrate transport and
                                   metabolism.
27411...........................  Uric acid nephrolithiasis.

[[Page 25032]]

 
2760............................  Hyperosmolality and/or hypernatremia.
2761............................  Hyposmolality and/or hyponatremia.
2762............................  Acidosis.
2763............................  Alkalosis.
2764............................  Mixed acid-base balance disorder.
27700...........................  Cystic fibrosis without mention of
                                   meconium ileus.
27703...........................  Cystic fibrosis with gastrointestinal
                                   manifestations.
27709...........................  Cystic fibrosis with other
                                   manifestations.
2771............................  Disorders of porphyrin metabolism.
2772............................  Other disorders of purine and
                                   pyrimidine metabolism.
27730...........................  Amyloidosis, unspecified.
27731...........................  Familial Mediterranean fever.
27739...........................  Other amyloidosis.
2775............................  Mucopolysaccharidosis.
27785...........................  Disorders of fatty acid oxidation.
27786...........................  Peroxisomal disorders.
27787...........................  Disorders of mitochondrial metabolism.
27789...........................  Other specified disorders of
                                   metabolism.
27900...........................  Hypogammaglobulinemia, unspecified.
27901...........................  Selective iga immunodeficiency.
27902...........................  Selective igm immunodeficiency.
27903...........................  Other selective immunoglobulin
                                   deficiencies.
27904...........................  Congenital hypogammaglobulinemia.
27905...........................  Immunodeficiency with increased igm.
27906...........................  Common variable immunodeficiency.
27909...........................  Other deficiency of humoral immunity.
27910...........................  Immunodeficiency with predominant T-
                                   cell defect, unspecified.
27911...........................  Digeorge's syndrome.
27912...........................  Wiskott-aldrich syndrome.
27913...........................  Nezelof's syndrome.
27919...........................  Other deficiency of cell-mediated
                                   immunity.
2792............................  Combined immunity deficiency.
2793............................  Unspecified immunity deficiency.
2828............................  Other specified hereditary hemolytic
                                   anemias.
2829............................  Hereditary hemolytic anemia,
                                   unspecified.
2830............................  Autoimmune hemolytic anemias.
28310...........................  Non-autoimmune hemolytic anemia,
                                   unspecified.
28319...........................  Other non-autoimmune hemolytic
                                   anemias.
2839............................  Acquired hemolytic anemia,
                                   unspecified.
28401...........................  Constitutional red blood cell aplasia.
28409...........................  Other constitutional aplastic anemia.
2841............................  Pancytopenia.
2842............................  Myelophthisis.
2849............................  Aplastic anemia, unspecified.
2862............................  Congenital factor xi deficiency.
2863............................  Congenital deficiency of other
                                   clotting factors.
2864............................  Von willebrand's disease.
2865............................  Hemorrhagic disorder due to intrinsic
                                   circulating anticoagulants.
2867............................  Acquired coagulation factor
                                   deficiency.
2869............................  Other and unspecified coagulation
                                   defects.
2870............................  Allergic purpura.
28731...........................  Immune thrombocytopenic purpura.
28732...........................  Evans' syndrome.
28733...........................  Congenital and hereditary
                                   thrombocytopenic purpura.
2884............................  Hemophagocytic syndromes.
2897............................  Methemoglobinemia.
28981...........................  Primary hypercoagulable state.
28982...........................  Secondary hypercoagulable state.
28983...........................  Myelofibrosis.
29011...........................  Presenile dementia with delirium.
29012...........................  Presenile dementia with delusional
                                   features.
29013...........................  Presenile dementia with depressive
                                   features.
29020...........................  Senile dementia with delusional
                                   features.
29021...........................  Senile dementia with depressive
                                   features.
2903............................  Senile dementia with delirium.
29041...........................  Vascular dementia, with delirium.
29042...........................  Vascular dementia, with delusions.
29043...........................  Vascular dementia, with depressed
                                   mood.
2908............................  Other specified senile psychotic
                                   conditions.
2909............................  Unspecified senile psychotic
                                   condition.
2910............................  Alcohol withdrawal delirium.
2912............................  Alcohol-induced persisting dementia.

[[Page 25033]]

 
2913............................  Alcohol-induced psychotic disorder
                                   with hallucinations.
29181...........................  Alcohol withdrawal.
29189...........................  Other alcohol-induced mental
                                   disorders.
2919............................  Unspecified alcohol-induced mental
                                   disorders.
2920............................  Drug withdrawal.
29211...........................  Drug-induced psychotic disorder with
                                   delusions.
29212...........................  Drug-induced psychotic disorder with
                                   hallucinations.
29281...........................  Drug-induced delirium.
29282...........................  Drug-induced persisting dementia.
2930............................  Delirium due to conditions classified
                                   elsewhere.
2931............................  Subacute delirium.
29381...........................  Psychotic disorder with delusions in
                                   conditions classified elsewhere.
29382...........................  Psychotic disorder with hallucinations
                                   in conditions classified elsewhere.
2939............................  Unspecified transient mental disorder
                                   in conditions classified elsewhere.
29411...........................  Dementia in conditions classified
                                   elsewhere with behavioral
                                   disturbance.
29500...........................  Simple type schizophrenia, unspecified
                                   state.
29501...........................  Simple type schizophrenia, subchronic
                                   state.
29502...........................  Simple type schizophrenia, chronic
                                   state.
29503...........................  Simple type schizophrenia, subchronic
                                   state with acute exacerbation.
29504...........................  Simple type schizophrenia, chronic
                                   state with acute exacerbation.
29510...........................  Disorganized type schizophrenia,
                                   unspecified state.
29511...........................  Disorganized type schizophrenia,
                                   subchronic state.
29512...........................  Disorganized type schizophrenia,
                                   chronic state.
29513...........................  Disorganized type schizophrenia,
                                   subchronic state with acute
                                   exacerbation.
29514...........................  Disorganized type schizophrenia,
                                   chronic state with acute
                                   exacerbation.
29520...........................  Catatonic type schizophrenia,
                                   unspecified state.
29521...........................  Catatonic type schizophrenia,
                                   subchronic state.
29522...........................  Catatonic type schizophrenia, chronic
                                   state.
29523...........................  Catatonic type schizophrenia,
                                   subchronic state with acute
                                   exacerbation.
29524...........................  Catatonic type schizophrenia, chronic
                                   state with acute exacerbation.
29530...........................  Paranoid type schizophrenia,
                                   unspecified state.
29531...........................  Paranoid type schizophrenia,
                                   subchronic state.
29532...........................  Paranoid type schizophrenia, chronic
                                   state.
29533...........................  Paranoid type schizophrenia,
                                   subchronic state with acute
                                   exacerbation.
29534...........................  Paranoid type schizophrenia, chronic
                                   state with acute exacerbation.
29540...........................  Schizophreniform disorder,
                                   unspecified.
29541...........................  Schizophreniform disorder, subchronic.
29542...........................  Schizophreniform disorder, chronic.
29543...........................  Schizophreniform disorder, subchronic
                                   with acute exacerbation.
29544...........................  Schizophreniform disorder, chronic
                                   with acute exacerbation.
29553...........................  Latent schizophrenia, subchronic state
                                   with acute exacerbation.
29554...........................  Latent schizophrenia, chronic state
                                   with acute exacerbation.
29560...........................  Schizophrenic disorders, residual
                                   type, unspecified.
29561...........................  Schizophrenic disorders, residual
                                   type, subchronic.
29562...........................  Schizophrenic disorders, residual
                                   type, chronic.
29563...........................  Schizophrenic disorders, residual
                                   type, subchronic with acute
                                   exacerbation.
29564...........................  Schizophrenic disorders, residual
                                   type, chronic with acute
                                   exacerbation.
29571...........................  Schizoaffective disorder, subchronic.
29572...........................  Schizoaffective disorder, chronic.
29573...........................  Schizoaffective disorder, subchronic
                                   with acute exacerbation.
29574...........................  Schizoaffective disorder, chronic with
                                   acute exacerbation.
29580...........................  Other specified types of
                                   schizophrenia, unspecified state.
29581...........................  Other specified types of
                                   schizophrenia, subchronic state.
29582...........................  Other specified types of
                                   schizophrenia, chronic state.
29583...........................  Other specified types of
                                   schizophrenia, subchronic state with
                                   acute exacerbation.
29584...........................  Other specified types of
                                   schizophrenia, chronic state with
                                   acute exacerbation.
29591...........................  Unspecified type schizophrenia,
                                   subchronic state.
29592...........................  Unspecified type schizophrenia,
                                   chronic state.
29593...........................  Unspecified type schizophrenia,
                                   subchronic state with acute
                                   exacerbation.
29594...........................  Unspecified type schizophrenia,
                                   chronic state with acute
                                   exacerbation.
29600...........................  Bipolar I disorder, single manic
                                   episode, unspecified.
29601...........................  Bipolar I disorder, single manic
                                   episode, mild.
29602...........................  Bipolar I disorder, single manic
                                   episode, moderate.
29603...........................  Bipolar I disorder, single manic
                                   episode, severe, without mention of
                                   psychotic behavior.
29604...........................  Bipolar I disorder, single manic
                                   episode, severe, specified as with
                                   psychotic behavior.
29610...........................  Manic affective disorder, recurrent
                                   episode, unspecified degree.
29611...........................  Manic affective disorder, recurrent
                                   episode, mild degree.
29612...........................  Manic affective disorder, recurrent
                                   episode, moderate degree.
29613...........................  Manic affective disorder, recurrent
                                   episode, severe degree, without
                                   mention of psychotic behavior.
29614...........................  Manic affective disorder, recurrent
                                   episode, severe degree, specified as
                                   with psychotic behavior.
29620...........................  Major depressive affective disorder,
                                   single episode, unspecified degree.
29621...........................  Major depressive affective disorder,
                                   single episode, mild degree.

[[Page 25034]]

 
29622...........................  Major depressive affective disorder,
                                   single episode, moderate degree.
29623...........................  Major depressive affective disorder,
                                   single episode, severe degree,
                                   without mention of psychotic
                                   behavior.
29624...........................  Major depressive affective disorder,
                                   single episode, severe degree,
                                   specified as with psychotic behavior.
29630...........................  Major depressive affective disorder,
                                   recurrent episode, unspecified
                                   degree.
29631...........................  Major depressive affective disorder,
                                   recurrent episode, mild degree.
29632...........................  Major depressive affective disorder,
                                   recurrent episode, moderate degree.
29633...........................  Major depressive affective disorder,
                                   recurrent episode, severe degree,
                                   without mention of psychotic
                                   behavior.
29634...........................  Major depressive affective disorder,
                                   recurrent episode, severe degree,
                                   specified as with psychotic behavior.
29640...........................  Bipolar I disorder, most recent
                                   episode (or current) manic,
                                   unspecified.
29641...........................  Bipolar I disorder, most recent
                                   episode (or current) manic, mild.
29642...........................  Bipolar I disorder, most recent
                                   episode (or current) manic, moderate.
29643...........................  Bipolar I disorder, most recent
                                   episode (or current) manic, severe,
                                   without mention of psychotic
                                   behavior.
29644...........................  Bipolar I disorder, most recent
                                   episode (or current) manic, severe,
                                   specified as with psychotic behavior.
29650...........................  Bipolar I disorder, most recent
                                   episode (or current) depressed,
                                   unspecified.
29651...........................  Bipolar I disorder, most recent
                                   episode (or current) depressed, mild.
29652...........................  Bipolar I disorder, most recent
                                   episode (or current) depressed,
                                   moderate.
29653...........................  Bipolar I disorder, most recent
                                   episode (or current) depressed,
                                   severe, without mention of psychotic
                                   behavior.
29654...........................  Bipolar I disorder, most recent
                                   episode (or current) depressed,
                                   severe, specified as with psychotic
                                   behavior.
29660...........................  Bipolar I disorder, most recent
                                   episode (or current) mixed,
                                   unspecified.
29661...........................  Bipolar I disorder, most recent
                                   episode (or current) mixed, mild.
29662...........................  Bipolar I disorder, most recent
                                   episode (or current) mixed, moderate.
29663...........................  Bipolar I disorder, most recent
                                   episode (or current) mixed, severe,
                                   without mention of psychotic
                                   behavior.
29664...........................  Bipolar I disorder, most recent
                                   episode (or current) mixed, severe,
                                   specified as with psychotic behavior.
29689...........................  Other and unspecified bipolar
                                   disorders, other.
29699...........................  Other specified episodic mood
                                   disorder.
2980............................  Depressive type psychosis.
2981............................  Excitative type psychosis.
2983............................  Acute paranoid reaction.
2984............................  Psychogenic paranoid psychosis.
29900...........................  Autistic disorder, current or active
                                   state.
29901...........................  Autistic disorder, residual state.
29910...........................  Childhood disintegrative disorder,
                                   current or active state.
29911...........................  Childhood disintegrative disorder,
                                   residual state.
29980...........................  Other specified pervasive
                                   developmental disorders, current or
                                   active state.
29981...........................  Other specified pervasive
                                   developmental disorders, residual
                                   state.
29990...........................  Unspecified pervasive developmental
                                   disorder, current or active state.
29991...........................  Unspecified pervasive developmental
                                   disorder, residual state.
30151...........................  Chronic factitious illness with
                                   physical symptoms.
30401...........................  Opioid type dependence, continuous
                                   use.
30411...........................  Sedative, hypnotic or anxiolytic
                                   dependence, continuous.
30421...........................  Cocaine dependence, continuous use.
30441...........................  Amphetamine and other psychostimulant
                                   dependence, continuous use.
30451...........................  Hallucinogen dependence, continuous
                                   use.
30461...........................  Other specified drug dependence,
                                   continuous use.
30471...........................  Combinations of opioid type drug with
                                   any other drug dependence, continuous
                                   use.
30481...........................  Combinations of drug dependence
                                   excluding opioid type drug,
                                   continuous use.
30491...........................  Unspecified drug dependence,
                                   continuous use.
3071............................  Anorexia nervosa.
30751...........................  Bulimia nervosa.
3181............................  Severe mental retardation.
3182............................  Profound mental retardation.
3222............................  Chronic meningitis.
3300............................  Leukodystrophy.
3301............................  Cerebral lipidoses.
3302............................  Cerebral degeneration in generalized
                                   lipidoses.
3303............................  Cerebral degeneration of childhood in
                                   other diseases classified elsewhere.
3308............................  Other specified cerebral degenerations
                                   in childhood.
3309............................  Unspecified cerebral degeneration in
                                   childhood.
3313............................  Communicating hydrocephalus.
3314............................  Obstructive hydrocephalus.
3315............................  Idiopathic normal pressure
                                   hydrocephalus (INPH).
3321............................  Secondary parkinsonism.
3330............................  Other degenerative diseases of the
                                   basal ganglia.
3334............................  Huntington's chorea.
33371...........................  Athetoid cerebral palsy.
33372...........................  Acute dystonia due to drugs.
33379...........................  Other acquired torsion dystonia.
33390...........................  Unspecified extrapyramidal disease and
                                   abnormal movement disorder.
33391...........................  Stiff-man syndrome.
3340............................  Friedreich's ataxia.
3341............................  Hereditary spastic paraplegia.
3342............................  Primary cerebellar degeneration.

[[Page 25035]]

 
3343............................  Other cerebellar ataxia.
3344............................  Cerebellar ataxia in diseases
                                   classified elsewhere.
3348............................  Other spinocerebellar diseases.
3349............................  Spinocerebellar disease, unspecified.
3350............................  Werdnig-hoffmann disease.
33510...........................  Spinal muscular atrophy, unspecified.
33511...........................  Kugelberg-welander disease.
33519...........................  Other spinal muscular atrophy.
33520...........................  Amyotrophic lateral sclerosis.
33521...........................  Progressive muscular atrophy.
33522...........................  Progressive bulbar palsy.
33523...........................  Pseudobulbar palsy.
33524...........................  Primary lateral sclerosis.
33529...........................  Other motor neuron diseases.
3358............................  Other anterior horn cell diseases.
3359............................  Anterior horn cell disease,
                                   unspecified.
3360............................  Syringomyelia and syringobulbia.
3362............................  Subacute combined degeneration of
                                   spinal cord in diseases classified
                                   elsewhere.
3363............................  Myelopathy in other diseases
                                   classified elsewhere.
3368............................  Other myelopathy.
3369............................  Unspecified disease of spinal cord.
3370............................  Idiopathic peripheral autonomic
                                   neuropathy.
3371............................  Peripheral autonomic neuropathy in
                                   disorders classified elsewhere.
33720...........................  Reflex sympathetic dystrophy,
                                   unspecified.
33721...........................  Reflex sympathetic dystrophy of the
                                   upper limb.
33722...........................  Reflex sympathetic dystrophy of the
                                   lower limb.
33729...........................  Reflex sympathetic dystrophy of other
                                   specified site.
3410............................  Neuromyelitis optica.
3411............................  Schilder's disease.
34120...........................  Acute (transverse) myelitis NOS.
34121...........................  Acute (transverse) myelitis in
                                   conditions classified elsewhere.
34122...........................  Idiopathic transverse myelitis.
3418............................  Other demyelinating diseases of
                                   central nervous system.
3419............................  Demyelinating disease of central
                                   nervous system, unspecified.
34200...........................  Flaccid hemiplegia and hemiparesis
                                   affecting unspecified side.
34201...........................  Flaccid hemiplegia and hemiparesis
                                   affecting dominant side.
34202...........................  Flaccid hemiplegia and hemiparesis
                                   affecting nondominant side.
34210...........................  Spastic hemiplegia and hemiparesis
                                   affecting unspecified side.
34211...........................  Spastic hemiplegia and hemiparesis
                                   affecting dominant side.
34212...........................  Spastic hemiplegia and hemiparesis
                                   affecting nondominant side.
34280...........................  Other specified hemiplegia and
                                   hemiparesis affecting unspecified
                                   side.
34281...........................  Other specified hemiplegia and
                                   hemiparesis affecting dominant side.
34282...........................  Other specified hemiplegia and
                                   hemiparesis affecting nondominant
                                   side.
34290...........................  Unspecified hemiplegia and hemiparesis
                                   affecting unspecified side.
34291...........................  Unspecified hemiplegia and hemiparesis
                                   affecting dominant side.
34292...........................  Unspecified hemiplegia and hemiparesis
                                   affecting nondominant side.
3430............................  Congenital diplegia.
3431............................  Congenital hemiplegia.
3434............................  Infantile hemiplegia.
3441............................  Paraplegia.
3442............................  Diplegia of upper limbs.
34460...........................  Cauda equina syndrome without mention
                                   of neurogenic bladder.
34461...........................  Cauda equina syndrome with neurogenic
                                   bladder.
34501...........................  Generalized nonconvulsive epilepsy,
                                   with intractable epilepsy.
34511...........................  Generalized convulsive epilepsy, with
                                   intractable epilepsy.
3452............................  Petit mal status, epileptic.
34540...........................  Localization-related (focal) (partial)
                                   epilepsy and epileptic syndromes with
                                   complex partial seizures, without
                                   mention of intractable epilepsy.
34541...........................  Localization-related (focal) (partial)
                                   epilepsy and epileptic syndromes with
                                   complex partial seizures, with
                                   intractable epilepsy.
34550...........................  Localization-related (focal) (partial)
                                   epilepsy and epileptic syndromes with
                                   simple partial seizures, without
                                   mention of intractable epilepsy.
34551...........................  Localization-related (focal) (partial)
                                   epilepsy and epileptic syndromes with
                                   simple partial seizures, with
                                   intractable epilepsy.
34560...........................  Infantile spasms, without mention of
                                   intractable epilepsy.
34561...........................  Infantile spasms, with intractable
                                   epilepsy.
34570...........................  Epilepsia partialis continua, without
                                   mention of intractable epilepsy.
34571...........................  Epilepsia partialis continua, with
                                   intractable epilepsy.
34580...........................  Other forms of epilepsy and recurrent
                                   seizures, without mention of
                                   intractable epilepsy.
34581...........................  Other forms of epilepsy and recurrent
                                   seizures, with intractable epilepsy.
34591...........................  Epilepsy, unspecified, with
                                   intractable epilepsy.
3481............................  Anoxic brain damage.

[[Page 25036]]

 
3491............................  Nervous system complications from
                                   surgically implanted device.
34981...........................  Cerebrospinal fluid rhinorrhea.
3563............................  Refsum's disease.
3570............................  Acute infective polyneuritis.
35781...........................  Chronic inflammatory demyelinating
                                   polyneuritis.
35782...........................  Critical illness polyneuropathy.
3581............................  Myasthenic syndromes in diseases
                                   classified elsewhere.
3590............................  Congenital hereditary muscular
                                   dystrophy.
3591............................  Hereditary progressive muscular
                                   dystrophy.
3594............................  Toxic myopathy.
3596............................  Symptomatic inflammatory myopathy in
                                   diseases classified elsewhere.
35981...........................  Critical illness myopathy.
36000...........................  Purulent endophthalmitis, unspecified.
36001...........................  Acute endophthalmitis.
36002...........................  Panophthalmitis.
36004...........................  Vitreous abscess.
36011...........................  Sympathetic uveitis.
36012...........................  Panuveitis.
36013...........................  Parasitic endophthalmitis nos.
36019...........................  Other endophthalmitis.
3612............................  Serous retinal detachment.
36181...........................  Traction detachment of retina.
36189...........................  Other forms of retinal detachment.
3619............................  Unspecified retinal detachment.
36230...........................  Retinal vascular occlusion,
                                   unspecified.
36231...........................  Central retinal artery occlusion.
36232...........................  Retinal arterial branch occlusion.
36233...........................  Partial retinal arterial occlusion.
36234...........................  Transient retinal arterial occlusion.
36235...........................  Central retinal vein occlusion.
36240...........................  Retinal layer separation, unspecified.
36242...........................  Serous detachment of retinal pigment
                                   epithelium.
36243...........................  Hemorrhagic detachment of retinal
                                   pigment epithelium.
36284...........................  Retinal ischemia.
36310...........................  Disseminated chorioretinitis,
                                   unspecified.
36311...........................  Disseminated choroiditis and
                                   chorioretinitis, posterior pole.
36312...........................  Disseminated choroiditis and
                                   chorioretinitis, peripheral.
36313...........................  Disseminated choroiditis and
                                   chorioretinitis, generalized.
36314...........................  Disseminated retinitis and
                                   retinochoroiditis, metastatic.
36315...........................  Disseminated retinitis and
                                   retinochoroiditis, pigment
                                   epitheliopathy.
36320...........................  Chorioretinitis, unspecified.
36363...........................  Choroidal rupture.
36370...........................  Choroidal detachment, unspecified.
36371...........................  Serous choroidal detachment.
36372...........................  Hemorrhagic choroidal detachment.
36400...........................  Acute and subacute iridocyclitis,
                                   unspecified.
36401...........................  Primary iridocyclitis.
36402...........................  Recurrent iridocyclitis.
36403...........................  Secondary iridocyclitis, infectious.
36422...........................  Glaucomatocyclitic crises.
3643............................  Unspecified iridocyclitis.
36522...........................  Acute angle-closure glaucoma.
36811...........................  Sudden visual loss.
36812...........................  Transient visual loss.
37601...........................  Orbital cellulitis.
37602...........................  Orbital periostitis.
37603...........................  Orbital osteomyelitis.
37700...........................  Papilledema, unspecified.
37701...........................  Papilledema associated with increased
                                   intracranial pressure.
37730...........................  Optic neuritis, unspecified.
37731...........................  Optic papillitis.
37732...........................  Retrobulbar neuritis (acute).
37739...........................  Other optic neuritis.
37751...........................  Disorders of optic chiasm associated
                                   with pituitary neoplasms and
                                   disorders.
37752...........................  Disorders of optic chiasm associated
                                   with other neoplasms.
37753...........................  Disorders of optic chiasm associated
                                   with vascular disorders.
37754...........................  Disorders of optic chiasm associated
                                   with inflammatory disorders.
37761...........................  Disorders of other visual pathways
                                   associated with neoplasms.
37762...........................  Disorders of other visual pathways
                                   associated with vascular disorders.
37763...........................  Disorders of other visual pathways
                                   associated with inflammatory
                                   disorders.
37771...........................  Disorders of visual cortex associated
                                   with neoplasms.
37772...........................  Disorders of visual cortex associated
                                   with vascular disorders.

[[Page 25037]]

 
37773...........................  Disorders of visual cortex associated
                                   with inflammatory disorders.
38014...........................  Malignant otitis externa.
38300...........................  Acute mastoiditis without
                                   complications.
38301...........................  Subperiosteal abscess of mastoid.
38302...........................  Acute mastoiditis with other
                                   complications.
38861...........................  Cerebrospinal fluid otorrhea.
3910............................  Acute rheumatic pericarditis.
3911............................  Acute rheumatic endocarditis.
3912............................  Acute rheumatic myocarditis.
3918............................  Other acute rheumatic heart disease.
3919............................  Acute rheumatic heart disease,
                                   unspecified.
3920............................  Rheumatic chorea with heart
                                   involvement.
3929............................  Rheumatic chorea without mention of
                                   heart involvement.
393.............................  Chronic rheumatic pericarditis.
3980............................  Rheumatic myocarditis.
39891...........................  Rheumatic heart failure (congestive).
4010............................  Malignant essential hypertension.
40200...........................  Malignant hypertensive heart disease
                                   without congestive heart failure.
40201...........................  Malignant hypertensive heart disease
                                   with congestive heart failure.
40211...........................  Benign hypertensive heart disease with
                                   congestive heart failure.
40291...........................  Unspecified hypertensive heart disease
                                   with congestive heart failure.
40300...........................  Hypertensive chronic kidney disease,
                                   malignant, with chronic kidney
                                   disease stage I through stage IV, or
                                   unspecified.
40301...........................  Hypertensive chronic kidney disease,
                                   malignant, with chronic kidney
                                   disease stage V or end stage renal
                                   disease.
40311...........................  Hypertensive chronic kidney disease,
                                   benign, with chronic kidney disease
                                   stage V or end stage renal disease.
40400...........................  Hypertensive heart and chronic kidney
                                   disease, malignant, without heart
                                   failure and with chronic kidney
                                   disease stage I through stage IV, or
                                   unspecified.
40401...........................  Hypertensive heart and chronic kidney
                                   disease, malignant, with heart
                                   failure and with chronic kidney
                                   disease stage I through stage IV, or
                                   unspecified.
40402...........................  Hypertensive heart and chronic kidney
                                   disease, malignant, without heart
                                   failure and with chronic kidney
                                   disease stage V or end stage renal
                                   disease.
40403...........................  Hypertensive heart and chronic kidney
                                   disease, malignant, with heart
                                   failure and with chronic kidney
                                   disease stage V or end stage renal
                                   disease.
40411...........................  Hypertensive heart and chronic kidney
                                   disease, benign, with heart failure
                                   and with chronic kidney disease stage
                                   I through stage IV, or unspecified.
40412...........................  Hypertensive heart and chronic kidney
                                   disease, benign, without heart
                                   failure and with chronic kidney
                                   disease stage V or end stage renal
                                   disease.
40413...........................  Hypertensive heart and chronic kidney
                                   disease, benign, with heart failure
                                   and chronic kidney disease stage V or
                                   end stage renal disease.
40491...........................  Hypertensive heart and chronic kidney
                                   disease, unspecified, with heart
                                   failure and with chronic kidney
                                   disease stage I through stage IV, or
                                   unspecified.
40492...........................  Hypertensive heart and chronic kidney
                                   disease, unspecified, without heart
                                   failure and with chronic kidney
                                   disease stage V or end stage renal
                                   disease.
40493...........................  Hypertensive heart and chronic kidney
                                   disease, unspecified, with heart
                                   failure and chronic kidney disease
                                   stage V or end stage renal disease.
40501...........................  Malignant renovascular hypertension.
40509...........................  Other malignant secondary
                                   hypertension.
4110............................  Postmyocardial infarction syndrome.
4111............................  Intermediate coronary syndrome.
41181...........................  Other acute and subacute forms of
                                   ischemic heart disease, acute
                                   ischemic heart disease without
                                   myocardial infarction.
41189...........................  Other acute and subacute forms of
                                   ischemic heart disease, other.
4130............................  Angina decubitus.
4131............................  Prinzmetal angina.
41402...........................  Coronary atherosclerosis of autologous
                                   vein bypass graft.
41403...........................  Coronary atherosclerosis of
                                   nonautologous biological bypass
                                   graft.
41404...........................  Coronary atherosclerosis of artery
                                   bypass graft.
41406...........................  Coronary atherosclerosis of native
                                   coronary artery of transplanted
                                   heart.
41407...........................  Coronary atherosclerosis, of bypass
                                   graft (artery) (vein) of transplanted
                                   heart.
41410...........................  Aneurysm of heart (wall).
41419...........................  Other aneurysm of heart.
4160............................  Primary pulmonary hypertension.
4161............................  Kyphoscoliotic heart disease.
4170............................  Arteriovenous fistula of pulmonary
                                   vessels.
4171............................  Aneurysm of pulmonary artery.
4200............................  Acute pericarditis in diseases
                                   classified elsewhere.
42090...........................  Acute pericarditis, unspecified.
42091...........................  Acute idiopathic pericarditis.
42099...........................  Other acute pericarditis.
4230............................  Hemopericardium.
4231............................  Adhesive pericarditis.

[[Page 25038]]

 
4232............................  Constrictive pericarditis.
4233............................  Cardiac tamponade.
4238............................  Other specified diseases of
                                   pericardium.
4239............................  Unspecified disease of pericardium.
42490...........................  Endocarditis, valve unspecified,
                                   unspecified cause.
42491...........................  Endocarditis in diseases classified
                                   elsewhere.
42499...........................  Other endocarditis, valve unspecified.
4250............................  Endomyocardial fibrosis.
4251............................  Hypertrophic obstructive
                                   cardiomyopathy.
4252............................  Obscure cardiomyopathy of africa.
4253............................  Endocardial fibroelastosis.
4254............................  Other primary cardiomyopathies.
4255............................  Alcoholic cardiomyopathy.
4257............................  Nutritional and metabolic
                                   cardiomyopathy.
4258............................  Cardiomyopathy in other diseases
                                   classified elsewhere.
4259............................  Secondary cardiomyopathy, unspecified.
4260............................  Atrioventricular block, complete.
42612...........................  Mobitz (type) ii atrioventricular
                                   block.
42689...........................  Other specified conduction disorders.
4270............................  Paroxysmal supraventricular
                                   tachycardia.
4271............................  Paroxysmal ventricular tachycardia.
42732...........................  Atrial flutter.
4281............................  Left heart failure.
42820...........................  Unspecified systolic heart failure.
42822...........................  Chronic systolic heart failure.
42830...........................  Unspecified diastolic heart failure.
42832...........................  Chronic diastolic heart failure.
42840...........................  Unspecified combined systolic and
                                   diastolic heart failure.
42842...........................  Chronic combined systolic and
                                   diastolic heart failure.
42971...........................  Certain sequelae of myocardial
                                   infarction, not elsewhere classified,
                                   acquired cardiac septal defect.
42979...........................  Certain sequelae of myocardial
                                   infarction, not elsewhere classified,
                                   other.
42981...........................  Other disorders of papillary muscle.
42982...........................  Hyperkinetic heart disease.
42983...........................  Takotsubo syndrome.
4329............................  Unspecified intracranial hemorrhage.
4350............................  Basilar artery syndrome.
4351............................  Vertebral artery syndrome.
4352............................  Subclavian steal syndrome.
4353............................  Vertebrobasilar artery syndrome.
4358............................  Other specified transient cerebral
                                   ischemias.
4359............................  Unspecified transient cerebral
                                   ischemia.
436.............................  Acute, but ill-defined,
                                   cerebrovascular disease.
4371............................  Other generalized ischemic
                                   cerebrovascular disease.
4372............................  Hypertensive encephalopathy.
4374............................  Cerebral arteritis.
4375............................  Moyamoya disease.
4376............................  Nonpyogenic thrombosis of intracranial
                                   venous sinus.
43820...........................  Hemiplegia affecting unspecified side.
43821...........................  Hemiplegia affecting dominant side.
43822...........................  Hemiplegia affecting nondominant side.
44024...........................  Atherosclerosis of native arteries of
                                   the extremities with gangrene.
4440............................  Embolism and thrombosis of abdominal
                                   aorta.
4441............................  Embolism and thrombosis of thoracic
                                   aorta.
44421...........................  Arterial embolism and thrombosis of
                                   upper extremity.
44422...........................  Arterial embolism and thrombosis of
                                   lower extremity.
44481...........................  Embolism and thrombosis of iliac
                                   artery.
44489...........................  Embolism and thrombosis of other
                                   artery.
4449............................  Embolism and thrombosis of unspecified
                                   artery.
44501...........................  Atheroembolism, upper extremity.
44502...........................  Atheroembolism, lower extremity.
44581...........................  Atheroembolism, kidney.
44589...........................  Atheroembolism, other site.
4460............................  Polyarteritis nodosa.
4461............................  Acute febrile mucocutaneous lymph node
                                   syndrome (mcls).
44620...........................  Hypersensitivity angiitis,
                                   unspecified.
44621...........................  Goodpasture's syndrome.
44629...........................  Other specified hypersensitivity
                                   angiitis.
4463............................  Lethal midline granuloma.
4464............................  Wegener's granulomatosis.
4467............................  Takayasu's disease.
4472............................  Rupture of artery.
4474............................  Celiac artery compression syndrome.

[[Page 25039]]

 
4475............................  Necrosis of artery.
449.............................  Septic arterial embolism.
45119...........................  Phlebitis and thrombophlebitis of
                                   other.
45181...........................  Phlebitis and thrombophlebitis of
                                   iliac vein.
45183...........................  Phlebitis and thrombophlebitis of deep
                                   veins of upper extremities.
45189...........................  Phlebitis and thrombophlebitis of
                                   other sites.
4531............................  Thrombophlebitis migrans.
4533............................  Embolism and thrombosis of renal vein.
45340...........................  Venous embolism and thrombosis of
                                   unspecified deep vessels of lower
                                   extremity.
45341...........................  Venous embolism and thrombosis of deep
                                   vessels of proximal lower extremity.
45342...........................  Venous embolism and thrombosis of deep
                                   vessels of distal lower extremity.
4538............................  Embolism and thrombosis of other
                                   specified veins.
4539............................  Embolism and thrombosis of unspecified
                                   site.
4542............................  Varicose veins of lower extremities
                                   with ulcer and inflammation.
4561............................  Esophageal varices without mention of
                                   bleeding.
45621...........................  Esophageal varices in diseases
                                   classified elsewhere, without mention
                                   of bleeding.
45911...........................  Postphlebetic syndrome with ulcer.
45913...........................  Postphlebetic syndrome with ulcer and
                                   inflammation.
4592............................  Compression of vein.
45931...........................  Chronic venous hypertension with
                                   ulcer.
45933...........................  Chronic venous hypertension with ulcer
                                   and inflammation.
46430...........................  Acute epiglottitis without mention of
                                   obstruction.
46611...........................  Acute bronchiolitis due to respiratory
                                   syncytial virus (RSV).
46619...........................  Acute bronciolitis due to other
                                   infectious organisms.
475.............................  Peritonsillar abscess.
47821...........................  Cellulitis of pharynx or nasopharynx.
47822...........................  Parapharyngeal abscess.
47824...........................  Retropharyngeal abscess.
47834...........................  Complete bilateral paralysis of vocal
                                   cords.
47871...........................  Cellulitis and perichondritis of
                                   larynx.
49121...........................  Obstructive chronic bronchitis, with
                                   (acute) exacerbation.
49122...........................  Obstructive chronic bronchitis with
                                   acute bronchitis.
49301...........................  Extrinsic asthma with status
                                   asthmaticus.
49302...........................  Extrinsic asthma, with (acute)
                                   exacerbation.
49311...........................  Intrinsic asthma with status
                                   asthmaticus.
49312...........................  Intrinsic asthma, with (acute)
                                   exacerbation.
49321...........................  Chronic obstructive asthma with status
                                   asthmaticus.
49322...........................  Chronic obstructive asthma, with
                                   (acute) exacerbation.
49391...........................  Asthma, unspecified type, with status
                                   asthmaticus.
49392...........................  Asthma, unspecified type, with (acute)
                                   exacerbation.
4941............................  Bronchiectasis with acute
                                   exacerbation.
4957............................  'Ventilation' pneumonitis.
4958............................  Other specified allergic alveolitis
                                   and pneumonitis.
4959............................  Unspecified allergic alveolitis and
                                   pneumonitis.
5060............................  Bronchitis and pneumonitis due to
                                   fumes and vapors.
5080............................  Acute pulmonary manifestations due to
                                   radiation.
5081............................  Chronic and other pulmonary
                                   manifestations due to radiation.
5119............................  Unspecified pleural effusion.
5121............................  Iatrogenic pneumothorax.
5128............................  Other spontaneous pneumothorax.
514.............................  Pulmonary congestion and hypostasis.
5160............................  Pulmonary alveolar proteinosis.
5161............................  Idiopathic pulmonary hemosiderosis.
5162............................  Pulmonary alveolar microlithiasis.
5163............................  Idiopathic fibrosing alveolitis.
5168............................  Other specified alveolar and
                                   parietoalveolar pneumonopathies.
5169............................  Unspecified alveolar and
                                   parietoalveolar pneumonopathy.
5171............................  Rheumatic pneumonia.
5172............................  Lung involvement in systemic
                                   sclerosis.
5173............................  Acute chest syndrome.
5180............................  Pulmonary collapse.
5183............................  Pulmonary eosinophilia.
5186............................  Allergic bronchopulmonary
                                   aspergilliosis.
5187............................  Transfusion related acute lung injury
                                   (TRALI).
51882...........................  Other pulmonary insufficiency, not
                                   elsewhere classified.
51883...........................  Chronic respiratory failure.
51900...........................  Tracheostomy complication,
                                   unspecified.
51901...........................  Infection of tracheostomy.
51902...........................  Mechanical complication of
                                   tracheostomy.
51909...........................  Other tracheostomy complications.
5220............................  Pulpitis.
5224............................  Acute apical periodontitis of pulpal
                                   origin.

[[Page 25040]]

 
5273............................  Abscess of salivary gland.
5274............................  Fistula of salivary gland.
5283............................  Cellulitis and abscess of oral soft
                                   tissues.
53012...........................  Acute esophagitis.
53020...........................  Ulcer of esophagus without bleeding.
53086...........................  Infection of esophagostomy.
53087...........................  Mechanical complication of
                                   esophagostomy.
53130...........................  Acute gastric ulcer without mention of
                                   hemorrhage or perforation, without
                                   mention of obstruction.
53230...........................  Acute duodenal ulcer without mention
                                   of hemorrhage or perforation, without
                                   mention of obstruction.
53330...........................  Acute peptic ulcer of unspecified site
                                   without mention of hemorrhage and
                                   perforation, without mention of
                                   obstruction.
53430...........................  Acute gastrojejunal ulcer without
                                   mention of hemorrhage or perforation,
                                   without mention of obstruction.
5361............................  Acute dilatation of stomach.
53641...........................  Infection of gastrostomy.
53642...........................  Mechanical complication of
                                   gastrostomy.
5370............................  Acquired hypertrophic pyloric
                                   stenosis.
5373............................  Other obstruction of duodenum.
5374............................  Fistula of stomach or duodenum.
538.............................  Gastrointestinal mucositis
                                   (ulcerative).
5409............................  Acute appendicitis without mention of
                                   peritonitis.
55010...........................  Unilateral or unspecified inguinal
                                   hernia, with obstruction, without
                                   mention of gangrene.
55011...........................  Recurrent unilateral or unspecified
                                   inguinal hernia with obstruction,
                                   without mention of gangrene.
55012...........................  Bilateral inguinal hernia, with
                                   obstruction, without mention of
                                   gangrene.
55013...........................  Recurrent bilateral inguinal hernia,
                                   with obstruction, without mention of
                                   gangrene.
55200...........................  Unilateral or unspecified femoral
                                   hernia with obstruction.
55201...........................  Recurrent unilateral or unspecified
                                   femoral hernia with obstruction.
55202...........................  Bilateral femoral hernia with
                                   obstruction.
55203...........................  Recurrent bilateral femoral hernia
                                   with obstruction.
5521............................  Umbilical hernia with obstruction.
55220...........................  Unspecified ventral hernia with
                                   obstruction.
55221...........................  Incisional hernia with obstruction.
55229...........................  Other ventral hernia with obstruction.
5523............................  Diaphragmatic hernia with obstruction.
5528............................  Hernia of other specified sites, with
                                   obstruction.
5529............................  Hernia of unspecified site, with
                                   obstruction.
5550............................  Regional enteritis of small intestine.
5551............................  Regional enteritis of large intestine.
5552............................  Regional enteritis of small intestine
                                   with large intestine.
5559............................  Regional enteritis of unspecified
                                   site.
5560............................  Ulcerative (chronic) enterocolitis.
5561............................  Ulcerative (chronic) ileocolitis.
5562............................  Ulcerative (chronic) proctitis.
5563............................  Ulcerative (chronic)
                                   proctosigmoiditis.
5564............................  Pseudopolyposis of colon.
5565............................  Left-sided ulcerative (chronic)
                                   colitis.
5566............................  Universal ulcerative (chronic)
                                   colitis.
5568............................  Other ulcerative colitis.
5569............................  Ulcerative colitis, unspecified.
5571............................  Chronic vascular insufficiency of
                                   intestine.
5579............................  Unspecified vascular insufficiency of
                                   intestine.
5581............................  Gastroenteritis and colitis due to
                                   radiation.
5582............................  Toxic gastroenteritis and colitis.
5600............................  Intussusception.
5601............................  Paralytic ileus.
56030...........................  Impaction of intestine, unspecified.
56031...........................  Gallstone ileus.
56039...........................  Other impaction of intestine.
56081...........................  Intestinal or peritoneal adhesions
                                   with obstruction (postoperative)
                                   (postinfection).
56089...........................  Other specified intestinal
                                   obstruction.
5609............................  Unspecified intestinal obstruction.
56201...........................  Diverticulitis of small intestine
                                   (without mention of hemorrhage).
56211...........................  Diverticulitis of colon (without
                                   mention of hemorrhage).
5647............................  Megacolon, other than hirschsprung's.
56481...........................  Neurogenic bowel.
566.............................  Abscess of anal and rectal regions.
56782...........................  Sclerosing mesenteritis.
56882...........................  Peritoneal effusion (chronic).
5693............................  Hemorrhage of rectum and anus.
56941...........................  Ulcer of anus and rectum.
5695............................  Abscess of intestine.
56961...........................  Infection of colostomy or enterostomy.
56962...........................  Mechanical complication of colostomy
                                   and enterostomy.

[[Page 25041]]

 
56969...........................  Other colostomy and enterostomy
                                   complication.
56981...........................  Fistula of intestine, excluding rectum
                                   and anus.
56982...........................  Ulceration of intestine.
5723............................  Portal hypertension.
5731............................  Hepatitis in viral diseases classified
                                   elsewhere.
5732............................  Hepatitis in other infectious diseases
                                   classified elsewhere.
57400...........................  Calculus of gallbladder with acute
                                   cholecystitis, without mention of
                                   obstruction.
57401...........................  Calculus of gallbladder with acute
                                   cholecystitis, with obstruction.
57410...........................  Calculus of gallbladder with other
                                   cholecystitis, without mention of
                                   obstruction.
57411...........................  Calculus of gallbladder with other
                                   cholecystitis, with obstruction.
57421...........................  Calculus of gallbladder without
                                   mention of cholecystitis, with
                                   obstruction.
57430...........................  Calculus of bile duct with acute
                                   cholecystitis without mention of
                                   obstruction.
57431...........................  Calculus of bile duct with acute
                                   cholecystitis, with obstruction.
57440...........................  Calculus of bile duct with other
                                   cholecystitis, without mention of
                                   obstruction.
57441...........................  Calculus of bile duct with other
                                   cholecystitis, with obstruction.
57451...........................  Calculus of bile duct without mention
                                   of cholecystitis, with obstruction.
57460...........................  Calculus of gallbladder and bile duct
                                   with acute cholecystitis, without
                                   mention of obstruction.
57461...........................  Calculus of gallbladder and bile duct
                                   with acute cholecystitis, with
                                   obstruction.
57470...........................  Calculus of gallbladder and bile duct
                                   with other cholecystitis, without
                                   mention of obstruction.
57471...........................  Calculus of gallbladder and bile duct
                                   with other cholecystitis, with
                                   obstruction.
57480...........................  Calculus of gallbladder and bile duct
                                   with acute and chronic cholecystitis,
                                   without mention of obstruction.
57491...........................  Calculus of gallbladder and bile duct
                                   without cholecystitis, with
                                   obstruction.
5750............................  Acute cholecystitis.
57512...........................  Acute and chronic cholecystitis.
5752............................  Obstruction of gallbladder.
5753............................  Hydrops of gallbladder.
5755............................  Fistula of gallbladder.
5761............................  Cholangitis.
5764............................  Fistula of bile duct.
5771............................  Chronic pancreatitis.
5772............................  Cyst and pseudocyst of pancreas.
5780............................  Hematemesis.
5781............................  Blood in stool.
5789............................  Hemorrhage of gastrointestinal tract,
                                   unspecified.
5791............................  Tropical sprue.
5792............................  Blind loop syndrome.
5793............................  Other and unspecified postsurgical
                                   nonabsorption.
5794............................  Pancreatic steatorrhea.
5798............................  Other specified intestinal
                                   malabsorption.
5799............................  Unspecified intestinal malabsorption.
5810............................  Nephrotic syndrome with lesion of
                                   proliferative glomerulonephritis.
5811............................  Nephrotic syndrome with lesion of
                                   membranous glomerulonephritis.
5812............................  Nephrotic syndrome with lesion of
                                   membranoproliferative
                                   glomerulonephritis.
5813............................  Nephrotic syndrome with lesion of
                                   minimal change glomerulonephritis.
58181...........................  Nephrotic syndrome in diseases
                                   classified elsewhere.
58189...........................  Other nephrotic syndrome with
                                   specified pathological lesion in
                                   kidney.
5819............................  Nephrotic syndrome with unspecified
                                   pathological lesion in kidney.
5820............................  Chronic glomerulonephritis with lesion
                                   of proliferative glomerulonephritis.
5821............................  Chronic glomerulonephritis with lesion
                                   of membranous glomerulonephritis.
5822............................  Chronic glomerulonephritis with lesion
                                   of membranoproliferative
                                   glomerulonephritis.
5824............................  Chronic glomerulonephritis with lesion
                                   of rapidly progressive
                                   glomerulonephritis.
58281...........................  Chronic glomerulonephritis in diseases
                                   classified elsewhere.
58289...........................  Other chronic glomerulonephritis with
                                   specified pathological lesion in
                                   kidney.
5829............................  Chronic glomerulonephritis with
                                   unspecified pathological lesion in
                                   kidney.
5830............................  Nephritis and nephropathy, not
                                   specified as acute or chronic, with
                                   lesion of proliferative
                                   glomerulonephritis.
5831............................  Nephritis and nephropathy, not
                                   specified as acute or chronic, with
                                   lesion of membranous
                                   glomerulonephritis.
5832............................  Nephritis and nephropathy, not
                                   specified as acute or chronic, with
                                   lesion of membranoproliferative
                                   glomerulonephritis.
5837............................  Nephritis and nephropathy, not
                                   specified as acute or chronic, with
                                   lesion of renal medullary necrosis.
5854............................  Chronic kidney disease, Stage IV
                                   (severe).
5855............................  Chronic kidney disease, Stage V.
5881............................  Nephrogenic diabetes insipidus.
58881...........................  Secondary hyperparathyroidism (of
                                   renal origin).
59001...........................  Chronic pyelonephritis with lesion of
                                   renal medullary necrosis.
59010...........................  Acute pyelonephritis without lesion of
                                   renal medullary necrosis.
5903............................  Pyeloureteritis cystica.
59080...........................  Pyelonephritis, unspecified.
59081...........................  Pyelitis or pyelonephritis in diseases
                                   classified elsewhere.
591.............................  Hydronephrosis.
5921............................  Calculus of ureter.
5934............................  Other ureteric obstruction.
5935............................  Hydroureter.

[[Page 25042]]

 
59381...........................  Vascular disorders of kidney.
59382...........................  Ureteral fistula.
5950............................  Acute cystitis.
59582...........................  Irradiation cystitis.
5961............................  Intestinovesical fistula.
5962............................  Vesical fistula, not elsewhere
                                   classified.
5967............................  Hemorrhage into bladder wall.
5970............................  Urethral abscess.
5990............................  Urinary tract infection, site not
                                   specified.
5991............................  Urethral fistula.
6010............................  Acute prostatitis.
6012............................  Abscess of prostate.
6031............................  Infected hydrocele.
6040............................  Orchitis, epididymitis, and epididymo-
                                   orchitis, with abscess.
6073............................  Priapism.
60782...........................  Vascular disorders of penis.
60820...........................  Torsion of testis, unspecified.
60821...........................  Extravaginal torsion of spermatic
                                   cord.
60822...........................  Intravaginal torsion of spermatic
                                   cord.
60823...........................  Torsion of appendix testis.
60824...........................  Torsion of appendix epididymis.
6140............................  Acute salpingitis and oophoritis.
6143............................  Acute parametritis and pelvic
                                   cellulitis.
6147............................  Other chronic pelvic peritonitis,
                                   female.
6150............................  Acute inflammatory diseases of uterus,
                                   except cervix.
6163............................  Abscess of bartholin's gland.
6164............................  Other abscess of vulva.
61681...........................  Mucositis (ulcerative) of cervix,
                                   vagina, and vulva.
6190............................  Urinary-genital tract fistula, female.
6191............................  Digestive-genital tract fistula,
                                   female.
6192............................  Genital tract-skin fistula, female.
6198............................  Other specified fistulas involving
                                   female genital tract.
6199............................  Unspecified fistula involving female
                                   genital tract.
6205............................  Torsion of ovary, ovarian pedicle, or
                                   fallopian tube.
63300...........................  Abdominal pregnancy without
                                   intrauterine pregnancy.
63301...........................  Abdominal pregnancy with intrauterine
                                   pregnancy.
63310...........................  Tubal pregnancy without intrauterine
                                   pregnancy.
63311...........................  Tubal pregnancy with intrauterine
                                   pregnancy.
63320...........................  Ovarian pregnancy without intrauterine
                                   pregnancy.
63321...........................  Ovarian pregnancy with intrauterine
                                   pregnancy.
63380...........................  Other ectopic pregnancy without
                                   intrauterine pregnancy.
63381...........................  Other ectopic pregnancy with
                                   intrauterine pregnancy.
63390...........................  Unspecified ectopic pregnancy without
                                   intrauterine pregnancy.
63391...........................  Unspecified ectopic pregnancy with
                                   intrauterine pregnancy.
63400...........................  Spontaneous abortion, unspecified,
                                   complicated by genital tract and
                                   pelvic infection.
63401...........................  Spontaneous abortion, incomplete,
                                   complicated by genital tract and
                                   pelvic infection.
63402...........................  Spontaneous abortion, complete,
                                   complicated by genital tract and
                                   pelvic infection.
63420...........................  Spontaneous abortion, unspecified,
                                   complicated by damage to pelvic
                                   organs or tissues.
63421...........................  Spontaneous abortion, incomplete,
                                   complicated by damage to pelvic
                                   organs or tissues.
63422...........................  Spontaneous abortion, complete,
                                   complicated by damage to pelvic
                                   organs or tissues.
63440...........................  Spontaneous abortion, unspecified,
                                   complicated by metabolic disorder.
63441...........................  Spontaneous abortion, incomplete,
                                   complicated by metabolic disorder.
63442...........................  Spontaneous abortion, complete,
                                   complicated by metabolic disorder.
63460...........................  Spontaneous abortion, unspecified,
                                   complicated by embolism.
63470...........................  Spontaneous abortion, unspecified,
                                   with other specified complications.
63471...........................  Spontaneous abortion, incomplete, with
                                   other specified complications.
63472...........................  Spontaneous abortion, complete, with
                                   other specified complications.
63480...........................  Spontaneous abortion, unspecified,
                                   with unspecified complication.
63481...........................  Spontaneous abortion, incomplete, with
                                   unspecified complication.
63482...........................  Spontaneous abortion, complete, with
                                   unspecified complication.
63500...........................  Legally induced abortion, unspecified,
                                   complicated by genital tract and
                                   pelvic infection.
63501...........................  Legally induced abortion, incomplete,
                                   complicated by genital tract and
                                   pelvic infection.
63502...........................  Legally induced abortion, complete,
                                   complicated by genital tract and
                                   pelvic infection.
63520...........................  Legally induced abortion, unspecified,
                                   complicated by damage to pelvic
                                   organs or tissues.
63521...........................  Legally induced abortion, incomplete,
                                   complicated by damage to pelvic
                                   organs or tissues.
63522...........................  Legally induced abortion, complete,
                                   complicated by damage to pelvic
                                   organs or tissues.
63540...........................  Legally induced abortion, unspecified,
                                   complicated by metabolic disorder.
63541...........................  Legally induced abortion, incomplete,
                                   complicated by metabolic disorder.
63542...........................  Legally induced abortion, complete,
                                   complicated by metabolic disorder.
63570...........................  Legally induced abortion, unspecified,
                                   with other specified complications.
63571...........................  Legally induced abortion, incomplete,
                                   with other specified complications.
63572...........................  Legally induced abortion, complete,
                                   with other specified complications.

[[Page 25043]]

 
63580...........................  Legally induced abortion, unspecified,
                                   with unspecified complication.
63581...........................  Legally induced abortion, incomplete,
                                   with unspecified complication.
63582...........................  Legally induced abortion, complete,
                                   with unspecified complication.
63600...........................  Illegal abortion, unspecified,
                                   complicated by genital tract and
                                   pelvic infection.
63601...........................  Illegal abortion, incomplete,
                                   complicated by genital tract and
                                   pelvic infection.
63602...........................  Illegal abortion, complete,
                                   complicated by genital tract and
                                   pelvic infection.
63620...........................  Illegal abortion, unspecified,
                                   complicated by damage to pelvic
                                   organs or tissues.
63621...........................  Illegal abortion, incomplete,
                                   complicated by damage to pelvic
                                   organs or tissues.
63622...........................  Illegal abortion, complete,
                                   complicated by damage to pelvic
                                   organs or tissues.
63640...........................  Illegal abortion, unspecified,
                                   complicated by metabolic disorder.
63641...........................  Illegal abortion, incomplete,
                                   complicated by metabolic disorder.
63642...........................  Illegal abortion, complete,
                                   complicated by metabolic disorder.
63670...........................  Illegal abortion, unspecified, with
                                   other specified complications.
63671...........................  Illegal abortion, incomplete, with
                                   other specified complications.
63672...........................  Illegal abortion, complete, with other
                                   specified complications.
63680...........................  Illegal abortion, unspecified, with
                                   unspecified complication.
63681...........................  Illegal abortion, incomplete, with
                                   unspecified complication.
63682...........................  Illegal abortion, complete, with
                                   unspecified complication.
63700...........................  Unspecified type of abortion,
                                   unspecified, complicated by genital
                                   tract and pelvic infection.
63701...........................  Unspecified abortion, incomplete,
                                   complicated by genital tract and
                                   pelvic infection.
63702...........................  Unspecified abortion, complete,
                                   complicated by genital tract and
                                   pelvic infection.
63720...........................  Legally unspecified type of abortion,
                                   unspecified, complicated by damage to
                                   pelvic organs or tissues.
63721...........................  Legally unspecified abortion,
                                   incomplete, complicated by damage to
                                   pelvic organs or tissues.
63722...........................  Legally unspecified abortion,
                                   complete, complicated by damage to
                                   pelvic organs or tissues.
63740...........................  Legally unspecified type of abortion,
                                   unspecified, complicated by metabolic
                                   disorder.
63741...........................  Legally unspecified abortion,
                                   incomplete, complicated by metabolic
                                   disorder.
63742...........................  Legally unspecified abortion,
                                   complete, complicated by metabolic
                                   disorder.
63770...........................  Legally unspecified type of abortion,
                                   unspecified, with other specified
                                   complications.
63771...........................  Legally unspecified abortion,
                                   incomplete, with other specified
                                   complications.
63772...........................  Legally unspecified abortion,
                                   complete, with other specified
                                   complications.
63780...........................  Legally unspecified type of abortion,
                                   unspecified, with unspecified
                                   complication.
63781...........................  Legally unspecified abortion,
                                   incomplete, with unspecified
                                   complication.
63782...........................  Legally unspecified abortion,
                                   complete, with unspecified
                                   complication.
6380............................  Failed attempted abortion complicated
                                   by genital tract and pelvic
                                   infection.
6381............................  Failed attempted abortion complicated
                                   by delayed or excessive hemorrhage.
6382............................  Failed attempted abortion complicated
                                   by damage to pelvic organs or
                                   tissues.
6384............................  Failed attempted abortion complicated
                                   by metabolic disorder.
6387............................  Failed attempted abortion with other
                                   specified complications.
6388............................  Failed attempted abortion with
                                   unspecified complication.
6390............................  Genital tract and pelvic infection
                                   following abortion or ectopic and
                                   molar pregnancies.
6391............................  Delayed or excessive hemorrhage
                                   following abortion or ectopic and
                                   molar pregnancies.
6392............................  Damage to pelvic organs and tissues
                                   following abortion or ectopic and
                                   molar pregnancies.
6394............................  Metabolic disorders following abortion
                                   or ectopic and molar pregnancies.
6398............................  Other specified complications
                                   following abortion or ectopic and
                                   molar pregnancies.
6399............................  Unspecified complication following
                                   abortion or ectopic and molar
                                   pregnancies.
64001...........................  Threatened abortion, delivered.
64003...........................  Threatened abortion, antepartum.
64093...........................  Unspecified hemorrhage in early
                                   pregnancy, antepartum.
64101...........................  Placenta previa without hemorrhage,
                                   with delivery.
64103...........................  Placenta previa without hemorrhage,
                                   antepartum.
64123...........................  Premature separation of placenta,
                                   antepartum.
64201...........................  Benign essential hypertension with
                                   delivery.
64202...........................  Benign essential hypertension, with
                                   delivery, with mention of postpartum
                                   complication.
64203...........................  Antepartum benign essential
                                   hypertension.
64213...........................  Hypertension secondary to renal
                                   disease, antepartum.
64214...........................  Hypertension secondary to renal
                                   disease, postpartum.
64231...........................  Transient hypertension of pregnancy,
                                   with delivery.
64232...........................  Transient hypertension of pregnancy,
                                   with delivery, with mention of
                                   postpartum complication.
64241...........................  Mild or unspecified pre-eclampsia,
                                   with delivery.
64243...........................  Mild or unspecified pre-eclampsia,
                                   antepartum.
64244...........................  Mild or unspecified pre-eclampsia,
                                   postpartum.
64291...........................  Unspecified hypertension, with
                                   delivery.
64292...........................  Unspecified hypertension, with
                                   delivery, with mention of postpartum
                                   complication.
64293...........................  Unspecified antepartum hypertension.
64294...........................  Unspecified postpartum hypertension.
64413...........................  Other threatened labor, antepartum.
64420...........................  Early onset of delivery, unspecified
                                   as to episode of care.
64621...........................  Unspecified renal disease in
                                   pregnancy, with delivery.
64622...........................  Unspecified renal disease in
                                   pregnancy, with delivery, with
                                   mention of postpartum complication.
64623...........................  Unspecified antepartum renal disease.
64624...........................  Unspecified postpartum renal disease.
64631...........................  Habitual aborter, delivered, with or
                                   without mention of antepartum
                                   condition.

[[Page 25044]]

 
64661...........................  Infections of genitourinary tract in
                                   pregnancy, with delivery.
64662...........................  Infections of genitourinary tract in
                                   pregnancy, with delivery, with
                                   mention of postpartum complication.
64663...........................  Antepartum infections of genitourinary
                                   tract.
64664...........................  Postpartum infections of genitourinary
                                   tract.
64671...........................  Liver disorders in pregnancy, with
                                   delivery.
64673...........................  Antepartum liver disorders.
64701...........................  Syphilis of mother, complicating
                                   pregnancy, with delivery.
64702...........................  Syphilis of mother, complicating
                                   pregnancy, with delivery, with
                                   mention of postpartum complication.
64703...........................  Antepartum syphilis.
64704...........................  Postpartum syphilis.
64711...........................  Gonorrhea of mother, with delivery.
64712...........................  Gonorrhea of mother, with delivery,
                                   with mention of postpartum
                                   complication.
64713...........................  Antepartum gonorrhea.
64714...........................  Postpartum gonorrhea.
64721...........................  Other venereal diseases of mother,
                                   with delivery.
64722...........................  Other venereal diseases of mother,
                                   with delivery, with mention of
                                   postpartum complication.
64723...........................  Other antepartum venereal diseases.
64724...........................  Other postpartum venereal diseases.
64731...........................  Tuberculosis of mother, with delivery.
64732...........................  Tuberculosis of mother, with delivery,
                                   with mention of postpartum
                                   complication.
64733...........................  Antepartum tuberculosis.
64734...........................  Postpartum tuberculosis.
64741...........................  Malaria of mother, with delivery.
64742...........................  Malaria of mother, with delivery, with
                                   mention of postpartum complication.
64743...........................  Antepartum malaria.
64744...........................  Postpartum malaria.
64751...........................  Rubella of mother, with delivery.
64752...........................  Rubella of mother, with delivery, with
                                   mention of postpartum complication.
64753...........................  Antepartum rubella.
64754...........................  Postpartum rubella.
64761...........................  Other viral diseases of mother, with
                                   delivery.
64762...........................  Other viral diseases of mother, with
                                   delivery, with mention of postpartum
                                   complication.
64763...........................  Other antepartum viral diseases.
64764...........................  Other postpartum viral diseases.
64781...........................  Other specified infectious and
                                   parasitic diseases of mother, with
                                   delivery.
64782...........................  Other specified infectious and
                                   parasitic diseases of mother, with
                                   delivery, with mention of postpartum
                                   complication.
64783...........................  Other specified infectious and
                                   parasitic diseases of mother,
                                   antepartum.
64784...........................  Other specified infectious and
                                   parasitic diseases of mother,
                                   postpartum.
64791...........................  Unspecified infection or infestation
                                   of mother, with delivery.
64792...........................  Unspecified infection or infestation
                                   of mother, with delivery, with
                                   mention of postpartum complication.
64793...........................  Unspecified infection or infestation
                                   of mother, antepartum.
64794...........................  Unspecified infection or infestation
                                   of mother, postpartum.
64800...........................  Diabetes mellitus of mother,
                                   complicating pregnancy, childbirth,
                                   or the puerperium, unspecified as to
                                   episode of care.
64803...........................  Antepartum diabetes mellitus.
64804...........................  Postpartum diabetes mellitus.
64831...........................  Drug dependence of mother, with
                                   delivery.
64832...........................  Drug dependence of mother, with
                                   delivery, with mention of postpartum
                                   complication.
64833...........................  Antepartum drug dependence.
64834...........................  Postpartum drug dependence.
64851...........................  Congenital cardiovascular disorders of
                                   mother, with delivery.
64852...........................  Congenital cardiovascular disorders of
                                   mother, with delivery, with mention
                                   of postpartum complication.
64853...........................  Congenital cardiovascular disorders of
                                   mother, antepartum.
64854...........................  Congenital cardiovascular disorders of
                                   mother, postpartum.
64861...........................  Other cardiovascular diseases of
                                   mother, with delivery.
64862...........................  Other cardiovascular diseases of
                                   mother, with delivery, with mention
                                   of postpartum complication.
64863...........................  Other cardiovascular diseases of
                                   mother, antepartum.
64864...........................  Other cardiovascular diseases of
                                   mother, postpartum.
64871...........................  Bone and joint disorders of back,
                                   pelvis, and lower limbs of mother,
                                   with delivery.
64872...........................  Bone and joint disorders of back,
                                   pelvis, and lower limbs of mother,
                                   with delivery, with mention of
                                   postpartum complication.
64873...........................  Bone and joint disorders of back,
                                   pelvis, and lower limbs of mother,
                                   antepartum.
64874...........................  Bone and joint disorders of back,
                                   pelvis, and lower limbs of mother,
                                   postpartum.
64930...........................  Coagulation defects complicating
                                   pregnancy, childbirth, or the
                                   puerperium, unspecified as to episode
                                   of care or not applicable.
64931...........................  Coagulation defects complicating
                                   pregnancy, childbirth, or the
                                   puerperium, delivered, with or
                                   without mention of antepartum
                                   condition.
64932...........................  Coagulation defects complicating
                                   pregnancy, childbirth, or the
                                   puerperium, delivered, with mention
                                   of postpartum complication.
64933...........................  Coagulation defects complicating
                                   pregnancy, childbirth, or the
                                   puerperium, antepartum condition or
                                   complication.

[[Page 25045]]

 
64934...........................  Coagulation defects complicating
                                   pregnancy, childbirth, or the
                                   puerperium, postpartum condition or
                                   complication.
64941...........................  Epilepsy complicating pregnancy,
                                   childbirth, or the puerperium,
                                   delivered, with or without mention of
                                   antepartum condition.
64942...........................  Epilepsy complicating pregnancy,
                                   childbirth, or the puerperium,
                                   delivered, with mention of postpartum
                                   complication.
64943...........................  Epilepsy complicating pregnancy,
                                   childbirth, or the puerperium,
                                   antepartum condition or complication.
64944...........................  Epilepsy complicating pregnancy,
                                   childbirth, or the puerperium,
                                   postpartum condition or complication.
65101...........................  Twin pregnancy, delivered.
65111...........................  Triplet pregnancy, delivered.
65113...........................  Triplet pregnancy, antepartum
                                   condition or complication.
65121...........................  Quadruplet pregnancy, delivered.
65123...........................  Quadruplet pregnancy, antepartum
                                   condition or complication.
65141...........................  Triplet pregnancy with fetal loss and
                                   retention of one or more fetus(es),
                                   delivered, with or without mention of
                                   antepartum condition.
65143...........................  Triplet pregnancy with fetal loss and
                                   retention of one or more fetus(es),
                                   antepartum condition or complication.
65151...........................  Quadruplet pregnancy with fetal loss
                                   and retention of one or more
                                   fetus(es), delivered, with or without
                                   mention of antepartum condition.
65153...........................  Quadruplet pregnancy with fetal loss
                                   and retention of one or more
                                   fetus(es), antepartum condition or
                                   complication.
65181...........................  Other specified multiple gestation,
                                   delivered.
65183...........................  Other specified multiple gestation,
                                   antepartum condition or complication.
65613...........................  Rhesus isoimmunization, affecting
                                   management of mother, antepartum
                                   condition.
65631...........................  Fetal distress, affecting management
                                   of mother, delivered.
65641...........................  Intrauterine death, affecting
                                   management of mother, delivered.
65643...........................  Intrauterine death, affecting
                                   management of mother, antepartum.
65651...........................  Poor fetal growth, affecting
                                   management of mother, delivered.
65701...........................  Polyhydramnios, with delivery.
65801...........................  Oligohydramnios, delivered.
65803...........................  Oligohydramnios, antepartum.
65881...........................  Other problems associated with
                                   amniotic cavity and membranes,
                                   delivered.
65921...........................  Unspecified type maternal pyrexia
                                   during labor, delivered.
66003...........................  Obstruction caused by malposition of
                                   fetus at onset of labor, antepartum.
66211...........................  Unspecified type prolonged labor,
                                   delivered.
66421...........................  Third-degree perineal laceration, with
                                   delivery.
66431...........................  Fourth-degree perineal laceration,
                                   with delivery.
66461...........................  Anal sphincter tear complicating
                                   delivery, not associated with third-
                                   degree perineal laceration,delivered,
                                   with or without mention of antepartum
                                   condition.
66464...........................  Anal sphincter tear complicating
                                   delivery, not associated with third-
                                   degree perineal laceration,postpartum
                                   condition or complication.
66522...........................  Inversion of uterus, delivered with
                                   postpartum complication.
66531...........................  Laceration of cervix, with delivery.
66541...........................  High vaginal laceration, with
                                   delivery.
66551...........................  Other injury to pelvic organs, with
                                   delivery.
66561...........................  Damage to pelvic joints and ligaments,
                                   with delivery.
66571...........................  Pelvic hematoma, with delivery.
66572...........................  Pelvic hematoma, delivered with
                                   postpartum complication.
66602...........................  Third-stage postpartum hemorrhage,
                                   with delivery.
66604...........................  Third-stage postpartum hemorrhage.
66612...........................  Other immediate postpartum hemorrhage,
                                   with delivery.
66614...........................  Other immediate postpartum hemorrhage.
66622...........................  Delayed and secondary postpartum
                                   hemorrhage, with delivery.
66624...........................  Delayed and secondary postpartum
                                   hemorrhage.
66632...........................  Postpartum coagulation defects, with
                                   delivery.
66924...........................  Maternal hypotension syndrome,
                                   postpartum.
67120...........................  Superficial thrombophlebitis
                                   complicating pregnancy and the
                                   puerperium, unspecified as to episode
                                   of care.
67121...........................  Superficial thrombophlebitis with
                                   delivery, with or without mention of
                                   antepartum condition.
67122...........................  Superficial thrombophlebitis with
                                   delivery, with mention of postpartum
                                   complication.
67123...........................  Antepartum superficial
                                   thrombophlebitis.
67124...........................  Postpartum superficial
                                   thrombophlebitis.
67130...........................  Deep phlebothrombosis, antepartum,
                                   unspecified as to episode of care.
67140...........................  Deep phlebothrombosis, postpartum,
                                   unspecified as to episode of care.
67150...........................  Other phlebitis and thrombosis
                                   complicating pregnancy and the
                                   puerperium, unspecified as to episode
                                   of care.
67151...........................  Other phlebitis and thrombosis with
                                   delivery, with or without mention of
                                   antepartum condition.
67152...........................  Other phlebitis and thrombosis with
                                   delivery, with mention of postpartum
                                   complication.
67153...........................  Other antepartum phlebitis and
                                   thrombosis.
67154...........................  Other postpartum phlebitis and
                                   thrombosis.
67180...........................  Other venous complications of
                                   pregnancy and the puerperium,
                                   unspecified as to episode of care.
67181...........................  Other venous complications, with
                                   delivery, with or without mention of
                                   antepartum condition.
67182...........................  Other venous complications, with
                                   delivery, with mention of postpartum
                                   complication.
67183...........................  Other antepartum venous complications.
67184...........................  Other postpartum venous complications.

[[Page 25046]]

 
67190...........................  Unspecified venous complication of
                                   pregnancy and the puerperium,
                                   unspecified as to episode of care.
67191...........................  Unspecified venous complication, with
                                   delivery, with or without mention of
                                   antepartum condition.
67192...........................  Unspecified venous complication, with
                                   delivery, with mention of postpartum
                                   complication.
67202...........................  Puerperal pyrexia of unknown origin,
                                   delivered, with mention of postpartum
                                   complication.
67204...........................  Puerperal pyrexia of unknown origin,
                                   postpartum.
67330...........................  Obstetrical pyemic and septic
                                   embolism, unspecified as to episode
                                   of care.
67402...........................  Cerebrovascular disorders, with
                                   delivery, with mention of postpartum
                                   complication.
67403...........................  Antepartum cerebrovascular disorders.
67404...........................  Postpartum cerebrovascular disorders.
67511...........................  Abscess of breast associated with
                                   childbirth, delivered, with or
                                   without mention of antepartum
                                   condition.
67512...........................  Abscess of breast associated with
                                   childbirth, delivered, with mention
                                   of postpartum complication.
6820............................  Cellulitis and abscess of face.
6821............................  Cellulitis and abscess of neck.
6822............................  Cellulitis and abscess of trunk.
6823............................  Cellulitis and abscess of upper arm
                                   and forearm.
6824............................  Cellulitis and abscess of hand, except
                                   fingers and thumb.
6825............................  Cellulitis and abscess of buttock.
6826............................  Cellulitis and abscess of leg, except
                                   foot.
6827............................  Cellulitis and abscess of foot, except
                                   toes.
6828............................  Cellulitis and abscess of other
                                   specified sites.
6829............................  Cellulitis and abscess of unspecified
                                   sites.
6850............................  Pilonidal cyst with abscess.
68601...........................  Pyoderma gangrenosum.
6944............................  Pemphigus.
6945............................  Pemphigoid.
6950............................  Toxic erythema.
6951............................  Erythema multiforme.
70700...........................  Decubitus ulcer, unspecified site.
70701...........................  Decubitus ulcer, elbow.
70709...........................  Decubitus ulcer, other site.
70710...........................  Unspecified ulcer of lower limb.
70711...........................  Ulcer of thigh.
70712...........................  Ulcer of calf.
70713...........................  Ulcer of ankle.
70714...........................  Ulcer of heel and midfoot.
70719...........................  Ulcer of other part of lower limb.
7103............................  Dermatomyositis.
7104............................  Polymyositis.
7105............................  Eosinophilia myalgia syndrome.
7108............................  Other specified diffuse diseases of
                                   connective tissue.
71100...........................  Pyogenic arthritis, site unspecified.
71101...........................  Pyogenic arthritis involving shoulder
                                   region.
71102...........................  Pyogenic arthritis involving upper
                                   arm.
71103...........................  Pyogenic arthritis involving forearm.
71104...........................  Pyogenic arthritis involving hand.
71105...........................  Pyogenic arthritis involving pelvic
                                   region and thigh.
71106...........................  Pyogenic arthritis involving lower
                                   leg.
71107...........................  Pyogenic arthritis involving ankle and
                                   foot.
71108...........................  Pyogenic arthritis involving other
                                   specified sites.
71109...........................  Pyogenic arthritis involving multiple
                                   sites.
71110...........................  Arthropathy, site unspecified,
                                   associated with reiter's disease and
                                   nonspecific urethritis.
71111...........................  Arthropathy involving shoulder region
                                   associated with reiter's disease and
                                   nonspecific urethritis.
71112...........................  Arthropathy involving upper arm
                                   associated with reiter's disease and
                                   nonspecific urethritis.
71113...........................  Arthropathy involving forearm
                                   associated with reiter's disease and
                                   nonspecific urethritis.
71114...........................  Arthropathy involving hand associated
                                   with reiter's disease and nonspecific
                                   urethritis.
71115...........................  Arthropathy involving pelvic region
                                   and thigh associated with reiter's
                                   disease and nonspecific urethritis.
71116...........................  Arthropathy involving lower leg
                                   associated with reiter's disease and
                                   nonspecific urethritis.
71117...........................  Arthropathy involving ankle and foot
                                   associated with reiter's disease and
                                   nonspecific urethritis.
71118...........................  Arthropathy involving other specified
                                   sites associated with reiter's
                                   disease and nonspecific urethritis.
71119...........................  Arthropathy involving multiple sites
                                   associated with reiter's disease and
                                   nonspecific urethritis.
71120...........................  Arthropathy in behcet's syndrome, site
                                   unspecified.
71121...........................  Arthropathy in behcet's syndrome
                                   involving shoulder region.
71122...........................  Arthropathy in behcet's syndrome
                                   involving upper arm.
71123...........................  Arthropathy in behcet's syndrome
                                   involving forearm.
71124...........................  Arthropathy in behcet's syndrome
                                   involving hand.
71125...........................  Arthropathy in behcet's syndrome
                                   involving pelvic region and thigh.
71126...........................  Arthropathy in behcet's syndrome
                                   involving lower leg.
71127...........................  Arthropathy in behcet's syndrome
                                   involving ankle and foot.
71128...........................  Arthropathy in behcet's syndrome
                                   involving other specified sites.
71129...........................  Arthropathy in behcet's syndrome
                                   involving multiple sites.
71130...........................  Postdysenteric arthropathy, site
                                   unspecified.
71131...........................  Postdysenteric arthropathy involving
                                   shoulder region.

[[Page 25047]]

 
71132...........................  Postdysenteric arthropathy involving
                                   upper arm.
71133...........................  Postdysenteric arthropathy involving
                                   forearm.
71134...........................  Postdysenteric arthropathy involving
                                   hand.
71135...........................  Postdysenteric arthropathy involving
                                   pelvic region and thigh.
71136...........................  Postdysenteric arthropathy involving
                                   lower leg.
71137...........................  Postdysenteric arthropathy involving
                                   ankle and foot.
71138...........................  Postdysenteric arthropathy involving
                                   other specified sites.
71139...........................  Postdysenteric arthropathy involving
                                   multiple sites.
71140...........................  Arthropathy, site unspecified,
                                   associated with other bacterial
                                   diseases.
71141...........................  Arthropathy involving shoulder region
                                   associated with other bacterial
                                   diseases.
71142...........................  Arthropathy involving upper arm
                                   associated with other bacterial
                                   diseases.
71143...........................  Arthropathy involving forearm
                                   associated with other bacterial
                                   diseases.
71144...........................  Arthropathy involving hand associated
                                   with other bacterial diseases.
71145...........................  Arthropathy involving pelvic region
                                   and thigh associated with other
                                   bacterial diseases.
71146...........................  Arthropathy involving lower leg
                                   associated with other bacterial
                                   diseases.
71147...........................  Arthropathy involving ankle and foot
                                   associated with other bacterial
                                   disease.
71148...........................  Arthropathy involving other specified
                                   sites associated with other bacterial
                                   diseases.
71149...........................  Arthropathy involving multiple sites
                                   associated with other bacterial
                                   diseases.
71150...........................  Arthropathy, site unspecified,
                                   associated with other viral diseases.
71151...........................  Arthropathy involving shoulder region
                                   associated with other viral diseases.
71152...........................  Arthropathy involving upper arm
                                   associated with other viral diseases.
71153...........................  Arthropathy involving forearm
                                   associated with other viral diseases.
71154...........................  Arthropathy involving hand associated
                                   with other viral diseases.
71155...........................  Arthropathy involving pelvic region
                                   and thigh associated with other viral
                                   diseases.
71156...........................  Arthropathy involving lower leg
                                   associated with other viral diseases.
71157...........................  Arthropathy involving ankle and foot
                                   associated with other viral diseases.
71158...........................  Arthropathy involving other specified
                                   sites associated with other viral
                                   diseases.
71159...........................  Arthropathy involving multiple sites
                                   associated with other viral diseases.
71160...........................  Arthropathy, site unspecified,
                                   associated with mycoses.
71161...........................  Arthropathy involving shoulder region
                                   associated with mycoses.
71162...........................  Arthropathy involving upper arm
                                   associated with mycoses.
71163...........................  Arthropathy involving forearm
                                   associated with mycoses.
71164...........................  Arthropathy involving hand associated
                                   with mycoses.
71165...........................  Arthropathy involving pelvic region
                                   and thigh associated with mycoses.
71166...........................  Arthropathy involving lower leg
                                   associated with mycoses.
71167...........................  Arthropathy involving ankle and foot
                                   associated with mycoses.
71168...........................  Arthropathy involving other specified
                                   sites associated with mycoses.
71169...........................  Arthropathy involving multiple sites
                                   associated with mycoses.
71170...........................  Arthropathy, site unspecified,
                                   associated with helminthiasis.
71171...........................  Arthropathy involving shoulder region
                                   associated with helminthiasis.
71172...........................  Arthropathy involving upper arm
                                   associated with helminthiasis.
71173...........................  Arthropathy involving forearm
                                   associated with helminthiasis.
71174...........................  Arthropathy involving hand associated
                                   with helminthiasis.
71175...........................  Arthropathy involving pelvic region
                                   and thigh associated with
                                   helminthiasis.
71176...........................  Arthropathy involving lower leg
                                   associated with helminthiasis.
71177...........................  Arthropathy involving ankle and foot
                                   associated with helminthiasis.
71178...........................  Arthropathy involving other specified
                                   sites associated with helminthiasis.
71179...........................  Arthropathy involving multiple sites
                                   associated with helminthiasis.
71180...........................  Arthropathy, site unspecified,
                                   associated with other infectious and
                                   parasitic diseases.
71181...........................  Arthropathy involving shoulder region
                                   associated with other infectious and
                                   parasitic diseases.
71182...........................  Arthropathy involving upper arm
                                   associated with other infectious and
                                   parasitic diseases.
71183...........................  Arthropathy involving forearm
                                   associated with other infectious and
                                   parasitic diseases.
71184...........................  Arthropathy involving hand associated
                                   with other infectious and parasitic
                                   diseases.
71185...........................  Arthropathy involving pelvic region
                                   and thigh associated with other
                                   infectious and parasitic diseases.
71186...........................  Arthropathy involving lower leg
                                   associated with other infectious and
                                   parasitic diseases.
71187...........................  Arthropathy involving ankle and foot
                                   associated with other infectious and
                                   parasitic diseases.
71188...........................  Arthropathy involving other specified
                                   sites associated with other
                                   infectious and parasitic diseases.
71189...........................  Arthropathy involving multiple sites
                                   associated with other infectious and
                                   parasitic diseases.
71190...........................  Unspecified infective arthritis, site
                                   unspecified.
71191...........................  Unspecified infective arthritis
                                   involving shoulder region.
71192...........................  Unspecified infective arthritis
                                   involving upper arm.
71193...........................  Unspecified infective arthritis
                                   involving forearm.
71194...........................  Unspecified infective arthritis
                                   involving hand.
71195...........................  Unspecified infective arthritis
                                   involving pelvic region and thigh.
71196...........................  Unspecified infective arthritis
                                   involving lower leg.
71197...........................  Unspecified infective arthritis
                                   involving ankle and foot.
71198...........................  Unspecified infective arthritis
                                   involving other specified sites.
71199...........................  Unspecified infective arthritis
                                   involving multiple sites.
71431...........................  Acute polyarticular juvenile
                                   rheumatoid arthritis.
71910...........................  Hemarthrosis, site unspecified.
71911...........................  Herarthrosis involving shoulder
                                   region.
71912...........................  Hemarthorsis involving upper arm.

[[Page 25048]]

 
71913...........................  Hemarthrosis involving forearm.
71914...........................  Hemarthrosis involving hand.
71915...........................  Hemarthrosis involving pelvic region
                                   and thigh.
71916...........................  Hemarthrosis involving lower leg.
71917...........................  Hemarthrosis involving ankle and foot.
71918...........................  Hemarthrosis involving other specified
                                   sites.
71919...........................  Hemarthrosis involving multiple sites.
7211............................  Cervical spondylosis with myelopathy.
72141...........................  Spondylosis with myelopathy, thoracic
                                   region.
72142...........................  Spondylosis with myelopathy, lumbar
                                   region.
7217............................  Traumatic spondylopathy.
72191...........................  Spondylosis of unspecified site with
                                   myelopathy.
72271...........................  Intervertebral disc disorder with
                                   myelopathy, cervical region.
72272...........................  Intervertebral disc disorder with
                                   myelopathy, thoracic region.
72273...........................  Intervertebral disc disorder with
                                   myelopathy, lumbar region.
7280............................  Infective myositis.
72888...........................  Rhabdomyolysis.
72971...........................  Nontraumatic compartment syndrome of
                                   upper extremity.
72972...........................  Nontraumatic compartment syndrome of
                                   lower extremity.
72973...........................  Nontraumatic compartment syndrome of
                                   abdomen.
72979...........................  Nontraumatic compartment syndrome of
                                   other sites.
73000...........................  Acute osteomyelitis, site unspecified.
73001...........................  Acute osteomyelitis involving shoulder
                                   region.
73002...........................  Acute osteomyelitis involving upper
                                   arm.
73003...........................  Acute osteomyelitis involving forearm.
73004...........................  Acute osteomyelitis involving hand.
73005...........................  Acute osteomyelitis involving pelvic
                                   region and thigh.
73006...........................  Acute osteomyelitis involving lower
                                   leg.
73007...........................  Acute osteomyelitis involving ankle
                                   and foot.
73008...........................  Acute osteomyelitis involving other
                                   specified sites.
73009...........................  Acute osteomyelitis involving multiple
                                   sites.
73010...........................  Chronic osteomyelitis, site
                                   unspecified.
73011...........................  Chronic osteomyelitis involving
                                   shoulder region.
73012...........................  Chronic osteomyelitis involving upper
                                   arm.
73013...........................  Chronic osteomyelitis involving
                                   forearm.
73014...........................  Chronic osteomyelitis involving hand.
73015...........................  Chronic osteomyelitis involving pelvic
                                   region and thigh.
73016...........................  Chronic osteomyelitis involving lower
                                   leg.
73017...........................  Chronic osteomyelitis involving ankle
                                   and foot.
73018...........................  Chronic osteomyelitis involving other
                                   specified sites.
73019...........................  Chronic osteomyelitis involving
                                   multiple sites.
73020...........................  Unspecified osteomyelitis, site
                                   unspecified.
73021...........................  Unspecified osteomyelitis involving
                                   shoulder region.
73022...........................  Unspecified osteomyelitis involving
                                   upper arm.
73023...........................  Unspecified osteomyelitis involving
                                   forearm.
73024...........................  Unspecified osteomyelitis involving
                                   hand.
73025...........................  Unspecified osteomyelitis involving
                                   pelvic region and thigh.
73026...........................  Unspecified osteomyelitis involving
                                   lower leg.
73027...........................  Unspecified osteomyelitis involving
                                   ankle and foot.
73028...........................  Unspecified osteomyelitis involving
                                   other specified sites.
73029...........................  Unspecified osteomyelitis involving
                                   multiple sites.
73080...........................  Other infections involving bone in
                                   diseases classified elsewhere, site
                                   unspecified.
73081...........................  Other infections involving bone of
                                   shoulder region in diseases
                                   classified elsewhere.
73082...........................  Other infections involving upper arm
                                   bone in diseases classified
                                   elsewhere.
73083...........................  Other infections involving forearm
                                   bone in diseases classified
                                   elsewhere.
73084...........................  Other infections involving hand bone
                                   in diseases classified elsewhere.
73085...........................  Other infections involving bone of
                                   pelvic region and thigh in diseases
                                   classified elsewhere.
73086...........................  Other infections involving lower leg
                                   bone in diseases classified
                                   elsewhere.
73087...........................  Other infections involving ankle and
                                   foot bone in diseases classified
                                   elsewhere.
73088...........................  Other infections involving bone, of
                                   other specified sites, in diseases
                                   classified elsewhere.
73089...........................  Other infections involving bone, of
                                   multiple sites, in diseases
                                   classified elsewhere.
73090...........................  Unspecified infection of bone, site
                                   unspecified.
73091...........................  Unspecified infection of bone of
                                   shoulder region.
73092...........................  Unspecified infection of upper arm
                                   bone.
73093...........................  Unspecified infection of forearm bone.
73094...........................  Unspecified infection of hand bone.
73095...........................  Unspecified infection of bone of
                                   pelvic region and thigh.
73096...........................  Unspecified infection of lower leg
                                   bone.
73097...........................  Unspecified infection of ankle and
                                   foot bone.
73098...........................  Unspecified infection of bone of other
                                   specified sites.
73099...........................  Unspecified infection of bone in
                                   multiple sites.
73310...........................  Pathologic fracture, unspecified site.

[[Page 25049]]

 
73311...........................  Pathologic fracture of humerus.
73312...........................  Pathologic fracture of distal radius
                                   and ulna.
73313...........................  Pathologic fracture of vertebrae.
73314...........................  Pathologic fracture of neck of femur.
73315...........................  Pathologic fracture of other specified
                                   part of femur.
73316...........................  Pathologic fracture of tibia or
                                   fibula.
73319...........................  Pathologic fracture of other specified
                                   site.
73340...........................  Aseptic necrosis of bone, site
                                   unspecified.
73341...........................  Aseptic necrosis of head of humerus.
73342...........................  Aseptic necrosis of head and neck of
                                   femur.
73343...........................  Aseptic necrosis of medial femoral
                                   condyle.
73344...........................  Aseptic necrosis of talus.
73345...........................  Aseptic necrosis of bone, jaw.
73349...........................  Aseptic necrosis of other bone sites.
73381...........................  Malunion of fracture.
73382...........................  Nonunion of fracture.
74100...........................  Spina bifida, unspecified region, with
                                   hydrocephalus.
74101...........................  Spina bifida, cervical region, with
                                   hydrocephalus.
74102...........................  Spina bifida, dorsal (thoracic)
                                   region, with hydrocephalus.
74103...........................  Spina bifida, lumbar region, with
                                   hydrocephalus.
7420............................  Encephalocele.
7424............................  Other specified congenital anomalies
                                   of brain.
74512...........................  Corrected transposition of great
                                   vessels.
7454............................  Ventricular septal defect.
7455............................  Ostium secundum type atrial septal
                                   defect.
74560...........................  Endocardial cushion defect,
                                   unspecified type.
74561...........................  Ostium primum defect.
74569...........................  Other endocardial cushion defects.
74600...........................  Congenital pulmonary valve anomaly,
                                   unspecified.
74602...........................  Stenosis of pulmonary valve,
                                   congenital.
74609...........................  Other congenital anomalies of
                                   pulmonary valve.
7463............................  Congenital stenosis of aortic valve.
7464............................  Congenital insufficiency of aortic
                                   valve.
7465............................  Congenital mitral stenosis.
7466............................  Congenital mitral insufficiency.
74683...........................  Infundibular pulmonic stenosis,
                                   congenital.
74685...........................  Coronary artery anomaly, congenital.
74687...........................  Malposition of heart and cardiac apex.
7470............................  Patent ductus arteriosus.
74710...........................  Coarctation of aorta (preductal)
                                   (postductal).
74720...........................  Congenital anomaly of aorta,
                                   unspecified.
74721...........................  Congenital anomalies of aortic arch.
74722...........................  Congenital atresia and stenosis of
                                   aorta.
74729...........................  Other congenital anomalies of aorta.
74740...........................  Congenital anomaly of great veins,
                                   unspecified.
74741...........................  Total anomalous pulmonary venous
                                   connection.
74742...........................  Partial anomalous pulmonary venous
                                   connection.
74749...........................  Other anomalies of great veins.
74782...........................  Spinal vessel anolmaly.
74789...........................  Other specified congenital anomalies
                                   of circulatory system.
7479............................  Unspecified congenital anomaly of
                                   circulatory system.
7483............................  Other congenital anomalies of larynx,
                                   trachea, and bronchus.
7484............................  Congenital cystic lung.
74861...........................  Congenital bronchiectasis.
7504............................  Other specified congenital anomalies
                                   of esophagus.
7511............................  Congenital atresia and stenosis of
                                   small intestine.
7512............................  Congenital atresia and stenosis of
                                   large intestine, rectum, and anal
                                   canal.
7513............................  Hirschsprung's disease and other
                                   congenital functional disorders of
                                   colon.
7514............................  Congenital anomalies of intestinal
                                   fixation.
7515............................  Other congenital anomalies of
                                   intestine.
75160...........................  Unspecified congenital anomaly of
                                   gallbladder, bile ducts, and liver.
75162...........................  Congenital cystic disease of liver.
75169...........................  Other congenital anomalies of
                                   gallbladder, bile ducts, and liver.
7517............................  Congenital anomalies of pancreas.
7530............................  Renal agenesis and dysgenesis.
75310...........................  Cystic kidney disease, unspecified.
75311...........................  Congenital single renal cyst.
75312...........................  Polycystic kidney, unspecified type.
75313...........................  Polycystic kidney, autosomal dominant.
75314...........................  Polycystic kidney, autosomal
                                   recessive.
75315...........................  Renal dysplasia.
75316...........................  Medullary cystic kidney.

[[Page 25050]]

 
75317...........................  Medullary sponge kidney.
75319...........................  Other specified cystic kidney disease.
75320...........................  Unspecified obstructive defect of
                                   renal pelvis and ureter.
75321...........................  Congenital obstruction of
                                   ureteropelvic junction.
75322...........................  Congenital obstruction of
                                   ureterovesical junction.
75323...........................  Congenital ureterocele.
75329...........................  Other obstructive defect of renal
                                   pelvis and ureter.
7535............................  Exstrophy of urinary bladder.
7536............................  Congenital atresia and stenosis of
                                   urethra and bladder neck.
7542............................  Congenital musculoskeletal deformities
                                   of spine.
75489...........................  Other specified nonteratogenic
                                   anomalies.
75613...........................  Absence of vertebra, congenital.
7563............................  Other congenital anomalies of ribs and
                                   sternum.
75651...........................  Osteogenesis imperfecta.
75652...........................  Osteopetrosis.
75683...........................  Ehlers-danlos syndrome.
7581............................  Patau's syndrome.
7582............................  Edwards' syndrome.
75831...........................  Cri-du-chat syndrome.
75833...........................  Other microdeletions.
75839...........................  Other autosomal deletions.
7590............................  Anomalies of spleen, congenital.
7593............................  Situs inversus.
7595............................  Tuberous sclerosis.
7596............................  Other congenital hamartoses, not
                                   elsewhere classified.
7597............................  Multiple congenital anomalies, so
                                   described.
75981...........................  Prader-willi syndrome.
75982...........................  Marfan syndrome.
75989...........................  Other specified congenital anomalies.
76711...........................  Epicranial subaponeurotic hemorrhage
                                   (massive).
7704............................  Primary atelectasis of newborn.
7705............................  Other and unspecified atelectasis of
                                   newborn.
77081...........................  Primary apnea of newborn.
77082...........................  Other apnea of newborn.
77083...........................  Cyanotic attacks of newborn.
7710............................  Congenital rubella.
7714............................  Omphalitis of the newborn.
7715............................  Neonatal infective mastitis.
77182...........................  Urinary tract infection of newborn.
77183...........................  Bacteremia of newborn.
77189...........................  Other infections specific to the
                                   perinatal period.
77210...........................  Intraventricular hemorrhage
                                   unspecified grade.
77211...........................  Intraventricular hemorrhage grade i.
77212...........................  Intraventricular hemorrhage grade ii.
7725............................  Adrenal hemorrhage of fetus or
                                   newborn.
7751............................  Neonatal diabetes mellitus.
7752............................  Neonatal myasthenia gravis.
7753............................  Neonatal thyrotoxicosis.
7754............................  Hypocalcemia and hypomagnesemia of
                                   newborn.
77581...........................  Other acidosis of newborn.
77589...........................  Other neonatal endocrine and metabolic
                                   disturbances.
7760............................  Hemorrhagic disease of newborn.
7763............................  Other transient neonatal disorders of
                                   coagulation.
7765............................  Congenital anemia.
7766............................  Anemia of prematurity.
7774............................  Transitory ileus of newborn.
7781............................  Sclerema neonatorum.
7785............................  Other and unspecified edema of
                                   newborn.
7794............................  Drug reactions and intoxications
                                   specific to newborn.
7795............................  Drug withdrawal syndrome in newborn.
78001...........................  Coma.
78003...........................  Persistent vegetative state.
7801............................  Hallucinations.
78031...........................  Febrile convulsions (simple),
                                   unspecified.
78032...........................  Complex febrile convulsions.
7814............................  Transient paralysis of limb.
7816............................  Meningismus.
7817............................  Tetany.
7818............................  Neurological neglect syndrome.
7824............................  Jaundice, unspecified, not of newborn.
7843............................  Aphasia.
7854............................  Gangrene.

[[Page 25051]]

 
78550...........................  Shock, unspecified.
78604...........................  Cheyne-stokes respiration.
7863............................  Hemoptysis.
7888............................  Extravasation of urine.
78951...........................  Malignant ascites.
78959...........................  Other ascites.
79001...........................  Precipitous drop in hematocrit.
7907............................  Bacteremia.
7911............................  Chyluria.
7913............................  Myoglobinuria.
79901...........................  Asphyxia.
7994............................  Cachexia.
80000...........................  Closed fracture of vault of skull
                                   without mention of intracranial
                                   injury, with state of consciousness
                                   unspecified.
80001...........................  Closed fracture of vault of skull
                                   without mention of intracranial
                                   injury, with no loss of
                                   consciousness.
80002...........................  Closed fracture of vault of skull
                                   without mention of intracranial
                                   injury, with brief (less than one
                                   hour) loss of consciousness.
80006...........................  Closed fracture of vault of skull
                                   without mention of intra cranial
                                   injury, with loss of consciousness of
                                   unspecified duration.
80009...........................  Closed fracture of vault of skull
                                   without mention of intracranial
                                   injury, with concussion, unspecified.
80040...........................  Closed fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with state of
                                   consciousness unspecified.
80041...........................  Closed fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with no loss of
                                   consciousness.
80042...........................  Closed fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with brief (less
                                   than one hour) loss of consciousness.
80046...........................  Closed fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with loss of
                                   consciousness of unspecified
                                   duration.
80049...........................  Closed fracture of vault of skull with
                                   intracranial injury of other and
                                   unspecified nature, with concussion,
                                   unspecified.
80100...........................  Closed fracture of base of skull
                                   without mention of intra cranial
                                   injury, with state of consciousness
                                   unspecified.
80101...........................  Closed fracture of base of skull
                                   without mention of intra cranial
                                   injury, with no loss of
                                   consciousness.
80102...........................  Closed fracture of base of skull
                                   without mention of intra cranial
                                   injury, with brief (less than one
                                   hour) loss of consciousness.
80106...........................  Closed fracture of base of skull
                                   without mention of intra cranial
                                   injury, with loss of consciousness of
                                   unspecified duration.
80109...........................  Closed fracture of base of skull
                                   without mention of intra cranial
                                   injury, with concussion, unspecified.
80140...........................  Closed fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with state of
                                   consciousness unspecified.
80141...........................  Closed fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with no loss of
                                   consciousness.
80142...........................  Closed fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with brief (less
                                   than one hour) loss of consciousness.
80146...........................  Closed fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with loss of
                                   consciousness of unspecified
                                   duration.
80149...........................  Closed fracture of base of skull with
                                   intracranial injury of other and
                                   unspecified nature, with concussion,
                                   unspecified.
8021............................  Open fracture of nasal bones.
80220...........................  Closed fracture of unspecified site of
                                   mandible.
80221...........................  Closed fracture of condylar process of
                                   mandible.
80222...........................  Closed fracture of subcondylar process
                                   of mandible.
80223...........................  Closed fracture of coronoid process of
                                   mandible.
80224...........................  Closed fracture of unspecified part of
                                   ramus of mandible.
80225...........................  Closed fracture of angle of jaw.
80226...........................  Closed fracture of symphysis of body
                                   of mandible.
80227...........................  Closed fracture of alveolar border of
                                   body of mandible.
80228...........................  Closed fracture of other and
                                   unspecified part of body of mandible.
80229...........................  Closed fracture of multiple sites of
                                   mandible.
80230...........................  Open fracture of unspecified site of
                                   mandible.
80231...........................  Open fracture of condylar process of
                                   mandible.
80232...........................  Open fracture of subcondylar process
                                   of mandible.
80233...........................  Open fracture of coronoid process of
                                   mandible.
80234...........................  Open fracture of unspecified part of
                                   ramus of mandible.
80235...........................  Open fracture of angle of jaw.
80236...........................  Open fracture of symphysis of body of
                                   mandible.
80237...........................  Open fracture of alveolar border of
                                   body of mandible.
80238...........................  Open fracture of body of mandible,
                                   other and unspecified.
80239...........................  Open fracture of multiple sites of
                                   mandible.
8024............................  Closed fracture of malar and maxillary
                                   bones.
8025............................  Open fracture of malar and maxillary
                                   bones.
8026............................  Closed fracture of orbital floor (blow-
                                   out).
8027............................  Open fracture of orbital floor (blow-
                                   out).
8028............................  Closed fracture of other facial bones.

[[Page 25052]]

 
8029............................  Open fracture of other facial bones.
80300...........................  Other closed skull fracture without
                                   mention of intracranial injury, with
                                   state of consciousness unspecified.
80301...........................  Other closed skull fracture without
                                   mention of intracranial injury, with
                                   no loss of consciousness.
80302...........................  Other closed skull fracture without
                                   mention of intracranial injury, with
                                   brief (less than one hour) loss of
                                   consciousness.
80306...........................  Other closed skull fracture without
                                   mention of intracranial injury, with
                                   loss of consciousness of unspecified
                                   duration.
80309...........................  Other closed skull fracture without
                                   mention of intracranial injury, with
                                   concussion, unspecified.
80340...........................  Other closed skull fracture with
                                   intracranial injury of other and
                                   unspecified nature, with state of
                                   consciousness unspecified.
80341...........................  Other closed skull fracture with
                                   intracranial injury of other and
                                   unspecified nature, with no loss of
                                   consciousness.
80342...........................  Other closed skull fracture with
                                   intracranial injury of other and
                                   unspecified nature, with brief (less
                                   than one hour) loss of consciousness.
80346...........................  Other site of closed skull fracture
                                   with intracranial injury of other and
                                   unspecified nature, with loss of
                                   consciousness of unspecified
                                   duration.
80349...........................  Other site of closed skull fracture
                                   with intracranial injury of other and
                                   unspecified nature, with concussion,
                                   unspecified.
80400...........................  Closed fractures involving skull or
                                   face with other bones, without
                                   mention of intracranial injury, with
                                   state of consciousness unspecified.
80401...........................  Closed fractures involving skull or
                                   face with other bones, without
                                   mention of intracranial injury, with
                                   no loss of consciousness.
80402...........................  Closed fractures involving skull or
                                   face with other bones, without
                                   mention of intracranial injury, with
                                   brief (less than one hour) loss of
                                   consciousness.
80406...........................  Closed fractures involving skull of
                                   face with other bones, without
                                   mention of intracranial injury, with
                                   loss of consciousness of unspecified
                                   duration.
80409...........................  Closed fractures involving skull of
                                   face with other bones, without
                                   mention of intracranial injury, with
                                   concussion, unspecified.
80440...........................  Closed fractures involving skull or
                                   face with other bones, with
                                   intracranial injury of other and
                                   unspecified nature, with state of
                                   consciousness unspecified.
80441...........................  Closed fractures involving skull or
                                   face with other bones, with
                                   intracranial injury of other and
                                   unspecified nature, with no loss of
                                   consciousness.
80442...........................  Closed fractures involving skull or
                                   face with other bones, with
                                   intracranial injury of other and
                                   unspecified nature, with brief (less
                                   than one hour) loss of consciousness.
80446...........................  Closed fractures involving skull or
                                   face with other bones, with
                                   intracranial injury of other and
                                   unspecified nature, with loss of
                                   consciousness of unspecified
                                   duration.
80449...........................  Closed fractures involving skull or
                                   face with other bones, with
                                   intracranial injury of other and
                                   unspecified nature, with concussion,
                                   unspecified.
80450...........................  Open fractures involving skull or face
                                   with other bones, without mention of
                                   intracranial injury, with state of
                                   consciousness unspecified.
80451...........................  Open fractures involving skull or face
                                   with other bones, without mention of
                                   intracranial injury, with no loss of
                                   consciousness.
80452...........................  Open fractures involving skull or face
                                   with other bones, without mention of
                                   intracranial injury, with brief (less
                                   than one hour) loss of consciousness.
80456...........................  Open fractures involving skull or face
                                   with other bones, without mention of
                                   intracranial injury, with loss of
                                   consciousness of unspecified
                                   duration.
80459...........................  Open fractures involving skull or face
                                   with other bones, without mention of
                                   intracranial injury, with concussion,
                                   unspecified.
80490...........................  Open fractures involving skull or face
                                   with other bones, with intracranial
                                   injury of other and unspecified
                                   nature, with state of consciousness
                                   unspecified.
80491...........................  Open fractures involving skull or face
                                   with other bones, with intracranial
                                   injury of other and unspecified
                                   nature, with no loss of
                                   consciousness.
80492...........................  Open fractures involving skull or face
                                   with other bones, with intracranial
                                   injury of other and unspecified
                                   nature, with brief (less than one
                                   hour) loss of consciousness.
80496...........................  Open fractures involving skull or face
                                   with other bones, with intracranial
                                   injury of other and unspecified
                                   nature, with loss of consciousness of
                                   unspecified duration.
80499...........................  Open fractures involving skull or face
                                   with other bones, with intracranial
                                   injury of other and unspecified
                                   nature, with concussion, unspecified.
80500...........................  Closed fracture of cervical vertebra,
                                   unspecified level.
80501...........................  Closed fracture of first cervical
                                   vertebra.
80502...........................  Closed fracture of second cervical
                                   vertebra.
80503...........................  Closed fracture of third cervical
                                   vertebra.
80504...........................  Closed fracture of fourth cervical
                                   vertebra.
80505...........................  Closed fracture of fifth cervical
                                   vertebra.
80506...........................  Closed fracture of sixth cervical
                                   vertebra.
80507...........................  Closed fracture of seventh cervical
                                   vertebra.
80508...........................  Closed fracture of multiple cervical
                                   vertebrae.
8052............................  Closed fracture of dorsal (thoracic)
                                   vertebra without mention of spinal
                                   cord injury.
8054............................  Closed fracture of lumbar vertebra
                                   without mention of spinal cord
                                   injury.
8056............................  Closed fracture of sacrum and coccyx
                                   without mention of spinal cord
                                   injury.
8058............................  Closed fracture of unspecified part of
                                   vertebral column without mention of
                                   spinal cord injury.
80700...........................  Closed fracture of rib(s),
                                   unspecified.

[[Page 25053]]

 
80701...........................  Closed fracture of one rib.
80702...........................  Closed fracture of two ribs.
80703...........................  Closed fracture of three ribs.
80704...........................  Closed fracture of four ribs.
80705...........................  Closed fracture of five ribs.
80706...........................  Closed fracture of six ribs.
80707...........................  Closed fracture of seven ribs.
80708...........................  Closed fracture of eight or more ribs.
80709...........................  Closed fracture of multiple ribs,
                                   unspecified.
8072............................  Closed fracture of sternum.
8082............................  Closed fracture of pubis.
80841...........................  Closed fracture of ilium.
80842...........................  Closed fracture of ischium.
80843...........................  Multiple closed pelvic fractures with
                                   disruption of pelvic circle.
80849...........................  Closed fracture of other specified
                                   part of pelvis.
8088............................  Unspecified closed fracture of pelvis.
8090............................  Fracture of bones of trunk, closed.
81010...........................  Open fracture of clavicle, unspecified
                                   part.
81011...........................  Open fracture of sternal end of
                                   clavicle.
81012...........................  Open fracture of shaft of clavicle.
81013...........................  Open fracture of acromial end of
                                   clavicle.
81110...........................  Open fracture of scapula, unspecified
                                   part.
81111...........................  Open fracture of acromial process of
                                   scapula.
81112...........................  Open fracture of coracoid process.
81113...........................  Open fracture of glenoid cavity and
                                   neck of scapula.
81119...........................  Open fracture of other part of
                                   scapula.
81200...........................  Fracture of unspecified part of upper
                                   end of humerus, closed.
81201...........................  Fracture of surgical neck of humerus,
                                   closed.
81202...........................  Fracture of anatomical neck of
                                   humerus, closed.
81203...........................  Fracture of greater tuberosity of
                                   humerus, closed.
81209...........................  Other closed fractures of upper end of
                                   humerus.
81220...........................  Fracture of unspecified part of
                                   humerus, closed.
81221...........................  Fracture of shaft of humerus, closed.
81240...........................  Fracture of unspecified part of lower
                                   end of humerus, closed.
81241...........................  Supracondylar fracture of humerus,
                                   closed.
81242...........................  Fracture of lateral condyle of
                                   humerus, closed.
81243...........................  Fracture of medial condyle of humerus,
                                   closed.
81244...........................  Fracture of unspecified condyle(s) of
                                   humerus, closed.
81249...........................  Other closed fractures of lower end of
                                   humerus.
81320...........................  Fracture of shaft of radius or ulna,
                                   unspecified, closed.
81321...........................  Fracture of shaft of radius (alone),
                                   closed.
81322...........................  Fracture of shaft of ulna (alone),
                                   closed.
81323...........................  Fracture of shaft of radius with ulna,
                                   closed.
81340...........................  Closed fracture of lower end of
                                   forearm, unspecified.
81341...........................  Colles' fracture, closed.
81342...........................  Other closed fractures of distal end
                                   of radius (alone).
81343...........................  Fracture of distal end of ulna
                                   (alone), closed.
81344...........................  Fracture of lower end of radius with
                                   ulna, closed.
81345...........................  Torus fracture of radius.
81380...........................  Closed fracture of unspecified part of
                                   forearm.
81382...........................  Fracture of unspecified part of ulna
                                   (alone), closed.
81383...........................  Fracture of unspecified part of radius
                                   with ulna, closed.
81410...........................  Open fracture of carpal bone,
                                   unspecified.
81411...........................  Open fracture of navicular (scaphoid)
                                   bone of wrist.
81412...........................  Open fracture of lunate (semilunar)
                                   bone of wrist.
81413...........................  Open fracture of triquetral
                                   (cuneiform) bone of wrist.
81414...........................  Open fracture of pisiform bone of
                                   wrist.
81415...........................  Open fracture of trapezium bone
                                   (larger multangular) of wrist.
81416...........................  Open fracture of trapezoid bone
                                   (smaller multangular) of wrist.
81417...........................  Open fracture of capitate bone (os
                                   magnum) of wrist.
81418...........................  Open fracture of hamate (unciform)
                                   bone of wrist.
81419...........................  Open fracture of other bone of wrist.
81510...........................  Open fracture of metacarpal bone(s),
                                   site unspecified.
81511...........................  Open fracture of base of thumb (first)
                                   metacarpal.
81512...........................  Open fracture of base of other
                                   metacarpal bone(s).
81513...........................  Open fracture of shaft of metacarpal
                                   bone(s).
81514...........................  Open fracture of neck of metacarpal
                                   bone(s).
81519...........................  Open fracture of multiple sites of
                                   metacarpus.
81610...........................  Open fracture of phalanx or phalanges
                                   of hand, unspecified.
81611...........................  Open fracture of middle or proximal
                                   phalanx or phalanges of hand.
81612...........................  Open fracture of distal phalanx or
                                   phalanges of hand.
81613...........................  Open fracture of multiple sites of
                                   phalanx or phalanges of hand.

[[Page 25054]]

 
8171............................  Multiple open fractures of hand bones.
8181............................  Ill-defined open fractures of upper
                                   limb.
8190............................  Multiple closed fractures involving
                                   both upper limbs, and upper limb with
                                   rib(s) and sternum.
8191............................  Multiple open fractures involving both
                                   upper limbs, and upper limb with
                                   rib(s) and sternum.
82120...........................  Fracture of lower end of femur,
                                   unspecified part, closed.
82121...........................  Fracture of femoral condyle, closed.
82122...........................  Fracture of lower epiphysis of femur,
                                   closed.
82123...........................  Supracondylar fracture of femur,
                                   closed.
82129...........................  Other fracture of lower end of femur,
                                   closed.
8220............................  Closed fracture of patella.
8221............................  Open fracture of patella.
82300...........................  Closed fracture of upper end of tibia.
82302...........................  Closed fracture of upper end of fibula
                                   with tibia.
82320...........................  Closed fracture of shaft of tibia.
82322...........................  Closed fracture of shaft of fibula
                                   with tibia.
82340...........................  Torus fracture, tibia alone.
82342...........................  Torus fracture, fibula with tibia.
82380...........................  Closed fracture of unspecified part of
                                   tibia.
82382...........................  Closed fracture of unspecified part of
                                   fibula with tibia.
8241............................  Fracture of medial malleolus, open.
8243............................  Fracture of lateral malleolus, open.
8245............................  Bimalleolar fracture, open.
8247............................  Trimalleolar fracture, open.
8249............................  Unspecified fracture of ankle, open.
8251............................  Fracture of calcaneus, open.
82530...........................  Fracture of unspecified bone(s) of
                                   foot (except toes), open.
82531...........................  Fracture of astragalus, open.
82532...........................  Fracture of navicular (scaphoid) bone
                                   of foot, open.
82533...........................  Fracture of cuboid bone, open.
82534...........................  Fracture of cuneiform bone of foot,
                                   open.
82535...........................  Fracture of metatarsal bone(s), open.
82539...........................  Other fractures of tarsal and
                                   metatarsal bones, open.
8271............................  Other, multiple and ill-defined
                                   fractures of lower limb, open.
8301............................  Open dislocation of jaw.
83110...........................  Open dislocation of shoulder,
                                   unspecified.
83111...........................  Open anterior dislocation of humerus.
83112...........................  Open posterior dislocation of humerus.
83113...........................  Open inferior dislocation of humerus.
83114...........................  Open dislocation of acromioclavicular
                                   (joint).
83119...........................  Open dislocation of other site of
                                   shoulder.
83210...........................  Open dislocation of elbow, unspecified
                                   site.
83211...........................  Open anterior dislocation of elbow.
83212...........................  Open posterior dislocation of elbow.
83213...........................  Open medial dislocation of elbow.
83214...........................  Open lateral dislocation of elbow.
83219...........................  Open dislocation of other site of
                                   elbow.
83310...........................  Open dislocation of wrist, unspecified
                                   part.
83311...........................  Open dislocation of radioulnar
                                   (joint), distal.
83312...........................  Open dislocation of radiocarpal
                                   (joint).
83313...........................  Open dislocation of midcarpal (joint).
83314...........................  Open dislocation of carpometacarpal
                                   (joint).
83315...........................  Open dislocation of metacarpal (bone),
                                   proximal end.
83319...........................  Open dislocation of other part of
                                   wrist.
83500...........................  Closed dislocation of hip, unspecified
                                   site.
83501...........................  Closed posterior dislocation of hip.
83502...........................  Closed obturator dislocation of hip.
83503...........................  Other closed anterior dislocation of
                                   hip.
8364............................  Dislocation of patella, open.
83660...........................  Dislocation of knee, unspecified part,
                                   open.
83661...........................  Anterior dislocation of tibia,
                                   proximal end, open.
83662...........................  Posterior dislocation of tibia,
                                   proximal end, open.
83663...........................  Medial dislocation of tibia, proximal
                                   end, open.
83664...........................  Lateral dislocation of tibia, proximal
                                   end, open.
83669...........................  Other dislocation of knee, open.
8371............................  Open dislocation of ankle.
83900...........................  Closed dislocation, cervical vertebra,
                                   unspecified.
83901...........................  Closed dislocation, first cervical
                                   vertebra.
83902...........................  Closed dislocation, second cervical
                                   vertebra.
83903...........................  Closed dislocation, third cervical
                                   vertebra.
83904...........................  Closed dislocation, fourth cervical
                                   vertebra.
83905...........................  Closed dislocation, fifth cervical
                                   vertebra.
83906...........................  Closed dislocation, sixth cervical
                                   vertebra.

[[Page 25055]]

 
83907...........................  Closed dislocation, seventh cervical
                                   vertebra.
83908...........................  Closed dislocation, multiple cervical
                                   vertebrae.
83951...........................  Open dislocation, coccyx.
83952...........................  Open dislocation, sacrum.
83961...........................  Closed dislocation, sternum.
83979...........................  Open dislocation, other location.
8399............................  Open dislocation, multiple and ill-
                                   defined sites.
85011...........................  Concussion, with loss of consciousness
                                   of 30 minutes or less.
85012...........................  Concussion, with loss of consciousness
                                   from 31 to 59 minutes.
8502............................  Concussion with moderate loss of
                                   consciousness.
8503............................  Concussion with prolonged loss of
                                   consciousness and return to pre-
                                   existing conscious level.
8505............................  Concussion with loss of consciousness
                                   of unspecified duration.
85102...........................  Cortex (cerebral) contusion without
                                   mention of open intracranial wound,
                                   with brief (less than one hour) loss
                                   of consciousness.
85103...........................  Cortex (cerebral) contusion without
                                   mention of open intracranial wound,
                                   with moderate (1-24 hours) loss of
                                   consciousness.
85104...........................  Cortex (cerebral) contusion without
                                   mention of open intracranial wound,
                                   with prolonged (more than 24 hours)
                                   loss of consciousness and return to
                                   pre-exisiting conscious level.
85106...........................  Cortex (cerebral) contusion without
                                   mention of open intracranial wound,
                                   with loss of consciousness of
                                   unspecified duration.
85142...........................  Cerebellar or brain stem contusion
                                   without mention of open intracranial
                                   wound, with brief (less than one
                                   hour) loss of consciousness.
85143...........................  Cerebellar or brain stem contusion
                                   without mention of open intracranial
                                   wound, with moderate (1-24 hours)
                                   loss of consciousness.
85144...........................  Cerebellar or brain stem contusion
                                   without mention of open intracranial
                                   wound, with prolonged (more than 24
                                   hours) loss consciousness and return
                                   to pre-existing conscious level.
85146...........................  Cerebellar or brain stem contusion
                                   without mention of open intracranial
                                   wound, with loss of consciousness of
                                   unspecified duration.
85402...........................  Intracranial injury of other and
                                   unspecified nature, without mention
                                   of open intracranial wound, with
                                   brief (less than one hour) loss of
                                   consciousness.
85403...........................  Intracranial injury of other and
                                   unspecified nature, without mention
                                   of open intracranial wound, with
                                   moderate (1-24 hours) loss of
                                   consciousness.
85404...........................  Intracranial injury of other and
                                   unspecified nature, without mention
                                   of open intracranial wound, with
                                   prolonged (more than 24 hours) loss
                                   of consciousness and return to pre-
                                   existing conscious level.
85406...........................  Intracranial injury of other and
                                   unspecified nature, without mention
                                   of open intracranial wound, with loss
                                   of consciousness of unspecified
                                   duration.
8600............................  Traumatic pneumothorax without mention
                                   of open wound into thorax.
86100...........................  Unspecified injury of heart without
                                   mention of open wound into thorax.
86101...........................  Contusion of heart without mention of
                                   open wound into thorax.
86120...........................  Unspecified injury of lung without
                                   open wound into thorax.
86121...........................  Contusion of lung without open wound
                                   into thorax.
8620............................  Injury to diaphragm without mention of
                                   open wound into cavity.
86229...........................  Injury to other specified
                                   intrathoracic organs without mention
                                   of open wound into cavity.
8628............................  Injury to multiple and unspecified
                                   intrathoracic organs without mention
                                   of open wound into cavity.
8630............................  Injury to stomach without mention of
                                   open wound into cavity.
86320...........................  Injury to small intestine, unspecified
                                   site, without open wound into cavity.
86321...........................  Injury to duodenum without open wound
                                   into cavity.
86329...........................  Other injury to small intestine
                                   without open wound into cavity.
86340...........................  Injury to colon, unspecified site,
                                   without mention of open wound into
                                   cavity.
86341...........................  Injury to ascending (right) colon
                                   without open wound into cavity.
86342...........................  Injury to transverse colon without
                                   open wound into cavity.
86343...........................  Injury to descending (left) colon
                                   without open wound into cavity.
86344...........................  Injury to sigmoid colon without open
                                   wound into cavity.
86345...........................  Injury to rectum without open wound
                                   into cavity.
86346...........................  Injury to multiple sites in colon and
                                   rectum without open wound into
                                   cavity.
86349...........................  Other injury to colon and rectum,
                                   without open wound into cavity.
86380...........................  Injury to gastrointestinal tract,
                                   unspecified site, without open wound
                                   into cavity.
86381...........................  Injury to pancreas head without
                                   mention of open wound into cavity.
86382...........................  Injury to pancreas body without
                                   mention of open wound into cavity.
86383...........................  Injury to pancreas tail without
                                   mention of open wound into cavity.
86384...........................  Injury to pancreas, multiple and
                                   unspecified sites, without open wound
                                   into cavity.
86385...........................  Injury to appendix without open wound
                                   into cavity.
86389...........................  Injury to other and unspecified
                                   gastrointestinal sites without open
                                   wound into cavity.
86400...........................  Unspecified injury to liver without
                                   mention of open wound into cavity.
86401...........................  Hematoma and contusion of liver
                                   without mention of open wound into
                                   cavity.
86402...........................  Laceration of liver, minor, without
                                   mention of open wound into cavity.
86405...........................  Laceration of liver, unspecified,
                                   without mention of open wound into
                                   cavity.
86409...........................  Other injury to liver without mention
                                   of open wound into cavity.
86500...........................  Unspecified injury to spleen without
                                   mention of open wound into cavity.
86501...........................  Hematoma of spleen, without rupture of
                                   capsule, without mention of open
                                   wound into cavity.
86502...........................  Capsular tears to spleen, without
                                   major disruption of parenchyma,
                                   without mention of open wound into
                                   cavity.
86509...........................  Other injury into spleen without
                                   mention of open wound into cavity.

[[Page 25056]]

 
86600...........................  Unspecified injury to kidney without
                                   mention of open wound into cavity.
86601...........................  Hematoma of kidney, without rupture of
                                   capsule, without mention of open
                                   wound into cavity.
86602...........................  Laceration of kidney without mention
                                   of open wound into cavity.
8670............................  Injury to bladder and urethra without
                                   mention of open wound into cavity.
8672............................  Injury to ureter without mention of
                                   open wound into cavity.
8674............................  Injury to uterus without mention of
                                   open wound into cavity.
8676............................  Injury to other specified pelvic
                                   organs without mention of open wound
                                   into cavity.
8678............................  Injury to unspecified pelvic organ
                                   without mention of open wound into
                                   cavity.
86800...........................  Injury to unspecified intra-abdominal
                                   organ without mention of open wound
                                   into cavity.
86801...........................  Injury to adrenal gland without
                                   mention of open wound into cavity.
86802...........................  Injury to bile duct and gallbladder
                                   without mention of open wound into
                                   cavity.
86803...........................  Injury to peritoneum without mention
                                   of open wound into cavity.
86804...........................  Injury to retroperitoneum without
                                   mention of open wound into cavity.
86809...........................  Injury to other and multiple intra-
                                   abdominal organs without mention of
                                   open wound into cavity.
8690............................  Internal injury to unspecified or ill-
                                   defined organs without mention of
                                   open wound into cavity.
8702............................  Laceration of eyelid involving
                                   lacrimal passages.
8703............................  Penetrating wound of orbit, without
                                   mention of foreign body.
8704............................  Penetrating wound of orbit with
                                   foreign body.
8708............................  Other specified open wounds of ocular
                                   adnexa.
8709............................  Unspecified open wound of ocular
                                   adnexa.
8710............................  Ocular laceration without prolapse of
                                   intraocular tissue.
8711............................  Ocular laceration with prolapse or
                                   exposure of intraocular tissue.
8712............................  Rupture of eye with partial loss of
                                   intraocular tissue.
8713............................  Avulsion of eye.
8715............................  Penetration of eyeball with magnetic
                                   foreign body.
8716............................  Penetration of eyeball with
                                   (nonmagnetic) foreign body.
8719............................  Unspecified open wound of eyeball.
87212...........................  Open wound of auditory canal,
                                   complicated.
87261...........................  Open wound of ear drum, uncomplicated.
87262...........................  Open wound of ossicles, uncomplicated.
87263...........................  Open wound of eustachian tube,
                                   uncomplicated.
87264...........................  Open wound of cochlea, uncomplicated.
87269...........................  Open wound of other and multiple
                                   sites, uncomplicated.
87271...........................  Open wound of ear drum, complicated.
87272...........................  Open wound of ossicles, complicated.
87273...........................  Open wound of eustachian tube,
                                   complicated.
87274...........................  Open wound of cochlea, complicated.
87279...........................  Open wound of other and multiple
                                   sites, complicated.
87323...........................  Open wound of nasal sinus,
                                   uncomplicated.
87333...........................  Open wound of nasal sinus,
                                   complicated.
8742............................  Open wound of thyroid gland, without
                                   mention of complication.
8743............................  Open wound of thyroid gland,
                                   complicated.
8744............................  Open wound of pharynx, without mention
                                   of complication.
8745............................  Open wound of pharynx, complicated.
8750............................  Open wound of chest (wall), without
                                   mention of complication.
8751............................  Open wound of chest (wall),
                                   complicated.
88020...........................  Open wound of shoulder region, with
                                   tendon involvement.
88021...........................  Open wound of scapular region, with
                                   tendon involvement.
88022...........................  Open wound of axillary region, with
                                   tendon involvement.
88023...........................  Open wound of upper arm, with tendon
                                   involvement.
88029...........................  Open wound of multiple sites of
                                   shoulder and upper arm, with tendon
                                   involvement.
88120...........................  Open wound of forearm, with tendon
                                   involvement.
88121...........................  Open wound of elbow, with tendon
                                   involvement.
88122...........................  Open wound of wrist, with tendon
                                   involvement.
8822............................  Open wound of hand except fingers
                                   alone, with tendon involvement.
8832............................  Open wound of fingers, with tendon
                                   involvement.
8842............................  Multiple and unspecified open wound of
                                   upper limb, with tendon involvement.
8870............................  Traumatic amputation of arm and hand
                                   (complete) (partial), unilateral,
                                   below elbow, without mention of
                                   complication.
8871............................  Traumatic amputation of arm and hand
                                   (complete) (partial), unilateral,
                                   below elbow, complicated.
8872............................  Traumatic amputation of arm and hand
                                   (complete) (partial), unilateral, at
                                   or above elbow, without mention of
                                   complication.
8873............................  Traumatic amputation of arm and hand
                                   (complete) (partial), unilateral, at
                                   or above elbow, complicated.
8874............................  Traumatic amputation of arm and hand
                                   (complete) (partial), unilateral,
                                   level not specified, without mention
                                   of complication.
8875............................  Traumatic amputation of arm and hand
                                   (complete) (partial), unilateral,
                                   level not specified, complicated.
8902............................  Open wound of hip and thigh, with
                                   tendon involvement.
8912............................  Open wound of knee, leg (except
                                   thigh), and ankle, with tendon
                                   involvement.
8922............................  Open wound of foot except toe(s)
                                   alone, with tendon involvement.
8932............................  Open wound of toe(s), with tendon
                                   involvement.
8942............................  Multiple and unspecified open wound of
                                   lower limb, with tendon involvement.
8960............................  Traumatic amputation of foot
                                   (complete) (partial), unilateral,
                                   without mention of complication.

[[Page 25057]]

 
8961............................  Traumatic amputation of foot
                                   (complete) (partial), unilateral,
                                   complicated.
8970............................  Traumatic amputation of leg(s)
                                   (complete) (partial), unilateral,
                                   below knee, without mention of
                                   complication.
8971............................  Traumatic amputation of leg(s)
                                   (complete) (partial), unilateral,
                                   below knee, complicated.
8972............................  Traumatic amputation of leg(s)
                                   (complete) (partial), unilateral, at
                                   or above knee, without mention of
                                   complication.
8973............................  Traumatic amputation of leg(s)
                                   (complete) (partial), unilateral, at
                                   or above knee, complicated.
8974............................  Traumatic amputation of leg(s)
                                   (complete) (partial), unilateral,
                                   level not specified, without mention
                                   of complication.
8975............................  Traumatic amputation of leg(s)
                                   (complete) (partial), unilateral,
                                   level not specified, complicated.
90000...........................  Injury to carotid artery, unspecified.
90001...........................  Injury to common carotid artery.
90002...........................  Injury to external carotid artery.
90003...........................  Injury to internal carotid artery.
9001............................  Injury to internal jugular vein.
90081...........................  Injury to external jugular vein.
90082...........................  Injury to multiple blood vessels of
                                   head and neck.
90089...........................  Injury to other specified blood
                                   vessels of head and neck.
9009............................  Injury to unspecified blood vessel of
                                   head and neck.
90181...........................  Injury to intercostal artery or vein.
90182...........................  Injury to internal mammary artery or
                                   vein.
90189...........................  Injury to other specified blood
                                   vessels of thorax.
9019............................  Injury to unspecified blood vessel of
                                   thorax.
90255...........................  Injury to uterine artery.
90256...........................  Injury to uterine vein.
90281...........................  Injury to ovarian artery.
90282...........................  Injury to ovarian vein.
90289...........................  Injury to other specified blood
                                   vessels of abdomen and pelvis.
9029............................  Injury to unspecified blood vessel of
                                   abdomen and pelvis.
9031............................  Injury to brachial blood vessels.
9032............................  Injury to radial blood vessels.
9033............................  Injury to ulnar blood vessels.
9034............................  Injury to palmar artery.
9035............................  Injury to digital blood vessels.
9038............................  Injury to other specified blood
                                   vessels of upper extremity.
9039............................  Injury to unspecified blood vessel of
                                   upper extremity.
9043............................  Injury to saphenous veins.
90450...........................  Injury to tibial vessel(s),
                                   unspecified.
90451...........................  Injury to anterior tibial artery.
90452...........................  Injury to anterior tibial vein.
90453...........................  Injury to posterior tibial artery.
90454...........................  Injury to posterior tibial vein.
9046............................  Injury to deep plantar blood vessels.
9047............................  Injury to other specified blood
                                   vessels of lower extremity.
9048............................  Injury to unspecified blood vessel of
                                   lower extremity.
9049............................  Injury to blood vessels of unspecified
                                   site.
9251............................  Crushing injury of face and scalp.
9252............................  Crushing injury of neck.
92800...........................  Crushing injury of thigh.
92801...........................  Crushing injury of hip.
9340............................  Foreign body in trachea.
9341............................  Foreign body in main bronchus.
9348............................  Foreign body in other specified parts
                                   bronchus and lung.
9405............................  Burn with resulting rupture and
                                   destruction of eyeball.
94130...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of unspecified
                                   site of face and head.
94131...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of ear (any part).
94132...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of of eye (with
                                   other parts of face, head, and neck).
94133...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of lip(s).
94134...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of chin.
94135...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of nose (septum).
94136...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of scalp (any
                                   part).
94137...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of forehead and
                                   cheek.
94138...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of neck.
94139...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of multiple sites
                                   (except with eye) of face, head, and
                                   neck.
94140...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   unspecified site of face and head,
                                   without mention of loss of body part.
94141...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   ear (any part), without mention of
                                   loss of ear.
94142...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   eye (with other parts of face, head,
                                   and neck), without mention of loss of
                                   body part.
94143...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   lip(s), without mention of loss of
                                   lip(s).
94144...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   chin, without mention of loss of
                                   chin.

[[Page 25058]]

 
94145...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   nose (septum), without mention of
                                   loss of nose.
94146...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   scalp (any part), without mention of
                                   loss of scalp.
94147...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   forehead and cheek, without mention
                                   of loss of forehead and cheek.
94148...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   neck, without mention of loss of
                                   neck.
94149...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   multiple sites (except with eye) of
                                   face, head, and neck, without mention
                                   of loss of a body part.
94150...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   face and head, unspecified site, with
                                   loss of body part.
94151...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   ear (any part), with loss of ear.
94152...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   eye (with other parts of face, head,
                                   and neck), with loss of a body part.
94153...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   lip(s), with loss of lip(s).
94154...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   chin, with loss of chin.
94155...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   nose (septum), with loss of nose.
94156...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   scalp (any part), with loss of scalp.
94157...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   forehead and cheek, with loss of
                                   forehead and cheek.
94158...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   neck, with loss of neck.
94159...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   multiple sites (except eye) of face,
                                   head, and neck, with loss of a body
                                   part.
94230...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of unspecified
                                   site of trunk.
94231...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of breast.
94232...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of chest wall,
                                   excluding breast and nipple.
94233...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of abdominal wall.
94234...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of back (any
                                   part).
94235...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of genitalia.
94239...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of other and
                                   multiple sites of trunk.
94240...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   trunk, unspecified site, without
                                   mention of loss of body part.
94241...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   breast, without mention of loss of
                                   breast.
94242...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   chest wall, excluding breast and
                                   nipple, without mention of loss of
                                   chest wall.
94243...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   abdominal wall, without mention of
                                   loss of abdominal wall.
94244...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   back (any part), without mention of
                                   loss of back.
94245...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   genitalia, without mention of loss of
                                   genitalia.
94249...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   other and multiple sites of trunk,
                                   without mention of loss of body part.
94250...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   unspecified site of trunk, with loss
                                   of body part.
94251...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   breast, with loss of breast.
94252...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   chest wall, excluding breast and
                                   nipple, with loss of chest wall.
94253...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   abdominal wall with loss of abdominal
                                   wall.
94254...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   back (any part), with loss of back.
94255...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   genitalia, with loss of genitalia.
94259...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   other and multiple sites of trunk,
                                   with loss of a body part.
94330...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of unspecified
                                   site of upper limb.
94331...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of forearm.
94332...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of elbow.
94333...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of upper arm.
94334...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of axilla.
94335...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of shoulder.
94336...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of scapular
                                   region.
94339...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of multiple sites
                                   of upper limb, except wrist and hand.
94340...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   unspecified site of upper limb,
                                   without mention of loss of a body
                                   part.
94341...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   forearm, without mention of loss of
                                   forearm.
94342...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   elbow, without mention of loss of
                                   elbow.
94343...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   upper arm, without mention of loss of
                                   upper arm.
94344...........................  Deep necrosis of underlying tissues
                                   due to burn of axilla, without
                                   mention of loss of axilla.

[[Page 25059]]

 
94345...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   shoulder, without mention of loss of
                                   shoulder.
94346...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   scapular region, without mention of
                                   loss of scapula.
94349...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   multiple sites of upper limb, except
                                   wrist and hand, without mention of
                                   loss of upper limb.
94350...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   unspecified site of upper limb, with
                                   loss of a body part.
94351...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   forearm, with loss of forearm.
94352...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   elbow, with loss of elbow.
94353...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   upper arm, with loss of upper arm.
94354...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   axilla, with loss of axilla.
94355...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   shoulder, with loss of shoulder.
94356...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   scapular region, with loss of
                                   scapula.
94359...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   multiple sites of upper limb, except
                                   wrist and hand, with loss of upper
                                   limb.
94430...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of unspecified
                                   site of hand.
94431...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of single digit
                                   (finger (nail)) other than thumb.
94432...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of thumb (nail).
94433...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of two or more
                                   digits of hand, not including thumb.
94434...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of two or more
                                   digits of hand including thumb.
94435...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of palm of hand.
94436...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of back of hand.
94437...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of wrist.
94438...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of multiple sites
                                   of wrist(s) and hand(s).
94440...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   unspecified site of hand, without
                                   mention of loss of hand.
94441...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   single digit (finger (nail)) other
                                   than thumb, without mention of loss
                                   of finger.
94442...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   thumb (nail), without mention of loss
                                   of thumb.
94443...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   two or more digits of hand, not
                                   including thumb, without mention of
                                   fingers.
94444...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   two or more digits of hand including
                                   thumb, without mention of loss of
                                   fingers.
94445...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   palm of hand, without mention of loss
                                   of palm.
94446...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   back of hand, without mention of loss
                                   of back of hand.
94447...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   wrist, without mention of loss of
                                   wrist.
94448...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   multiple sites of wrist(s) and
                                   hand(s), without mention of loss of a
                                   body part.
94450...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   unspecified site of hand, with loss
                                   of hand.
94451...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   single digit (finger (nail)) other
                                   than thumb, with loss of finger.
94452...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   thumb (nail), with loss of thumb.
94453...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   two or more digits of hand, not
                                   including thumb, with loss of
                                   fingers.
94454...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   two or more digits of hand including
                                   thumb, with loss of fingers.
94455...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   palm of hand, with loss of palm of
                                   hand.
94456...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   back of hand, with loss of back of
                                   hand.
94457...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   wrist, with loss of wrist.
94458...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   multiple sites of wrist(s) and
                                   hand(s), with loss of a body part.
94530...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of unspecified
                                   site of lower limb.
94531...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of toe(s) (nail).
94532...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of foot.
94533...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of ankle.
94534...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of lower leg.
94535...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of knee.
94536...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of thigh (any
                                   part).
94539...........................  Full-thickness skin loss due to burn
                                   (third degree nos) of multiple sites
                                   of lower limb(s).
94540...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   unspecified site of lower limb (leg),
                                   without mention of loss of a body
                                   part.
94541...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   toe(s) (nail), without mention of
                                   loss of toe(s).
94542...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   foot, without mention of loss of
                                   foot.
94543...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   ankle, without mention of loss of
                                   ankle.

[[Page 25060]]

 
94544...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   lower leg, without mention of loss of
                                   lower leg.
94545...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   knee, without mention of loss of
                                   knee.
94546...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   thigh (any part), without mention of
                                   loss of thigh.
94549...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   multiple sites of lower limb(s),
                                   without mention of loss of a body
                                   part.
94550...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   unspecified site lower limb (leg),
                                   with loss of a body part.
94551...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   toe(s) (nail), with loss of toe(s).
94552...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   foot, with loss of foot.
94553...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   ankle, with loss of ankle.
94554...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   lower leg, with loss of lower leg.
94555...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   knee, with loss of knee.
94556...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   thigh (any part), with loss of thigh.
94559...........................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   multiple sites of lower limb(s), with
                                   loss of a body part.
9463............................  Full-thickness skin loss due to burn
                                   (third degree nos) of multiple
                                   specified sites.
9464............................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   multiple specified sites, without
                                   mention of loss of a body part.
9465............................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree) of
                                   multiple specified sites, with loss
                                   of a body part.
9471............................  Burn of larynx, trachea, and lung.
9472............................  Burn of esophagus.
9473............................  Burn of gastrointestinal tract.
9474............................  Burn of vagina and uterus.
94810...........................  Burn (any degree) involving 10-19
                                   percent of body surface with third
                                   degree burn of less than 10 percent
                                   or unspecified amount.
94811...........................  Burn (any degree) involving 10-19
                                   percent of body surface with third
                                   degree burn of 10-19%.
94820...........................  Burn (any degree) involving 20-29
                                   percent of body surface with third
                                   degree burn of less than 10 percent
                                   or unspecified amount.
94830...........................  Burn (any degree) involving 30-39
                                   percent of body surface with third
                                   degree burn of less than 10 percent
                                   or unspecified amount.
94840...........................  Burn (any degree) involving 40-49
                                   percent of body surface with third
                                   degree burn of less than 10 percent
                                   or unspecified amount.
94850...........................  Burn (any degree) involving 50-59
                                   percent of body surface with third
                                   degree burn of less than 10 percent
                                   or unspecified amount.
94860...........................  Burn (any degree) involving 60-69
                                   percent of body surface with third
                                   degree burn of less than 10 percent
                                   or unspecified amount.
94870...........................  Burn (any degree) involving 70-79
                                   percent of body surface with third
                                   degree burn of less than 10 percent
                                   or unspecified amount.
94880...........................  Burn (any degree) involving 80-89
                                   percent of body surface with third
                                   degree burn of less than 10 percent
                                   or unspecified amount.
94890...........................  Burn (any degree) involving 90 percent
                                   or more of body surface with third
                                   degree burn of less than 10 percent
                                   or unspecified amount.
9493............................  Full-thickness skin loss due to burn
                                   (third degree nos), unspecified site.
9494............................  Deep necrosis of underlying tissue due
                                   to burn (deep third degree),
                                   unspecified site without mention of
                                   loss of a body part.
9495............................  Deep necrosis of underlying tissues
                                   due to burn (deep third degree,
                                   unspecified site with loss of a body
                                   part.
9500............................  Optic nerve injury.
9501............................  Injury to optic chiasm.
9502............................  Injury to optic pathways.
9503............................  Injury to visual cortex.
9509............................  Injury to unspecified optic nerve and
                                   pathways.
9510............................  Injury to oculomotor nerve.
9511............................  Injury to trochlear nerve.
9512............................  Injury to trigeminal nerve.
9513............................  Injury to abducens nerve.
9514............................  Injury to facial nerve.
9515............................  Injury to acoustic nerve.
9516............................  Injury to accessory nerve.
9517............................  Injury to hypoglossal nerve.
9518............................  Injury to other specified cranial
                                   nerves.
9519............................  Injury to unspecified cranial nerve.
9582............................  Secondary and recurrent hemorrhage as
                                   an early complication of trauma.
9583............................  Posttraumatic wound infection not
                                   elsewhere classified.
9587............................  Traumatic subcutaneous emphysema.
95890...........................  Compartment syndrome, unspecified.
95891...........................  Traumatic compartment syndrome of
                                   upper extremity.
95892...........................  Traumatic compartment syndrome of
                                   lower extremity.
95893...........................  Traumatic compartment syndrome of
                                   abdomen.
95899...........................  Traumatic compartment syndrome of
                                   other sites.

[[Page 25061]]

 
9910............................  Frostbite of face.
9911............................  Frostbite of hand.
9912............................  Frostbite of foot.
9913............................  Frostbite of other and unspecified
                                   sites.
9914............................  Immersion foot.
9920............................  Heat stroke and sunstroke.
9933............................  Caisson disease.
9941............................  Drowning and nonfatal submersion.
9947............................  Asphyxiation and strangulation.
9950............................  Other anaphylactic shock, not
                                   elsewhere classified.
9954............................  Shock due to anesthesia, not elsewhere
                                   classified.
99550...........................  Unspecified child abuse.
99551...........................  Child emotional/psychological abuse.
99552...........................  Child neglect (nutritional).
99553...........................  Child sexual abuse.
99554...........................  Child physical abuse.
99555...........................  Shaken baby syndrome.
99559...........................  Other child abuse and neglect.
99560...........................  Anaphylactic shock due to unspecified
                                   food.
99561...........................  Anaphylactic shock due to peanuts.
99562...........................  Anaphylactic shock due to crustaceans.
99563...........................  Anaphylactic shock due to fruits and
                                   vegetables.
99564...........................  Anaphylactic shock due to tree nuts
                                   and seeds.
99565...........................  Anaphylactic shock due to fish.
99566...........................  Anaphylactic shock due to food
                                   additives.
99567...........................  Anaphylactic shock due to milk
                                   products.
99568...........................  Anaphylactic shock due to eggs.
99569...........................  Anaphylactic shock due to other
                                   specified food.
99580...........................  Unspecified adult maltreatment.
99581...........................  Adult physical abuse.
99583...........................  Adult sexual abuse.
99584...........................  Adult neglect (nutritional).
99585...........................  Other adult abuse and neglect.
99586...........................  Malignant hyperthermia.
99590...........................  Systemic inflammatory response
                                   syndrome, unspecified.
99593...........................  Systemic inflammatory response
                                   syndrome due to noninfectious process
                                   without acute organ dysfunction.
99600...........................  Mechanical complications of
                                   unspecified cardiac device, implant,
                                   and graft.
99601...........................  Mechanical complication due to cardiac
                                   pacemaker (electrode).
99602...........................  Mechanical complication due to heart
                                   valve prosthesis.
99603...........................  Mechanical complication due to
                                   coronary bypass graft.
99604...........................  Mechanical complication of automatic
                                   implantable cardiac defibrillator.
99609...........................  Other mechanical complication of
                                   cardiac device, implant, and graft.
9961............................  Mechanical complication of other
                                   vascular device, implant, and graft.
9962............................  Mechanical complication of nervous
                                   system device, implant, and graft.
99630...........................  Mechanical complication of unspecified
                                   genitourinary device, implant, and
                                   graft.
99639...........................  Other mechanical complication of
                                   genitourinary device, implant, and
                                   graft.
99640...........................  Unspecified mechanical complication of
                                   internal orthopedic device, implant,
                                   and graft.
99641...........................  Mechanical loosening of prosthetic
                                   joint.
99642...........................  Dislocation of prosthetic joint.
99643...........................  Prosthetic joint implant failure.
99644...........................  Peri-prosthetic fracture around
                                   prosthetic joint.
99645...........................  Peri-prosthetic osteolysis.
99646...........................  Articular bearing surface wear of
                                   prosthetic joint.
99647...........................  Other mechanical complication of
                                   prosthetic joint implant.
99649...........................  Other mechanical complication of other
                                   internal orthopedic device, implant,
                                   and graft.
99651...........................  Mechanical complication of prosthetic
                                   corneal graft.
99652...........................  Mechanical complication of prosthetic
                                   graft of other tissue, not elsewhere
                                   classified.
99653...........................  Mechanical complication of prosthetic
                                   ocular lens prosthesis.
99654...........................  Mechanical complication of breast
                                   prosthesis.
99655...........................  Mechanical complication due to
                                   artificial skin graft and
                                   decellularized allodermis.
99656...........................  Mechanical complication due to
                                   peritoneal dialysis catheter.
99657...........................  COMPLICATION, DUE TO INSULIN PUMP.
99659...........................  Mechanical complication of other
                                   implant and internal device, not
                                   elsewhere classfied.
99660...........................  Infection and inflammatory reaction
                                   due to unspecified device, implant,
                                   and graft.
99661...........................  Infection and inflammatory reaction
                                   due to cardiac device, implant, and
                                   graft.
99662...........................  Infection and inflammatory reaction
                                   due to other vascular device,
                                   implant, and graft.
99663...........................  Infection and inflammatory reaction
                                   due to nervous system device,
                                   implant, and graft.
99664...........................  Infection and inflammatory reaction
                                   due to indwelling urinary catheter.
99665...........................  Infection and inflammatory reaction
                                   due to other genitourinary device,
                                   implant, and graft.
99666...........................  Infection and inflammatory reaction
                                   due to internal joint prosthesis.
99667...........................  Infection and inflammatory reaction
                                   due to other internal orthopedic
                                   device, implant, and graft.
99668...........................  Infection and inflammatory reaction
                                   due to peritoneal dialysis catheter.

[[Page 25062]]

 
99669...........................  Infection and inflammatory reaction
                                   due to other internal prosthetic
                                   device, implant, and graft.
99671...........................  Other complications due to heart valve
                                   prosthesis.
99672...........................  Other complications due to other
                                   cardiac device, implant, and graft.
99673...........................  Other complications due to renal
                                   dialysis device, implant, and graft.
99674...........................  Other complications due to other
                                   vascular device, implant, and graft.
99675...........................  Other complications due to nervous
                                   system device, implant, and graft.
99676...........................  Other complications due to
                                   genitourinary device, implant, and
                                   graft.
99677...........................  Other complications due to internal
                                   joint prosthesis.
99678...........................  Other complications due to other
                                   internal orthopedic device, implant,
                                   and graft.
99679...........................  Other complications due to other
                                   internal prosthetic device, implant,
                                   and graft.
99680...........................  Complications of unspecified
                                   transplanted organ.
99681...........................  Complications of transplanted kidney.
99682...........................  Complications of transplanted liver.
99683...........................  Complications of transplanted heart.
99684...........................  Complications of transplanted lung.
99685...........................  Complications of transplanted bone
                                   marrow.
99686...........................  Complications of transplanted
                                   pancreas.
99687...........................  Complications of transplanted organ,
                                   intestine.
99689...........................  Complications of other specified
                                   transplanted organ.
99690...........................  Complications of unspecified
                                   reattached extremity.
99691...........................  Complications of reattached forearm.
99692...........................  Complications of reattached hand.
99693...........................  Complications of reattached finger(s).
99694...........................  Complications of reattached upper
                                   extremity, other and unspecified.
99695...........................  Complication of reattached foot and
                                   toe(s).
99696...........................  Complication of reattached lower
                                   extremity, other and unspecified.
99699...........................  Complication of other specified
                                   reattached body part.
99701...........................  Central nervous system complication.
99702...........................  Iatrogenic cerebrovascular infarction
                                   or hemorrhage.
99709...........................  Other nervous system complications.
9971............................  Cardiac complications, not elsewhere
                                   classified.
9972............................  Peripheral vascular complications, not
                                   elsewhere classified.
9973............................  Respiratory complications, not
                                   elsewhere classified.
9974............................  Digestive system complications, not
                                   elsewhere classified.
99762...........................  Infection (chronic) of amputation
                                   stump.
99771...........................  Vascular complications of mesenteric
                                   artery.
99772...........................  Vascular complications of renal
                                   artery.
99779...........................  Vascular complications of other
                                   vessels.
99799...........................  Complications affecting other
                                   specified body systems, not elsewhere
                                   classified.
9980............................  Postoperative shock, not elsewhere
                                   classified.
99811...........................  Hemorrhage complicating a procedure.
99812...........................  Hematoma complicating a procedure.
99813...........................  Seroma complicating a procedure.
9982............................  Accidental puncture or laceration
                                   during a procedure, not elsewhere
                                   classified.
99831...........................  Disruption of internal operation
                                   wound.
99832...........................  Disruption of external operation
                                   wound.
9984............................  Foreign body accidentally left during
                                   a procedure, not elsewhere
                                   classified.
99851...........................  Infected postoperative seroma.
99859...........................  Other postoperative infection.
9986............................  Persistent postoperative fistula, not
                                   elsewhere classified.
9987............................  Acute reaction to foreign substance
                                   accidentally left during a procedure,
                                   not elsewhere classified.
99883...........................  Non-healing surgical wound.
9990............................  Generalized vaccinia as a complication
                                   of medical care, not elsewhere
                                   classified.
9992............................  Other vascular complications of
                                   medical care, not elsewhere
                                   classified.
9993............................  Other infection due to medical care,
                                   not elsewhere classified.
9994............................  Anaphylactic shock due to serum, not
                                   elsewhere classified.
9995............................  Other serum reaction, not elsewhere
                                   classified.
9996............................  Abo incompatibility reaction, not
                                   elsewhere classified.
9997............................  Rh incompatibility reaction, not
                                   elsewhere classified.
9998............................  Other transfusion reaction, not
                                   elsewhere classified.
V420............................  Kidney replaced by transplant.
V421............................  Heart replaced by transplant.
V426............................  Lung replaced by transplant.
V427............................  Liver replaced by transplant.
V4281...........................  Bone marrow replaced by transplant.
V4282...........................  Peripheral stem cells replaced by
                                   transplant.
V4283...........................  Pancreas replaced by transplant.
V4284...........................  Organ or tissue replaced by
                                   transplant, intestines.
V4321...........................  Organ or tissue replaced by other
                                   means, heart assist device.
V4322...........................  Organ or tissue replaced by other
                                   means, fully implantable artificial
                                   heart.
V4611...........................  Dependence on respirator, status.
V4612...........................  Encounter for respirator dependence
                                   during power failure.

[[Page 25063]]

 
V4613...........................  Encounter for weaning from respirator
                                   [ventilator].
V4614...........................  Mechanical complication of respirator
                                   [ventilator].
V551............................  Attention to gastrostomy.
V6284...........................  Suicidal ideation.
V850............................  Body Mass Index less than 19, adult.
V854............................  Body Mass Index 40 and over, adult.
------------------------------------------------------------------------


     Table 7A.--Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 2006 MedPAR Update--December 2006 Grouper V24.0 CMS DRGs
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                             Number of      Arithmetic         10th            25th            50th            75th            90th
                   DRG                      discharges       mean LOS       percentile      percentile      percentile      percentile      percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1.......................................          24,941          9.4334               2               4               7              12              19
2.......................................           9,519          4.2485               1               2               3               6               8
3.......................................               3         31.6667               2               2              42              51              51
6.......................................             254          2.9409               1               1               2               4               6
7.......................................          14,373          9.0353               2               4               7              11              18
8.......................................           3,072          2.7119               1               1               2               3               6
9.......................................           1,749          5.7616               1               2               4               7              11
10......................................          18,799          5.7674               2               3               4               7              11
11......................................           2,768          3.6120               1               2               3               5               7
12......................................          56,172          5.3189               2               3               4               6              10
13......................................           7,636          4.8707               2               3               4               6               8
14......................................         262,424          5.2666               2               3               4               6              10
15......................................          13,780          3.8482               1               2               3               5               7
16......................................          20,050          6.2493               2               3               5               8              12
17......................................           3,109          3.2078               1               1               2               4               6
18......................................          33,745          5.1228               2               3               4               6              10
19......................................           7,451          3.3182               1               2               3               4               6
21......................................           2,071          6.1772               2               3               5               8              12
22......................................           3,366          5.1242               2               2               4               6              10
23......................................          10,269          3.7083               1               2               3               5               7
26......................................              32          2.8750               1               1               2               4               7
27......................................           6,179          4.6716               1               1               3               6              10
28......................................          21,197          5.4894               1               2               4               7              11
29......................................           6,674          3.0853               1               1               3               4               6
31......................................           4,986          3.7706               1               2               3               5               7
32......................................           1,691          2.2389               1               1               2               3               4
34......................................          29,326          4.6962               1               2               4               6               9
35......................................           7,738          2.9340               1               1               2               4               5
36......................................             270          1.9370               1               1               1               2               4
37......................................           1,171          4.1076               1               1               3               5               9
38......................................              52          2.3846               1               1               2               3               4
39......................................             274          2.2336               1               1               1               2               5
40......................................           1,098          4.4791               1               2               4               5               9
42......................................           1,470          2.5966               1               1               1               3               6
43......................................             127          3.0236               1               1               2               4               5
44......................................           1,261          4.8882               2               3               4               6               9
45......................................           2,846          2.9301               1               2               2               4               5
46......................................           4,002          3.9725               1               2               3               5               8
47......................................           1,258          2.9754               1               1               2               4               6
49......................................           2,449          4.2450               1               2               3               5               8
50......................................           1,973          1.7988               1               1               1               2               3
51......................................             177          2.7910               1               1               1               3               6
52......................................             181          1.5304               1               1               1               2               2
53......................................           1,896          3.8745               1               1               2               5               9
55......................................           1,234          2.7626               1               1               1               3               6
56......................................             369          2.5799               1               1               2               3               5
57......................................             732          3.4549               1               1               2               4               7
58......................................               1          1.0000               1               1               1               1               1
59......................................             111          2.4414               1               1               1               3               4
60......................................               5          3.4000               1               1               1               6               8
61......................................             212          5.8821               1               1               4               7              13
62......................................               1          4.0000               4               4               4               4               4
63......................................           2,551          4.5468               1               2               3               6              10
64......................................           3,044          6.0798               1               2               4               8              13
65......................................          39,254          2.7302               1               1               2               3               5
66......................................           7,743          3.2033               1               1               2               4               6
67......................................             348          3.6063               1               2               3               4               7
68......................................          14,437          3.7100               1               2               3               5               7

[[Page 25064]]

 
69......................................           3,512          2.7958               1               2               2               4               5
70......................................              22          2.4545               1               1               2               3               4
71......................................              64          3.8125               1               2               3               5               7
72......................................           1,377          3.3834               1               2               3               4               6
73......................................           9,817          4.3653               1               2               3               6               8
75......................................          46,052          9.3570               3               4               7              12              19
76......................................          45,066         10.1322               3               5               8              13              19
77......................................           1,766          4.4077               1               2               4               6               9
78......................................          52,142          5.9448               2               4               5               7              10
79......................................         149,996          7.8785               3               4               6              10              15
80......................................           5,865          5.2055               2               3               4               6              10
81......................................               8          3.1250               1               2               3               3               4
82......................................          60,815          6.5333               2               3               5               8              13
83......................................           7,094          5.0369               2               3               4               6               9
84......................................           1,294          3.0077               1               2               3               4               5
85......................................          22,232          6.1018               2               3               5               8              12
86......................................           1,423          3.3710               1               2               3               4               7
87......................................         104,584          6.2374               2               3               5               8              12
88......................................         375,666          4.7615               2               3               4               6               9
89......................................         468,634          5.3910               2               3               4               7              10
90......................................          33,813          3.5880               1               2               3               4               6
91......................................              42          5.1667               1               2               3               6               8
92......................................          15,894          5.8223               2               3               5               7              11
93......................................           1,094          3.5932               1               2               3               5               7
94......................................          13,571          5.8596               2               3               5               8              11
95......................................           1,396          3.4362               1               2               3               4               7
96......................................          52,187          4.1808               1               2               3               5               8
97......................................          20,991          3.2644               1               2               3               4               6
98......................................              11          4.6364               1               2               4               6               7
99......................................          20,681          3.0888               1               1               2               4               6
100.....................................           5,367          2.0781               1               1               2               3               4
101.....................................          24,043          4.1874               1               2               3               5               8
102.....................................           4,155          2.4363               1               1               2               3               5
103.....................................             957         36.6813               8              13              25              46              80
104.....................................          19,277         14.5529               6               8              12              18              26
105.....................................          31,935          9.9262               4               6               8              11              18
106.....................................           3,273         10.9050               5               7               9              13              19
108.....................................           9,206         10.4328               4               6               8              13              19
110.....................................          56,354          7.8017               1               3               6              10              16
111.....................................          10,370          2.7754               1               1               2               4               6
113.....................................          30,526         12.4437               4               6              10              15              24
114.....................................           7,216          8.1332               2               4               7              10              16
117.....................................           7,054          4.0186               1               1               2               5               9
118.....................................           7,940          3.0072               1               1               2               4               7
119.....................................             788          5.5063               1               1               4               8              12
120.....................................          30,139          9.0112               1               3               6              12              19
121.....................................         131,942          5.9604               2               3               5               8              11
122.....................................          47,504          3.2315               1               1               3               4               6
123.....................................          24,024          4.6391               1               1               3               6              11
124.....................................         110,702          4.4070               1               2               3               6               9
125.....................................          85,159          2.6783               1               1               2               3               5
126.....................................           5,156         10.7455               3               6               8              13              20
127.....................................         627,657          5.0473               2               3               4               6               9
128.....................................           3,363          4.9854               2               3               4               6               8
129.....................................           3,233          2.6087               1               1               1               3               6
130.....................................          83,923          5.2374               1               3               4               7              10
131.....................................          20,275          3.6403               1               2               3               5               6
132.....................................          84,452          2.7444               1               1               2               3               5
133.....................................           4,929          2.0801               1               1               2               3               4
134.....................................          37,743          3.0024               1               1               2               4               6
135.....................................           6,937          4.2093               1               2               3               5               8
136.....................................             893          2.4894               1               1               2               3               5
138.....................................         206,453          3.8403               1               2               3               5               7
139.....................................          67,628          2.3918               1               1               2               3               4
140.....................................          24,872          2.3395               1               1               2               3               4
141.....................................         125,207          3.3954               1               2               3               4               6
142.....................................          44,070          2.4524               1               1               2               3               4
143.....................................         220,824          2.1144               1               1               2               3               4
144.....................................         105,937          5.8550               1               2               4               7              12
145.....................................           4,992          2.5032               1               1               2               3               5

[[Page 25065]]

 
146.....................................           9,704          9.6600               4               6               8              11              17
147.....................................           2,408          5.3218               2               4               5               7               8
149.....................................          18,456          5.4416               3               4               5               7               8
150.....................................          23,405         10.4474               3               6               9              13              19
151.....................................           5,118          4.9334               1               2               4               7               9
152.....................................           4,885          7.8047               3               4               6               9              14
153.....................................           1,840          4.7315               2               3               4               6               7
155.....................................           5,761          3.7808               1               2               3               5               8
156.....................................               3         19.0000               2               2              16              39              39
157.....................................           8,102          5.5242               1               2               4               7              11
158.....................................           3,241          2.6245               1               1               2               3               5
159.....................................          18,979          5.0830               1               2               4               6              10
160.....................................          10,791          2.5814               1               1               2               3               5
161.....................................           9,709          4.5090               1               2               3               6               9
162.....................................           4,384          2.0739               1               1               2               3               4
163.....................................               7          4.7143               2               3               4               5               7
164.....................................           5,991          7.6306               3               4               6               9              14
165.....................................           2,312          3.8824               1               2               4               5               7
166.....................................           5,472          4.2149               1               2               3               5               8
167.....................................           4,821          2.0797               1               1               2               3               4
168.....................................           1,635          4.5976               1               2               3               6               9
169.....................................             846          2.1572               1               1               2               3               4
170.....................................          17,758         10.3417               2               5               8              13              21
171.....................................           1,371          3.9081               1               2               3               5               8
172.....................................          32,071          6.7286               2               3               5               8              13
173.....................................           1,902          3.4332               1               1               3               4               7
174.....................................         239,405          4.6424               2               3               4               6               8
175.....................................          24,762          2.8116               1               2               2               4               5
176.....................................          13,258          5.0499               2               3               4               6               9
177.....................................           7,710          4.4132               2               2               4               5               8
178.....................................           2,265          3.1007               1               2               3               4               5
179.....................................          14,563          5.7533               2               3               4               7              11
180.....................................          89,516          5.2296               2               3               4               6              10
181.....................................          23,153          3.2759               1               2               3               4               6
182.....................................         281,768          4.0590               1               2               3               5               8
183.....................................          72,273          2.8170               1               1               2               4               5
184.....................................              78          3.6026               1               2               2               4               7
185.....................................           5,963          4.4223               1               2               3               6               9
186.....................................               4          4.7500               3               3               3               6               7
187.....................................             635          3.9984               1               2               3               5               8
188.....................................          84,689          5.2986               1               2               4               7              10
189.....................................          11,667          2.9734               1               1               2               4               6
190.....................................               8          5.2500               1               2               3               5               9
191.....................................          10,210         12.1666               3               6               9              15              25
192.....................................           1,287          5.2883               1               3               5               7               9
193.....................................           3,705         12.0302               4               6              10              15              22
194.....................................             425          6.6165               3               4               6               8              11
195.....................................           2,428         10.2105               4               6               9              13              18
196.....................................             498          5.5542               2               3               5               7               9
197.....................................          15,180          8.9159               3               5               7              11              16
198.....................................           3,553          4.2651               2               3               4               5               7
199.....................................           1,320          8.7841               2               3               6              11              19
200.....................................             884         10.3801               2               4               7              13              21
201.....................................           2,591         13.0475               3               6              10              17              26
202.....................................          26,311          6.0668               2               3               5               8              12
203.....................................          30,311          6.3680               2               3               5               8              13
204.....................................          66,617          5.3058               2               3               4               6              10
205.....................................          31,699          5.7534               2               3               4               7              11
206.....................................           1,725          3.8458               1               2               3               5               7
207.....................................          37,546          5.1840               2               2               4               6              10
208.....................................           8,523          2.8941               1               1               2               4               5
210.....................................         126,659          6.5368               3               4               5               7              11
211.....................................          23,197          4.5195               3               3               4               5               7
212.....................................               6          4.6667               1               1               2               8               8
213.....................................           8,062          9.2446               2               4               7              12              18
216.....................................          19,672          5.4472               1               1               3               8              12
217.....................................          14,549         11.8718               3               5               8              15              24
218.....................................          30,810          5.4129               2               3               4               7              10
219.....................................          19,731          3.1027               1               2               3               4               5
220.....................................               4          6.5000               1               1               2               4              19

[[Page 25066]]

 
223.....................................          11,839          3.3929               1               1               3               4               7
224.....................................           8,611          1.9527               1               1               1               2               4
225.....................................           6,109          5.1627               1               2               4               7              11
226.....................................           7,188          6.3445               1               3               4               8              13
227.....................................           4,669          2.5740               1               1               2               3               5
228.....................................           2,587          4.2041               1               1               3               6               9
229.....................................             951          2.3060               1               1               2               3               5
230.....................................           2,423          5.7693               1               2               4               7              12
232.....................................             465          2.9441               1               1               2               3               7
233.....................................          22,278          5.9501               1               2               5               8              12
234.....................................          10,535          2.4870               1               1               1               3               6
235.....................................           4,464          4.5459               1               2               4               6               8
236.....................................          41,174          4.3733               2               3               4               5               8
237.....................................           1,818          3.7041               1               2               3               5               7
238.....................................           9,430          7.9829               3               4               6               9              15
239.....................................          37,225          5.9285               2               3               5               7              11
240.....................................          12,432          6.4345               2               3               5               8              13
241.....................................           2,370          3.5924               1               2               3               4               6
242.....................................           2,575          6.3763               2               3               5               8              12
243.....................................          97,388          4.4757               1               2               4               6               8
244.....................................          16,696          4.3404               1               2               4               5               8
245.....................................           5,092          3.0330               1               1               3               4               6
246.....................................           1,268          3.5804               1               2               3               4               7
247.....................................          21,168          3.3470               1               2               3               4               6
248.....................................          17,364          4.7551               2               3               4               6               8
249.....................................          13,232          3.9306               1               1               3               5               8
250.....................................           4,411          3.8601               1               2               3               5               7
251.....................................           1,877          2.7475               1               1               3               3               5
253.....................................          25,596          4.5348               2               3               4               5               8
254.....................................           9,175          3.0765               1               2               3               4               5
255.....................................               1          3.0000               3               3               3               3               3
256.....................................           7,625          5.0515               1               2               4               6              10
257.....................................          12,191          2.5461               1               1               2               3               5
258.....................................          10,164          1.6868               1               1               1               2               3
259.....................................           2,447          2.9918               1               1               1               3               7
260.....................................           1,978          1.3519               1               1               1               1               2
261.....................................           1,466          2.1296               1               1               1               2               4
262.....................................             562          4.8986               1               2               4               6              10
263.....................................          20,802         10.1605               3               5               7              12              20
264.....................................           3,458          5.9974               2               3               5               7              11
265.....................................           3,941          6.3144               1               2               4               8              14
266.....................................           2,095          3.0897               1               1               2               4               6
267.....................................             213          4.9437               1               2               3               5               9
268.....................................             993          3.3625               1               1               2               4               7
269.....................................          11,402          8.0560               2               4               6              10              16
270.....................................           2,537          3.7040               1               1               3               5               7
271.....................................          19,773          6.7454               2               3               5               8              12
272.....................................           5,748          5.6475               2               3               4               7              10
273.....................................           1,091          3.7993               1               2               3               5               7
274.....................................           2,206          6.1215               2               3               5               8              12
275.....................................             176          2.8750               1               1               2               4               6
276.....................................           1,437          4.4628               1               2               4               6               8
277.....................................         121,125          5.3596               2               3               4               7              10
278.....................................          31,136          3.8929               2               2               3               5               7
279.....................................               9          2.5556               1               1               3               4               4
280.....................................          19,413          3.9496               1               2               3               5               7
281.....................................           5,892          2.8130               1               1               3               4               5
283.....................................           6,796          4.3792               1               2               3               5               8
284.....................................           1,736          2.9891               1               1               2               4               6
285.....................................           8,300          9.7928               3               5               8              13              18
286.....................................           3,003          5.2148               1               2               4               6              10
287.....................................           4,991          9.5642               3               5               7              11              18
288.....................................           9,102          3.3196               1               2               2               4               6
289.....................................           5,813          2.5230               1               1               1               2               5
290.....................................          12,096          2.0051               1               1               1               2               3
291.....................................              50          1.5200               1               1               1               2               2
292.....................................           7,589         10.0137               2               4               8              12              19
293.....................................             322          4.6863               1               2               3               6               9
294.....................................          93,724          4.1793               1               2               3               5               8
295.....................................           4,525          3.6320               1               2               3               4               7

[[Page 25067]]

 
296.....................................         207,831          4.4830               1               2               3               6               8
297.....................................          35,935          2.9945               1               2               3               4               5
298.....................................              81          3.3827               1               2               2               4               7
299.....................................           1,546          5.2523               1               2               4               6              10
300.....................................          21,703          5.7447               2               3               5               7              11
301.....................................           3,570          3.3908               1               2               3               4               6
302.....................................          10,439          7.9171               4               5               6               9              14
303.....................................          19,565          6.0558               2               3               5               7              11
304.....................................          13,755          7.8484               2               3               6              10              16
305.....................................           2,882          2.9139               1               2               2               4               5
306.....................................           5,206          5.8832               1               2               3               8              14
307.....................................           1,648          1.9205               1               1               2               2               3
308.....................................           5,035          5.4111               1               2               3               7              12
309.....................................           2,761          1.6092               1               1               1               2               3
310.....................................          24,646          4.5628               1               2               3               6              10
311.....................................           5,023          1.8176               1               1               1               2               3
312.....................................           1,369          4.8254               1               1               3               6              10
313.....................................             480          2.1250               1               1               2               3               4
315.....................................          34,790          6.7300               1               1               4               9              16
316.....................................         231,484          5.9894               2               3               5               7              12
317.....................................           2,498          3.5020               1               1               2               4               7
318.....................................           5,778          5.7885               1               3               4               7              12
319.....................................             324          2.7593               1               1               2               4               5
320.....................................         225,977          4.9150               2               3               4               6               9
321.....................................          29,439          3.4932               1               2               3               4               6
322.....................................              79          3.2658               1               2               3               4               6
323.....................................          19,180          3.0764               1               1               2               4               6
324.....................................           3,829          1.9128               1               1               1               2               3
325.....................................           9,248          3.6718               1               2               3               5               7
326.....................................           2,288          2.5013               1               1               2               3               4
327.....................................               5          2.6000               1               1               2               2               6
328.....................................             525          3.4400               1               1               2               4               6
329.....................................              49          1.6531               1               1               1               2               2
330.....................................               1          1.0000               1               1               1               1               1
331.....................................          55,533          5.4057               1               2               4               7              10
332.....................................           3,151          3.0378               1               1               2               4               6
333.....................................             301          5.5681               1               2               4               7              13
334.....................................           9,233          3.9509               1               2               3               5               7
335.....................................          12,674          2.2587               1               1               2               3               4
336.....................................          25,171          3.1752               1               1               2               3               7
337.....................................          19,038          1.7807               1               1               2               2               3
338.....................................             614          5.5684               1               2               4               8              12
339.....................................           1,126          5.6536               1               1               3               7              12
340.....................................               1          1.0000               1               1               1               1               1
341.....................................           2,792          3.1866               1               1               1               3               7
342.....................................             458          3.3952               1               1               2               4               7
344.....................................           2,027          2.9842               1               1               1               3               7
345.....................................           1,253          5.1875               1               2               3               6              12
346.....................................           3,369          5.7133               2               3               4               7              11
347.....................................             207          2.9517               1               1               1               4               6
348.....................................           4,244          4.0224               1               2               3               5               8
349.....................................             491          2.5682               1               1               2               3               5
350.....................................           7,160          4.4365               2               2               4               5               8
352.....................................           1,127          4.2316               1               2               3               5               9
353.....................................           2,799          5.7153               2               3               4               6              11
354.....................................           7,293          5.4880               2               3               4               6              10
355.....................................           4,614          2.9272               2               2               3               3               4
356.....................................          21,201          1.8026               1               1               1               2               3
357.....................................           5,224          7.8335               3               4               6               9              15
358.....................................          19,606          3.7991               1               2               3               4               7
359.....................................          26,471          2.2429               1               2               2               3               3
360.....................................          13,718          2.3371               1               1               2               3               4
361.....................................             267          3.0749               1               1               2               3               6
362.....................................               2          1.5000               1               1               2               2               2
363.....................................           1,787          4.1365               1               2               3               4               9
364.....................................           1,636          3.8863               1               1               3               5               8
365.....................................           1,522          7.8160               2               3               5              10              18
366.....................................           4,653          6.2102               1               3               4               8              13
367.....................................             414          2.9928               1               1               2               4               6
368.....................................           4,106          6.5933               2               3               5               8              13

[[Page 25068]]

 
369.....................................           3,621          3.1188               1               1               2               4               6
370.....................................           2,353          5.2660               2               3               4               5               8
371.....................................           2,785          3.4032               2               3               3               4               5
372.....................................           1,443          3.2467               2               2               3               3               4
373.....................................           5,236          2.3067               1               2               2               3               3
374.....................................             119          2.8824               1               2               2               3               5
375.....................................              10          5.8000               2               3               4               8               9
376.....................................             492          3.5691               1               2               2               4               7
377.....................................              86          5.7326               1               2               3               7              12
378.....................................             178          2.0674               1               1               2               3               3
379.....................................             489          2.7607               1               1               2               3               5
380.....................................             107          2.6449               1               1               1               2               4
381.....................................             181          2.7017               1               1               1               2               6
382.....................................              47          2.7021               1               1               1               1               2
383.....................................           3,004          3.8129               1               1               3               4               7
384.....................................             125          2.7920               1               1               1               2               5
386.....................................               1         65.0000              65              65              65              65              65
389.....................................               1          7.0000               7               7               7               7               7
390.....................................               7          1.2857               1               1               1               1               2
392.....................................           1,925          9.1771               2               4               6              11              20
394.....................................           2,690          6.9978               1               2               5               9              15
395.....................................         101,460          4.0582               1               2               3               5               8
396.....................................              15          3.0667               1               2               2               3               6
397.....................................          15,074          5.1932               1               2               4               7              11
398.....................................           6,358          5.2378               1               2               4               7              10
399.....................................             975          3.1241               1               2               2               4               6
401.....................................           6,310         11.0125               2               5               9              14              22
402.....................................           1,179          3.9763               1               1               3               5               8
403.....................................          30,542          7.8445               2               3               6              10              16
404.....................................           3,385          4.0148               1               2               3               5               8
406.....................................           2,200          9.6227               2               4               7              12              20
407.....................................             552          3.4094               1               2               3               4               7
408.....................................           1,906          8.5661               1               2               5              11              20
409.....................................           1,500          5.9887               1               3               4               6              13
410.....................................          27,864          3.7178               1               2               3               4               6
411.....................................               3          5.0000               1               1               2              12              12
412.....................................               8          3.0000               1               1               2               5               5
413.....................................           4,888          6.6970               2               3               5               8              14
414.....................................             445          3.6584               1               2               3               4               7
417.....................................              34          6.3235               1               2               4               7              14
418.....................................          29,239          5.9953               2               3               5               7              11
419.....................................          17,140          4.2593               1               2               3               5               8
420.....................................           2,658          3.0865               1               2               3               4               6
421.....................................          11,406          4.0990               1               2               3               5               8
422.....................................              54          3.4815               1               2               3               4               7
423.....................................           8,780          8.1794               2               3               6              10              17
424.....................................             968         11.1746               1               4               8              14              24
425.....................................          10,497          3.2223               1               1               2               4               6
426.....................................           4,577          4.1534               1               2               3               5               8
427.....................................           1,656          4.4771               1               2               3               5               8
428.....................................             786          7.4288               1               2               4               8              16
429.....................................          21,621          5.3979               2               3               4               6              10
430.....................................          77,784          7.5960               2               3               6               9              15
431.....................................             376          5.8963               1               2               4               6              11
432.....................................             424          4.5825               1               2               3               5               8
433.....................................           4,480          2.9406               1               1               2               3               6
439.....................................           1,739          8.8902               1               3               5               9              17
440.....................................           4,793          8.1083               2               3               5               9              17
441.....................................             745          3.2725               1               1               2               4               7
442.....................................          18,713          8.6001               2               3               6              10              18
443.....................................           3,247          3.3760               1               1               3               4               7
444.....................................           5,714          4.0441               1               2               3               5               8
445.....................................           2,057          2.6719               1               1               2               3               5
446.....................................               1          1.0000               1               1               1               1               1
447.....................................           6,286          2.5021               1               1               2               3               5
449.....................................          42,005          3.6920               1               1               3               4               7
450.....................................           7,022          1.9939               1               1               1               2               4
451.....................................               2          4.0000               2               2               6               6               6
452.....................................          29,335          4.8062               1               2               3               6              10
453.....................................           5,041          2.8252               1               1               2               3               5

[[Page 25069]]

 
454.....................................           4,454          4.0624               1               2               3               5               8
455.....................................             763          2.4862               1               1               2               3               5
461.....................................           2,190          5.6918               1               2               4               7              13
462.....................................           8,257          9.4810               4               6               8              11              16
463.....................................          33,398          3.8312               1               2               3               5               7
464.....................................           7,481          2.9051               1               1               2               4               5
465.....................................             189          3.1746               1               1               2               4               6
466.....................................           1,029          4.0049               1               1               2               4               8
467.....................................             990          3.7434               1               1               2               3               6
468.....................................          51,687         12.1152               3               6              10              15              24
471.....................................          15,315          4.5714               3               3               4               5               7
473.....................................           8,258         11.7129               2               3               6              15              31
476.....................................           2,607          9.4941               2               4               8              13              19
477.....................................          26,467          8.6280               1               3               7              11              18
479.....................................          28,424          2.2886               1               1               1               3               5
480.....................................             914         19.3184               6               9              13              23              42
481.....................................           1,237         21.5618              12              16              20              24              32
482.....................................           4,697         11.1901               4               6               8              13              21
484.....................................             446         12.2825               2               6              10              16              23
485.....................................           3,720          9.4664               4               5               7              11              18
486.....................................           2,710         12.6207               2               6              10              16              25
487.....................................           4,989          6.7019               1               3               5               8              13
488.....................................             830         17.0000               4               7              13              21              35
489.....................................          13,468          8.2464               2               3               6              10              17
490.....................................           4,959          5.2503               1               2               4               6              10
491.....................................          23,713          3.0033               1               2               2               3               5
492.....................................           3,909         13.6723               3               5               6              23              32
493.....................................          60,142          5.9490               2               3               5               8              11
494.....................................          22,403          2.7073               1               1               2               4               5
495.....................................             363         17.3251               8              10              14              20              29
496.....................................           4,220          8.4123               3               4               6              10              17
497.....................................          32,341          5.5152               3               3               4               6               9
498.....................................          21,707          3.5698               2               3               3               4               6
499.....................................          34,248          4.0122               1               2               3               5               8
500.....................................          44,035          2.1007               1               1               2               3               4
501.....................................           3,031          9.3817               4               5               7              11              17
502.....................................             688          5.4230               2               3               5               7               9
503.....................................           5,421          3.8493               1               2               3               5               7
504.....................................             182         28.9670               9              15              25              40              54
505.....................................             155          5.9097               1               1               2               6              14
506.....................................             980         14.7245               3               7              12              19              29
507.....................................             274          7.3869               1               3               6              11              15
508.....................................             557          7.3878               2               3               5               9              14
509.....................................             137          4.5766               1               2               3               5              10
510.....................................           1,681          6.0684               1               2               4               7              13
511.....................................             498          3.8313               1               1               3               5               8
512.....................................             560         11.8982               6               7               9              13              20
513.....................................             177         10.2486               6               7               9              12              16
515.....................................          57,719          3.5718               1               1               1               4               9
518.....................................          24,896          2.4103               1               1               1               3               5
519.....................................          13,824          4.5428               1               1               2               6              11
520.....................................          17,200          1.8812               1               1               1               2               4
521.....................................          30,284          5.3526               2               3               4               6              10
522.....................................           3,408         10.4745               3               5               8              14              21
523.....................................          13,997          3.7162               1               2               3               4               6
524.....................................         103,803          3.0689               1               2               3               4               6
525.....................................             150         11.9600               1               2               6              15              34
528.....................................           1,710         16.5509               5               9              15              22              29
529.....................................           5,094          6.8828               1               2               4               9              16
530.....................................           3,221          2.8712               1               1               2               3               5
531.....................................           5,251          9.2400               2               3               7              12              19
532.....................................           2,973          3.6266               1               1               3               5               7
533.....................................          40,452          3.5306               1               1               2               4               8
534.....................................          34,384          1.6709               1               1               1               2               3
535.....................................           8,642          8.7836               2               4               7              11              17
536.....................................           7,797          7.1789               2               3               6               9              14
537.....................................           9,423          6.5040               1               3               5               8              13
538.....................................           5,014          2.8957               1               1               2               4               6
539.....................................           4,747         10.5886               2               3               7              14              23
540.....................................           1,406          3.3940               1               1               2               4               7

[[Page 25070]]

 
541.....................................          24,001         40.4864              16              23              34              49              72
542.....................................          21,753         29.2444              11              17              24              36              51
543.....................................           5,669         11.3277               2               4               9              16              23
544.....................................         440,451          4.3239               3               3               4               5               7
545.....................................          43,688          5.0764               3               3               4               6               8
546.....................................           3,558          7.8111               3               4               6               9              15
547.....................................          29,673         12.1403               6               8              10              14              20
548.....................................          26,417          8.6920               5               6               8              10              13
549.....................................          12,901         10.1190               5               6               8              12              18
550.....................................          29,627          6.6683               4               5               6               8              10
551.....................................          51,141          6.0806               1               2               5               8              12
552.....................................          78,452          3.3411               1               1               2               4               7
553.....................................          44,355          8.8636               1               3               7              12              19
554.....................................          77,753          5.1191               1               2               3               7              11
555.....................................          37,647          4.6506               1               2               3               6              10
556.....................................          17,813          1.9014               1               1               1               2               4
557.....................................         128,804          3.9579               1               2               3               5               8
558.....................................         184,255          1.7491               1               1               1               2               3
559.....................................           4,814          6.8467               2               4               5               8              13
560.....................................           3,365          9.9964               3               5               8              13              19
561.....................................           2,944          9.4440               3               5               8              12              18
562.....................................          52,768          4.7011               1               2               4               6               9
563.....................................          19,974          3.1487               1               2               3               4               6
564.....................................          16,370          3.3764               1               2               3               4               6
565.....................................          46,197         14.9311               6               9              13              18              26
566.....................................          79,447          7.2748               1               3               6              10              14
567.....................................           9,976         15.6049               6               8              12              19              29
568.....................................          16,065         11.0504               2               5               9              14              22
569.....................................          58,700         14.1940               5               8              12              18              26
570.....................................          68,714          9.8921               4               6               8              12              18
571.....................................          10,974          4.8136               2               2               4               6               9
572.....................................          54,656          6.9428               2               4               5               8              13
573.....................................           6,467         10.8919               4               6               8              12              20
574.....................................          27,588          5.7540               2               3               4               7              11
575.....................................          13,709         15.2387               6               8              13              19              27
576.....................................         295,836          7.0992               2               3               6               9              14
577.....................................          11,072          2.3475               1               1               1               2               5
578.....................................          38,795         15.6194               5               8              12              19              29
579.....................................          19,756         10.6732               3               5               8              13              22
                                              11,663,472
--------------------------------------------------------------------------------------------------------------------------------------------------------


      Table 7B.--Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 2006 MedPAR Update--December 2006 Grouper V25.0 MS-DRGs
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                             Number of      Arithmetic         10th            25th            50th            75th            90th
                   DRG                      discharges       mean LOS       percentile      percentile      percentile      percentile      percentile
--------------------------------------------------------------------------------------------------------------------------------------------------------
1.......................................             628         43.9968              10              17              32              56              92
2.......................................             329         22.7173               8              10              15              27              46
3.......................................          24,007         40.4921              16              23              34              49              72
4.......................................          21,748         29.2363              11              17              24              36              51
5.......................................             842         22.5713               7              10              16              28              50
6.......................................             495          9.9717               5               7               9              11              16
7.......................................             413         17.3123               8              10              14              20              29
8.......................................             560         11.8982               6               7               9              13              20
9.......................................           1,359         21.7454              10              15              20              24              33
10......................................             177         10.2486               6               7               9              12              16
11......................................           1,290         16.1558               6               8              13              19              28
12......................................           1,923         10.9111               4               6               9              13              19
13......................................           1,484          7.2352               3               4               7               9              12
20......................................             901         19.1088               6              11              18              25              34
21......................................             558         15.5430               7              10              14              20              26
22......................................             251          9.6096               3               5               9              13              17
23......................................           3,113         13.5888               3               6              11              19              27
24......................................           2,576          8.5901               1               3               7              12              18
25......................................           8,419         13.3480               4               7              11              17              25
26......................................          11,628          8.2665               3               4               7              11              15
27......................................          14,459          4.6581               1               2               4               6               9
28......................................           1,611         14.6629               4               7              11              18              28

[[Page 25071]]

 
29......................................           2,862          7.6530               2               4               6              10              15
30......................................           3,751          3.6726               1               1               3               5               7
31......................................           1,058         13.1361               3               5              10              18              26
32......................................           2,989          5.7969               1               2               4               7              13
33......................................           4,270          3.0745               1               1               2               4               6
34......................................             814          7.2715               1               2               5              10              15
35......................................           2,510          3.0351               1               1               2               4               7
36......................................           7,748          1.6075               1               1               1               2               3
37......................................           4,777          8.6847               2               3               7              11              18
38......................................          14,603          3.8074               1               1               2               5               9
39......................................          55,391          1.8575               1               1               1               2               3
40......................................           4,549         13.5997               4               6              10              17              26
41......................................           7,720          7.4211               2               4               6               9              14
42......................................           5,430          3.6440               1               1               2               5               8
52......................................           1,156          6.6678               2               3               5               8              13
53......................................             593          3.9949               1               2               3               5               8
54......................................           4,665          7.2223               2               3               5               9              14
55......................................          16,902          5.0128               1               2               4               6              10
56......................................           7,719          7.8009               2               4               6               9              15
57......................................          48,453          4.9236               2               3               4               6               9
58......................................             789          8.0279               2               4               6               9              16
59......................................           2,640          5.2098               2               3               4               6               9
60......................................           4,205          4.0587               2               2               4               5               7
61......................................           1,340          9.7060               3               5               8              12              19
62......................................           2,289          6.3451               3               4               5               8              11
63......................................           1,185          4.5823               2               3               4               6               8
64......................................          55,567          7.6787               2               4               6              10              15
65......................................         112,235          5.3134               2               3               4               7              10
66......................................          94,622          3.7946               1               2               3               5               7
67......................................           1,383          6.2133               2               3               5               8              12
68......................................          12,397          3.5843               1               2               3               5               7
69......................................         103,803          3.0689               1               2               3               4               6
70......................................           7,093          7.9026               2               4               6              10              15
71......................................          10,005          5.6338               2               3               5               7              10
72......................................           6,061          3.7703               1               2               3               5               7
73......................................           8,660          6.4130               2               3               5               8              13
74......................................          32,536          4.3661               1               2               4               5               8
75......................................           1,197          7.6115               3               4               6              10              14
76......................................             874          4.2128               2               2               3               5               8
77......................................           1,101          7.1599               2               3               6               9              14
78......................................           1,307          4.5792               2               2               4               6               8
79......................................             958          3.5282               1               2               3               4               6
80......................................           2,077          4.8681               1               2               4               6               9
81......................................           8,192          3.4143               1               2               3               4               6
82......................................           1,646          6.3991               1               1               4               9              15
83......................................           1,941          5.2849               1               2               4               7              10
84......................................           2,592          3.1154               1               1               2               4               6
85......................................           5,330          7.9328               2               3               6              10              16
86......................................          10,385          5.1475               1               3               4               7              10
87......................................          12,156          3.3901               1               2               3               4               6
88......................................             717          6.1046               1               3               4               7              12
89......................................           2,641          3.7830               1               2               3               5               7
90......................................           3,319          2.4760               1               1               2               3               5
91......................................           6,678          6.5861               2               3               5               8              13
92......................................          14,897          4.4665               1               2               4               6               8
93......................................          15,489          3.2219               1               2               3               4               6
94......................................           1,521         12.4938               4               7              11              16              23
95......................................           1,089          9.1726               3               5               8              12              16
96......................................             755          6.1536               2               3               5               8              11
97......................................           1,253         11.8164               4               6              10              16              22
98......................................           1,048          8.5334               3               5               7              11              15
99......................................             643          6.3048               2               3               6               8              11
100.....................................          15,840          6.2835               2               3               5               8              13
101.....................................          56,927          3.7154               1               2               3               5               7
102.....................................           1,352          5.0473               1               2               4               6              10
103.....................................          15,025          3.2255               1               2               3               4               6
113.....................................             568          5.6039               1               2               4               7              12
114.....................................             603          2.6982               1               1               2               3               6
115.....................................           1,098          4.4791               1               2               4               5               9
116.....................................             665          3.4602               1               1               2               4               8

[[Page 25072]]

 
117.....................................           1,401          1.9807               1               1               1               2               4
121.....................................             587          5.8245               2               3               5               7              11
122.....................................             674          4.0727               1               2               3               5               8
123.....................................           2,846          2.9301               1               2               2               4               5
124.....................................             679          5.2901               1               2               4               7              11
125.....................................           4,708          3.4904               1               2               3               4               7
129.....................................           1,374          5.0786               1               2               4               6              10
130.....................................           1,075          3.1795               1               1               2               4               6
131.....................................             655          5.6260               1               2               4               7              11
132.....................................             728          2.5742               1               1               2               3               5
133.....................................           1,352          6.3750               1               2               4               8              14
134.....................................           2,662          2.3020               1               1               1               3               5
135.....................................             781          6.0948               1               2               4               8              13
136.....................................           1,115          2.3193               1               1               1               3               5
137.....................................           1,109          5.4238               1               2               4               7              11
138.....................................           1,372          2.4249               1               1               2               3               5
139.....................................           2,150          1.8805               1               1               1               2               3
146.....................................             687         10.2227               2               4               7              13              20
147.....................................           1,422          5.7771               1               2               4               7              12
148.....................................             935          3.4963               1               1               2               5               7
149.....................................          39,254          2.7302               1               1               2               3               5
150.....................................             939          5.4494               1               2               4               7              11
151.....................................           6,804          2.8933               1               1               2               4               5
152.....................................           2,352          4.6947               1               2               4               6               9
153.....................................          16,031          3.3617               1               2               3               4               6
154.....................................           1,843          6.4704               2               3               5               8              12
155.....................................           4,208          4.5696               1               2               4               6               9
156.....................................           5,143          3.1808               1               2               3               4               6
157.....................................           1,145          6.9092               2               3               5               9              14
158.....................................           3,039          4.4659               1               2               3               6               9
159.....................................           2,418          3.0790               1               1               2               4               6
163.....................................          13,433         14.9768               5               8              13              19              27
164.....................................          18,051          8.3639               3               5               7              10              15
165.....................................          14,557          5.3898               2               3               5               7               9
166.....................................          20,293         13.0059               4               7              10              16              24
167.....................................          20,775          8.1439               3               4               7              10              15
168.....................................           5,758          5.4139               1               2               5               7              10
175.....................................          11,958          7.4075               3               4               6               9              13
176.....................................          40,184          5.5095               2               4               5               7               9
177.....................................          57,194          9.1881               3               5               8              12              17
178.....................................          71,205          7.4692               3               4               6               9              14
179.....................................          27,468          5.6397               2               3               5               7              10
180.....................................          22,478          7.9687               2               4               7              10              15
181.....................................          32,170          5.9642               2               3               5               8              12
182.....................................           6,167          4.2701               1               2               3               6               8
183.....................................           1,654          7.1826               2               4               6               9              14
184.....................................           4,141          4.6450               2               3               4               6               8
185.....................................           2,593          3.2815               1               2               3               4               6
186.....................................           8,534          7.5378               2               4               6              10              14
187.....................................           9,970          5.4881               2               3               4               7              11
188.....................................           5,151          4.1561               1               2               3               5               8
189.....................................         104,581          6.2368               2               3               5               8              12
190.....................................          57,046          6.4788               2               3               5               8              12
191.....................................         121,674          5.1201               2               3               4               6               9
192.....................................         196,930          4.0420               2               2               3               5               7
193.....................................          88,072          6.8766               2               4               6               9              13
194.....................................         266,642          5.3586               2               3               5               7               9
195.....................................         147,775          4.1514               2               2               4               5               7
196.....................................           5,143          7.3502               2               4               6               9              14
197.....................................           6,895          5.4181               2               3               5               7              10
198.....................................           4,944          4.2945               1               2               4               5               8
199.....................................           3,258          8.4936               3               4               7              11              16
200.....................................           8,186          5.1467               1               2               4               7              10
201.....................................           3,523          4.1198               1               2               3               5               8
202.....................................          31,594          4.5021               2               2               4               6               8
203.....................................          41,595          3.4745               1               2               3               4               6
204.....................................          26,048          2.8805               1               1               2               4               6
205.....................................           5,777          5.6382               1               3               4               7              11
206.....................................          22,421          3.4891               1               2               3               4               7
207.....................................          46,195         14.9298               6               9              13              18              26

[[Page 25073]]

 
208.....................................          79,446          7.2748               1               3               6              10              14
215.....................................             150         11.9600               1               2               6              15              34
216.....................................           8,411         18.6918               8              11              16              23              32
217.....................................           7,610         12.3029               6               8              11              15              20
218.....................................           3,256          9.1198               5               6               8              11              14
219.....................................          10,063         14.4558               6               8              11              18              27
220.....................................          13,483          8.6970               5               6               7              10              14
221.....................................           8,389          6.4682               4               5               6               7              10
222.....................................           2,869         13.2426               5               7              11              17              24
223.....................................           5,773          6.5676               1               3               6               9              13
224.....................................           1,920         11.5104               4               6               9              14              22
225.....................................           5,877          5.7638               2               3               5               7              11
226.....................................           7,049          9.3723               1               3               8              13              19
227.....................................          50,670          2.7649               1               1               1               3               7
228.....................................           3,087         14.6317               6               8              12              18              26
229.....................................           4,130          9.1191               4               6               8              11              15
230.....................................           1,989          6.6435               3               4               6               8              11
231.....................................           1,478         13.2104               5               7              11              16              24
232.....................................           1,795          9.0067               5               6               8              11              14
233.....................................          16,914         14.2938               7               9              12              17              24
234.....................................          39,176          8.8853               5               6               8              11              13
235.....................................           9,630         11.4974               5               7               9              14              21
236.....................................          32,898          6.6079               4               5               6               8              10
237.....................................          21,792         11.4604               2               5               9              15              23
238.....................................          44,932          4.8672               1               2               4               7              10
239.....................................          13,821         15.5449               5               8              12              19              29
240.....................................          13,355         10.5939               4               6               8              13              20
241.....................................           3,350          7.0236               3               4               6               9              13
242.....................................          17,182          8.9305               3               4               7              11              17
243.....................................          37,874          5.1880               1               2               4               7              10
244.....................................          68,296          2.9635               1               1               2               4               6
245.....................................           6,241          3.3249               1               1               2               4               8
246.....................................          32,667          6.3103               1               2               5               8              13
247.....................................         280,392          2.2324               1               1               1               3               5
248.....................................           5,013          6.5163               1               3               5               9              13
249.....................................          29,674          2.5339               1               1               2               3               5
250.....................................           5,740          7.5240               1               3               6              10              15
251.....................................          39,929          2.9531               1               1               2               4               6
252.....................................          44,611          8.7554               1               3               6              12              19
253.....................................          46,868          6.2739               1               2               5               8              13
254.....................................          59,053          2.9056               1               1               2               4               6
255.....................................           2,609          9.9279               2               4               8              13              19
256.....................................           3,833          7.5458               2               4               6              10              14
257.....................................             774          4.9922               1               2               4               7              10
258.....................................             598          7.5769               2               3               6              10              15
259.....................................           7,342          2.6350               1               1               2               3               6
260.....................................             867         10.1753               2               4               8              13              20
261.....................................           2,804          3.9675               1               1               3               5               8
262.....................................           3,383          2.4830               1               1               2               3               5
263.....................................             788          5.5063               1               1               4               8              12
264.....................................          30,138          9.0102               1               3               6              12              19
280.....................................          60,743          7.4498               2               4               6               9              14
281.....................................          57,742          4.9623               2               3               4               6               9
282.....................................          60,961          3.2953               1               2               3               4               6
283.....................................          15,856          5.4845               1               1               3               7              13
284.....................................           4,912          3.4770               1               1               2               4               8
285.....................................           3,256          2.2752               1               1               1               3               5
286.....................................          23,286          7.0619               2               3               6               9              14
287.....................................         172,575          3.1957               1               1               2               4               6
288.....................................           3,248         12.2155               4               7              10              15              23
289.....................................           1,423          8.7850               3               5               7              11              15
290.....................................             485          6.6536               2               4               6               8              12
291.....................................         183,811          6.6240               2               3               5               8              13
292.....................................         217,099          5.0937               2               3               4               6               9
293.....................................         226,747          3.7248               1               2               3               5               7
294.....................................           1,705          5.5666               2               3               5               7               9
295.....................................           1,658          4.3878               2               3               4               6               7
296.....................................           1,732          3.3256               1               1               1               4               8
297.....................................             945          1.9725               1               1               1               2               4
298.....................................             556          1.4568               1               1               1               1               2

[[Page 25074]]

 
299.....................................          17,445          6.8633               2               3               6               9              13
300.....................................          46,825          5.1739               2               3               4               7               9
301.....................................          39,928          3.7906               1               2               3               5               7
302.....................................           7,876          4.3526               1               2               3               5               9
303.....................................          81,505          2.5488               1               1               2               3               5
304.....................................           2,087          5.2386               1               2               4               7              10
305.....................................          35,655          2.8710               1               1               2               4               5
306.....................................           1,379          6.4141               2               3               5               8              12
307.....................................           6,451          3.4999               1               2               3               4               7
308.....................................          33,533          5.7559               1               3               4               7              11
309.....................................          79,767          3.9679               1               2               3               5               7
310.....................................         160,781          2.7683               1               1               2               4               5
311.....................................          24,872          2.3395               1               1               2               3               4
312.....................................         169,277          3.1499               1               2               3               4               6
313.....................................         220,824          2.1144               1               1               2               3               4
314.....................................          60,079          7.1189               2               3               5               9              14
315.....................................          30,738          4.6782               1               2               4               6               9
316.....................................          20,111          3.0454               1               1               2               4               6
326.....................................          11,568         17.2235               6               9              14              22              32
327.....................................          10,903         10.3403               3               6               9              13              19
328.....................................           9,334          4.6128               1               2               3               6               9
329.....................................          48,146         15.8920               6               9              13              20              29
330.....................................          66,316          9.8949               4               6               8              12              17
331.....................................          31,408          6.1136               3               4               5               7              10
332.....................................           1,891         14.7361               6               8              12              18              26
333.....................................           6,198          8.9923               4               6               8              11              15
334.....................................           4,023          5.7062               2               4               5               7               9
335.....................................           7,164         14.3626               6               8              12              18              25
336.....................................          12,520          9.3056               3               5               8              12              16
337.....................................           8,839          5.6987               2               3               5               8              11
338.....................................           1,500         10.8567               4               6               9              14              19
339.....................................           3,195          7.1894               3               4               6               9              12
340.....................................           3,608          4.2783               2               2               4               6               7
341.....................................             874          7.2563               2               3               5              10              15
342.....................................           2,537          4.3532               1               2               3               6               8
343.....................................           6,882          2.2819               1               1               2               3               4
344.....................................             899         12.0445               4               6               9              15              23
345.....................................           2,917          7.3318               3               4               6               9              13
346.....................................           2,909          5.0248               2               3               5               6               8
347.....................................           1,568          8.3412               2               4               7              11              16
348.....................................           3,986          5.5738               1               2               4               7              11
349.....................................           5,789          3.1036               1               1               2               4               6
350.....................................           1,669          8.0617               2               4               7              11              16
351.....................................           3,998          4.6791               1               2               4               6               9
352.....................................           8,429          2.4582               1               1               2               3               5
353.....................................           3,184          8.7148               2               4               7              11              17
354.....................................           9,129          5.0778               1               3               4               7               9
355.....................................          17,461          2.8775               1               1               2               4               5
356.....................................           8,367         13.2579               3               6              10              17              26
357.....................................           8,046          8.1130               2               4               7              10              16
358.....................................           2,716          4.7128               1               2               4               6               9
368.....................................           3,052          6.6432               2               3               5               8              13
369.....................................           4,006          4.7791               2               3               4               6               9
370.....................................           3,916          3.4229               1               2               3               4               6
371.....................................          16,846          8.7684               3               4               7              11              17
372.....................................          22,911          6.8602               3               4               6               8              13
373.....................................          14,899          5.0055               2               3               4               6               9
374.....................................           9,417          8.8178               2               4               7              11              17
375.....................................          19,736          6.0537               2               3               5               8              12
376.....................................           4,820          4.1102               1               2               3               5               8
377.....................................          50,521          6.4758               2               3               5               8              12
378.....................................          84,839          4.7121               2               3               4               6               8
379.....................................         128,807          3.5255               1               2               3               4               6
380.....................................           2,917          7.2129               2               4               5               9              14
381.....................................           4,895          5.3263               2               3               4               7              10
382.....................................           5,446          3.6430               1               2               3               5               6
383.....................................           1,303          5.8496               2               3               5               7              11
384.....................................           8,672          3.8546               1               2               3               5               7
385.....................................           2,107          9.0128               3               4               7              11              18
386.....................................           7,223          5.7597               2               3               5               7              11

[[Page 25075]]

 
387.....................................           5,233          4.4323               2               2               4               6               8
388.....................................          18,272          7.4310               2               3               6               9              15
389.....................................          46,336          5.0762               2               3               4               6               9
390.....................................          48,061          3.5994               1               2               3               5               6
391.....................................          47,516          5.4690               2               2               4               7              11
392.....................................         306,603          3.5476               1               2               3               4               7
393.....................................          23,924          6.9569               2               3               5               9              14
394.....................................          45,966          4.9372               1               2               4               6               9
395.....................................          26,474          3.4027               1               2               3               4               6
405.....................................           3,903         17.3051               5               8              13              22              34
406.....................................           5,246          9.5141               2               5               8              12              18
407.....................................           2,310          5.6078               1               3               5               7              10
408.....................................           1,645         14.8182               5               8              12              19              27
409.....................................           1,713          9.9440               4               6               8              12              18
410.....................................             722          6.8172               3               4               6               8              11
411.....................................             978         13.0276               5               7              11              16              23
412.....................................           1,063          8.8579               4               5               8              11              15
413.....................................             882          6.0907               2               4               5               8              11
414.....................................           5,599         11.8391               5               7              10              15              21
415.....................................           6,852          7.7478               3               5               7              10              13
416.....................................           6,228          4.9045               2               3               4               6               8
417.....................................          16,677          8.4020               3               4               7              10              16
418.....................................          27,572          5.6679               2               3               5               7              10
419.....................................          38,296          3.1868               1               1               3               4               6
420.....................................             714         14.0126               3               6              11              18              27
421.....................................           1,091          7.8570               2               3               6              10              16
422.....................................             364          4.4615               1               2               4               6               8
423.....................................           1,501         15.3911               4               7              12              19              29
424.....................................             912         10.2664               3               5               8              13              20
425.....................................             157          5.8790               2               3               5               8              11
432.....................................          16,264          6.8549               2               3               5               8              14
433.....................................           9,022          4.8422               1               2               4               6               9
434.....................................             946          3.5888               1               2               3               5               7
435.....................................          11,915          7.6726               2               3               6              10              15
436.....................................          13,991          5.8723               2               3               5               8              11
437.....................................           4,359          4.3595               1               2               3               6               9
438.....................................          14,432          7.7379               2               3               6              10              16
439.....................................          24,824          5.4652               2               3               4               7              10
440.....................................          27,361          3.8783               1               2               3               5               7
441.....................................          13,922          6.9813               2               3               5               9              14
442.....................................          12,759          5.1323               2               3               4               6              10
443.....................................           6,703          3.8532               1               2               3               5               7
444.....................................          12,453          6.6271               2               3               5               8              13
445.....................................          16,759          4.8121               2               2               4               6               9
446.....................................          16,857          3.3299               1               2               3               4               6
453.....................................             846         15.8995               6               8              13              20              28
454.....................................           1,497          8.6306               3               5               7              11              16
455.....................................           1,877          4.8636               2               3               4               6               8
456.....................................             765         15.6693               5               7              12              19              30
457.....................................           1,764          8.2874               3               5               7              10              15
458.....................................           1,535          4.7466               2               3               4               6               7
459.....................................           3,183          9.6183               4               5               7              11              18
460.....................................          50,358          4.3516               2               3               4               5               7
461.....................................           1,062          8.3606               4               5               7              10              15
462.....................................          14,253          4.2891               3               3               4               5               7
463.....................................           5,285         16.7069               5               7              12              21              33
464.....................................           6,322         10.3945               3               5               8              13              20
465.....................................           2,942          6.3606               2               3               5               8              12
466.....................................           4,153          9.5538               4               5               7              11              18
467.....................................          10,821          6.0700               3               4               5               7              10
468.....................................          28,714          4.0543               2               3               4               5               6
469.....................................          29,744          8.4430               4               5               7              10              15
470.....................................         410,707          4.0256               3               3               4               4               6
471.....................................           2,229         10.0983               2               4               8              13              20
472.....................................           6,221          4.3728               1               1               3               6              10
473.....................................          22,573          2.0132               1               1               1               2               4
474.....................................           2,831         12.4822               4               6              10              16              24
475.....................................           3,533          8.6575               3               4               7              11              16
476.....................................           1,698          5.0683               1               2               4               7              10
477.....................................           2,257         12.5109               4               6              10              15              23

[[Page 25076]]

 
478.....................................           7,144          6.9120               1               3               6               9              14
479.....................................          10,271          2.8762               1               1               1               4               7
480.....................................          25,882          9.4645               4               6               8              11              17
481.....................................          59,159          6.2065               3               4               5               7              10
482.....................................          64,819          4.9470               3               4               5               6               7
483.....................................           5,732          4.5700               2               2               3               6               9
484.....................................          17,981          2.5039               1               2               2               3               4
485.....................................             968         12.6715               5               7              10              15              23
486.....................................           1,536          8.3665               3               5               7              10              15
487.....................................           1,215          5.8025               3               4               5               7              10
488.....................................           1,552          5.6746               2               3               4               7              11
489.....................................           3,869          3.1171               1               2               3               4               6
490.....................................          19,809          4.8572               1               2               3               6              10
491.....................................          58,474          2.2865               1               1               2               3               4
492.....................................           4,704          8.7245               3               5               7              11              16
493.....................................          15,253          5.3926               2               3               4               7               9
494.....................................          30,588          3.4237               1               2               3               4               6
495.....................................           1,867         11.0664               3               5               9              14              21
496.....................................           5,049          6.0594               1               3               5               8              12
497.....................................           7,520          3.2645               1               1               2               4               7
498.....................................           1,177          8.4274               2               3               6              11              16
499.....................................           1,246          3.2584               1               1               3               4               6
500.....................................           1,349         11.1979               3               5               8              14              22
501.....................................           3,679          6.0294               2               3               5               8              12
502.....................................           6,829          2.9776               1               1               2               4               6
503.....................................             736          8.8628               3               4               7              11              17
504.....................................           2,155          6.5225               2               3               5               8              12
505.....................................           3,218          3.4058               1               2               3               4               7
506.....................................             909          3.2288               1               1               2               4               7
507.....................................             779          5.3286               1               2               4               7              11
508.....................................           2,723          2.0525               1               1               2               2               4
509.....................................             465          2.9441               1               1               2               3               7
510.....................................             957          6.6029               2               3               5               8              12
511.....................................           4,009          3.8735               1               2               3               5               7
512.....................................          11,982          2.1194               1               1               2               3               4
513.....................................           1,288          5.1250               1               2               4               7              10
514.....................................           1,341          2.6346               1               1               2               3               5
515.....................................           3,577         10.8784               3               5               9              14              20
516.....................................          10,964          6.0369               1               3               5               8              12
517.....................................          18,272          2.9365               1               1               2               4               7
533.....................................             829          6.9035               2               3               5               9              13
534.....................................           3,635          4.0083               1               2               3               5               7
535.....................................           6,844          6.3819               2               3               5               8              12
536.....................................          34,330          3.9729               1               3               3               5               7
537.....................................             654          4.7156               2               3               4               6               9
538.....................................           1,164          3.1357               1               2               3               4               5
539.....................................           3,382         10.1730               3               5               8              12              19
540.....................................           4,190          7.2535               3               4               6               9              13
541.....................................           1,858          5.6416               2               3               5               7              10
542.....................................           6,162          8.6883               3               4               7              11              17
543.....................................          18,418          5.9972               2               3               5               7              11
544.....................................          12,645          4.4837               2               3               4               6               8
545.....................................           4,019          9.0109               2               4               7              11              18
546.....................................           5,885          5.5694               2               3               4               7              10
547.....................................           4,888          3.9544               1               2               3               5               7
548.....................................             592          9.3125               3               4               7              11              17
549.....................................           1,078          6.3163               2               3               5               8              12
550.....................................             905          4.5271               1               3               4               6               8
551.....................................           9,504          7.2317               2               3               6               9              14
552.....................................          87,884          4.1777               1               2               3               5               8
553.....................................           2,793          6.0859               2               3               5               8              11
554.....................................          20,263          3.7237               1               2               3               5               7
555.....................................           1,995          4.9133               1               2               4               6              10
556.....................................          19,173          3.1840               1               2               3               4               6
557.....................................           3,184          6.9416               2               4               6               8              13
558.....................................          14,180          4.2641               2               3               4               5               7
559.....................................           1,635          7.2765               2               3               5               9              14
560.....................................           3,979          4.8030               1               2               4               6               9
561.....................................           7,618          2.7569               1               1               2               3               5
562.....................................           5,000          6.5032               2               3               5               8              12

[[Page 25077]]

 
563.....................................          36,060          3.7152               1               2               3               4               6
564.....................................           1,607          7.1413               2               3               6               9              14
565.....................................           3,238          5.1115               2               3               4               7               9
566.....................................           2,780          3.7737               1               2               3               5               7
573.....................................           5,688         13.7773               4               6              10              16              28
574.....................................          12,103          9.4910               3               5               7              11              18
575.....................................           6,469          6.0077               2               3               5               7              11
576.....................................             558         12.1505               2               4               8              15              26
577.....................................           2,179          6.0069               1               2               4               8              13
578.....................................           3,299          3.4826               1               1               2               4               7
579.....................................           3,088         11.4058               3               5               9              14              22
580.....................................           6,767          7.2707               2               3               6               9              14
581.....................................           5,290          4.0115               1               2               3               5               8
582.....................................           8,978          2.7738               1               1               2               3               5
583.....................................          15,578          1.7536               1               1               1               2               3
584.....................................           1,431          4.5206               1               1               2               6              11
585.....................................           2,821          1.9018               1               1               1               2               4
592.....................................           3,984          8.8542               3               4               7              11              17
593.....................................          12,834          6.5156               2               4               5               8              12
594.....................................           2,955          4.9005               2               3               4               6               9
595.....................................           1,083          8.1782               2               4               6              10              16
596.....................................           5,756          4.8211               2               2               4               6               9
597.....................................             549          8.0729               2               3               6              10              16
598.....................................           1,483          5.6109               2               3               4               7              11
599.....................................             350          3.5914               1               1               3               5               8
600.....................................             572          5.4143               2               3               4               7              10
601.....................................             865          3.8335               1               2               3               5               7
602.....................................          21,315          7.0332               2               4               6               9              13
603.....................................         130,955          4.7383               2               3               4               6               8
604.....................................           2,627          5.4328               1               3               4               7              11
605.....................................          22,678          3.4824               1               2               3               4               6
606.....................................           1,363          5.8782               1               2               4               7              12
607.....................................           7,169          3.7576               1               2               3               5               7
614.....................................           1,377          7.3682               2               3               5               9              15
615.....................................           1,626          3.3911               1               2               3               4               6
616.....................................           1,133         15.5119               6               8              13              19              27
617.....................................           6,824          9.0098               3               5               8              12              16
618.....................................             343          6.4781               2               3               6               8              12
619.....................................             663          9.2926               3               4               6              10              21
620.....................................           1,878          4.2572               2               2               3               5               7
621.....................................           6,561          2.4476               1               1               2               3               4
622.....................................           1,234         13.1118               4               6               9              16              27
623.....................................           3,269          8.7641               3               5               7              10              16
624.....................................             488          5.9529               2               3               5               7              11
625.....................................           1,099          7.5332               2               3               5               9              17
626.....................................           2,523          3.3096               1               1               2               4               7
627.....................................          14,337          1.5601               1               1               1               2               2
628.....................................           3,267         11.7410               2               4               8              15              24
629.....................................           3,958          8.9277               3               5               7              11              16
630.....................................             684          5.4883               1               2               4               7              11
637.....................................          16,290          6.1765               2               3               5               7              12
638.....................................          40,817          4.4088               1               2               4               6               8
639.....................................          41,142          3.1006               1               2               3               4               6
640.....................................          55,697          5.6186               1               2               4               7              11
641.....................................         188,150          3.8620               1               2               3               5               7
642.....................................           1,544          5.2448               1               2               4               6              10
643.....................................           5,019          7.7675               2               4               6              10              15
644.....................................          11,848          5.4716               2               3               4               7              10
645.....................................           8,406          3.9222               1               2               3               5               7
652.....................................          10,439          7.9171               4               5               6               9              14
653.....................................           1,585         16.7584               7               9              13              20              31
654.....................................           3,231         10.1619               5               7               9              12              17
655.....................................           1,651          6.6887               3               4               7               8              10
656.....................................           3,721         10.7788               4               5               8              13              21
657.....................................           7,360          6.1595               3               4               5               7              10
658.....................................           8,484          3.8944               2               3               4               5               6
659.....................................           4,442         11.3197               3               5               8              14              23
660.....................................           7,446          6.6108               2               3               5               8              13
661.....................................           4,749          3.5475               1               2               3               4               7
662.....................................             988         10.4686               2               4               8              14              21

[[Page 25078]]

 
663.....................................           2,131          5.2407               1               2               4               7              11
664.....................................           4,677          2.1760               1               1               1               2               4
665.....................................             690         12.1942               3               6              10              15              22
666.....................................           2,213          6.3448               1               2               4               9              14
667.....................................           3,951          2.8697               1               1               2               3               6
668.....................................           3,757          8.6191               2               4               7              11              17
669.....................................          12,494          4.3597               1               2               3               6               9
670.....................................          13,418          2.5885               1               1               2               3               6
671.....................................             884          5.7896               1               2               4               8              12
672.....................................             965          2.5990               1               1               2               3               5
673.....................................          12,578         10.1248               1               3               7              13              22
674.....................................          10,504          7.2773               1               2               5              10              16
675.....................................          11,707          2.5849               1               1               1               3               6
682.....................................          75,855          7.2988               2               3               6               9              15
683.....................................         112,156          5.8525               2               3               5               7              11
684.....................................          43,471          4.0578               1               2               3               5               7
685.....................................           2,498          3.5020               1               1               2               4               7
686.....................................           1,582          8.0493               2               4               6              10              15
687.....................................           3,322          5.3058               1               3               4               7              10
688.....................................           1,198          3.3222               1               1               3               4               6
689.....................................          55,402          6.3745               2               3               5               8              12
690.....................................         200,093          4.3011               2               2               4               5               8
691.....................................             898          4.1648               1               2               3               5               9
692.....................................             655          2.2580               1               1               2               3               4
693.....................................           2,235          5.2098               1               2               4               7              10
694.....................................          19,221          2.5735               1               1               2               3               5
695.....................................             975          5.7323               2               3               4               7              12
696.....................................          10,566          3.2277               1               2               3               4               6
697.....................................             575          3.2835               1               1               2               4               6
698.....................................          21,065          6.7737               2               3               5               8              13
699.....................................          22,826          5.0096               1               2               4               6              10
700.....................................          15,094          3.6045               1               2               3               5               7
707.....................................           4,875          4.8568               2               2               4               6               9
708.....................................          17,032          2.4324               1               1               2               3               4
709.....................................             755          6.6715               1               2               4               8              15
710.....................................           2,037          1.8949               1               1               1               2               3
711.....................................             922          7.9469               1               3               6              10              16
712.....................................             819          3.0024               1               1               2               4               7
713.....................................          11,760          4.1367               1               2               3               5               9
714.....................................          32,760          2.0154               1               1               2               2               3
715.....................................             638          6.1661               1               2               4               8              14
716.....................................           1,389          1.5227               1               1               1               1               2
717.....................................             635          7.6567               1               3               5              10              16
718.....................................             633          2.7994               1               1               2               4               5
722.....................................             871          7.4409               2               3               6               9              14
723.....................................           2,038          5.4328               2               3               4               7              10
724.....................................             666          3.3498               1               1               3               4               7
725.....................................             802          5.6160               2               3               4               7              11
726.....................................           3,941          3.5202               1               2               3               4               7
727.....................................           1,098          6.5556               2               3               5               8              12
728.....................................           6,177          4.0570               1               2               3               5               7
729.....................................             578          5.1488               1               2               4               7              10
730.....................................             552          3.2591               1               1               2               4               6
734.....................................           1,470          7.7129               3               4               5               9              15
735.....................................           1,329          3.5056               1               2               3               4               6
736.....................................             840         13.8619               5               8              12              18              25
737.....................................           3,429          7.4278               3               4               6               9              13
738.....................................             955          3.9874               2               3               4               5               6
739.....................................             975         10.2318               4               5               7              13              20
740.....................................           4,370          5.2190               2               3               4               6               9
741.....................................           6,562          3.1617               2               2               3               4               5
742.....................................          10,709          4.7158               2               2               3               5               9
743.....................................          35,368          2.3568               1               2               2               3               4
744.....................................           1,498          5.9012               1               2               4               7              12
745.....................................           2,194          2.6135               1               1               2               3               5
746.....................................           2,487          4.2059               1               2               3               5               8
747.....................................          11,231          1.9232               1               1               2               2               3
748.....................................          21,201          1.8026               1               1               1               2               3
749.....................................           1,038          9.9075               2               4               7              13              21
750.....................................             484          3.3306               1               2               3               4               6

[[Page 25079]]

 
754.....................................           1,083          8.8144               2               4               7              11              19
755.....................................           3,152          5.6551               1               3               4               7              11
756.....................................             832          3.3221               1               1               3               4               7
757.....................................           1,323          8.9131               3               4               7              11              17
758.....................................           1,597          6.1327               2               3               5               8              11
759.....................................           1,186          4.6256               2               2               4               6               8
760.....................................           1,703          3.8227               1               2               3               5               7
761.....................................           1,918          2.4937               1               1               2               3               5
765.....................................           2,501          5.3215               2               3               4               5               8
766.....................................           2,637          3.2461               2               2               3               4               4
767.....................................             119          2.8824               1               2               2               3               5
768.....................................              10          5.8000               2               3               4               8               9
769.....................................              86          5.7326               1               2               3               7              12
770.....................................             181          2.7017               1               1               1               2               6
774.....................................           1,443          3.2467               2               2               3               3               4
775.....................................           5,236          2.3067               1               2               2               3               3
776.....................................             492          3.5691               1               2               2               4               7
777.....................................             178          2.0674               1               1               2               3               3
778.....................................             489          2.7607               1               1               2               3               5
779.....................................             107          2.6449               1               1               1               2               4
780.....................................              47          2.7021               1               1               1               1               2
781.....................................           3,004          3.8129               1               1               3               4               7
782.....................................             125          2.7920               1               1               1               2               5
790.....................................               1         65.0000              65              65              65              65              65
793.....................................               1          7.0000               7               7               7               7               7
794.....................................               7          1.2857               1               1               1               1               2
799.....................................             623         14.2472               4               7              11              19              28
800.....................................             700          8.3700               3               4               6              11              17
801.....................................             602          4.8688               2               2               4               6               9
802.....................................             692         12.9538               3               6              10              16              26
803.....................................           1,004          6.5787               1               3               5               8              13
804.....................................             996          3.3203               1               1               2               4               7
808.....................................           8,316          7.9752               2               4               6              10              15
809.....................................          15,532          5.0147               2               2               4               6               9
810.....................................           3,819          3.9296               1               2               3               5               7
811.....................................          18,353          5.5474               1               2               4               7              11
812.....................................          83,122          3.7292               1               2               3               5               7
813.....................................          15,074          5.1932               1               2               4               7              11
814.....................................           1,631          7.1594               2               3               5               9              15
815.....................................           3,340          4.9177               2               2               4               6               9
816.....................................           2,359          3.4349               1               2               3               4               7
820.....................................           1,481         18.3849               5               8              14              24              37
821.....................................           2,530          7.8375               1               3               6              10              16
822.....................................           2,142          3.7250               1               1               3               5               8
823.....................................           2,437         15.3943               5               8              13              20              28
824.....................................           3,039          8.8427               2               4               7              12              17
825.....................................           2,010          4.7866               1               2               3               7              10
826.....................................             562         17.3488               5               8              13              21              34
827.....................................           1,318          7.6115               2               4               6               9              15
828.....................................             872          3.7500               1               2               3               5               7
829.....................................           1,375         10.4611               2               4               7              14              23
830.....................................             531          3.6591               1               1               2               4               8
834.....................................           5,260         14.6249               2               4               9              23              35
835.....................................           1,469          8.2178               1               3               5               9              20
836.....................................           1,526          5.0125               1               2               3               6              10
837.....................................           1,624         22.6558               5               9              23              30              39
838.....................................             900          9.2122               3               4               5               7              25
839.....................................           1,385          6.0368               3               4               5               6               8
840.....................................          15,155          9.5956               2               4               7              12              20
841.....................................          11,017          6.6239               2               3               5               8              13
842.....................................           7,682          4.2890               1               2               3               6               8
843.....................................           1,477          8.7204               2               4               7              11              17
844.....................................           2,856          6.0007               2               3               5               8              12
845.....................................           1,008          4.3065               1               2               3               6               9
846.....................................           2,481          8.4869               2               3               5              10              19
847.....................................          23,676          3.2722               1               2               3               4               6
848.....................................           1,701          2.9259               1               1               2               4               5
849.....................................           1,500          5.9887               1               3               4               6              13
853.....................................          31,446         16.7084               5               8              13              21              31
854.....................................           6,882         11.1935               4               6               9              14              20

[[Page 25080]]

 
855.....................................             467          7.5096               2               4               6              10              14
856.....................................           6,188         16.1577               5               7              12              20              32
857.....................................          10,066          8.8965               3               4               7              11              17
858.....................................           3,502          6.0888               2               3               5               7              11
862.....................................           7,426          8.2665               2               4               6              10              16
863.....................................          21,813          5.2222               2               3               4               7               9
864.....................................          19,829          4.0996               1               2               3               5               8
865.....................................           2,019          6.8366               2               3               5               8              15
866.....................................           9,410          3.5129               1               2               3               4               6
867.....................................           5,307          9.9354               3               4               7              13              20
868.....................................           2,371          6.0017               2               3               5               7              11
869.....................................           1,101          4.3697               2               2               4               5               8
870.....................................          13,711         15.2393               6               8              13              19              27
871.....................................         203,725          7.6898               2               4               6              10              15
872.....................................          92,141          5.7923               2               3               5               7              10
876.....................................             968         11.1746               1               4               8              14              24
880.....................................          10,497          3.2223               1               1               2               4               6
881.....................................           4,577          4.1534               1               2               3               5               8
882.....................................           1,656          4.4771               1               2               3               5               8
883.....................................             786          7.4288               1               2               4               8              16
884.....................................          21,621          5.3979               2               3               4               6              10
885.....................................          77,784          7.5960               2               3               6               9              15
886.....................................             376          5.8963               1               2               4               6              11
887.....................................             424          4.5825               1               2               3               5               8
894.....................................           4,480          2.9406               1               1               2               3               6
895.....................................           6,477         10.4868               3               5               8              14              21
896.....................................           5,372          6.6035               2               3               5               8              13
897.....................................          35,839          4.0848               1               2               3               5               7
901.....................................             917         14.4275               3               5               9              17              30
902.....................................           2,136          8.0108               2               3               6              10              16
903.....................................           1,740          4.8977               1               2               4               6              10
904.....................................             941         12.3528               2               4               7              14              22
905.....................................             798          4.8070               1               2               4               6               9
906.....................................             745          3.2725               1               1               2               4               7
907.....................................           8,101         11.6595               3               5               8              14              24
908.....................................           7,885          7.0411               2               3               5               9              14
909.....................................           5,974          3.6696               1               2               3               5               7
913.....................................             813          6.0873               2               3               5               8              12
914.....................................           6,959          3.3993               1               2               3               4               6
915.....................................             915          4.6120               1               2               3               6              10
916.....................................           5,370          2.1391               1               1               2               3               4
917.....................................          14,156          5.2280               1               2               4               6              11
918.....................................          34,873          2.7266               1               1               2               3               5
919.....................................          10,570          6.2364               1               3               4               8              13
920.....................................          12,143          4.4851               1               2               3               6               9
921.....................................          11,663          2.9882               1               1               2               4               6
922.....................................           1,005          6.0836               1               2               4               8              14
923.....................................           4,212          3.2946               1               1               2               4               6
927.....................................             182         28.9670               9              15              25              40              54
928.....................................             795         16.1975               4               8              14              20              31
929.....................................             459          7.7930               2               3               6              11              16
933.....................................             155          5.9097               1               1               2               6              14
934.....................................             694          6.8329               1               3               5               8              14
935.....................................           2,179          5.5571               1               2               4               7              12
939.....................................             423         10.9622               2               4               8              14              22
940.....................................             690          6.4580               1               3               5               8              14
941.....................................           1,077          3.1309               1               1               2               4               6
945.....................................           5,058         10.5042               4               6               9              13              19
946.....................................           3,199          7.8634               4               5               7               9              12
947.....................................           6,546          4.9904               1               2               4               6              10
948.....................................          34,333          3.4084               1               2               3               4               6
949.....................................             742          4.1631               1               1               2               5               8
950.....................................             476          3.4286               1               1               2               4               6
951.....................................             990          3.7434               1               1               2               3               6
955.....................................             446         12.2825               2               6              10              16              23
956.....................................           3,720          9.4664               4               5               7              11              18
957.....................................           1,157         16.7398               3               8              14              21              31
958.....................................             737         11.5875               3               6              10              14              21
959.....................................             816          7.7132               1               4               6              10              15
963.....................................           1,395          9.4803               1               4               8              13              19

[[Page 25081]]

 
964.....................................           1,578          6.8054               2               4               6               9              12
965.....................................           2,016          4.6984               1               3               4               6               9
969.....................................             598         19.0033               5               8              14              24              38
970.....................................             231         11.7965               2               5               8              15              25
974.....................................           7,276          9.3487               2               4               7              12              20
975.....................................           3,463          8.0323               2               3               6              10              16
976.....................................           2,729          5.5790               2               3               4               7              11
977.....................................           4,874          5.2154               1               2               4               6              10
981.....................................          26,287         15.2524               5               8              12              19              28
982.....................................          18,597         10.0533               3               5               8              13              19
983.....................................           6,767          5.5626               1               2               5               7              11
984.....................................             669         14.6114               5               8              13              18              27
985.....................................           1,048          9.8559               2               5               9              13              18
986.....................................             890          5.2213               1               2               4               8              11
987.....................................           8,037         13.1528               4               6              11              17              25
988.....................................          11,880          7.9806               2               4               7              10              15
989.....................................           6,538          4.2389               1               1               3               6               9
                                              11,663,472
--------------------------------------------------------------------------------------------------------------------------------------------------------


 Table 8A.--Proposed Statewide Average Operating Cost-to-Charge Ratios--
                               March 2007
------------------------------------------------------------------------
                       State                          Urban      Rural
------------------------------------------------------------------------
Alabama...........................................       0.26       0.34
Alaska............................................       0.42      0.714
Arizona...........................................       0.28       0.43
Arkansas..........................................      0.332      0.353
California........................................       0.23       0.33
Colorado..........................................      0.302      0.446
Connecticut.......................................      0.417      0.502
Delaware..........................................      0.496      0.462
District of Columbia..............................      0.351  .........
Florida...........................................      0.246      0.288
Georgia...........................................      0.341      0.392
Hawaii............................................       0.37      0.444
Idaho.............................................       0.47      0.565
Illinois..........................................      0.319      0.403
Indiana...........................................      0.411      0.447
Iowa..............................................      0.374      0.455
Kansas............................................      0.296      0.441
Kentucky..........................................      0.379      0.375
Louisiana.........................................      0.307      0.355
Maine.............................................      0.495      0.466
Maryland..........................................      0.732      0.799
Massachusetts.....................................       0.48  .........
Michigan..........................................      0.371      0.467
Minnesota.........................................      0.385      0.526
Mississippi.......................................      0.317      0.369
Missouri..........................................      0.329      0.372
Montana...........................................      0.431       0.49
Nebraska..........................................      0.363      0.457
Nevada............................................      0.224      0.483
New Hampshire.....................................      0.456      0.443
New Jersey........................................      0.183  .........
New Mexico........................................      0.379      0.386
New York..........................................      0.358      0.523
North Carolina....................................      0.434      0.414
North Dakota......................................      0.443      0.467
Ohio..............................................      0.361      0.534
Oklahoma..........................................      0.308      0.394
Oregon............................................      0.467       0.42
Pennsylvania......................................      0.275      0.436
Puerto Rico.......................................      0.452  .........
Rhode Island......................................      0.394  .........
South Carolina....................................      0.284      0.317
South Dakota......................................      0.352      0.442
Tennessee.........................................      0.316      0.379
Texas.............................................      0.271      0.348
Utah..............................................      0.418      0.571
Vermont...........................................       0.54      0.637
Virginia..........................................      0.363       0.37
Washington........................................      0.401      0.447
West Virginia.....................................      0.484      0.474
Wisconsin.........................................      0.425      0.476
Wyoming...........................................      0.431       0.53
------------------------------------------------------------------------


  Table 8B.--Proposed Statewide Average Capital Cost-to-Charge Ratios--
                               March 2007
------------------------------------------------------------------------
                            State                                Ratio
------------------------------------------------------------------------
Alabama......................................................      0.025
Alaska.......................................................      0.039
Arizona......................................................      0.024
Arkansas.....................................................      0.025
California...................................................      0.016
Colorado.....................................................      0.029
Connecticut..................................................      0.028
Delaware.....................................................      0.036
District of Columbia.........................................      0.025
Florida......................................................      0.023
Georgia......................................................      0.029
Hawaii.......................................................      0.032
Idaho........................................................       0.04
Illinois.....................................................      0.026
Indiana......................................................      0.037
Iowa.........................................................      0.028
Kansas.......................................................       0.03
Kentucky.....................................................      0.029
Louisiana....................................................       0.03
Maine........................................................      0.033
Maryland.....................................................      0.055
Massachusetts................................................      0.032
Michigan.....................................................       0.03
Minnesota....................................................      0.028
Mississippi..................................................      0.028
Missouri.....................................................      0.027
Montana......................................................      0.036
Nebraska.....................................................      0.038
Nevada.......................................................      0.023
New Hampshire................................................      0.034
New Jersey...................................................      0.013
New Mexico...................................................      0.032
New York.....................................................      0.029
North Carolina...............................................      0.036
North Dakota.................................................       0.04
Ohio.........................................................      0.029
Oklahoma.....................................................      0.029
Oregon.......................................................      0.032
Pennsylvania.................................................      0.023
Puerto Rico..................................................      0.035
Rhode Island.................................................      0.021
South Carolina...............................................      0.025
South Dakota.................................................      0.033
Tennessee....................................................      0.031
Texas........................................................      0.027
Utah.........................................................      0.037
Vermont......................................................      0.042
Virginia.....................................................      0.037
Washington...................................................      0.031
West Virginia................................................      0.033
Wisconsin....................................................      0.039
Wyoming......................................................      0.044
------------------------------------------------------------------------


  Table 8C.--Proposed Statewide Average Total Cost-to-Charge Ratios for
                            LTCHS--March 2007
------------------------------------------------------------------------
                       State                          Urban      Rural
------------------------------------------------------------------------
Alabama...........................................      0.283      0.372
Alaska............................................      0.453      0.776
Arizona...........................................      0.305      0.465
Arkansas..........................................      0.355      0.383
California........................................      0.244      0.351
Colorado..........................................      0.329      0.491
Connecticut.......................................      0.445      0.543
Delaware..........................................      0.532      0.504

[[Page 25082]]

 
District of Columbia *............................      0.376  .........
Florida...........................................      0.269       0.32
Georgia...........................................      0.369      0.427
Hawaii............................................        0.4      0.482
Idaho.............................................      0.509      0.609
Illinois..........................................      0.344      0.436
Indiana...........................................      0.448      0.493
Iowa..............................................      0.398      0.496
Kansas............................................      0.323      0.482
Kentucky..........................................      0.408      0.405
Louisiana.........................................      0.337      0.385
Maine.............................................       0.53      0.495
Maryland **.......................................      0.445      0.351
Massachusetts *...................................      0.512  .........
Michigan..........................................        0.4      0.503
Minnesota.........................................      0.412      0.564
Mississippi.......................................      0.344      0.398
Missouri..........................................      0.354      0.406
Montana...........................................      0.463      0.533
Nebraska..........................................      0.398      0.504
Nevada............................................      0.246      0.549
New Hampshire.....................................      0.491      0.475
New Jersey *......................................      0.196  .........
New Mexico........................................      0.412      0.417
New York..........................................      0.387       0.56
North Carolina....................................       0.47      0.449
North Dakota......................................       0.48      0.515
Ohio..............................................      0.388      0.575
Oklahoma..........................................      0.336      0.425
Oregon............................................        0.5      0.451
Pennsylvania......................................      0.295      0.469
Puerto Rico *.....................................      0.487  .........
Rhode Island *....................................      0.415  .........
South Carolina....................................      0.309      0.344
South Dakota......................................      0.381      0.481
Tennessee.........................................      0.346      0.413
Texas.............................................      0.297      0.379
Utah..............................................      0.454      0.627
Vermont...........................................      0.584      0.676
Virginia..........................................        0.4      0.408
Washington........................................      0.432       0.48
West Virginia.....................................      0.517      0.507
Wisconsin.........................................      0.464      0.516
Wyoming...........................................      0.466     0.583
------------------------------------------------------------------------
* All counties in the State or Territory are classified as urban, with
  the exception of Massachusetts, which has areas designated as rural.
  However, no short-term acute care IPPS hospitals or LTCHs are located
  in those areas as of March 2007.
**National average IPPS total cost-to-charge ratios, as discussed in
  section VI.E. of this proposed rule.


                        Table 9A.--Hospital Reclassifications and Redesignations--FY 2008
----------------------------------------------------------------------------------------------------------------
                                                                Reclassified
               Provider No.                  Geographic CBSA        CBSA                      LUGAR
----------------------------------------------------------------------------------------------------------------
010005....................................                01             26620  ................................
010009....................................             19460             26620  ................................
010010....................................                01             13820  ................................
010012....................................                01             40660  ................................
010022....................................                01             12060  LUGAR
010025....................................                01             17980  ................................
010029....................................             12220             17980  ................................
010035....................................                01             13820  ................................
010044....................................                01             13820  ................................
010045....................................                01             13820  ................................
010054....................................             19460             26620  ................................
010059....................................             19460             26620  ................................
010065....................................                01             13820  ................................
010072....................................                01             11500  LUGAR
010083....................................                01             33660  ................................
010085....................................             19460             26620  ................................
010090....................................             33660             37700  ................................
010100....................................                01             37860  ................................
010101....................................                01             13820  LUGAR
010118....................................                01             46220  ................................
010126....................................                01             33860  ................................
010143....................................                01             13820  ................................
010150....................................                01             33860  ................................
010158....................................                01             19460  ................................
010164....................................                01             11500  LUGAR
020008....................................                02             11260  ................................
030007....................................             39140             22380  LUGAR
030033....................................                03             22380  ................................
030055....................................             29420             39140  ................................
030101....................................             29420             29820  ................................
040014....................................                04             30780  ................................
040017....................................                04             22220  ................................
040019....................................                04             32820  ................................
040020....................................             27860             32820  ................................
040027....................................                04             44180  ................................
040039....................................                04                26  ................................
040041....................................                04             30780  ................................
040069....................................                04             32820  ................................
040071....................................             38220             30780  ................................
040076....................................                04             30780  LUGAR
040078....................................             26300             30780  ................................
040080....................................                04             27860  ................................
040085....................................                04             32820  ................................
040088....................................                04             33740  ................................
040091....................................                04             45500  ................................

[[Page 25083]]

 
040100....................................                04             30780  ................................
040119....................................                04             30780  ................................
050006....................................                05             39820  ................................
050009....................................             34900             46700  ................................
050013....................................             34900             46700  ................................
050014....................................                05             40900  ................................
050022....................................             40140             42044  ................................
050042....................................                05             39820  ................................
050046....................................             37100             31084  ................................
050054....................................             40140             42044  ................................
050065....................................             42044             31084  ................................
050069....................................             42044             31084  ................................
050071....................................             41940             36084  ................................
050073....................................             46700             36084  ................................
050076....................................             41884             36084  ................................
050082....................................             37100             31084  ................................
050089....................................             40140             31084  ................................
050090....................................             42220             41884  ................................
050099....................................             40140             31084  ................................
050101....................................             46700             36084  ................................
050102....................................             40140             42044  ................................
050118....................................             44700             33700  ................................
050129....................................             40140             31084  ................................
050133....................................             49700             40900  ................................
050136....................................             42220             41884  ................................
050140....................................             40140             31084  ................................
050150....................................                05              0900  ................................
050159....................................             37100             31084  ................................
050168....................................             42044             31084  ................................
050173....................................             42044             31084  ................................
050174....................................             42220             41884  ................................
050193....................................             42044             31084  ................................
050194....................................             42100             41940  ................................
050197....................................             41884             36084  ................................
050224....................................             42044             31084  ................................
050226....................................             42044             31084  ................................
050230....................................             42044             31084  ................................
050236....................................             37100             31084  ................................
050242....................................             42100             41940  ................................
050243....................................             40140             42044  ................................
050245....................................             40140             31084  ................................
050272....................................             40140             31084  ................................
050279....................................             40140             31084  ................................
050291....................................             42220             41884  ................................
050292....................................             40140             42044  ................................
050298....................................             40140             31084  ................................
050300....................................             40140             31084  ................................
050301....................................                05             42220  ................................
050327....................................             40140             31084  ................................
050329....................................             40140             42044  ................................
050348....................................             42044             31084  ................................
050367....................................             46700             36084  ................................
050385....................................             42220             41884  ................................
050390....................................             40140             42044  ................................
050394....................................             37100             31084  ................................
050423....................................             40140             42044  ................................
050426....................................             42044             31084  ................................
050476....................................                05             42220  ................................
050494....................................                05             40900  ................................
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  ................................
050549....................................             37100             31084  ................................
050550....................................             42044             31084  ................................
050551....................................             42044             31084  ................................

[[Page 25084]]

 
050567....................................             42044             31084  ................................
050570....................................             42044             31084  ................................
050573....................................             40140             42044  ................................
050580....................................             42044             31084  ................................
050584....................................             40140             31084  ................................
050585....................................             42044             31084  ................................
050586....................................             40140             31084  ................................
050589....................................             42044             31084  ................................
050592....................................             42044             31084  ................................
050594....................................             42044             31084  ................................
050603....................................             42044             31084  ................................
050609....................................             42044             31084  ................................
050616....................................             37100             31084  ................................
050667....................................             34900             46700  ................................
050678....................................             42044             31084  ................................
050680....................................             46700             36084  ................................
050684....................................             40140             42044  ................................
050686....................................             40140             42044  ................................
050690....................................             42220             41884  ................................
050693....................................             42044             31084  ................................
050694....................................             40140             42044  ................................
050701....................................             40140             42044  ................................
050709....................................             40140             31084  ................................
050714....................................             42100             41940  ................................
050718....................................             40140             42044  ................................
050720....................................             42044             31084  ................................
050749....................................             37100             31084  ................................
060001....................................             24540             19740  ................................
060003....................................             14500             19740  ................................
060023....................................             24300             19740  ................................
060027....................................             14500             19740  ................................
060049....................................                06             22660  ................................
060075....................................                06             24300  ................................
060096....................................                06             19740  ................................
060103....................................             14500             19740  ................................
060116....................................             14500             19740  ................................
070001....................................             35300             35004  ................................
070003....................................                07             25540  LUGAR
070005....................................             35300             35004  ................................
070006....................................             14860             35644  ................................
070010....................................             14860             35644  ................................
070015....................................             25540             35644  ................................
070016....................................             35300             35004  ................................
070017....................................             35300             35004  ................................
070018....................................             14860             35644  ................................
070019....................................             35300             35004  ................................
070022....................................             35300             35004  ................................
070028....................................             14860             35644  ................................
070031....................................             35300             35004  ................................
070033....................................             14860             35644  ................................
070034....................................             14860             35644  ................................
070036....................................             25540             35300  ................................
070038....................................             35300             35004  ................................
070039....................................             35300             35004  ................................
080001....................................             48864             37964  ................................
080003....................................             48864             37964  ................................
080004....................................             20100             48864  ................................
080006....................................                08             20100  ................................
080007....................................                08             36140  ................................
090011....................................             47894             13644  ................................
100002....................................             48424             22744  ................................
100014....................................             19660             36740  ................................
100017....................................             19660             36740  ................................
100022....................................             33124             22744  ................................
100023....................................                10             36740  ................................
100024....................................                10             33124  ................................
100045....................................             19660             36740  ................................
100047....................................             39460             42260  ................................
100049....................................                10             29460  ................................
100068....................................             19660             36740  ................................
100072....................................             19660             36740  ................................

[[Page 25085]]

 
100077....................................             39460             42260  ................................
100080....................................             48424             22744  ................................
100081....................................                10             23020  LUGAR
100105....................................             42680             38940  ................................
100109....................................                10             36740  ................................
100118....................................             37380             27260  ................................
100130....................................             48424             22744  ................................
100139....................................                10             23540  LUGAR
100150....................................                10             33124  ................................
100156....................................                10             23540  ................................
100157....................................             29460             45300  ................................
100168....................................             48424             22744  ................................
100176....................................             48424             22744  ................................
100217....................................             42680             38940  ................................
100232....................................                10             23540  ................................
100234....................................             48424             22744  ................................
100236....................................             39460             42260  ................................
100239....................................             45300             42260  ................................
100249....................................                10             45300  ................................
100252....................................                10             42680  ................................
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100275....................................             48424             22744  ................................
100287....................................             48424             22744  ................................
100288....................................             48424             22744  ................................
100292....................................                10             23020  LUGAR
110002....................................                11             12060  ................................
110016....................................                11             17980  ................................
110023....................................                11             12060  ................................
110029....................................             23580             12060  ................................
110038....................................                11             45220  ................................
110040....................................                11             12060  LUGAR
110041....................................                11             12060  ................................
110052....................................                11             16860  LUGAR
110054....................................             40660             12060  ................................
110069....................................             47580             31420  ................................
110075....................................                11             42340  ................................
110088....................................                11             12060  LUGAR
110095....................................                11             10500  ................................
110117....................................                11             12060  LUGAR
110121....................................                11             45220  ................................
110122....................................             46660             45220  ................................
110125....................................                11             31420  ................................
110128....................................                11             42340  ................................
110146....................................                11             27260  ................................
110150....................................                11             12060  ................................
110153....................................             47580             31420  ................................
110168....................................             40660             12060  ................................
110187....................................                11             12060  LUGAR
110189....................................                11             12060  ................................
120028....................................                12             26180  ................................
130002....................................                13                29  ................................
130003....................................             30300             28420  ................................
130018....................................             26820             38540  ................................
130049....................................             17660             44060  ................................
130067....................................                13             26820  LUGAR
140010....................................             16974             16974  ................................
140012....................................                14             16974  ................................
140015....................................                14             41180  ................................
140032....................................                14             41180  ................................
140033....................................             29404             16974  ................................
140034....................................                14             41180  ................................
140040....................................                14             37900  ................................
140043....................................                14             19340  ................................
140046....................................                14             41180  ................................
140058....................................                14             41180  ................................
140064....................................                14             37900  ................................
140084....................................             29404             16974  ................................
140100....................................             29404             16974  ................................

[[Page 25086]]

 
140110....................................                14             16974  ................................
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140161....................................                14             16974  ................................
140164....................................                14             41180  ................................
140186....................................             28100             16974  ................................
140202....................................             29404             16974  ................................
140233....................................             40420             16974  ................................
140236....................................                14             28100  LUGAR
140291....................................             29404             16974  ................................
150002....................................             23844             16974  ................................
150004....................................             23844             16974  ................................
150006....................................             33140             43780  ................................
150008....................................             23844             16974  ................................
150011....................................                15             26900  ................................
150018....................................             21140             43780  ................................
150026....................................             21140             43780  ................................
150030....................................                15             26900  LUGAR
150034....................................             23844             16974  ................................
150042....................................                15             14020  ................................
150045....................................                15             23060  ................................
150048....................................                15             17140  ................................
150051....................................             14020             26900  ................................
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150076....................................                15             43780  ................................
150088....................................             11300             26900  ................................
150090....................................             23844             16974  ................................
150091....................................                15             23060  ................................
150102....................................                15             23844  LUGAR
150112....................................             18020             26900  ................................
150113....................................             11300             26900  ................................
150115....................................                15             21780  ................................
150122....................................                15             26900  ................................
150125....................................             23844             16974  ................................
150126....................................             23844             16974  ................................
150133....................................                15             23060  ................................
150146....................................                15             23060  ................................
150147....................................             23844             16974  ................................
160001....................................                16             11180  ................................
160016....................................                16             11180  ................................
160057....................................                16             26980  ................................
160064....................................                16             47940  ................................
160080....................................                16             19340  ................................
160089....................................                16             26980  ................................
160147....................................                16             11180  ................................
170006....................................                17             27900  ................................
170012....................................                17             48620  ................................
170013....................................                17             48620  ................................
170020....................................                17             48620  ................................
170023....................................                17             48620  ................................
170033....................................                17             48620  ................................
170058....................................                17             28140  ................................
170068....................................                17             11100  ................................
170120....................................                17             27900  ................................
170142....................................                17             45820  ................................
170175....................................                17             48620  ................................
170190....................................                17             45820  ................................
170193....................................                17             48620  ................................
180002....................................                18                49  ................................
180005....................................                18             26580  ................................
180011....................................                18             30460  ................................
180012....................................             21060             31140  ................................
180013....................................             14540             34980  ................................
180017....................................                18             21060  ................................
180019....................................                18             17140  ................................
180024....................................                18             31140  ................................
180027....................................                18             17300  ................................
180029....................................                18             30460  ................................

[[Page 25087]]

 
180044....................................                18             26580  ................................
180048....................................                18             31140  ................................
180049....................................                18             30460  ................................
180050....................................                18             28700  ................................
180066....................................                18             34980  ................................
180069....................................                18             26580  ................................
180075....................................                18             14540  LUGAR
180078....................................                18             26580  ................................
180080....................................                18             28940  ................................
180093....................................                18             21780  ................................
180102....................................                18             17300  ................................
180104....................................                18             17300  ................................
180116....................................                18             17300  ................................
180124....................................             14540             34980  ................................
180127....................................                18             31140  ................................
180132....................................                18             30460  ................................
190003....................................                19             29180  ................................
190015....................................                19             35380  ................................
190086....................................                19             33740  ................................
190088....................................                19             43340  ................................
190099....................................                19             12940  ................................
190106....................................                19             10780  ................................
190144....................................                19             43340  ................................
190155....................................                19             12940  LUGAR
190164....................................                19                45  ................................
190167....................................                19             29180  ................................
190184....................................                19             33740  ................................
190191....................................                19             29180  ................................
190208....................................                19                04  ................................
190218....................................                19             43340  ................................
190223....................................                19             12940  LUGAR
200020....................................             38860             40484  ................................
200024....................................             30340             38860  ................................
200034....................................             30340             38860  ................................
200039....................................                20             38860  ................................
200050....................................                20             12620  ................................
200063....................................                20             38860  ................................
220001....................................             49340             14484  ................................
220002....................................             15764             14484  ................................
220008....................................             39300             14484  ................................
220010....................................             37764             14484  ................................
220011....................................             15764             14484  ................................
220019....................................             49340             14484  ................................
220020....................................             39300             14484  ................................
220025....................................             49340             14484  ................................
220028....................................             49340             14484  ................................
220029....................................             37764             14484  ................................
220033....................................             37764             14484  ................................
220035....................................             37764             14484  ................................
220049....................................             15764             14484  ................................
220058....................................             49340             14484  ................................
220062....................................             49340             14484  ................................
220063....................................             15764             14484  ................................
220070....................................             15764             14484  ................................
220073....................................             39300             14484  ................................
220077....................................             44140             25540  ................................
220080....................................             37764             14484  ................................
220082....................................             15764             14484  ................................
220084....................................             15764             14484  ................................
220090....................................             49340             14484  ................................
220095....................................             49340             14484  ................................
220098....................................             15764             14484  ................................
220101....................................             15764             14484  ................................
220105....................................             15764             14484  ................................
220133....................................             15764             14484  ................................
220163....................................             49340             14484  ................................
220171....................................             15764             14484  ................................
220174....................................             37764             14484  ................................
230002....................................             19804             11460  ................................
230003....................................             26100             34740  ................................
230013....................................             47644             22420  ................................

[[Page 25088]]

 
230019....................................             47644             22420  ................................
230020....................................             19804             11460  ................................
230021....................................             35660             28020  ................................
230022....................................                23             29620  ................................
230024....................................             19804             11460  ................................
230029....................................             47644             22420  ................................
230030....................................                23             40980  ................................
230035....................................                23             24340  LUGAR
230036....................................                23             13020  ................................
230037....................................                23             11460  ................................
230038....................................             24340             34740  ................................
230047....................................             47644             19804  ................................
230053....................................             19804             11460  ................................
230054....................................                23             24580  ................................
230059....................................             24340             34740  ................................
230065....................................             19804             11460  ................................
230069....................................             47644             11460  ................................
230071....................................             47644             22420  ................................
230072....................................             26100             34740  ................................
230077....................................             40980             22420  ................................
230080....................................                23             13020  ................................
230089....................................             19804             11460  ................................
230092....................................             27100             11460  ................................
230096....................................                23             28020  ................................
230097....................................                23             24340  ................................
230099....................................             33780             11460  ................................
230104....................................             19804             11460  ................................
230105....................................                23             13020  ................................
230106....................................             24340             34740  ................................
230119....................................             19804             11460  ................................
230121....................................                23             29620  LUGAR
230130....................................             47644             22420  ................................
230134....................................                23             26100  LUGAR
230135....................................             19804             11460  ................................
230142....................................             19804             11460  ................................
230146....................................             19804             11460  ................................
230151....................................             47644             22420  ................................
230165....................................             19804             11460  ................................
230174....................................             26100             34740  ................................
230176....................................             19804             11460  ................................
230195....................................             47644             19804  ................................
230204....................................             47644             19804  ................................
230207....................................             47644             22420  ................................
230208....................................                23             24340  LUGAR
230217....................................             12980             29620  ................................
230222....................................                23             13020  ................................
230223....................................             47644             22420  ................................
230227....................................             47644             19804  ................................
230236....................................             24340             34740  ................................
230244....................................             19804             11460  ................................
230254....................................             47644             22420  ................................
230257....................................             47644             19804  ................................
230264....................................             47644             19804  ................................
230269....................................             47644             22420  ................................
230270....................................             19804             11460  ................................
230273....................................             19804             11460  ................................
230277....................................             47644             22420  ................................
230279....................................             47644             11460  ................................
230293....................................             19804             11460  ................................
230295....................................                23             26100  LUGAR
240030....................................                24             41060  ................................
240036....................................             41060             33460  ................................
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
240187....................................                24             33460  ................................

[[Page 25089]]

 
250002....................................                25             22520  ................................
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  ................................
250044....................................                25             22520  ................................
250069....................................                25             46220  ................................
250078....................................             25620             25060  ................................
250079....................................                25             27140  ................................
250081....................................                25             46220  ................................
250082....................................                25             38220  ................................
250094....................................             25620             25060  ................................
250097....................................                25             12940  ................................
250099....................................                25             27140  ................................
250100....................................                25             46220  ................................
250104....................................                25             46220  ................................
250117....................................                25             25060  LUGAR
260009....................................                26             28140  ................................
260015....................................                26             27860  ................................
260017....................................                26             27620  ................................
260022....................................                26                16  ................................
260025....................................                26             41180  ................................
260049....................................                26             44180  LUGAR
260050....................................                26             41140  ................................
260064....................................                26             17860  ................................
260074....................................                26             17860  ................................
260094....................................                26             44180  ................................
260110....................................                26             41180  ................................
260113....................................                26                14  ................................
260119....................................                26             27860  ................................
260175....................................                26             28140  ................................
260183....................................                26             41180  ................................
260186....................................                26             27620  ................................
270003....................................                27             24500  ................................
270017....................................                27             33540  ................................
280009....................................                28             30700  ................................
280023....................................                28             30700  ................................
280032....................................                28             30700  ................................
280061....................................                28                53  ................................
280065....................................                28             24540  ................................
280125....................................                28             43580  ................................
290002....................................                29             16180  LUGAR
290006....................................                29             39900  ................................
290008....................................                29             41620  ................................
290019....................................             16180             39900  ................................
300011....................................             31700             15764  ................................
300012....................................             31700             15764  ................................
300014....................................             40484             31700  ................................
300018....................................             40484             31700  ................................
300019....................................                30             15764  ................................
300020....................................             31700             15764  ................................
300034....................................             31700             15764  ................................
310002....................................             35084             35644  ................................
310009....................................             35084             35644  ................................
310013....................................             35084             35644  ................................
310014....................................             15804             37964  ................................
310015....................................             35084             35644  ................................
310017....................................             35084             35644  ................................
310018....................................             35084             35644  ................................
310021....................................             45940             35084  ................................
310031....................................             15804             20764  ................................
310032....................................             47220             48864  ................................
310038....................................             20764             35644  ................................
310039....................................             20764             35644  ................................
310048....................................             20764             35084  ................................
310050....................................             35084             35644  ................................
310054....................................             35084             35644  ................................

[[Page 25090]]

 
310070....................................             20764             35644  ................................
310076....................................             35084             35644  ................................
310081....................................             15804             37964  ................................
310083....................................             35084             35644  ................................
310093....................................             35084             35644  ................................
310096....................................             35084             35644  ................................
310108....................................             20764             35644  ................................
310119....................................             35084             35644  ................................
320003....................................                32             42140  ................................
320005....................................             22140             10740  ................................
320006....................................                32             10740  ................................
320013....................................                32             42140  ................................
320014....................................                32             29740  ................................
320033....................................                32             42140  LUGAR
320063....................................                32             36220  ................................
320065....................................                32             36220  ................................
330004....................................             28740             39100  ................................
330008....................................                33             15380  LUGAR
330023....................................             39100             14860  ................................
330027....................................             35004             35644  ................................
330038....................................                33             40380  LUGAR
330049....................................             39100             14860  ................................
330067....................................             39100             14860  ................................
330073....................................                33             40380  LUGAR
330079....................................                33                47  ................................
330085....................................                33             45060  ................................
330094....................................                33             28740  ................................
330103....................................                33                39  ................................
330106....................................             35004             35644  ................................
330126....................................             39100             35644  ................................
330136....................................                33             45060  ................................
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330167....................................             35004             35644  ................................
330181....................................             35004             35644  ................................
330182....................................             35004             35644  ................................
330191....................................             24020             10580  ................................
330198....................................             35004             35644  ................................
330224....................................             28740             39100  ................................
330225....................................             35004             35644  ................................
330229....................................                33             21500
330235....................................                33             45060  LUGAR
330239....................................                33             21500  ................................
330250....................................                33             15540  ................................
330259....................................             35004             35644  ................................
330277....................................                33             27060  ................................
330331....................................             35004             35644  ................................
330332....................................             35004             35644  ................................
330372....................................             35004             35644  ................................
330386....................................                33             35084  ................................
340004....................................             24660             49180  ................................
340008....................................                34             16740  ................................
340010....................................             24140             39580  ................................
340013....................................                34             16740  ................................
340015....................................                34             16740  ................................
340021....................................                34             16740  ................................
340023....................................             11700             24860  ................................
340027....................................                34             24780  ................................
340039....................................                34             16740  ................................
340050....................................                34             22180  ................................
340051....................................                34             25860  ................................
340068....................................                34             48900  ................................
340069....................................             39580             20500  ................................
340070....................................             15500             24660  ................................
340071....................................                34             39580  LUGAR
340073....................................             39580             20500  ................................
340091....................................             24660             49180  ................................
340109....................................                34             47260  ................................
340114....................................             39580             20500  ................................
340115....................................                34             20500  ................................
340124....................................                34             39580  LUGAR
340126....................................                34             39580  ................................

[[Page 25091]]

 
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  ................................
350003....................................                35             13900  ................................
350006....................................                35             13900  ................................
350009....................................                35             22020  ................................
360008....................................                36             26580  ................................
360010....................................                36             15940  ................................
360011....................................                36             18140  ................................
360013....................................                36             30620  ................................
360014....................................                36             18140  ................................
360019....................................             10420             17460  ................................
360020....................................             10420             17460  ................................
360025....................................             41780             45780  ................................
360027....................................             10420             17460  ................................
360036....................................                36             17460  ................................
360039....................................                36             18140  ................................
360054....................................                36             26580  ................................
360065....................................                36             45780  ................................
360078....................................             10420             17460  ................................
360079....................................             19380             17140  ................................
360084....................................             15940             10420  ................................
360086....................................             44220             19380  ................................
360095....................................                36             45780  ................................
360096....................................                36             49660  LUGAR
360107....................................                36             45780  ................................
360121....................................                36             45780  ................................
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
360253....................................             19380             17140  ................................
370004....................................                37             27900  ................................
370006....................................                37             46140  ................................
370014....................................                37             43300  ................................
370015....................................                37             46140  ................................
370016....................................                37             36420  ................................
370018....................................                37             46140  ................................
370022....................................                37             30020  ................................
370025....................................                37             46140  ................................
370026....................................                37             36420  ................................
370047....................................                37             36420  ................................
370049....................................                37             36420  ................................
370113....................................                37             22220  ................................
370149....................................                37             36420  ................................
380001....................................                38             38900  ................................
380022....................................                38             18700  LUGAR
380027....................................                38             21660  ................................
380050....................................                38             32780  ................................
380090....................................                38             21660  ................................
390006....................................                39             25420  ................................
390013....................................                39             25420  ................................
390016....................................                39                36  ................................
390030....................................                39             10900  ................................
390031....................................                39             39740  LUGAR
390044....................................             39740             37964  ................................
390046....................................             49620             29540  ................................
390048....................................                39             25420  ................................
390065....................................                39             12580  ................................

[[Page 25092]]

 
390066....................................             30140             25420  ................................
390071....................................                39             48700  LUGAR
390079....................................                39             13780  ................................
390081....................................             37964             48864  ................................
390086....................................                39             27780  ................................
390091....................................                39             49660  ................................
390093....................................                39             38300  ................................
390096....................................             39740             37964  ................................
390110....................................             27780             38300  ................................
390113....................................                39             49660  ................................
390133....................................             10900             37964  ................................
390138....................................                39             25420  ................................
390150....................................                39             38300  LUGAR
390151....................................                39             13644  ................................
390156....................................             37964             48864  ................................
390162....................................             10900             35084  ................................
390180....................................             37964             48864  ................................
390222....................................             37964             48864  ................................
390246....................................                39             48700  ................................
390313....................................                39             39740  LUGAR
400048....................................             25020             41980  ................................
410001....................................             39300             14484  ................................
410004....................................             39300             14484  ................................
410005....................................             39300             14484  ................................
410007....................................             39300             14484  ................................
410010....................................             39300             14484  ................................
410011....................................             39300             14484  ................................
410012....................................             39300             14484  ................................
410013....................................             39300             35980  ................................
420007....................................             43900             24860  ................................
420009....................................                42             24860  LUGAR
420020....................................                42             16770  ................................
420027....................................             11340             24860  ................................
420028....................................                42             44940  LUGAR
420030....................................                42             16700  ................................
420036....................................                42             16740  ................................
420039....................................                42             43900  LUGAR
420062....................................                42             16740  ................................
420067....................................                42             42340  ................................
420068....................................                42             16700  ................................
420069....................................                42             44940  LUGAR
420071....................................                42             24860  ................................
420080....................................                42             42340  ................................
420083....................................             43900             24860  ................................
420085....................................             34820             48900  ................................
420098....................................                42             34820  ................................
430012....................................                43             43620  ................................
430013....................................                43             43620  ................................
430014....................................                43             22020  ................................
440002....................................             27180             32820  ................................
440008....................................                44             27180  ................................
440020....................................                44             26620  ................................
440024....................................             17420             16860  ................................
440025....................................                44                34  ................................
440035....................................             17300             34980  ................................
440056....................................             34100             28940  ................................
440060....................................                44             27180  ................................
440067....................................             34100             28700  ................................
440068....................................                44             16860  ................................
440072....................................                44             32820  ................................
440073....................................                44             34980  ................................
440148....................................                44             34980  ................................
440151....................................                44             34980  ................................
440175....................................                44             34980  ................................
440185....................................             17420             16860  ................................
440192....................................                44             34980  ................................
450007....................................                45             41700  ................................
450032....................................                45             43340  ................................
450039....................................             23104             19124  ................................
450059....................................             41700             12420  ................................
450064....................................             23104             19124  ................................

[[Page 25093]]

 
450080....................................                45             30980  ................................
450087....................................             23104             19124  ................................
450099....................................                45             11100  ................................
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450137....................................             23104             19124  ................................
450148....................................             23104             19124  ................................
450178....................................                45             36220  ................................
450187....................................                45             26420  ................................
450196....................................                45             19124  ................................
450211....................................                45             30980  ................................
450214....................................                45             26420  ................................
450224....................................                45             46340  ................................
450283....................................                45             19124  LUGAR
450286....................................                45             17780  LUGAR
450324....................................             43300             19124  ................................
450347....................................                45             26420  ................................
450351....................................                45             23104  ................................
450389....................................                45             19124  LUGAR
450393....................................             43300             19124  ................................
450395....................................                45             26420  ................................
450419....................................             23104             19124  ................................
450438....................................                45             26420  ................................
450447....................................                45             19124  ................................
450465....................................                45             26420  ................................
450469....................................             43300             19124  ................................
450484....................................                45             30980  ................................
450508....................................                45             30980  ................................
450563....................................             23104             19124  ................................
450596....................................                45             23104  ................................
450639....................................             23104             19124  ................................
450656....................................                45             30980  ................................
450672....................................             23104             19124  ................................
450675....................................             23104             19124  ................................
450677....................................             23104             19124  ................................
450747....................................                45             46340  ................................
450770....................................                45             12420  LUGAR
450779....................................             23104             19124  ................................
450813....................................                45             41700  ................................
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  ................................
460026....................................                46             39340  ................................
460039....................................                46             30860  ................................
460041....................................             36260             41620  ................................
460042....................................             36260             41620  ................................
470001....................................                47                30  ................................
470012....................................                47             38340  ................................
490004....................................             25500             16820  ................................
490005....................................             49020             47894  ................................
490013....................................                49             31340  ................................
490018....................................                49             16820  ................................
490019....................................                49             47894  ................................
490042....................................             13980             40220  ................................
490048....................................             40220             31340  ................................
490079....................................                49             49180  ................................
490092....................................                49             40060  ................................
490097....................................                49             40060  ................................
490105....................................                49             28700  ................................
490106....................................                49             16820  ................................
490109....................................             47260             40060  ................................
500002....................................                50             28420  ................................
500003....................................             34580             42644  ................................
500007....................................             34580             42644  ................................

[[Page 25094]]

 
500016....................................             48300             42644  ................................
500021....................................             45104             42644  ................................
500024....................................             36500             45104  ................................
500031....................................                50             36500  ................................
500039....................................             14740             42644  ................................
500041....................................             31020             38900  ................................
500072....................................                50             14740  ................................
500079....................................             45104             42644  ................................
500108....................................             45104             42644  ................................
500129....................................             45104             42644  ................................
500139....................................             36500             45104  ................................
500143....................................             36500             45104  ................................
510001....................................             34060             38300  ................................
510002....................................                51             40220  ................................
510006....................................                51             34060  ................................
510018....................................                51             16620  LUGAR
510024....................................             34060             38300  ................................
510030....................................                51             34060  ................................
510046....................................                51             13980  ................................
510047....................................                51             38300  ................................
510062....................................                51             16620  ................................
510070....................................                51             16620  ................................
510071....................................                51             13980  ................................
510077....................................                51             26580  ................................
520002....................................                52             48140  ................................
520021....................................             29404             16974  ................................
520028....................................                52             31540  LUGAR
520037....................................                52             48140  ................................
520059....................................             39540             29404  ................................
520071....................................                52             33340  LUGAR
520076....................................                52             31540  ................................
520095....................................                52             31540  ................................
520102....................................                52             33340  LUGAR
520107....................................                52             22540  ................................
520113....................................                52             24580  ................................
520116....................................                52             33340  LUGAR
520189....................................             29404             16974  ................................
530015....................................                53             26820  ................................
----------------------------------------------------------------------------------------------------------------


 Table 9C.--Hospitals Redesignated as Rural Under Section 1886(d)(8)(E)
                           of the Act--FY 2008
------------------------------------------------------------------------
                                            Geographic     Redesignated
              Provider No.                     CBSA         rural area
------------------------------------------------------------------------
050192..................................           23420              05
050528..................................           32900              05
050618..................................           40140              05
070004..................................           25540              07
100048..................................           37860              10
100134..................................           27260              10
140167..................................              14              14
170137..................................           29940              17
220051..................................           38340              22
230078..................................           35660              23
250126..................................           32820              25
260006..................................           41140              26
260047..................................           27620              26
260195..................................           44180              26
330044..................................           46540              33
330245..................................           46540              33
330268..................................           10580              33
360125..................................              36              36
370054..................................           36420              37
380040..................................           13460              38
390181..................................              39              39
390183..................................              39              39
390201..................................              39              39
440135..................................           34980              44
440144..................................              44              44
450052..................................              45              45

[[Page 25095]]

 
450078..................................           10180              45
450243..................................           10180              45
450348..................................              45              45
500148..................................           48300              50
520060..................................              52              52
------------------------------------------------------------------------


    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 Proposed Medicare Severity Diagnosisrelated Group (MS-
                           DRG) April 2007 \1\
------------------------------------------------------------------------
                                                 Number of
                Proposed MS-DRG                    cases      Threshold
------------------------------------------------------------------------
1.............................................          629     $368,015
2.............................................          328     $193,497
3.............................................       23,999     $290,254
4.............................................       21,742     $177,964
5.............................................          842     $174,380
6.............................................          495      $99,214
7.............................................          413     $141,623
8.............................................          560     $101,160
9.............................................        1,358     $104,436
10............................................          177      $78,629
11............................................        1,289      $77,495
12............................................        1,923      $55,136
13............................................        1,484      $39,385
20............................................          901     $151,503
21............................................          558     $117,026
22............................................          251      $80,993
23............................................        3,112      $88,345
24............................................        2,576      $65,146
25............................................        8,417      $85,623
26............................................       11,626      $56,519
27............................................       14,454      $43,781
28............................................        1,609      $79,474
29............................................        2,862      $48,075
30............................................        3,751      $32,131
31............................................        1,057      $64,226
32............................................        2,987      $37,367
33............................................        4,263      $30,935
34............................................          813      $61,467
35............................................        2,506      $44,314
36............................................        7,710      $38,140
37............................................        4,777      $54,615
38............................................       14,602      $34,542
39............................................       55,357      $25,687
40............................................        4,549      $62,715
41............................................        7,720      $41,782
42............................................        5,430      $36,036
52............................................        1,156      $31,042
53............................................          593      $23,808
54............................................        4,664      $32,133
55............................................       16,896      $25,987
56............................................        7,716      $30,536
57............................................       48,432      $19,657
58............................................          789      $29,810
59............................................        2,639      $23,219
60............................................        4,201      $17,679
61............................................        1,340      $56,598
62............................................        2,288      $44,319
63............................................        1,185      $38,047
64............................................       55,552      $36,315
65............................................      112,189      $28,253
66............................................       94,547      $21,586
67............................................        1,383      $32,331
68............................................       12,393      $23,593
69............................................      103,747      $18,936
70............................................        7,092      $35,876
71............................................       10,001      $27,570
72............................................        6,056      $20,628
73............................................        8,655      $28,280
74............................................       32,523      $21,427
75............................................        1,197      $35,846
76............................................          874      $24,623
77............................................        1,101      $34,912
78............................................        1,307      $25,663
79............................................          957      $20,523
80............................................        2,077      $25,444
81............................................        8,190      $17,502
82............................................        1,646      $36,204
83............................................        1,940      $30,062
84............................................        2,591      $23,356
85............................................        5,328      $37,792
86............................................       10,382      $27,625
87............................................       12,152      $20,144
88............................................          717      $31,775
89............................................        2,641      $24,257
90............................................        3,319      $17,874
91............................................        6,676      $31,194
92............................................       14,890      $22,313
93............................................       15,484      $17,172
94............................................        1,521      $60,743
95............................................        1,088      $45,389
96............................................          755      $38,576
97............................................        1,252      $54,573
98............................................        1,048      $37,845
99............................................          642      $31,587
100...........................................       15,837      $30,385
101...........................................       56,905      $19,341
102...........................................        1,352      $25,466
103...........................................       15,023      $17,133
113...........................................          568      $33,509
114...........................................          601      $21,640
115...........................................        1,098      $26,668
116...........................................          665      $24,976
117...........................................        1,400      $16,827
121...........................................          587      $23,703
122...........................................          674      $13,518
123...........................................        2,843      $19,108
124...........................................          679      $25,406
125...........................................        4,705      $16,568
129...........................................        1,374      $39,926
130...........................................        1,072      $30,097
131...........................................          655      $38,488
132...........................................          728      $28,470
133...........................................        1,352      $32,869
134...........................................        2,661      $20,306
135...........................................          781      $37,347
136...........................................        1,113      $24,451
137...........................................        1,108      $29,974
138...........................................        1,370      $20,587
139...........................................        2,145      $22,300
146...........................................          687      $37,368
147...........................................        1,422      $26,407
148...........................................          935      $18,944
149...........................................       39,248      $15,883
150...........................................          939      $26,227
151...........................................        6,801      $13,607
152...........................................        2,352      $23,720
153...........................................       16,028      $15,145
154...........................................        1,843      $29,263
155...........................................        4,207      $22,020
156...........................................        5,140      $16,103
157...........................................        1,145      $29,722
158...........................................        3,039      $21,662
159...........................................        2,418      $15,345
163...........................................       13,431      $84,838
164...........................................       18,047      $50,487
165...........................................       14,553      $39,842
166...........................................       20,290      $62,666
167...........................................       20,772      $42,250
168...........................................        5,758      $31,795
175...........................................       11,954      $35,088
176...........................................       40,173      $26,922
177...........................................       57,179      $38,623
178...........................................       71,192      $31,821
179...........................................       27,454      $25,264
180...........................................       22,474      $34,645
181...........................................       32,156      $27,982
182...........................................        6,163      $23,372
183...........................................        1,654      $31,015
184...........................................        4,141      $22,561
185...........................................        2,593      $15,740
186...........................................        8,533      $33,538

[[Page 25096]]

 
187...........................................        9,968      $26,845
188...........................................        5,148      $20,974
189...........................................      104,531      $30,042
190...........................................       57,041      $29,138
191...........................................      121,659      $24,641
192...........................................      196,903      $18,419
193...........................................       88,053      $31,201
194...........................................      266,599      $25,213
195...........................................      147,744      $18,274
196...........................................        5,143      $32,537
197...........................................        6,894      $26,836
198...........................................        4,943      $21,129
199...........................................        3,257      $34,933
200...........................................        8,185      $24,946
201...........................................        3,523      $17,676
202...........................................       31,587      $20,635
203...........................................       41,587      $15,003
204...........................................       26,039      $17,394
205...........................................        5,775      $27,595
206...........................................       22,415      $18,854
207...........................................       46,165      $89,753
208...........................................       79,432      $43,969
215...........................................          150     $161,680
216...........................................        8,411     $176,029
217...........................................        7,609     $124,842
218...........................................        3,256     $104,178
219...........................................       10,062     $140,684
220...........................................       13,481      $99,812
221...........................................        8,383      $85,690
222...........................................        2,865     $159,922
223...........................................        5,770     $123,934
224...........................................        1,919     $147,237
225...........................................        5,871     $115,628
226...........................................        7,048     $120,197
227...........................................       50,536      $93,738
228...........................................        3,084     $135,095
229...........................................        4,128      $94,076
230...........................................        1,989      $77,297
231...........................................        1,478     $147,555
232...........................................        1,795     $114,348
233...........................................       16,911     $128,139
234...........................................       39,167      $91,908
235...........................................        9,628     $103,136
236...........................................       32,871      $71,913
237...........................................       21,789      $90,628
238...........................................       44,929      $56,647
239...........................................       13,814      $69,191
240...........................................       13,349      $45,896
241...........................................        3,350      $33,094
242...........................................       17,179      $68,158
243...........................................       37,856      $52,815
244...........................................       68,201      $44,155
245...........................................        6,241      $57,244
246...........................................       32,661      $68,691
247...........................................      279,972      $49,206
248...........................................        5,013      $61,557
249...........................................       29,657      $43,877
250...........................................        5,739      $56,715
251...........................................       39,905      $40,116
252...........................................       44,602      $51,463
253...........................................       46,864      $45,888
254...........................................       59,029      $36,249
255...........................................        2,609      $42,857
256...........................................        3,833      $32,015
257...........................................          774      $23,818
258...........................................          598      $53,008
259...........................................        7,328      $36,819
260...........................................          867      $50,387
261...........................................        2,804      $29,564
262...........................................        3,378      $23,301
263...........................................          788      $30,589
264...........................................       30,137      $42,489
280...........................................       60,735      $38,714
281...........................................       57,734      $29,876
282...........................................       60,951      $23,031
283...........................................       15,852      $32,521
284...........................................        4,911      $24,328
285...........................................        3,254      $17,351
286...........................................       23,282      $42,720
287...........................................      172,488      $29,775
288...........................................        3,245      $53,565
289...........................................        1,423      $38,265
290...........................................          484      $29,384
291...........................................      183,774      $30,658
292...........................................      217,052      $24,625
293...........................................      226,688      $17,810
294...........................................        1,704      $21,989
295...........................................        1,658      $13,805
296...........................................        1,730      $28,035
297...........................................          943      $20,306
298...........................................          554      $12,889
299...........................................       17,443      $29,542
300...........................................       46,820      $21,997
301...........................................       39,910      $15,712
302...........................................        7,873      $24,885
303...........................................       81,458      $15,192
304...........................................        2,084      $25,286
305...........................................       35,646      $15,139
306...........................................        1,379      $29,019
307...........................................        6,447      $18,857
308...........................................       33,528      $28,534
309...........................................       79,751      $20,827
310...........................................      160,738      $14,816
311...........................................       24,867      $13,364
312...........................................      169,247      $18,273
313...........................................      220,769      $14,894
314...........................................       60,053      $32,586
315...........................................       30,730      $24,616
316...........................................       20,101      $16,823
326...........................................       11,567      $94,842
327...........................................       10,901      $52,780
328...........................................        9,333      $33,659
329...........................................       48,135      $85,323
330...........................................       66,303      $49,556
331...........................................       31,391      $36,640
332...........................................        1,890      $78,691
333...........................................        6,196      $48,432
334...........................................        4,023      $35,774
335...........................................        7,161      $72,588
336...........................................       12,516      $45,452
337...........................................        8,835      $34,087
338...........................................        1,499      $61,541
339...........................................        3,192      $41,786
340...........................................        3,607      $31,931
341...........................................          874      $45,417
342...........................................        2,536      $33,389
343...........................................        6,875      $24,258
344...........................................          898      $54,574
345...........................................        2,915      $35,196
346...........................................        2,909      $27,779
347...........................................        1,568      $38,823
348...........................................        3,985      $29,136
349...........................................        5,787      $19,265
350...........................................        1,669      $43,250
351...........................................        3,997      $29,564
352...........................................        8,419      $19,894
353...........................................        3,182      $46,944
354...........................................        9,118      $32,066
355...........................................       17,451      $23,281
356...........................................        8,366      $62,960
357...........................................        8,046      $42,318
358...........................................        2,714      $32,613
368...........................................        3,052      $33,308
369...........................................        4,005      $26,885
370...........................................        3,914      $20,084
371...........................................       16,843      $34,017
372...........................................       22,903      $27,955
373...........................................       14,897      $20,598
374...........................................        9,414      $36,691
375...........................................       19,730      $27,763
376...........................................        4,816      $22,720
377...........................................       50,503      $32,599
378...........................................       84,806      $25,682
379...........................................      128,748      $19,140
380...........................................        2,917      $34,352
381...........................................        4,894      $28,117
382...........................................        5,445      $20,581
383...........................................        1,303      $29,683
384...........................................        8,664      $21,556
385...........................................        2,107      $35,137
386...........................................        7,221      $26,066
387...........................................        5,230      $20,543
388...........................................       18,267      $31,162
389...........................................       46,328      $23,425
390...........................................       48,052      $16,336
391...........................................       47,511      $25,915
392...........................................      306,515      $17,829
393...........................................       23,917      $30,478
394...........................................       45,952      $24,292
395...........................................       26,460      $17,594
405...........................................        3,903      $90,226
406...........................................        5,241      $52,384
407...........................................        2,310      $38,743
408...........................................        1,644      $71,983
409...........................................        1,713      $49,309
410...........................................          722      $37,665
411...........................................          978      $69,625

[[Page 25097]]

 
412...........................................        1,063      $50,630
413...........................................          881      $39,302
414...........................................        5,596      $63,496
415...........................................        6,847      $42,806
416...........................................        6,222      $31,773
417...........................................       16,671      $49,010
418...........................................       27,563      $38,299
419...........................................       38,264      $29,285
420...........................................          714      $65,599
421...........................................        1,091      $38,623
422...........................................          364      $30,085
423...........................................        1,500      $68,219
424...........................................          912      $46,919
425...........................................          157      $38,094
432...........................................       16,259      $32,310
433...........................................        9,022      $23,457
434...........................................          945      $17,210
435...........................................       11,908      $34,335
436...........................................       13,987      $27,538
437...........................................        4,357      $24,539
438...........................................       14,426      $33,536
439...........................................       24,816      $26,419
440...........................................       27,346      $18,913
441...........................................       13,912      $30,900
442...........................................       12,756      $24,488
443...........................................        6,698      $18,374
444...........................................       12,447      $32,912
445...........................................       16,757      $26,999
446...........................................       16,849      $20,274
453...........................................          846     $174,685
454...........................................        1,496     $117,216
455...........................................        1,875      $90,966
456...........................................          764     $142,125
457...........................................        1,763     $100,035
458...........................................        1,534      $82,734
459...........................................        3,180      $98,971
460...........................................       50,317      $64,868
461...........................................        1,062      $82,101
462...........................................       14,234      $61,454
463...........................................        5,283      $68,787
464...........................................        6,322      $44,864
465...........................................        2,942      $32,894
466...........................................        4,152      $74,863
467...........................................       10,818      $55,556
468...........................................       28,701      $46,551
469...........................................       29,730      $60,216
470...........................................      410,173      $43,290
471...........................................        2,227      $76,468
472...........................................        6,218      $50,893
473...........................................       22,546      $41,804
474...........................................        2,829      $54,927
475...........................................        3,530      $37,782
476...........................................        1,698      $26,665
477...........................................        2,257      $60,431
478...........................................        7,144      $43,558
479...........................................       10,267      $34,775
480...........................................       25,866      $53,540
481...........................................       59,136      $40,012
482...........................................       64,739      $34,370
483...........................................        5,729      $46,686
484...........................................       17,949      $39,280
485...........................................          967      $59,138
486...........................................        1,535      $43,053
487...........................................        1,214      $34,867
488...........................................        1,551      $34,851
489...........................................        3,866      $26,609
490...........................................       19,803      $35,660
491...........................................       58,396      $24,028
492...........................................        4,700      $51,225
493...........................................       15,248      $38,100
494...........................................       30,563      $29,460
495...........................................        1,867      $54,818
496...........................................        5,049      $36,082
497...........................................        7,519      $28,326
498...........................................        1,177      $38,828
499...........................................        1,245      $22,858
500...........................................        1,349      $50,966
501...........................................        3,679      $32,218
502...........................................        6,825      $23,032
503...........................................          736      $40,314
504...........................................        2,155      $32,350
505...........................................        3,214      $24,352
506...........................................          909      $25,086
507...........................................          779      $34,570
508...........................................        2,722      $26,249
509...........................................          465      $25,608
510...........................................          957      $40,566
511...........................................        4,008      $31,428
512...........................................       11,961      $23,087
513...........................................        1,287      $31,071
514...........................................        1,339      $20,718
515...........................................        3,577      $54,297
516...........................................       10,963      $39,039
517...........................................       18,263      $31,703
533...........................................          828      $28,832
534...........................................        3,634      $15,819
535...........................................        6,844      $28,150
536...........................................       34,321      $15,408
537...........................................          654      $20,405
538...........................................        1,164      $12,954
539...........................................        3,379      $36,833
540...........................................        4,187      $28,818
541...........................................        1,858      $22,002
542...........................................        6,158      $34,845
543...........................................       18,413      $26,086
544...........................................       12,644      $18,008
545...........................................        4,016      $36,462
546...........................................        5,881      $25,135
547...........................................        4,880      $18,469
548...........................................          591      $34,989
549...........................................        1,077      $26,366
550...........................................          904      $18,381
551...........................................        9,502      $31,033
552...........................................       87,859      $18,492
553...........................................        2,790      $25,374
554...........................................       20,253      $14,944
555...........................................        1,995      $23,282
556...........................................       19,168      $14,428
557...........................................        3,184      $30,733
558...........................................       14,178      $19,372
559...........................................        1,635      $30,332
560...........................................        3,979      $20,901
561...........................................        7,617      $13,636
562...........................................        4,996      $28,213
563...........................................       36,056      $15,451
564...........................................        1,606      $28,809
565...........................................        3,237      $21,478
566...........................................        2,779      $15,695
573...........................................        5,687      $50,477
574...........................................       12,100      $35,412
575...........................................        6,468      $26,698
576...........................................          558      $47,915
577...........................................        2,179      $32,787
578...........................................        3,299      $23,686
579...........................................        3,088      $48,029
580...........................................        6,766      $33,258
581...........................................        5,288      $23,944
582...........................................        8,972      $24,930
583...........................................       15,549      $19,001
584...........................................        1,431      $29,247
585...........................................        2,818      $20,786
592...........................................        3,982      $32,110
593...........................................       12,832      $24,303
594...........................................        2,955      $16,562
595...........................................        1,082      $31,299
596...........................................        5,755      $19,571
597...........................................          548      $31,103
598...........................................        1,483      $24,558
599...........................................          350      $15,943
600...........................................          572      $22,870
601...........................................          865      $15,125
602...........................................       21,307      $28,307
603...........................................      130,923      $18,145
604...........................................        2,627      $26,277
605...........................................       22,672      $16,152
606...........................................        1,363      $24,074
607...........................................        7,169      $14,791
614...........................................        1,376      $47,229
615...........................................        1,626      $34,519
616...........................................        1,132      $65,696
617...........................................        6,822      $39,614
618...........................................          343      $29,975
619...........................................          663      $64,216
620...........................................        1,877      $43,862
621...........................................        6,556      $37,409
622...........................................        1,234      $49,435
623...........................................        3,268      $35,278
624...........................................          487      $26,158
625...........................................        1,098      $42,919
626...........................................        2,522      $28,885
627...........................................       14,305      $19,134
628...........................................        3,267      $55,480
629...........................................        3,958      $43,435
630...........................................          684      $33,106
637...........................................       16,283      $28,425
638...........................................       40,811      $20,070
639...........................................       41,135      $14,010

[[Page 25098]]

 
640...........................................       55,690      $25,143
641...........................................      188,104      $16,575
642...........................................        1,542      $24,193
643...........................................        5,014      $32,744
644...........................................       11,845      $25,227
645...........................................        8,402      $18,520
652...........................................       10,437      $62,402
653...........................................        1,585      $91,794
654...........................................        3,231      $57,305
655...........................................        1,650      $42,998
656...........................................        3,721      $59,955
657...........................................        7,359      $40,718
658...........................................        8,479      $33,723
659...........................................        4,442      $54,626
660...........................................        7,444      $38,339
661...........................................        4,745      $31,241
662...........................................          988      $44,122
663...........................................        2,131      $30,611
664...........................................        4,676      $23,754
665...........................................          690      $49,701
666...........................................        2,213      $31,959
667...........................................        3,948      $19,910
668...........................................        3,757      $41,676
669...........................................       12,491      $29,038
670...........................................       13,411      $19,410
671...........................................          884      $30,142
672...........................................          965      $19,128
673...........................................       12,577      $46,104
674...........................................       10,503      $42,636
675...........................................       11,704      $32,785
682...........................................       75,827      $31,972
683...........................................      112,129      $26,767
684...........................................       43,451      $19,020
685...........................................        2,493      $20,233
686...........................................        1,581      $32,841
687...........................................        3,322      $25,246
688...........................................        1,198      $18,441
689...........................................       55,398      $27,175
690...........................................      200,059      $18,352
691...........................................          898      $33,393
692...........................................          654      $25,534
693...........................................        2,235      $29,001
694...........................................       19,213      $17,667
695...........................................          974      $25,020
696...........................................       10,565      $14,808
697...........................................          575      $17,475
698...........................................       21,061      $29,461
699...........................................       22,820      $24,300
700...........................................       15,089      $17,723
707...........................................        4,874      $37,314
708...........................................       17,015      $29,414
709...........................................          755      $36,305
710...........................................        2,037      $29,222
711...........................................          921      $36,269
712...........................................          819      $20,449
713...........................................       11,755      $26,239
714...........................................       32,745      $15,644
715...........................................          638      $36,067
716...........................................        1,382      $28,098
717...........................................          634      $33,174
718...........................................          633      $19,455
722...........................................          871      $30,591
723...........................................        2,037      $24,888
724...........................................          666      $15,999
725...........................................          802      $24,549
726...........................................        3,940      $16,420
727...........................................        1,098      $27,652
728...........................................        6,176      $16,848
729...........................................          578      $23,477
730...........................................          552      $14,387
734...........................................        1,470      $42,020
735...........................................        1,328      $26,263
736...........................................          840      $73,881
737...........................................        3,429      $41,554
738...........................................          954      $29,484
739...........................................          975      $51,269
740...........................................        4,366      $33,218
741...........................................        6,554      $24,119
742...........................................       10,705      $31,515
743...........................................       35,310      $21,122
744...........................................        1,498      $30,509
745...........................................        2,189      $20,066
746...........................................        2,486      $29,036
747...........................................       11,218      $20,664
748...........................................       21,171      $19,841
749...........................................        1,037      $45,581
750...........................................          484      $24,671
754...........................................        1,083      $33,538
755...........................................        3,152      $25,336
756...........................................          831      $16,790
757...........................................        1,322      $32,841
758...........................................        1,597      $25,832
759...........................................        1,186      $19,161
760...........................................        1,703      $19,848
761...........................................        1,918      $13,557
765...........................................        2,497      $22,146
766...........................................        2,634      $14,889
767...........................................          119      $15,750
768...........................................           10      $29,739
769...........................................           86      $31,941
770...........................................          181      $18,191
774...........................................        1,442      $12,637
775...........................................        5,224       $9,066
776...........................................          491      $15,413
777...........................................          177      $19,480
778...........................................          489       $8,798
779...........................................          107      $14,082
780...........................................           47       $5,638
781...........................................        3,004      $13,343
782...........................................          125       $8,369
794...........................................            7       $2,880
799...........................................          623      $80,879
800...........................................          699      $48,145
801...........................................          602      $37,100
802...........................................          691      $55,325
803...........................................        1,003      $35,487
804...........................................          996      $25,527
808...........................................        8,315      $35,924
809...........................................       15,527      $25,920
810...........................................        3,818      $21,504
811...........................................       18,344      $25,759
812...........................................       83,082      $18,156
813...........................................       15,031      $26,262
814...........................................        1,631      $31,374
815...........................................        3,337      $24,871
816...........................................        2,355      $18,234
820...........................................        1,481      $89,134
821...........................................        2,529      $42,943
822...........................................        2,139      $30,127
823...........................................        2,436      $68,790
824...........................................        3,039      $42,669
825...........................................        2,009      $31,129
826...........................................          562      $82,779
827...........................................        1,318      $42,427
828...........................................          872      $30,710
829...........................................        1,374      $47,009
830...........................................          531      $26,963
834...........................................        5,257      $54,533
835...........................................        1,469      $32,379
836...........................................        1,526      $24,423
837...........................................        1,623      $91,611
838...........................................          900      $44,011
839...........................................        1,385      $28,304
840...........................................       15,152      $40,430
841...........................................       11,012      $30,388
842...........................................        7,678      $23,796
843...........................................        1,477      $34,387
844...........................................        2,854      $26,126
845...........................................        1,008      $21,865
846...........................................        2,480      $39,831
847...........................................       23,667      $26,464
848...........................................        1,699      $20,748
849...........................................        1,498      $28,295
853...........................................       31,444      $83,950
854...........................................        6,881      $53,045
855...........................................          467      $37,927
856...........................................        6,187      $74,156
857...........................................       10,059      $39,007
858...........................................        3,500      $30,128
862...........................................        7,425      $34,703
863...........................................       21,807      $21,882
864...........................................       19,826      $20,564
865...........................................        2,019      $29,189
866...........................................        9,406      $16,786
867...........................................        5,306      $40,813
868...........................................        2,369      $25,734
869...........................................        1,100      $20,520
870...........................................       13,710      $99,453
871...........................................      203,702      $35,587
872...........................................       92,118      $26,548
876...........................................          968      $43,100
880...........................................       10,494      $15,328
881...........................................        4,576      $11,727
882...........................................        1,656      $12,481
883...........................................          786      $17,701
884...........................................       21,619      $19,048
885...........................................       77,763      $16,598

[[Page 25099]]

 
886...........................................          376      $14,393
887...........................................          423      $18,850
894...........................................        4,480       $8,389
895...........................................        6,474      $16,201
896...........................................        5,369      $26,659
897...........................................       35,835      $13,689
901...........................................          917      $51,824
902...........................................        2,135      $33,272
903...........................................        1,739      $24,889
904...........................................          941      $42,415
905...........................................          798      $26,522
906...........................................          745      $24,393
907...........................................        8,098      $57,686
908...........................................        7,884      $37,304
909...........................................        5,971      $27,385
913...........................................          813      $27,433
914...........................................        6,958      $16,346
915...........................................          915      $25,250
916...........................................        5,369      $10,725
917...........................................       14,155      $30,038
918...........................................       34,847      $14,539
919...........................................       10,569      $29,326
920...........................................       12,135      $22,791
921...........................................       11,659      $15,316
922...........................................        1,005      $28,199
923...........................................        4,211      $16,053
927...........................................          182     $206,517
928...........................................          794      $66,194
929...........................................          459      $35,403
933...........................................          155      $33,800
934...........................................          694      $25,296
935...........................................        2,179      $22,619
939...........................................          423      $45,897
940...........................................          690      $34,557
941...........................................        1,077      $27,512
945...........................................        5,053      $21,694
946...........................................        3,199      $17,198
947...........................................        6,544      $24,507
948...........................................       34,325      $15,485
949...........................................          742      $18,955
950...........................................          476      $12,079
951...........................................          990      $14,489
955...........................................          446      $89,598
956...........................................        3,718      $58,558
957...........................................        1,157     $112,575
958...........................................          737      $76,928
959...........................................          816      $58,670
963...........................................        1,395      $49,648
964...........................................        1,578      $34,426
965...........................................        2,016      $29,169
969...........................................          598      $83,524
970...........................................          231      $52,404
974...........................................        7,276      $37,920
975...........................................        3,463      $32,068
976...........................................        2,728      $25,665
977...........................................        4,871      $24,657
981...........................................       26,280      $82,945
982...........................................       18,594      $56,659
983...........................................        6,766      $40,536
984...........................................          669      $59,799
985...........................................        1,048      $41,065
986...........................................          890      $29,062
987...........................................        8,036      $58,165
988...........................................       11,880      $38,036
989...........................................        6,537      $27,418
999...........................................           18     $16,006
------------------------------------------------------------------------
\1\ Cases taken from the FY 2006 MedPAR file; proposed MSDRGs are from
  GROUPER Version 25.0.


 Table 11.--Proposed FY 2008 MS-LTC-DRGs, Relative Weights, Geometric Average Length of Stay, and 5/6ths of the
                                        Geometric Average Length of Stay
----------------------------------------------------------------------------------------------------------------
                                                                                                     Proposed  5/
                                                                                          Proposed   6ths of the
                          Proposed MS-LTC-DRG    Base MS-LTC-   FY 2006      Proposed    geometric    Geometric
  Proposed MS-LTC-DRG         description            DRG       LTCH cases    relative     average      average
                                                                              weight     length of    length of
                                                                                            stay         stay
----------------------------------------------------------------------------------------------------------------
1.....................  Heart transplant or                1            0       0.0000          0.0          0.0
                         implant of heart
                         assist system w MCC
                         \7\.
2.....................  Heart transplant or                1            0       0.0000          0.0          0.0
                         implant of heart
                         assist system w/o MCC
                         \7\.
3.....................  ECMO or trach w MV 96+             3          270       4.2008         64.5         53.8
                         hrs or PDX exc face,
                         mouth & neck w maj O.R.
4.....................  Trach w MV 96+ hrs or              4        1,069       2.9804         46.7         38.9
                         PDX exc face, mouth &
                         neck w/o maj O.R.
5.....................  Liver transplant w MCC             5            0       0.0000          0.0          0.0
                         or intestinal
                         transplant \7\.
6.....................  Liver transplant w/o               5            0       0.0000          0.0          0.0
                         MCC \7\.
7.....................  Lung transplant \7\....            7            0       0.0000          0.0          0.0
8.....................  Simultaneous pancreas/             8            0       0.0000          0.0          0.0
                         kidney transplant \7\.
9.....................  Bone marrow transplant             9            0       1.0950         30.3         25.3
                         \8\.
10....................  Pancreas transplant \7\           10            0       0.0000          0.0          0.0
11....................  Tracheostomy for face,            11            0       1.6489         36.5         30.4
                         mouth & neck diagnoses
                         w MCC \9\.
12....................  Tracheostomy for face,            11            1       1.6489         36.5         30.4
                         mouth & neck diagnoses
                         w CC \5\.
13....................  Tracheostomy for face,            11            0       1.6489         36.5         30.4
                         mouth & neck diagnoses
                         w/o CC/MCC \9\.
20....................  Intracranial vascular             20            0       1.6489         36.5         30.4
                         procedures w PDX
                         hemorrhage w MCC \8\.
21....................  Intracranial vascular             20            0       0.4800         19.9         16.6
                         procedures w PDX
                         hemorrhage w CC \8\.

[[Page 25100]]

 
22....................  Intracranial vascular             20            0       0.4800         19.9         16.6
                         procedures w PDX
                         hemorrhage w/o CC/MCC
                         \8\.
23....................  Craniotomy w major                23            0       1.6489         36.5         30.4
                         device implant or
                         acute complex CNS PDX
                         w MCC \8\.
24....................  Craniotomy w major                23            0       0.4800         19.9         16.6
                         device implant or
                         acute complex CNS PDX
                         w/o MCC \8\.
25....................  Craniotomy &                      25            0       1.6489         36.5         30.4
                         endovascular
                         intracranial
                         procedures w MCC \9\.
26....................  Craniotomy &                      25            2       1.6489         36.5         30.4
                         endovascular
                         intracranial
                         procedures w CC \5\.
27....................  Craniotomy &                      25            0       1.6489         36.5         30.4
                         endovascular
                         intracranial
                         procedures w/o CC/MCC
                         \9\.
28....................  Spinal procedures w MCC           28            6       1.0950         30.3         25.3
                         \4\.
29....................  Spinal procedures w CC            28            4       1.0950         30.3         25.3
                         \4\.
30....................  Spinal procedures w/o             28            2       0.4800         19.9         16.6
                         CC/MCC \1\.
31....................  Ventricular shunt                 31            2       1.6489         36.5         30.4
                         procedures w MCC \5\.
32....................  Ventricular shunt                 31            1       0.4800         19.9         16.6
                         procedures w CC \1\.
33....................  Ventricular shunt                 31            1       0.4800         19.9         16.6
                         procedures w/o CC/MCC
                         \1\.
34....................  Carotid artery stent              34            0       1.6489         36.5         30.4
                         procedure w MCC \8\.
35....................  Carotid artery stent              34            0       1.0950         30.3         25.3
                         procedure w CC \8\.
36....................  Carotid artery stent              34            0       1.0950         30.3         25.3
                         procedure w/o CC/MCC
                         \8\.
37....................  Extracranial procedures           37           12       1.6489         36.5         30.4
                         w MCC \5\.
38....................  Extracranial procedures           37            7       1.0950         30.3         25.3
                         w CC \4\.
39....................  Extracranial procedures           37            1       1.0950         30.3         25.3
                         w/o CC/MCC \4\.
40....................  Periph & cranial nerve            40          156       1.3371         36.3         30.3
                         & other nerv syst proc
                         w MCC.
41....................  Periph & cranial nerve            40           99       0.9653         34.3         28.6
                         & other nerv syst proc
                         w CC.
42....................  Periph & cranial nerve            40           10       0.8072         24.6         20.5
                         & other nerv syst proc
                         w/o CC/MCC \3\.
52....................  Spinal disorders &                52           78       1.0786         32.8         27.3
                         injuries w CC/MCC.
53....................  Spinal disorders &                52           19       0.8072         24.6         20.5
                         injuries w/o CC/MCC
                         \3\.
54....................  Nervous system                    54           50       0.7245         23.6         19.7
                         neoplasms w MCC.
55....................  Nervous system                    54           67       0.6543         22.0         18.3
                         neoplasms w/o MCC.
56....................  Degenerative nervous              56        1,320       0.7993         26.4         22.0
                         system disorders w MCC.
57....................  Degenerative nervous              56        2,623       0.5844         24.4         20.3
                         system disorders w/o
                         MCC.
58....................  Multiple sclerosis &              58           23       0.5405         22.2         18.5
                         cerebellar ataxia w
                         MCC \6\.
59....................  Multiple sclerosis &              58           44       0.5405         22.2         18.5
                         cerebellar ataxia w CC.
60....................  Multiple sclerosis &              58           22       0.5405         22.2         18.5
                         cerebellar ataxia w/o
                         CC/MCC \6\.
61....................  Acute ischemic stroke w           61            0       0.8131         24.0         20.0
                         use of thrombolytic
                         agent w MCC \8\.
62....................  Acute ischemic stroke w           61            0       0.4800         19.9         16.6
                         use of thrombolytic
                         agent w CC \8\.
63....................  Acute ischemic stroke w           61            0       0.4800         19.9         16.6
                         use of thrombolytic
                         agent w/o CC/MCC \8\.
64....................  Intracranial hemorrhage           64          126       0.8199         25.1         20.9
                         or cerebral infarction
                         w MCC.
65....................  Intracranial hemorrhage           64          116       0.6159         23.5         19.6
                         or cerebral infarction
                         w CC.
66....................  Intracranial hemorrhage           64           24       0.4800         19.9         16.6
                         or cerebral infarction
                         w/o CC/MCC \1\.
67....................  Nonspecific cva &                 67            5       0.4800         19.9         16.6
                         precerebral occlusion
                         w/o infarct w MCC \1\.
68....................  Nonspecific cva &                 67            8       0.4800         19.9         16.6
                         precerebral occlusion
                         w/o infarct w/o MCC
                         \1\.
69....................  Transient ischemia \1\.           69           17       0.4800         19.9         16.6
70....................  Nonspecific                       70          103       0.8131         24.0         20.0
                         cerebrovascular
                         disorders w MCC.
71....................  Nonspecific                       70           86       0.5751         22.7         18.9
                         cerebrovascular
                         disorders w CC.
72....................  Nonspecific                       70            9       0.4800         19.9         16.6
                         cerebrovascular
                         disorders w/o CC/MCC
                         \1\.
73....................  Cranial & peripheral              73           83       0.8630         24.9         20.8
                         nerve disorders w MCC.
74....................  Cranial & peripheral              73          173       0.5645         23.3         19.4
                         nerve disorders w/o
                         MCC.
75....................  Viral meningitis w CC/            75           20       0.6513         22.7         18.9
                         MCC \2\.
76....................  Viral meningitis w/o CC/          75            1       0.4800         19.9         16.6
                         MCC \1\.
77....................  Hypertensive                      77            4       0.6513         22.7         18.9
                         encephalopathy w MCC
                         \2\.
78....................  Hypertensive                      77            9       0.6513         22.7         18.9
                         encephalopathy w CC 2,
                         6.
79....................  Hypertensive                      77            1       0.4800         19.9         16.6
                         encephalopathy w/o CC/
                         MCC \1\.
80....................  Nontraumatic stupor &             80           40       0.6767         24.6         20.5
                         coma w MCC.
81....................  Nontraumatic stupor &             80           71       0.5395         23.1         19.3
                         coma w/o MCC.
82....................  Traumatic stupor &                82           27       0.8821         29.5         24.6
                         coma, coma >1 hr w MCC.
83....................  Traumatic stupor &                82           12       0.6513         22.7         18.9
                         coma, coma >1 hr w CC2.

[[Page 25101]]

 
84....................  Traumatic stupor &                82            4       0.6513         22.7         18.9
                         coma, coma >1 hr w/o
                         CC/MCC \2\.
85....................  Traumatic stupor &                85          102       0.9666         28.3         23.6
                         coma, coma <1 hr w MCC.
86....................  Traumatic stupor &                85           86       0.6711         25.2         21.0
                         coma, coma <1 hr w CC.
87....................  Traumatic stupor &                85           30       0.5363         20.1         16.8
                         coma, coma <1 hr w/o
                         CC/MCC.
88....................  Concussion w MCC 4, 6..           88            1       1.0950         30.3         25.3
89....................  Concussion w CC \4\....           88            2       1.0950         30.3         25.3
90....................  Concussion w/o CC/MCC             88            0       1.0950         30.3         25.3
                         \9\.
91....................  Other disorders of                91          243       0.8500         25.7         21.4
                         nervous system w MCC.
92....................  Other disorders of                91          189       0.5981         21.9         18.3
                         nervous system w CC.
93....................  Other disorders of                91           54       0.4835         20.0         16.7
                         nervous system w/o CC/
                         MCC.
94....................  Bacterial & tuberculous           94          211       1.0574         28.0         23.3
                         infections of nervous
                         system w MCC.
95....................  Bacterial & tuberculous           94          105       0.8454         26.8         22.3
                         infections of nervous
                         system w CC.
96....................  Bacterial & tuberculous           94           26       0.8454         26.8         22.3
                         infections of nervous
                         system w/o CC/MCC.
97....................  Non-bacterial infect of           97           57       0.9189         26.2         21.8
                         nervous sys exc viral
                         meningitis w MCC.
98....................  Non-bacterial infect of           97           33       0.8242         22.7         18.9
                         nervous sys exc viral
                         meningitis w CC.
99....................  Non-bacterial infect of           97           10       0.6513         22.7         18.9
                         nervoussys exc viral
                         meningitis w/o CC/MCC
                         \2\.
100...................  Seizures w MCC.........          100           40       0.8295         26.5         22.1
101...................  Seizures w/o MCC.......          100           37       0.5564         21.4         17.8
102...................  Headaches w MCC 3, 6...          102            6       0.8072         24.6         20.5
103...................  Headaches w/o MCC \3\..          102           11       0.8072         24.6         20.5
113...................  Orbital procedures w CC/         113            1       0.6513         22.7         18.9
                         MCC \2\.
114...................  Orbital procedures w/o           113            0       0.6513         22.7         18.9
                         CC/MCC \9\.
115...................  Extraocular procedures           115            0       0.6513         22.7         18.9
                         exceptorbit \8\.
116...................  Intraocular procedures           116            0       0.6513         22.7         18.9
                         w CC/MCC \8\.
117...................  Intraocular procedures           116            0       0.6513         22.7         18.9
                         w/o CC/MCC \8\.
121...................  Acute major eye                  121            8       0.6513         22.7         18.9
                         infections w CC/MCC
                         \2\.
122...................  Acute major eye                  121            2       0.4800         19.9         16.6
                         infections w/o CC/MCC
                         \1\.
123...................  Neurological eye                 123            3       0.4800         19.9         16.6
                         disorders \1\.
124...................  Other disorders of the           124            2       1.0950         30.3         25.3
                         eye w MCC \4\.
125...................  Other disorders of the           124           10       0.6513         22.7         18.9
                         eye w/o MCC \2\.
129...................  Major head & neck                129            0       1.0950         30.3         25.3
                         procedures w CC/MCC or
                         major device \8\.
130...................  Major head & neck                129            0       0.6513         22.7         18.9
                         procedures w/o CC/MCC
                         \8\.
131...................  Cranial/facial                   131            2       1.6489         36.5         30.4
                         procedures w CC/MCC
                         \5\.
132...................  Cranial/facial                   131            0       1.6489         36.5         30.4
                         procedures w/o CC/MCC
                         \9\.
133...................  Other ear, nose, mouth           133            3       0.8072         24.6         20.5
                         & throat O.R.
                         procedures w CC/MCC 3,
                         6.
134...................  Other ear, nose, mouth           133            1       0.8072         24.6         20.5
                         & throat O.R.
                         procedures w/o CC/MCC
                         3, 6.
135...................  Sinus & mastoid                  135            0       0.8072         24.6         20.5
                         procedures w CC/MCC
                         \8\.
136...................  Sinus & mastoid                  135            0       0.8072         24.6         20.5
                         procedures w/o CC/MCC
                         \8\.
137...................  Mouth procedures w CC/           137            1       1.6489         36.5         30.4
                         MCC \5\.
138...................  Mouth procedures w/o CC/         137            0       1.6489         36.5         30.4
                         MCC \9\.
139...................  Salivary gland                   139            1       1.6489         36.5         30.4
                         procedures \5\.
146...................  Ear, nose, mouth &               146           44       1.2620         26.4         22.0
                         throat malignancy w
                         MCC.
147...................  Ear, nose, mouth &               146           37       0.9530         24.9         20.8
                         throat malignancy w CC.
148...................  Ear, nose, mouth &               146            4       0.6513         22.7         18.9
                         throat malignancy w/o
                         CC/MCC \2\.
149...................  Dysequilibrium \1\.....          149            9       0.4800         19.9         16.6
150...................  Epistaxis w MCC \8\....          150            0       0.6513         22.7         18.9
151...................  Epistaxis w/o MCC \8\..          150            0       0.4800         19.9         16.6
152...................  Otitis media & URI w             152           10       0.6513         22.7         18.9
                         MCC \2\.
153...................  Otitis media & URI w/o           152           23       0.4800         19.9         16.6
                         MCC \1\.
154...................  Nasal trauma &                   154           55       0.7560         21.2         17.7
                         deformity w MCC.
155...................  Nasal trauma &                   154           44       0.7320         20.4         17.0
                         deformity w CC.
156...................  Nasal trauma &                   154           11       0.6513         22.7         18.9
                         deformity w/o CC/MCC
                         \2\.
157...................  Dental & Oral Diseases           157            9       0.8072         24.6         20.5
                         w MCC 3, 6.
158...................  Dental & Oral Diseases           157           18       0.8072         24.6         20.5
                         w CC 3, 6.
159...................  Dental & Oral Diseases           157            2       0.8072         24.6         20.5
                         w/o CC/MCC 3, 6.
163...................  Major chest procedures           163           27       2.2983         39.7         33.1
                         w MCC.
164...................  Major chest procedures           163           10       1.6489         36.5         30.4
                         w CC \5\.

[[Page 25102]]

 
165...................  Major chest procedures           163            0       1.6489         36.5         30.4
                         w/o CC/MCC \9\.
166...................  Other resp system O.R.           166        1,568       2.4517         42.4         35.3
                         procedures w MCC.
167...................  Other resp system O.R.           166          233       1.8802         37.6         31.3
                         procedures w CC.
168...................  Other resp system O.R.           166           10       1.0950         30.3         25.3
                         procedures w/o CC/MCC
                         \4\.
175...................  Pulmonary embolism w             175          103       0.7766         22.9         19.1
                         MCC.
176...................  Pulmonary embolism w/o           175          139       0.5350         20.2         16.8
                         MCC.
177...................  Respiratory infections           177        2,943       0.8638         23.6         19.7
                         & inflammations w MCC.
178...................  Respiratory infections           177        2,247       0.7254         22.2         18.5
                         & inflammations w CC.
179...................  Respiratory infections           177          390       0.5896         19.2         16.0
                         & inflammations w/o CC/
                         MCC.
180...................  Respiratory neoplasms w          180          162       0.8433         20.1         16.8
                         MCC.
181...................  Respiratory neoplasms w          180          110       0.6481         19.3         16.1
                         CC.
182...................  Respiratory neoplasms w/         180           19       0.4800         19.9         16.6
                         o CC/MCC \1\.
183...................  Major chest trauma w             183            1       0.4800         19.9         16.6
                         MCC \1\.
184...................  Major chest trauma w CC          183            1       0.4800         19.9         16.6
                         1, 6.
185...................  Major chest trauma w/o           183            0       0.4800         19.9         16.6
                         CC/MCC \9\.
186...................  Pleural effusion w MCC.          186          136       0.8571         23.6         19.7
187...................  Pleural effusion w CC..          186           64       0.6165         21.1         17.6
188...................  Pleural effusion w/o CC/         186           14       0.6165         21.1         17.6
                         MCC \6\.
189...................  Pulmonary edema &                189        5,686       0.9560         23.9         19.9
                         respiratory failure.
190...................  Chronic obstructive              190        1,657       0.7195         20.9         17.4
                         pulmonary disease w
                         MCC.
191...................  Chronic obstructive              190        1,542       0.6024         19.6         16.3
                         pulmonary disease w CC.
192...................  Chronic obstructive              190          894       0.5192         17.2         14.3
                         pulmonary disease w/o
                         CC/MCC.
193...................  Simple pneumonia &               193        1,689       0.7400         21.6         18.0
                         pleurisy w MCC.
194...................  Simple pneumonia &               193        2,090       0.6108         19.8         16.5
                         pleurisy w CC.
195...................  Simple pneumonia &               193          475       0.5321         18.1         15.1
                         pleurisy w/o CC/MCC.
196...................  Interstitial lung                196          114       0.6613         20.0         16.7
                         disease w MCC.
197...................  Interstitial lung                196           94       0.5863         19.6         16.3
                         disease w CC.
198...................  Interstitial lung                196           45       0.5717         19.7         16.4
                         disease w/o CC/MCC.
199...................  Pneumothorax w MCC.....          199           25       0.7596         22.4         18.7
200...................  Pneumothorax w CC2.....          199           16       0.6513         22.7         18.9
201...................  Pneumothorax w/o CC/MCC          199           11       0.4800         19.9         16.6
                         \1\.
202...................  Bronchitis & asthma w            202           92       0.6915         21.4         17.8
                         CC/MCC.
203...................  Bronchitis & asthma w/o          202           38       0.4994         16.6         13.8
                         CC/MCC.
204...................  Respiratory signs &              204          313       0.8025         22.0         18.3
                         symptoms.
205...................  Other respiratory                205          260       0.8221         22.5         18.8
                         system diagnoses w MCC.
206...................  Other respiratory                205          169       0.7446         21.7         18.1
                         system diagnoses w/o
                         MCC.
207...................  Respiratory system               207       12,390       1.9944         34.2         28.5
                         diagnosis w ventilator
                         support 96+ hours.
208...................  Respiratory system               208        1,879       1.5234         27.8         23.2
                         diagnosis w ventilator
                         support 96 hours.
215...................  Other heart assist               215            0       0.8072         24.6         20.5
                         system implant \8\.
216...................  Cardiac valve & oth maj          216            0       1.6489         36.5         30.4
                         cardiothoracic proc w
                         card cath w MCC \8\.
217...................  Cardiac valve & oth maj          216            0       0.8072         24.6         20.5
                         cardiothoracic proc w
                         card cath w CC \8\.
218...................  Cardiac valve & oth maj          216            0       0.8072         24.6         20.5
                         cardiothoracic proc w
                         card cath w/o CC/MCC
                         \8\.
219...................  Cardiac valve & oth maj          219            0       1.6489         36.5         30.4
                         cardiothoracic proc w/
                         o card cath w MCC \8\.
220...................  Cardiac valve & oth maj          219            0       0.8072         24.6         20.5
                         cardiothoracic proc w/
                         o card cath w CC \8\.
221...................  Cardiac valve & oth maj          219            0       0.8072         24.6         20.5
                         cardiothoracic proc w/
                         o card cath w/o CC/MCC
                         \8\.
222...................  Cardiac defib implant w          222            0       1.6489         36.5         30.4
                         cardiaccath w AMI/HF/
                         shock w MCC \8\.
223...................  Cardiac defib implant w          222            0       1.6489         36.5         30.4
                         cardiac cath w AMI/HF/
                         shock w/o MCC \8\.
224...................  Cardiac defib implant w          224            0       1.6489         36.5         30.4
                         cardiac cath w/o AMI/
                         HF/shock w MCC \8\.
225...................  Cardiac defib implant w          224            0       1.6489         36.5         30.4
                         cardiac cath w/o AMI/
                         HF/shock w/o MCC \8\.
226...................  Cardiac defibrillator            226           11       1.6489         36.5         30.4
                         implant w/o cardiac
                         cath w MCC \5\.
227...................  Cardiac defibrillator            226            4       1.6489         36.5         30.4
                         implant w/o cardiac
                         cath w/o MCC \5\.
228...................  Other cardiothoracic             228            0       1.6489         36.5         30.4
                         procedures w MCC \8\.
229...................  Other cardiothoracic             228            0       1.0950         30.3         25.3
                         procedures w CC \8\.
230...................  Other cardiothoracic             228            0       1.0950         30.3         25.3
                         procedures w/o CC/MCC
                         \8\.

[[Page 25103]]

 
231...................  Coronary bypass w PTCA           231            0       1.6489         36.5         30.4
                         w MCC \8\.
232...................  Coronary bypass w PTCA           231            0       0.8072         24.6         20.5
                         w/o MCC \8\.
233...................  Coronary bypass w                233            0       1.6489         36.5         30.4
                         cardiac cath w MCC \8\.
234...................  Coronary bypass w                233            0       0.8072         24.6         20.5
                         cardiac cath w/o MCC
                         \8\.
235...................  Coronary bypass w/o              235            0       1.6489         36.5         30.4
                         cardiac cath w MCC \8\.
236...................  Coronary bypass w/o              235            0       0.8072         24.6         20.5
                         cardiac cath w/o MCC
                         \8\.
237...................  Major cardiovascular             237            3       1.6489         36.5         30.4
                         procedures w MCC \5\.
238...................  Major cardiovascular             237            3       0.8072         24.6         20.5
                         procedures w/o MCC \3\.
239...................  Amputation for circ sys          239          171       1.3954         37.4         31.2
                         disorders exc upper
                         limb & toe w MCC.
240...................  Amputation for circ sys          239           92       1.2100         36.1         30.1
                         disorders exc upper
                         limb & toe w CC.
241...................  Amputation for circ sys          239            6       1.0950         30.3         25.3
                         disorders exc upper
                         limb & toe w/o CC/MCC
                         \4\.
242...................  Permanent cardiac                242           14       1.6489         36.5         30.4
                         pacemaker implant w
                         MCC 5, 6.
243...................  Permanent cardiac                242            9       1.6489         36.5         30.4
                         pacemaker implant w CC
                         \5\.
244...................  Permanent cardiac                242            3       1.0950         30.3         25.3
                         pacemaker implant w/o
                         CC/MCC \4\.
245...................  AICD lead & generator            245            2       0.6513         22.7         18.9
                         procedures \2\.
246...................  Percutaneous                     246            1       0.8072         24.6         20.5
                         cardiovascular proc w
                         drug-eluting stent w
                         MCC \3\.
247...................  Percutaneous                     246            0       0.8072         24.6         20.5
                         cardiovascular proc w
                         drug-eluting stent w/o
                         MCC \9\.
248...................  Percutaneous cardiovasc          248            1       1.6489         36.5         30.4
                         proc w non-drug-
                         eluting stent w MCC
                         \5\.
249...................  Percutaneous cardiovasc          248            0       1.6489         36.5         30.4
                         proc w non-drug-
                         eluting stent w/o MCC
                         \9\.
250...................  Perc cardiovasc proc w/          250            1       0.8072         24.6         20.5
                         o coronary artery
                         stent or AMI w MCC \3\.
251...................  Perc cardiovasc proc w/          250            0       0.8072         24.6         20.5
                         o coronary artery
                         stent or AMI w/o MCC
                         \9\.
252...................  Other vascular                   252          107       1.5938         34.9         29.1
                         procedures w MCC.
253...................  Other vascular                   252           54       1.0987         30.8         25.7
                         procedures w CC.
254...................  Other vascular                   252            6       1.0950         30.3         25.3
                         procedures w/o CC/MCC
                         \4\.
255...................  Upper limb & toe                 255           45       1.2596         33.7         28.1
                         amputation for circ
                         system disorders w MCC.
256...................  Upper limb & toe                 255           37       0.8278         29.4         24.5
                         amputation for circ
                         system disorders w CC.
257...................  Upper limb & toe                 255            1       0.8278         29.4         24.5
                         amputation for circ
                         system disorders w/o
                         CC/MCC \6\.
258...................  Cardiac pacemaker                258            1       1.6489         36.5         30.4
                         device replacement w
                         MCC \5\.
259...................  Cardiac pacemaker                258            0       1.6489         36.5         30.4
                         device replacement w/o
                         MCC \9\.
260...................  Cardiac pacemaker                260            1       1.6489         36.5         30.4
                         revision except device
                         replacement w MCC \5\.
261...................  Cardiac pacemaker                260            1       0.4800         19.9         16.6
                         revision except device
                         replacement w CC \1\.
262...................  Cardiac pacemaker                260            1       0.4800         19.9         16.6
                         revision except device
                         replacement w/o CC/MCC
                         \1\.
263...................  Vein ligation &                  263            1       0.8072         24.6         20.5
                         stripping \3\.
264...................  Other circulatory                264          596       1.0516         31.6         26.3
                         system O.R. procedures.
280...................  Circulatory disorders w          280          107       0.7177         21.4         17.8
                         AMI, discharged alive
                         w MCC.
281...................  Circulatory disorders w          280           60       0.6709         23.3         19.4
                         AMI, discharged alive
                         w CC.
282...................  Circulatory disorders w          280            9       0.6513         22.7         18.9
                         AMI, discharged alive
                         w/o CC/MCC \2\.
283...................  Circulatory disorders w          283           26       0.6486         17.0         14.2
                         AMI, expired w MCC.
284...................  Circulatory disorders w          283            5       0.6486         17.0         14.2
                         AMI, expired w CC \6\.
285...................  Circulatory disorders w          283            1       0.6486         17.0         14.2
                         AMI, expired w/o CC/
                         MCC \6\.
286...................  Circulatory disorders            286           15       1.0950         30.3         25.3
                         except AMI, w card
                         cath w MCC \4\.
287...................  Circulatory disorders            286            7       0.8072         24.6         20.5
                         except AMI, w card
                         cath w/o MCC \3\.
288...................  Acute & subacute                 288          450       0.9199         26.4         22.0
                         endocarditis w MCC.
289...................  Acute & subacute                 288          216       0.8385         26.7         22.3
                         endocarditis w CC.
290...................  Acute & subacute                 288           61       0.6409         25.1         20.9
                         endocarditis w/o CC/
                         MCC.
291...................  Heart failure & shock w          291        1,603       0.7271         21.4         17.8
                         MCC.
292...................  Heart failure & shock w          291        1,115       0.5887         20.5         17.1
                         CC.
293...................  Heart failure & shock w/         291          461       0.5015         18.6         15.5
                         o CC/MCC.
294...................  Deep vein                        294            7       0.8072         24.6         20.5
                         thrombophlebitis w CC/
                         MCC \3\.
295...................  Deep vein                        294            0       0.8072         24.6         20.5
                         thrombophlebitis w/o
                         CC/MCC \9\.

[[Page 25104]]

 
296...................  Cardiac arrest,                  296            0       0.6513         22.7         18.9
                         unexplained w MCC \8\.
297...................  Cardiac arrest,                  296            0       0.6513         22.7         18.9
                         unexplained w CC \8\.
298...................  Cardiac arrest,                  296            0       0.6513         22.7         18.9
                         unexplained w/o CC/MCC
                         \8\.
299...................  Peripheral vascular              299          551       0.7657         24.7         20.6
                         disorders w MCC.
300...................  Peripheral vascular              299          790       0.5711         22.2         18.5
                         disorders w CC.
301...................  Peripheral vascular              299          103       0.4906         19.4         16.2
                         disorders w/o CC/MCC.
302...................  Atherosclerosis w MCC..          302           68       0.6324         22.3         18.6
303...................  Atherosclerosis w/o MCC          302           94       0.5383         20.3         16.9
304...................  Hypertension w MCC \2\.          304           12       0.6513         22.7         18.9
305...................  Hypertension w/o MCC...          304           42       0.5464         22.2         18.5
306...................  Cardiac congenital &             306           54       0.9077         24.2         20.2
                         valvular disorders w
                         MCC.
307...................  Cardiac congenital &             306           39       0.7090         23.1         19.3
                         valvular disorders w/o
                         MCC.
308...................  Cardiac arrhythmia &             308           87       0.8126         24.7         20.6
                         conduction disorders w
                         MCC.
309...................  Cardiac arrhythmia &             308           79       0.5311         20.6         17.2
                         conduction disorders w
                         CC.
310...................  Cardiac arrhythmia &             308           39       0.4341         16.5         13.8
                         conduction disorders w/
                         o CC/MCC.
311...................  Angina pectoris \2\....          311            4       0.6513         22.7         18.9
312...................  Syncope & collapse.....          312           44       0.5159         19.7         16.4
313...................  Chest pain \1\.........          313            5       0.4800         19.9         16.6
314...................  Other circulatory                314        1,393       0.8267         23.0         19.2
                         system diagnoses w MCC.
315...................  Other circulatory                314          426       0.6380         21.6         18.0
                         system diagnoses w CC.
316...................  Other circulatory                314          122       0.5126         19.4         16.2
                         system diagnoses w/o
                         CC/MCC.
326...................  Stomach, esophageal &            326           33       2.0279         36.0         30.0
                         duodenal proc w MCC.
327...................  Stomach, esophageal &            326            9       1.6489         36.5         30.4
                         duodenal proc w CC \5\.
328...................  Stomach, esophageal &            326            1       0.4800         19.9         16.6
                         duodenal proc w/o CC/
                         MCC \1\.
329...................  Major small & large              329           24       1.6489         36.5         30.4
                         bowel procedures w MCC
                         \5\.
330...................  Major small & large              329           20       1.6489         36.5         30.4
                         bowel procedures w CC
                         \5\.
331...................  Major small & large              329            1       0.4800         19.9         16.6
                         bowel procedures w/o
                         CC/MCC \1\.
332...................  Rectal resection w MCC           332            0       1.6489         36.5         30.4
                         \8\.
333...................  Rectal resection w CC            332            0       1.0950         30.3         25.3
                         \8\.
334...................  Rectal resection w/o CC/         332            0       0.8072         24.6         20.5
                         MCC \8\.
335...................  Peritoneal adhesiolysis          335            4       1.6489         36.5         30.4
                         w MCC \5\.
336...................  Peritoneal adhesiolysis          335            2       0.6513         22.7         18.9
                         w CC2.
337...................  Peritoneal adhesiolysis          335            0       0.6513         22.7         18.9
                         w/o CC/MCC \9\.
338...................  Appendectomy w                   338            0       0.8072         24.6         20.5
                         complicated principal
                         diag w MCC \8\.
339...................  Appendectomy w                   338            0       0.6513         22.7         18.9
                         complicated principal
                         diag w CC \8\.
340...................  Appendectomy w                   338            0       0.4800         19.9         16.6
                         complicated principal
                         diag w/o CC/MCC \8\.
341...................  Appendectomy w/o                 341            0       0.8072         24.6         20.5
                         complicated principal
                         diag w MCC \8\.
342...................  Appendectomy w/o                 341            0       0.6513         22.7         18.9
                         complicated principal
                         diag w CC \8\.
343...................  Appendectomy w/o                 341            0       0.4800         19.9         16.6
                         complicated principal
                         diag w/o CC/MCC \8\.
344...................  Minor small & large              344            0       0.8072         24.6         20.5
                         bowel procedures w MCC
                         \8\.
345...................  Minor small & large              344            0       0.6513         22.7         18.9
                         bowel procedures w CC
                         \8\.
346...................  Minor small & large              344            0       0.4800         19.9         16.6
                         bowel procedures w/o
                         CC/MCC \8\.
347...................  Anal & stomal                    347            5       0.8072         24.6         20.5
                         procedures w MCC \3\.
348...................  Anal & stomal                    347            3       0.8072         24.6         20.5
                         procedures w CC \3\.
349...................  Anal & stomal                    347            1       0.4800         19.9         16.6
                         procedures w/o CC/MCC
                         \1\.
350...................  Inguinal & femoral               350            1       1.6489         36.5         30.4
                         hernia procedures w
                         MCC \5\.
351...................  Inguinal & femoral               350            1       1.0950         30.3         25.3
                         hernia procedures w CC
                         \4\.
352...................  Inguinal & femoral               350            1       0.8072         24.6         20.5
                         hernia procedures w/o
                         CC/MCC \3\.
353...................  Hernia procedures                353            0       0.8072         24.6         20.5
                         except inguinal &
                         femoral w MCC \9\.
354...................  Hernia procedures                353            1       0.8072         24.6         20.5
                         except inguinal &
                         femoral w CC \3\.
355...................  Hernia procedures                353            0       0.8072         24.6         20.5
                         except inguinal &
                         femoral w/o CC/MCC \9\.
356...................  Other digestive system           356          107       1.4828         36.0         30.0
                         O.R. procedures w MCC.
357...................  Other digestive system           356           45       1.1816         30.8         25.7
                         O.R. procedures w CC.
358...................  Other digestive system           356            3       0.8072         24.6         20.5
                         O.R. procedures w/o CC/
                         MCC \3\.
368...................  Major esophageal                 368           22       1.0950         30.3         25.3
                         disorders w MCC \4\.
369...................  Major esophageal                 368            8       1.0950         30.3         25.3
                         disorders w CC \4\.
370...................  Major esophageal                 368            1       1.0950         30.3         25.3
                         disorders w/o CC/MCC
                         4, 6.
371...................  Major gastrointestinal           371          667       0.9214         24.0         20.0
                         disorders & peritoneal
                         infections w MCC.
372...................  Major gastrointestinal           371          422       0.6969         22.2         18.5
                         disorders & peritoneal
                         infections w CC.
373...................  Major gastrointestinal           371           55       0.5312         19.8         16.5
                         disorders & peritoneal
                         infections w/o CC/MCC.

[[Page 25105]]

 
374...................  Digestive malignancy w           374          122       0.8609         22.9         19.1
                         MCC.
375...................  Digestive malignancy w           374           83       0.7077         19.7         16.4
                         CC.
376...................  Digestive malignancy w/          374            9       0.4800         19.9         16.6
                         o CC/MCC \1\.
377...................  G.I. hemorrhage w MCC..          377           94       0.7327         22.5         18.8
378...................  G.I. hemorrhage w CC...          377           54       0.6107         21.7         18.1
379...................  G.I. hemorrhage w/o CC/          377           26       0.4401         19.0         15.8
                         MCC.
380...................  Complicated peptic               380           14       0.8072         24.6         20.5
                         ulcer w MCC \3\.
381...................  Complicated peptic               380           17       0.8072         24.6         20.5
                         ulcer w CC \3\.
382...................  Complicated peptic               380            6       0.6513         22.7         18.9
                         ulcer w/o CC/MCC \2\.
383...................  Uncomplicated peptic             383            6       0.8072         24.6         20.5
                         ulcer w MCC \3\.
384...................  Uncomplicated peptic             383            6       0.6513         22.7         18.9
                         ulcer w/o MCC \2\.
385...................  Inflammatory bowel               385           32       0.9337         24.6         20.5
                         disease w MCC.
386...................  Inflammatory bowel               385           26       0.6932         22.9         19.1
                         disease w CC.
387...................  Inflammatory bowel               385            5       0.6932         22.9         19.1
                         disease w/o CC/MCC \6\.
388...................  G.I. obstruction w MCC.          388          189       0.9293         22.7         18.9
389...................  G.I. obstruction w CC..          388           89       0.7306         22.2         18.5
390...................  G.I. obstruction w/o CC/         388           14       0.6513         22.7         18.9
                         MCC \2\.
391...................  Esophagitis, gastroent           391          246       0.9179         24.3         20.3
                         & misc digest
                         disorders w MCC.
392...................  Esophagitis, gastroent           391          270       0.6195         20.4         17.0
                         & misc digest
                         disorders w/o MCC.
393...................  Other digestive system           393          680       1.0363         25.6         21.3
                         diagnoses w MCC.
394...................  Other digestive system           393          385       0.7624         22.1         18.4
                         diagnoses w CC.
395...................  Other digestive system           393           33       0.5956         19.8         16.5
                         diagnoses w/o CC/MCC.
405...................  Pancreas, liver & shunt          405            9       1.6489         36.5         30.4
                         procedures w MCC \5\.
406...................  Pancreas, liver & shunt          405            2       1.6489         36.5         30.4
                         procedures w CC \5\.
407...................  Pancreas, liver & shunt          405            1       1.0950         30.3         25.3
                         procedures w/o CC/MCC
                         \4\.
408...................  Biliary tract proc               408            1       1.6489         36.5         30.4
                         except only cholecyst
                         w or w/o c.d.e. w MCC
                         5, 6.
409...................  Biliary tract proc               408            1       1.6489         36.5         30.4
                         except only cholecyst
                         w or w/o c.d.e. w CC
                         \5\.
410...................  Biliary tract proc               408            0       1.6489         36.5         30.4
                         except only cholecyst
                         w or w/o c.d.e. w/o CC/
                         MCC \9\.
411...................  Cholecystectomy w                411            0       1.0950         30.3         25.3
                         c.d.e. w MCC \9\.
412...................  Cholecystectomy w                411            1       1.0950         30.3         25.3
                         c.d.e. w CC \4\.
413...................  Cholecystectomy w                411            0       1.0950         30.3         25.3
                         c.d.e. w/o CC/MCC \9\.
414...................  Cholecystectomy except           414            2       1.0950         30.3         25.3
                         by laparoscope w/o
                         c.d.e. w MCC \4\.
415...................  Cholecystectomy except           414            3       1.0950         30.3         25.3
                         by laparoscope w/o
                         c.d.e. w CC \4\.
416...................  Cholecystectomy except           414            0       1.0950         30.3         25.3
                         by laparoscope w/o
                         c.d.e. w/o CC/MCC \9\.
417...................  Laparoscopic                     417            7       1.6489         36.5         30.4
                         cholecystectomy w/o
                         c.d.e. w MCC \5\.
418...................  Laparoscopic                     417            5       1.0950         30.3         25.3
                         cholecystectomy w/o
                         c.d.e. w CC \4\.
419...................  Laparoscopic                     417            0       1.0950         30.3         25.3
                         cholecystectomy w/o
                         c.d.e. w/o CC/MCC \9\.
420...................  Hepatobiliary                    420            2       0.8072         24.6         20.5
                         diagnostic procedures
                         w MCC \3\.
421...................  Hepatobiliary                    420            1       0.8072         24.6         20.5
                         diagnostic procedures
                         w CC \3\.
422...................  Hepatobiliary                    420            0       0.8072         24.6         20.5
                         diagnostic procedures
                         w/o CC/MCC \9\.
423...................  Other hepatobiliary or           423           23       1.0950         30.3         25.3
                         pancreas O.R.
                         procedures w MCC \4\.
424...................  Other hepatobiliary or           423            4       0.8072         24.6         20.5
                         pancreas O.R.
                         procedures w CC \3\.
425...................  Other hepatobiliary or           423            1       0.8072         24.6         20.5
                         pancreas O.R.
                         procedures w/o CC/MCC
                         \3\.
432...................  Cirrhosis & alcoholic            432           98       0.6000         18.7         15.6
                         hepatitis w MCC.
433...................  Cirrhosis & alcoholic            432           21       0.6000         18.7         15.6
                         hepatitis w CC \6\.
434...................  Cirrhosis & alcoholic            432            1       0.6000         18.7         15.6
                         hepatitis w/o CC/MCC
                         \6\.
435...................  Malignancy of                    435           48       0.7447         20.2         16.8
                         hepatobiliary system
                         or pancreas w MCC.
436...................  Malignancy of                    435           35       0.7039         20.5         17.1
                         hepatobiliary system
                         or pancreas w CC.
437...................  Malignancy of                    435            4       0.6513         22.7         18.9
                         hepatobiliary system
                         or pancreas w/o CC/MCC
                         \2\.
438...................  Disorders of pancreas            438          251       1.0728         24.3         20.3
                         except malignancy w
                         MCC.
439...................  Disorders of pancreas            438          167       0.7538         21.9         18.3
                         except malignancy w CC.
440...................  Disorders of pancreas            438           29       0.5185         19.0         15.8
                         except malignancy w/o
                         CC/MCC.
441...................  Disorders of liver               441          117       0.7825         21.8         18.2
                         except malig, cirr,
                         alc hepa w MCC.
442...................  Disorders of liver               441           66       0.6893         22.1         18.4
                         except malig, cirr,
                         alc hepa w CC.
443...................  Disorders of liver               441           13       0.6513         22.7         18.9
                         except malig, cirr,
                         alc hepa w/o CC/MCC
                         \2\.
444...................  Disorders of the                 444           71       0.8602         24.0         20.0
                         biliary tract w MCC.

[[Page 25106]]

 
445...................  Disorders of the                 444           39       0.6390         22.2         18.5
                         biliary tract w CC.
446...................  Disorders of the                 444            9       0.4800         19.9         16.6
                         biliary tract w/o CC/
                         MCC \1\.
453...................  Combined anterior/               453            0       1.6489         36.5         30.4
                         posterior spinal
                         fusion w MCC \9\.
454...................  Combined anterior/               453            1       1.6489         36.5         30.4
                         posterior spinal
                         fusion w CC \5\.
455...................  Combined anterior/               453            0       1.6489         36.5         30.4
                         posterior spinal
                         fusion w/o CC/MCC \9\.
456...................  Spinal fusion exc cerv           456            1       1.6489         36.5         30.4
                         w spinal curv, malig
                         or 9+ fusions w MCC
                         \5\.
457...................  Spinal fusion exc cerv           456            0       1.6489         36.5         30.4
                         w spinal curv, malig
                         or 9+ fusions w CC \8\.
458...................  Spinal fusion exc cerv           456            0       1.6489         36.5         30.4
                         w spinal curv, malig
                         or 9+ fusions w/o CC/
                         MCC \9\.
459...................  Spinal fusion except             459            2       1.6489         36.5         30.4
                         cervical w MCC \5\.
460...................  Spinal fusion except             459            3       1.6489         36.5         30.4
                         cervical w/o MCC \5\.
461...................  Bilateral or multiple            461            0       1.6489         36.5         30.4
                         major joint procs of
                         lower extremity w MCC
                         \8\.
462...................  Bilateral or multiple            461            0       1.0950         30.3         25.3
                         major joint procs of
                         lower extremity w/o
                         MCC \8\.
463...................  Wnd debrid & skn grft            463          506       1.4061         38.7         32.3
                         exc hand, for musculo-
                         conn tiss dis w MCC.
464...................  Wnd debrid & skn grft            463          310       1.0963         36.5         30.4
                         exc hand, for musculo-
                         conn tiss dis w CC.
465...................  Wnd debrid & skn grft            463           60       0.8588         28.5         23.8
                         exc hand, for musculo-
                         conn tiss dis w/o CC/
                         MCC.
466...................  Revision of hip or knee          466            3       1.6489         36.5         30.4
                         replacement w MCC \5\.
467...................  Revision of hip or knee          466            4       1.6489         36.5         30.4
                         replacement w CC \5\.
468...................  Revision of hip or knee          466            0       1.6489         36.5         30.4
                         replacement w/o CC/MCC
                         \9\.
469...................  Major joint replacement          469            2       1.6489         36.5         30.4
                         or reattachment of
                         lower extremity w MCC
                         \5\.
470...................  Major joint replacement          469            2       1.6489         36.5         30.4
                         or reattachment of
                         lower extremity w/o
                         MCC \5\.
471...................  Cervical spinal fusion           471            5       1.6489         36.5         30.4
                         w MCC \5\.
472...................  Cervical spinal fusion           471            2       1.0950         30.3         25.3
                         w CC \4\.
473...................  Cervical spinal fusion           471            0       1.0950         30.3         25.3
                         w/o CC/MCC \9\.
474...................  Amputation for                   474           91       1.3850         36.6         30.5
                         musculoskeletal sys &
                         conn tissue dis w MCC.
475...................  Amputation for                   474           52       0.9993         32.7         27.3
                         musculoskeletal sys &
                         conn tissue dis w CC.
476...................  Amputation for                   474           10       0.9993         32.7         27.3
                         musculoskeletal sys &
                         conn tissue dis w/o CC/
                         MCC \6\.
477...................  Biopsies of                      477           13       1.6489         36.5         30.4
                         musculoskeletal system
                         & connective tissue w
                         MCC \5\.
478...................  Biopsies of                      477           14       1.0950         30.3         25.3
                         musculoskeletal system
                         & connective tissue w
                         CC \4\.
479...................  Biopsies of                      477            5       1.0950         30.3         25.3
                         musculoskeletal system
                         & connective tissue w/
                         o CC/MCC \4\.
480...................  Hip & femur procedures           480           10       1.6489         36.5         30.4
                         except major joint w
                         MCC \5\.
481...................  Hip & femur procedures           480           19       1.6489         36.5         30.4
                         except major joint w
                         CC \5\.
482...................  Hip & femur procedures           480            1       1.0950         30.3         25.3
                         except major joint w/o
                         CC/MCC \4\.
483...................  Major joint & limb               483            0       1.6489         36.5         30.4
                         reattachment proc of
                         upper extremity w CC/
                         MCC \8\.
484...................  Major joint & limb               483            0       1.0950         30.3         25.3
                         reattachment proc of
                         upper extremity w/o CC/
                         MCC \8\.
485...................  Knee procedures w pdx            485           10       1.6489         36.5         30.4
                         of infection w MCC \5\.
486...................  Knee procedures w pdx            485            9       1.0950         30.3         25.3
                         of infection w CC \4\.
487...................  Knee procedures w pdx            485            1       1.0950         30.3         25.3
                         of infection w/o CC/
                         MCC \4\.
488...................  Knee procedures w/o pdx          488            2       1.6489         36.5         30.4
                         of infection w CC/MCC
                         \5\.
489...................  Knee procedures w/o pdx          488            0       1.6489         36.5         30.4
                         of infection w/o CC/
                         MCC \9\.
490...................  Back & neck procedures           490            7       1.0950         30.3         25.3
                         except spinal fusion w
                         CC/MCC or disc devices
                         \4\.
491...................  Back & neck procedures           490            0       1.0950         30.3         25.3
                         except spinal fusion w/
                         o CC/MCC \9\.
492...................  Lower extrem & humer             492            5       1.6489         36.5         30.4
                         proc except hip, foot,
                         femur w MCC \5\.
493...................  Lower extrem & humer             492           18       1.0950         30.3         25.3
                         proc except hip, foot,
                         femur w CC \4\.

[[Page 25107]]

 
494...................  Lower extrem & humer             492            2       0.8072         24.6         20.5
                         proc except hip, foot,
                         femur w/o CC/MCC \3\.
495...................  Local excision &                 495           32       1.4142         38.1         31.8
                         removal int fix
                         devices exc hip &
                         femur w MCC.
496...................  Local excision &                 495           26       1.1010         38.3         31.9
                         removal int fix
                         devices exc hip &
                         femur w CC.
497...................  Local excision &                 495            3       1.0950         30.3         25.3
                         removal int fix
                         devices exc hip &
                         femur w/o CC/MCC \4\.
498...................  Local excision &                 498            8       1.6489         36.5         30.4
                         removal int fix
                         devices of hip & femur
                         w CC/MCC \5\.
499...................  Local excision &                 498            2       0.6513         22.7         18.9
                         removal int fix
                         devices of hip & femur
                         w/o CC/MCC \2\.
500...................  Soft tissue procedures           500           46       1.3054         35.2         29.3
                         w MCC.
501...................  Soft tissue procedures           500           27       1.2940         30.9         25.8
                         w CC.
502...................  Soft tissue procedures           500            4       0.8072         24.6         20.5
                         w/o CC/MCC \3\.
503...................  Foot procedures w MCC            503           18       1.0950         30.3         25.3
                         \4\.
504...................  Foot procedures w CC             503           13       0.8072         24.6         20.5
                         \3\.
505...................  Foot procedures w/o CC/          503            1       0.4800         19.9         16.6
                         MCC \1\.
506...................  Major thumb or joint             506            0       0.6513         22.7         18.9
                         procedures \8\.
507...................  Major shoulder or elbow          507            3       0.8072         24.6         20.5
                         joint procedures w CC/
                         MCC \3\.
508...................  Major shoulder or elbow          507            0       0.8072         24.6         20.5
                         joint procedures w/o
                         CC/MCC \9\.
509...................  Arthroscopy \8\........          509            0       0.4800         19.9         16.6
510...................  Shoulder,elbow or                510            0       1.0950         30.3         25.3
                         forearm proc, exc
                         major joint proc w MCC
                         \9\.
511...................  Shoulder,elbow or                510            4       1.0950         30.3         25.3
                         forearm proc, exc
                         major joint proc w CC
                         \4\.
512...................  Shoulder,elbow or                510            1       0.4800         19.9         16.6
                         forearm proc, exc
                         major joint proc w/o
                         CC/MCC \1\.
513...................  Hand or wrist proc,              513            4       1.6489         36.5         30.4
                         except major thumb or
                         joint proc w CC/MCC
                         \5\.
514...................  Hand or wrist proc,              513            4       0.6513         22.7         18.9
                         except major thumb or
                         joint proc w/o CC/MCC
                         \2\.
515...................  Other musculoskelet sys          515           48       1.3557         34.7         28.9
                         & conn tiss O.R. proc
                         w MCC.
516...................  Other musculoskelet sys          515           21       1.0950         30.3         25.3
                         & conn tiss O.R. proc
                         w CC \4\.
517...................  Other musculoskelet sys          515            6       0.8072         24.6         20.5
                         & conn tiss O.R. proc
                         w/o CC/MCC \3\.
533...................  Fractures of femur w             533            3       0.8072         24.6         20.5
                         MCC \3\.
534...................  Fractures of femur w/o           533            7       0.6513         22.7         18.9
                         MCC \2\.
535...................  Fractures of hip &               535           18       0.6513         22.7         18.9
                         pelvis w MCC \2\.
536...................  Fractures of hip &               535           34       0.5447         23.7         19.8
                         pelvis w/o MCC.
537...................  Sprains, strains, &              537            0       0.4800         19.9         16.6
                         dislocations of hip,
                         pelvis & thigh w CC/
                         MCC \8\.
538...................  Sprains, strains, &              537            0       0.4800         19.9         16.6
                         dislocations of hip,
                         pelvis & thigh w/o CC/
                         MCC \8\.
539...................  Osteomyelitis w MCC....          539          932       0.9369         29.7         24.8
540...................  Osteomyelitis w CC.....          539          745       0.7697         28.9         24.1
541...................  Osteomyelitis w/o CC/            539          273       0.6853         26.4         22.0
                         MCC.
542...................  Pathological fractures           542           56       0.7914         21.7         18.1
                         & musculoskelet & conn
                         tiss malig w MCC.
543...................  Pathological fractures           542           61       0.5904         21.3         17.8
                         & musculoskelet & conn
                         tiss malig w CC.
544...................  Pathological fractures           542           18       0.4800         19.9         16.6
                         & musculoskelet & conn
                         tiss malig w/o CC/MCC
                         \1\.
545...................  Connective tissue                545           58       0.9349         24.0         20.0
                         disorders w MCC.
546...................  Connective tissue                545           39       0.5510         20.7         17.3
                         disorders w CC.
547...................  Connective tissue                545           13       0.4800         19.9         16.6
                         disorders w/o CC/MCC
                         \1\.
548...................  Septic arthritis w MCC.          548          166       0.9257         28.1         23.4
549...................  Septic arthritis w CC..          548          187       0.6862         26.4         22.0
550...................  Septic arthritis w/o CC/         548           72       0.5780         23.6         19.7
                         MCC.
551...................  Medical back problems w          551          109       0.8081         26.6         22.2
                         MCC.
552...................  Medical back problems w/         551          248       0.5575         22.8         19.0
                         o MCC.
553...................  Bone diseases &                  553           24       0.6513         22.7         18.9
                         arthropathies w MCC
                         \2\.
554...................  Bone diseases &                  553           66       0.4534         20.5         17.1
                         arthropathies w/o MCC.
555...................  Signs & symptoms of              555           13       0.6513         22.7         18.9
                         musculoskeletal system
                         & conn tissue w MCC
                         \2\.

[[Page 25108]]

 
556...................  Signs & symptoms of              555           15       0.6513         22.7         18.9
                         musculoskeletal system
                         & conn tissue w/o MCC
                         \2\.
557...................  Tendonitis, myositis &           557           86       0.8676         25.9         21.6
                         bursitis w MCC.
558...................  Tendonitis, myositis &           557          113       0.6167         21.4         17.8
                         bursitis w/o MCC.
559...................  Aftercare,                       559        1,366       0.7654         26.2         21.8
                         musculoskeletal system
                         & connective tissue w
                         MCC.
560...................  Aftercare,                       559        1,995       0.6174         24.7         20.6
                         musculoskeletal system
                         & connective tissue w
                         CC.
561...................  Aftercare,                       559        1,074       0.5146         21.6         18.0
                         musculoskeletal system
                         & connective tissue w/
                         o CC/MCC.
562...................  Fx, sprn, strn & disl            562            6       1.0950         30.3         25.3
                         except femur, hip,
                         pelvis & thigh w MCC
                         \4\.
563...................  Fx, sprn, strn & disl            562           23       0.4800         19.9         16.6
                         except femur, hip,
                         pelvis & thigh w/o MCC
                         \1\.
564...................  Other musculoskeletal            564          240       0.8462         24.9         20.8
                         sys & connective
                         tissue diagnoses w MCC.
565...................  Other musculoskeletal            564          225       0.6991         25.1         20.9
                         sys & connective
                         tissue diagnoses w CC.
566...................  Other musculoskeletal            564           75       0.6073         21.6         18.0
                         sys & connective
                         tissue diagnoses w/o
                         CC/MCC.
573...................  Skin graft &/or debrid           573        1,862       1.3619         38.0         31.7
                         for skn ulcer or
                         cellulitis w MCC.
574...................  Skin graft &/or debrid           573        1,898       1.0731         37.1         30.9
                         for skn ulcer or
                         cellulitis w CC.
575...................  Skin graft &/or debrid           573          215       0.8813         31.6         26.3
                         for skn ulcer or
                         cellulitis w/o CC/MCC.
576...................  Skin graft &/or debrid           576           22       1.0950         30.3         25.3
                         exc for skin ulcer or
                         cellulitis w MCC \4\.
577...................  Skin graft &/or debrid           576           24       1.0950         30.3         25.3
                         exc for skin ulcer or
                         cellulitis w CC \4\.
578...................  Skin graft &/or debrid           576            5       0.6513         22.7         18.9
                         exc for skin ulcer or
                         cellulitis w/o CC/MCC
                         \2\.
579...................  Other skin, subcut tiss          579          489       1.3275         36.7         30.6
                         & breast proc w MCC.
580...................  Other skin, subcut tiss          579          414       1.0027         34.9         29.1
                         & breast proc w CC.
581...................  Other skin, subcut tiss          579           35       0.7370         29.7         24.8
                         & breast proc w/o CC/
                         MCC.
582...................  Mastectomy for                   582            3       1.6489         36.5         30.4
                         malignancy w CC/MCC
                         \5\.
583...................  Mastectomy for                   582            0       1.6489         36.5         30.4
                         malignancy w/o CC/MCC
                         \9\.
584...................  Breast biopsy, local             584            2       1.0950         30.3         25.3
                         excision & other
                         breast procedures w CC/
                         MCC \4\.
585...................  Breast biopsy, local             584            0       1.0950         30.3         25.3
                         excision & other
                         breast procedures w/o
                         CC/MCC \9\.
592...................  Skin ulcers w MCC......          592        2,984       0.9267         27.0         22.5
593...................  Skin ulcers w CC.......          592        3,110       0.7339         26.8         22.3
594...................  Skin ulcers w/o CC/MCC.          592          437       0.6369         24.2         20.2
595...................  Major skin disorders w           595           30       0.8062         24.5         20.4
                         MCC.
596...................  Major skin disorders w/          595           54       0.5954         23.9         19.9
                         o MCC.
597...................  Malignant breast                 597           13       0.8072         24.6         20.5
                         disorders w MCC \3\.
598...................  Malignant breast                 597           17       0.6513         22.7         18.9
                         disorders w CC 2, 6.
599...................  Malignant breast                 597            4       0.6513         22.7         18.9
                         disorders w/o CC/MCC
                         2, 6.
600...................  Non-malignant breast             600           12       0.6513         22.7         18.9
                         disorders w CC/MCC \2\.
601...................  Non-malignant breast             600            9       0.6513         22.7         18.9
                         disorders w/o CC/MCC
                         \2\.
602...................  Cellulitis w MCC.......          602          757       0.7127         22.4         18.7
603...................  Cellulitis w/o MCC.....          602        1,492       0.5136         19.4         16.2
604...................  Trauma to the skin,              604           23       0.8072         24.6         20.5
                         subcut tiss & breast w
                         MCC \3\.
605...................  Trauma to the skin,              604           60       0.5413         21.5         17.9
                         subcut tiss & breast w/
                         o MCC.
606...................  Minor skin disorders w           606           60       0.8986         23.2         19.3
                         MCC.
607...................  Minor skin disorders w/          606           84       0.6120         22.6         18.8
                         o MCC.
614...................  Adrenal & pituitary              614            0       1.0950         30.3         25.3
                         proceduresw CC/MCC \8\.
615...................  Adrenal & pituitary              614            0       0.4800         19.9         16.6
                         procedures w/o CC/MCC
                         \8\.
616...................  Amputat of lower limb            616           62       1.5681         41.0         34.2
                         for endocrine,nutrit,&
                         metabol dis w MCC.
617...................  Amputat of lower limb            616          116       1.1395         32.9         27.4
                         for endocrine,nutrit,&
                         metabol dis w CC.
618...................  Amputat of lower limb            616            2       0.8072         24.6         20.5
                         for endocrine,nutrit,&
                         metabol dis w/o CC/MCC
                         \3\.
619...................  O.R. procedures for              619            2       0.8072         24.6         20.5
                         obesity w MCC \3\.
620...................  O.R. procedures for              619            3       0.8072         24.6         20.5
                         obesity w CC 3, 6.
621...................  O.R. procedures for              619            0       0.8072         24.6         20.5
                         obesity w/o CC/MCC \9\.

[[Page 25109]]

 
622...................  Skin grafts & wound              622          165       1.2199         35.6         29.7
                         debrid for endoc,
                         nutrit & metab dis w
                         MCC.
623...................  Skin grafts & wound              622          338       0.9703         32.2         26.8
                         debrid for endoc,
                         nutrit & metab dis w
                         CC.
624...................  Skin grafts & wound              622           15       0.8072         24.6         20.5
                         debrid for endoc,
                         nutrit & metab dis w/o
                         CC/MCC \3\.
625...................  Thyroid, parathyroid &           625            0       1.6489         36.5         30.4
                         thyroglossal
                         procedures w MCC \8\.
626...................  Thyroid, parathyroid &           625            0       1.0950         30.3         25.3
                         thyroglossal
                         procedures w CC \8\.
627...................  Thyroid, parathyroid &           625            0       0.4800         19.9         16.6
                         thyroglossal
                         procedures w/o CC/MCC
                         \8\.
628...................  Other endocrine, nutrit          628           52       1.4033         35.9         29.9
                         & metab O.R. proc w
                         MCC.
629...................  Other endocrine, nutrit          628           88       1.1143         33.3         27.8
                         & metab O.R. proc w CC.
630...................  Other endocrine, nutrit          628            5       0.4800         19.9         16.6
                         & metab O.R. proc w/o
                         CC/MCC \1\.
637...................  Diabetes w MCC.........          637          363       0.8347         25.8         21.5
638...................  Diabetes w CC..........          637        1,041       0.6491         24.1         20.1
639...................  Diabetes w/o CC/MCC....          637          114       0.5241         20.1         16.8
640...................  Nutritional & misc               640          606       0.8190         23.2         19.3
                         metabolic disorders w
                         MCC.
641...................  Nutritional & misc               640          620       0.6364         22.0         18.3
                         metabolic disorders w/
                         o MCC.
642...................  Inborn errors of                 642            4       0.6513         22.7         18.9
                         metabolism 2.
643...................  Endocrine disorders w            643           27       0.8880         27.3         22.8
                         MCC.
644...................  Endocrine disorders w            643           18       0.8072         24.6         20.5
                         CC \3\.
645...................  Endocrine disorders w/o          643            6       0.4800         19.9         16.6
                         CC/MCC \1\.
652...................  Kidney transplant \7\..          652            0       0.0000          0.0          0.0
653...................  Major bladder                    653            0       1.0950         30.3         25.3
                         procedures w MCC \8\.
654...................  Major bladder                    653            0       0.6513         22.7         18.9
                         procedures w CC \8\.
655...................  Major bladder                    653            0       0.4800         19.9         16.6
                         procedures w/o CC/MCC
                         \8\.
656...................  Kidney & ureter                  656            0       0.8072         24.6         20.5
                         procedures for
                         neoplasm w MCC \9\.
657...................  Kidney & ureter                  656            1       0.8072         24.6         20.5
                         procedures forneoplasm
                         w CC \3\.
658...................  Kidney & ureter                  656            0       0.8072         24.6         20.5
                         procedures for
                         neoplasm w/o CC/MCC
                         \9\.
659...................  Kidney & ureter                  659            9       1.0950         30.3         25.3
                         procedures for non-
                         neoplasm w MCC \4\.
660...................  Kidney & ureter                  659            4       0.6513         22.7         18.9
                         procedures for non-
                         neoplasm w CC2.
661...................  Kidney & ureter                  659            1       0.4800         19.9         16.6
                         procedures for non-
                         neoplasm w/o CC/MCC
                         \1\.
662...................  Minor bladder                    662            2       0.8072         24.6         20.5
                         procedures w MCC \3\.
663...................  Minor bladder                    662            0       0.8072         24.6         20.5
                         procedures w CC9.
664...................  Minor bladder                    662            1       1.6489         36.5         30.4
                         procedures w/o CC/MCC
                         \5\.
665...................  Prostatectomy w MCC \3\          665            2       0.8072         24.6         20.5
666...................  Prostatectomy w CC \8\.          665            0       0.8072         24.6         20.5
667...................  Prostatectomy w/o CC/            665            1       0.8072         24.6         20.5
                         MCC \3\.
668...................  Transurethral                    668            8       1.6489         36.5         30.4
                         procedures w MCC \5\.
669...................  Transurethral                    668            5       1.6489         36.5         30.4
                         procedures w CC \5\.
670...................  Transurethral                    668            1       1.6489         36.5         30.4
                         procedures w/o CC/MCC
                         \5\.
671...................  Urethral procedures w            671            0       0.6513         22.7         18.9
                         CC/MCC \8\.
672...................  Urethral procedures w/o          671            0       0.4800         19.9         16.6
                         CC/MCC \8\.
673...................  Other kidney & urinary           673          226       1.3376         33.5         27.9
                         tract procedures w MCC.
674...................  Other kidney & urinary           673           87       1.1684         30.6         25.5
                         tract procedures w CC.
675...................  Other kidney & urinary           673           13       1.0950         30.3         25.3
                         tract procedures w/o
                         CC/MCC \4\.
682...................  Renal failure w MCC....          682        1,334       0.8784         23.6         19.7
683...................  Renal failure w CC.....          682          726       0.7271         21.9         18.3
684...................  Renal failure w/o CC/            682          184       0.5951         20.1         16.8
                         MCC.
685...................  Admit for renal                  685           50       0.7543         25.9         21.6
                         dialysis.
686...................  Kidney & urinary tract           686           31       0.9234         23.6         19.7
                         neoplasms w MCC.
687...................  Kidney & urinary tract           686           17       0.6513         22.7         18.9
                         neoplasms w CC2.
688...................  Kidney & urinary tract           686            3       0.4800         19.9         16.6
                         neoplasms w/o CC/MCC
                         \1\.
689...................  Kidney & urinary tract           689          760       0.6796         22.8         19.0
                         infections w MCC.
690...................  Kidney & urinary tract           689          727       0.5158         20.2         16.8
                         infections w/o MCC.
691...................  Urinary stones w esw             691            4       1.6489         36.5         30.4
                         lithotripsy w CC/MCC
                         \5\.
692...................  Urinary stones w esw             691            0       1.6489         36.5         30.4
                         lithotripsy w/o CC/MCC
                         \9\.
693...................  Urinary stones w/o esw           693           16       0.6513         22.7         18.9
                         lithotripsy w MCC \2\.
694...................  Urinary stones w/ot esw          693           12       0.6513         22.7         18.9
                         lithotripsy w/o MCC 2,
                         6.
695...................  Kidney & urinary tract           695            4       0.8072         24.6         20.5
                         signs & symptoms w MCC
                         \3\.
696...................  Kidney & urinary tract           695            1       0.4800         19.9         16.6
                         signs & symptoms w/o
                         MCC \1\.
697...................  Urethral stricture \8\.          697            0       0.4800         19.9         16.6
698...................  Other kidney & urinary           698          270       0.8112         22.7         18.9
                         tract diagnoses w MCC.
699...................  Other kidney & urinary           698          155       0.7032         22.2         18.5
                         tract diagnoses w CC.
700...................  Other kidney & urinary           698           52       0.5387         20.2         16.8
                         tract diagnoses w CC.

[[Page 25110]]

 
707...................  Major male pelvic                707            0       0.6513         22.7         18.9
                         procedures w CC/MCC
                         \8\.
708...................  Major male pelvic                707            0       0.4800         19.9         16.6
                         procedures w/o CC/MCC
                         \8\.
709...................  Penis procedures w CC/           709            6       1.0950         30.3         25.3
                         MCC \4\.
710...................  Penis procedures w/o CC/         709            0       1.0950         30.3         25.3
                         MCC \9\.
711...................  Testes procedures w CC/          711            7       1.0950         30.3         25.3
                         MCC 4, 6.
712...................  Testes procedures w/o            711            1       1.0950         30.3         25.3
                         CC/MCC 4, 6.
713...................  Transurethral                    713            1       1.6489         36.5         30.4
                         prostatectomy w CC/MCC
                         \5\.
714...................  Transurethral                    713            1       0.4800         19.9         16.6
                         prostatectomy w/o CC/
                         MCC \1\.
715...................  Other male reproductive          715            1       1.6489         36.5         30.4
                         system O.R. proc for
                         malignancy w CC/MCC
                         \5\.
716...................  Other male reproductive          715            0       1.6489         36.5         30.4
                         system O.R. proc for
                         malignancy w/o CC/MCC
                         \9\.
717...................  Other male reproductive          717           17       1.0950         30.3         25.3
                         system O.R. proc exc
                         malignancy w CC/MCC
                         \4\.
718...................  Other male reproductive          717            2       0.4800         19.9         16.6
                         system O.R. proc exc
                         malignancy w/o CC/MCC
                         \1\.
722...................  Malignancy, male                 722           12       0.8072         24.6         20.5
                         reproductive system w
                         MCC \3\.
723...................  Malignancy, male                 722            7       0.6513         22.7         18.9
                         reproductive system w
                         CC2.
724...................  Malignancy, male                 722            2       0.4800         19.9         16.6
                         reproductive system w/
                         o CC/MCC \1\.
725...................  Benign prostatic                 725            2       1.0950         30.3         25.3
                         hypertrophy w MCC \4\.
726...................  Benign prostatic                 725            3       0.4800         19.9         16.6
                         hypertrophy w/o MCC
                         \1\.
727...................  Inflammation of the              727           37       0.8768         25.9         21.6
                         male reproductive
                         system w MCC.
728...................  Inflammation of the              727           57       0.5605         20.9         17.4
                         male reproductive
                         system w/o MCC.
729...................  Other male reproductive          729           34       1.0242         26.6         22.2
                         system diagnoses w CC/
                         MCC.
730...................  Other male reproductive          729            2       0.6513         22.7         18.9
                         system diagnoses w/o
                         CC/MCC \2\.
734...................  Pelvic evisceration,             734            0       1.0950         30.3         25.3
                         rad hysterectomy & rad
                         vulvectomy w CC/MCC
                         \8\.
735...................  Pelvic evisceration,             734            0       0.4800         19.9         16.6
                         rad hysterectomy & rad
                         vulvectomy w/o CC/MCC
                         \8\.
736...................  Uterine & adnexa proc            736            0       1.0950         30.3         25.3
                         for ovarian or adnexal
                         malignancy w MCC \8\.
737...................  Uterine & adnexa proc            736            0       0.8072         24.6         20.5
                         for ovarian or adnexal
                         malignancy w CC \8\.
738...................  Uterine & adnexa proc            736            0       0.4800         19.9         16.6
                         for ovarian or adnexal
                         malignancy w/o CC/MCC
                         \8\.
739...................  Uterine, adnexa proc             739            0       1.0950         30.3         25.3
                         for non-ovarian/
                         adnexal malig w MCC
                         \8\.
740...................  Uterine, adnexa proc             739            0       0.8072         24.6         20.5
                         for non-ovarian/
                         adnexal malig w CC \8\.
741...................  Uterine, adnexa proc             739            0       0.4800         19.9         16.6
                         for non-ovarian/
                         adnexal malig w/o CC/
                         MCC \8\.
742...................  Uterine & adnexa proc            742            0       0.8072         24.6         20.5
                         for non-malignancy w
                         CC/MCC \8\.
743...................  Uterine & adnexa proc            742            0       0.4800         19.9         16.6
                         for non-malignancy w/o
                         CC/MCC \8\.
744...................  D&C, conization,                 744            1       0.6513         22.7         18.9
                         laparascopy & tubal
                         interruption w CC/MCC
                         \2\.
745...................  D&C, conization,                 744            0       0.6513         22.7         18.9
                         laparascopy & tubal
                         interruption w/o CC/
                         MCC \9\.
746...................  Vagina, cervix & vulva           746            3       0.8072         24.6         20.5
                         procedures w CC/MCC
                         \3\.
747...................  Vagina, cervix & vulva           746            0       0.8072         24.6         20.5
                         procedures w/o CC/MCC
                         \9\.
748...................  Female reproductive              748            0       0.8072         24.6         20.5
                         system reconstructive
                         procedures \8\.
749...................  Other female                     749            3       0.8072         24.6         20.5
                         reproductive system
                         O.R. procedures w CC/
                         MCC \3\.
750...................  Other female                     749            0       0.8072         24.6         20.5
                         reproductive system
                         O.R. procedures w/o CC/
                         MCC \9\.
754...................  Malignancy, female               754           14       1.0950         30.3         25.3
                         reproductive system w
                         MCC \4\.
755...................  Malignancy, female               754           15       0.8072         24.6         20.5
                         reproductive system w
                         CC \3\.
756...................  Malignancy, female               754            1       0.4800         19.9         16.6
                         reproductive system w/
                         o CC/MCC \1\.
757...................  Infections, female               757           29       0.8441         22.6         18.8
                         reproductive system w
                         MCC.
758...................  Infections, female               757           25       0.8274         27.2         22.7
                         reproductive system w
                         CC.
759...................  Infections, female               757            5       0.4800         19.9         16.6
                         reproductive system w/
                         o CC/MCC \1\.
760...................  Menstrual & other                760            3       1.0950         30.3         25.3
                         female reproductive
                         system disorders w CC/
                         MCC \4\.
761...................  Menstrual & other                760            1       0.4800         19.9         16.6
                         female reproductive
                         system disorders w/o
                         CC/MCC \1\.
765...................  Cesarean section w CC/           765            0       0.6513         22.7         18.9
                         MCC \8\.

[[Page 25111]]

 
766...................  Cesarean section w/o CC/         765            0       0.6513         22.7         18.9
                         MCC \8\.
767...................  Vaginal delivery w               767            0       0.6513         22.7         18.9
                         sterilization &/or
                         D&C8.
768...................  Vaginal delivery w O.R.          768            0       0.6513         22.7         18.9
                         proc except steril &/
                         or D&C8.
769...................  Postpartum & post                769            1       0.6513         22.7         18.9
                         abortion diagnoses w
                         O.R. procedure \2\.
770...................  Abortion w D&C,                  770            0       0.6513         22.7         18.9
                         aspiration curettage
                         or hysterotomy \8\.
774...................  Vaginal delivery w               774            0       0.6513         22.7         18.9
                         complicating diagnoses
                         \8\.
775...................  Vaginal delivery w/o             775            0       0.6513         22.7         18.9
                         complicating diagnoses
                         \8\.
776...................  Postpartum & post                776            3       1.0950         30.3         25.3
                         abortion diagnoses w/o
                         O.R. procedure \4\.
777...................  Ectopic pregnancy \8\..          777            0       0.6513         22.7         18.9
778...................  Threatened abortion \8\          778            0       0.4800         19.9         16.6
779...................  Abortion w/o D&C \8\...          779            0       0.4800         19.9         16.6
780...................  False labor \8\........          780            0       0.4800         19.9         16.6
781...................  Other antepartum                 781            1       1.0950         30.3         25.3
                         diagnoses w medical
                         complications \4\.
782...................  Other antepartum                 782            0       0.4800         19.9         16.6
                         diagnoses w/o medical
                         complications \8\.
789...................  Neonates, died or                789            0       0.4800         19.9         16.6
                         transferred to another
                         acute care facility
                         \8\.
790...................  Extreme immaturity or            790            0       0.4800         19.9         16.6
                         respiratory distress
                         syndrome, neonate \8\.
791...................  Prematurity w major              791            0       1.0950         30.3         25.3
                         problems \8\.
792...................  Prematurity w/o major            792            0       0.4800         19.9         16.6
                         problems \8\.
793...................  Full term neonate w              793            0       1.0950         30.3         25.3
                         major problems \8\.
794...................  Neonate w other                  794            0       1.0950         30.3         25.3
                         significant problems
                         \8\.
795...................  Normal newborn \8\.....          795            0       0.4800         19.9         16.6
799...................  Splenectomy w MCC \8\..          799            0       1.0950         30.3         25.3
800...................  Splenectomy w CC \8\...          799            0       0.8072         24.6         20.5
801...................  Splenectomy w/o CC/MCC           799            0       0.8072         24.6         20.5
                         \8\.
802...................  Other O.R. proc of the           802            7       1.6489         36.5         30.4
                         blood & blood forming
                         organs w MCC \5\.
803...................  Other O.R. proc of the           802            3       0.6513         22.7         18.9
                         blood & blood forming
                         organs w CC2.
804...................  Other O.R. proc of the           802            0       0.6513         22.7         18.9
                         blood & blood forming
                         organs w/o CC/MCC \9\.
808...................  Major hematol/immun              808           26       0.8185         22.7         18.9
                         diag exc sickle cell
                         crisis & coagul w MCC.
809...................  Major hematol/immun              808           24       0.8072         24.6         20.5
                         diag exc sickle cell
                         crisis & coagul w CC
                         \3\.
810...................  Major hematol/immun              808            3       0.8072         24.6         20.5
                         diag exc sickle cell
                         crisis & coagul w/o CC/
                         MCC \3\.
811...................  Red blood cell                   811           35       0.6773         22.8         19.0
                         disorders w MCC.
812...................  Red blood cell                   811           48       0.5210         19.5         16.3
                         disorders w/o MCC.
813...................  Coagulation disorders..          813           49       0.7876         21.5         17.9
814...................  Reticuloendothelial &            814           40       0.7805         22.6         18.8
                         immunity disorders w
                         MCC.
815...................  Reticuloendothelial &            814           17       0.6513         22.7         18.9
                         immunity disorders w
                         CC2.
816...................  Reticuloendothelial &            814            6       0.6513         22.7         18.9
                         immunity disorders w/o
                         CC/MCC 2, 6.
820...................  Lymphoma & leukemia w            820            0       0.8072         24.6         20.5
                         major O.R. procedure w
                         MCC \9\.
821...................  Lymphoma & leukemia w            820            2       0.8072         24.6         20.5
                         major O.R. procedure w
                         CC \3\.
822...................  Lymphoma & leukemia w            820            0       0.8072         24.6         20.5
                         major O.R. procedure w/
                         o CC/MCC \9\.
823...................  Lymphoma & non-acute             823           12       1.0950         30.3         25.3
                         leukemia w other O.R.
                         proc w MCC \4\.
824...................  Lymphoma & non-acute             823            3       1.0950         30.3         25.3
                         leukemia w other O.R.
                         proc w CC \4\.
825...................  Lymphoma & non-acute             823            1       0.4800         19.9         16.6
                         leukemia w other O.R.
                         proc w/o CC/MCC \1\.
826...................  Myeloprolif disord or            826            1       0.8072         24.6         20.5
                         poorly diff neopl w
                         maj O.R. proc w MCC
                         \3\.
827...................  Myeloprolif disord or            826            0       0.8072         24.6         20.5
                         poorly diff neopl w
                         maj O.R. proc w CC \8\.
828...................  Myeloprolif disord or            826            0       0.8072         24.6         20.5
                         poorly diff neopl w
                         maj O.R. proc w/o CC/
                         MCC \?\.
829...................  Myeloprolif disord or            829            9       1.6489         36.5         30.4
                         poorly diff neopl w
                         other O.R. proc w CC/
                         MCC \5\.
830...................  Myeloprolif disord or            829            0       1.6489         36.5         30.4
                         poorly diff neopl w
                         other O.R. proc w/o CC/
                         MCC \9\.

[[Page 25112]]

 
834...................  Acute leukemia w/o               834           20       0.8072         24.6         20.5
                         major O.R. procedure w
                         MCC \3\.
835...................  Acute leukemia w/o               834            3       0.8072         24.6         20.5
                         major O.R. procedure w
                         CC \3\.
836...................  Acute leukemia w/o               834            1       0.4800         19.9         16.6
                         major O.R. procedure w/
                         o CC/MCC \1\.
837...................  Chemo w acute leukemia           837            1       1.6489         36.5         30.4
                         as sdxor w high dose
                         chemo agent w MCC \5\.
838...................  Chemo w acute leukemia           837            2       0.8072         24.6         20.5
                         as sdx or w high dose
                         chemo agent w CC \3\.
839...................  Chemo w acute leukemia           837            0       0.8072         24.6         20.5
                         as sdx or w high dose
                         chemo agent w/o CC/MCC
                         \9\.
840...................  Lymphoma & non-acute             174       0.8758         20.8         17.3
                         leukemia w MCC ENT>840.
841...................  Lymphoma & non-acute             840           65       0.7405         20.1         16.8
                         leukemia w CC.
842...................  Lymphoma & non-acute             840           11       0.6513         22.7         18.9
                         leukemia w/o CC/MCC
                         \2\.
843...................  Other myeloprolif dis            843           19       1.0950         30.3         25.3
                         or poorly diff neopl
                         diag w MCC 4, 6.
844...................  Other myeloprolif dis            843           13       1.0950         30.3         25.3
                         or poorly diff neopl
                         diag w CC 4, 6.
845...................  Other myeloprolif dis            843            3       1.0950         30.3         25.3
                         or poorly diff neopl
                         diag w/o CC/MCC 4, 6.
846...................  Chemotherapy w/o acute           846           31       1.8155         37.9         31.6
                         leukemia as secondary
                         diagnosis w MCC.
847...................  Chemotherapy w/o acute           846           61       1.3078         27.6         23.0
                         leukemia as secondary
                         diagnosis w CC.
848...................  Chemotherapy w/o acute           846            1       0.6513         22.7         18.9
                         leukemia as secondary
                         diagnosis w/o CC/MCC
                         \2\.
849...................  Radiotherapy...........          849          141       0.8756         23.5         19.6
853...................  Infectious & parasitic           853          698       1.7901         38.1         31.8
                         diseases w O.R.
                         procedure w MCC.
854...................  Infectious & parasitic           853           94       1.1472         31.0         25.8
                         diseases w O.R.
                         procedure w CC.
855...................  Infectious & parasitic           853            3       0.8072         24.6         20.5
                         diseases w O.R.
                         procedure w/o CC/MCC
                         \3\.
856...................  Postoperative or post-           856          338       1.5473         36.2         30.2
                         traumatic infections w
                         O.R. proc w MCC.
857...................  Postoperative or post-           856          230       1.0438         31.6         26.3
                         traumatic infections w
                         O.R. proc w CC.
858...................  Postoperative or post-           856           30       0.8873         27.9         23.3
                         traumatic infections w
                         O.R. proc w/o CC/MCC.
862...................  Postoperative & post-            862        1,172       0.9120         25.1         20.9
                         traumatic infections w
                         MCC.
863...................  Postoperative & post-            862        1,298       0.6802         23.4         19.5
                         traumatic infections w/
                         o MCC.
864...................  Fever of unknown origin          864           16       0.6513         22.7         18.9
                         \2\.
865...................  Viral illness w MCC....          865           56       0.8213         21.8         18.2
866...................  Viral illness w/o MCC..          865           33       0.5498         21.2         17.7
867...................  Other infectious &               867          293       1.1329         23.6         19.7
                         parasitic diseases
                         diagnoses w MCC.
868...................  Other infectious &               867           80       0.7220         22.0         18.3
                         parasitic diseases
                         diagnoses w CC.
869...................  Other infectious &               867           11       0.4800         19.9         16.6
                         parasitic diseases
                         diagnoses w/o CC/MCC
                         \1\.
870...................  Septicemia w MV 96+              870          585       1.9084         30.4         25.3
                         hours.
871...................  Septicemia w/o MV 96+            871        3,871       0.8437         23.5         19.6
                         hours w MCC.
872...................  Septicemia w/o MV 96+            871        1,532       0.6551         21.8         18.2
                         hours w/o MCC.
876...................  O.R. procedure w                 876            5       0.4800         19.9         16.6
                         principal diagnoses of
                         mental illness \1\.
880...................  Acute adjustment                 880           21       1.0950         30.3         25.3
                         reaction &
                         psychosocial
                         dysfunction \4\.
881...................  Depressive neuroses \1\          881           15       0.4800         19.9         16.6
882...................  Neuroses except                  882           16       0.4800         19.9         16.6
                         depressive \1\.
883...................  Disorders of                     883           15       0.4800         19.9         16.6
                         personality & impulse
                         control \1\.
884...................  Organic disturbances &           884          201       0.4785         23.2         19.3
                         mental retardation.
885...................  Psychoses..............          885        1,386       0.4066         23.7         19.8
886...................  Behavioral &                     886           18       0.4800         19.9         16.6
                         developmental
                         disorders \1\.
887...................  Other mental disorder            887            0       0.4800         19.9         16.6
                         diagnoses \8\.
894...................  Alcohol/drug abuse or            894            1       0.4800         19.9         16.6
                         dependence, left ama
                         \1\.
895...................  Alcohol/drug abuse or            895            1       0.4800         19.9         16.6
                         dependence w
                         rehabilitation therapy
                         \1\.
896...................  Alcohol/drug abuse or            896           10       0.8072         24.6         20.5
                         dependence w/o
                         rehabilitation therapy
                         w MCC \3\.
897...................  Alcohol/drug abuse or            896           24       0.6513         22.7         18.9
                         dependence w/o
                         rehabilitation therapy
                         w/o MCC \2\.
901...................  Wound debridements for           901          222       1.4003         35.2         29.3
                         injuries w MCC.
902...................  Wound debridements for           901          159       1.0434         33.4         27.8
                         injuries w CC.
903...................  Wound debridements for           901           23       0.6513         22.7         18.9
                         injuries w/o CC/MCC
                         \2\.
904...................  Skin grafts for                  904           87       1.3377         40.7         33.9
                         injuries w CC/MCC.
905...................  Skin grafts for                  904            8       0.6513         22.7         18.9
                         injuries w/o CC/MCC
                         \2\.

[[Page 25113]]

 
906...................  Hand procedures for              906            1       0.4800         19.9         16.6
                         injuries \1\.
907...................  Other O.R. procedures            907           85       1.7294         36.8         30.7
                         for injuries w MCC.
908...................  Other O.R. procedures            907           44       1.1963         34.2         28.5
                         for injuries w CC.
909...................  Other O.R. procedures            907            7       1.0950         30.3         25.3
                         for injuries w/o CC/
                         MCC \4\.
913...................  Traumatic injury w MCC.          913           50       0.9333         26.8         22.3
914...................  Traumatic injury w/o             913           70       0.5330         21.3         17.8
                         MCC.
915...................  Allergic reactions w             915            0       0.4800         19.9         16.6
                         MCC \9\.
916...................  Allergic reactions w/o           915            1       0.4800         19.9         16.6
                         MCC \1\.
917...................  Poisoning & toxic                917            7       0.6513         22.7         18.9
                         effects of drugs w MCC
                         \2\.
918...................  Poisoning & toxic                917            6       0.6513         22.7         18.9
                         effects of drugs w/o
                         MCC \2\.
919...................  Complications of                 919        1,066       1.0291         26.2         21.8
                         treatment w MCC.
920...................  Complications of                 919          811       0.7703         24.6         20.5
                         treatment w CC.
921...................  Complications of                 919          113       0.6374         22.6         18.8
                         treatment w/o CC/MCC.
922...................  Other injury, poisoning          922            5       0.4800         19.9         16.6
                         & toxic effect diag w
                         MCC \1\.
923...................  Other injury, poisoning          922            9       0.4800         19.9         16.6
                         & toxic effect diag w/
                         o MCC \1\.
927...................  Extensive burns or full          927            0       1.0950         30.3         25.3
                         thickness burns w MV
                         96+ hrs w skin graft
                         \8\.
928...................  Full thickness burn w            928           10       1.0950         30.3         25.3
                         skin graft or inhal
                         inj w CC/MCC \4\.
929...................  Full thickness burn w            928            1       0.6513         22.7         18.9
                         skin graft or inhal
                         inj w/o CC/MCC \2\.
933...................  Extensive burns or full          933            7       1.0950         30.3         25.3
                         thickness burns w MV
                         96+ hrs w/o skin graft
                         \4\.
934...................  Full thickness burn w/o          934           48       0.6866         24.2         20.2
                         skin grft or inhal inj.
935...................  Non-extensive burns....          935           40       0.7294         24.9         20.8
939...................  O.R. proc w diagnoses            939          378       1.2925         33.8         28.2
                         of other contact w
                         health services w MCC.
940...................  O.R. proc w diagnoses            939          210       1.0280         33.9         28.3
                         of other contact w
                         health services w CC.
941...................  O.R. proc w diagnoses            939           38       0.7470         28.9         24.1
                         of other contact w
                         health services w/o CC/
                         MCC.
945...................  Rehabilitation w CC/MCC          945        2,173       0.5928         22.3         18.6
946...................  Rehabilitation w/o CC/           945          527       0.4271         18.9         15.8
                         MCC.
947...................  Signs & symptoms w MCC.          947           88       0.6459         22.8         19.0
948...................  Signs & symptoms w/o             947          168       0.5300         23.5         19.6
                         MCC.
949...................  Aftercare w CC/MCC.....          949        4,486       0.6728         22.1         18.4
950...................  Aftercare w/o CC/MCC...          949          839       0.4847         18.5         15.4
951...................  Other factors                    951           38       1.2107         24.0         20.0
                         influencing health
                         status.
955...................  Craniotomy for multiple          955            0       1.6489         36.5         30.4
                         significant trauma \8\.
956...................  Limb reattachment, hip           956            1       0.6513         22.7         18.9
                         & femur proc for
                         multiple significant
                         trauma \2\.
957...................  Other O.R. procedures            957            3       1.6489         36.5         30.4
                         for multiple
                         significant trauma w
                         MCC \5\.
958...................  Other O.R. procedures            957            1       1.0950         30.3         25.3
                         for multiple
                         significant trauma w
                         CC \4\.
959...................  Other O.R. procedures            957            0       1.0950         30.3         25.3
                         for multiple
                         significant trauma w/o
                         CC/MCC \9\.
963...................  Other multiple                   963           12       0.8072         24.6         20.5
                         significant trauma w
                         MCC \3\.
964...................  Other multiple                   963            9       0.6513         22.7         18.9
                         significant trauma w
                         CC \2\.
965...................  Other multiple                   963            3       0.6513         22.7         18.9
                         significant trauma w/o
                         CC/MCC \2\.
969...................  HIV w extensive O.R.             969            7       1.6489         36.5         30.4
                         procedure w MCC \5\.
970...................  HIV w extensive O.R.             969            3       1.6489         36.5         30.4
                         procedure w/o MCC \5\.
974...................  HIV w major related              974          160       0.9279         21.8         18.2
                         condition w MCC.
975...................  HIV w major related              974           70       0.6707         20.7         17.3
                         condition w CC.
976...................  HIV w major related              974           43       0.6703         19.2         16.0
                         condition w/o CC/MCC.
977...................  HIV w or w/o other               977           21       0.6513         22.7         18.9
                         related condition \2\.
981...................  Extensive O.R.                   981        1,065       2.2695         41.8         34.8
                         procedure unrelated to
                         principal diagnosis w
                         MCC.
982...................  Extensive O.R.                   981          279       1.4994         37.8         31.5
                         procedure unrelated to
                         principal diagnosis w
                         CC.
983...................  Extensive O.R.                   981           24       1.0950         30.3         25.3
                         procedure unrelated to
                         principal diagnosis w/
                         o CC/MCC \4\.
984...................  Prostatic O.R.                   984           14       1.6489         36.5         30.4
                         procedure unrelated to
                         principal diagnosis w
                         MCC \5\.
985...................  Prostatic O.R.                   984           13       1.0950         30.3         25.3
                         procedure unrelated to
                         principal diagnosis w
                         CC \4\.
986...................  Prostatic O.R.                   984            1       1.0950         30.3         25.3
                         procedure unrelated to
                         principal diagnosis w/
                         o CC/MCC \4\.

[[Page 25114]]

 
987...................  Non-extensive O.R. proc          987          391       1.8112         37.9         31.6
                         unrelated to principal
                         diagnosis w MCC.
988...................  Non-extensive O.R. proc          987          182       1.0902         33.0         27.5
                         unrelated to principal
                         diagnosis w CC.
989...................  Non-extensive O.R. proc          987           21       0.8072         24.6         20.5
                         unrelated to principal
                         diagnosis w/o CC/MCC
                         \3\.
998...................  Ungroupable \7\........          998            0       0.0000          0.0          0.0
999...................  Principal diagnosis              999            0       0.0000          0.0         0.0
                         invalid as discharge
                         diagnosis \7\.
----------------------------------------------------------------------------------------------------------------
\1\ Proposed relative weights for these proposed MS-LTC-DRGs were determined by assigning these cases to
  proposed low-volume quintile 1.
\2\ Proposed relative weights for these proposed MS-LTC-DRGs were determined by assigning these cases to
  proposed low-volume quintile 2.
\3\ Proposed relative weights for these proposed MS-LTC-DRGs were determined by assigning these cases to
  proposed low-volume quintile 3.
\4\ Proposed relative weights for these proposed MS-LTC-DRGs were determined by assigning these cases to
  proposed low-volume quintile 4.
\5\ Proposed relative weights for these proposed MS-LTC-DRGs were determined by assigning these cases to
  proposed low-volume quintile 5.
\6\ Proposed relative weights for these proposed MS-LTC-DRGs were determined after adjusting to account for
  nonmonotonicity (see step 4 in section II.I.4. of the Addendum of this proposed rule).
\7\ Proposed relative weights for these proposed MS-LTC-DRGs were assigned a proposed relative weight of 0.0000.
 
\8\ Proposed relative weights for these proposed MS-LTC-DRGs were determined by cross-walking these cases to the
  appropriate proposed MS-LTC-DRG and then assigning them to the appropriate proposed low volume quintile
  because they had no LTCH cases in the FY 2006 MedPAR file (see step 5 in section II.I.4 of the Addendum of
  this proposed rule).
\9\ Proposed relative weights for these proposed MS-LTC-DRGs were determined by combining with its base MS-LTC-
  DRG because they had no LTCH cases in the FY 2006 MedPAR file (see step 5 in section II.I.4 of the Addendum of
  this proposed rule).

Appendix A--Regulatory Impact Analysis

I. Overall Impact

    We have examined the impacts of this proposed rule as required 
by Executive Order 12866 (September 1993, Regulatory Planning and 
Review) and the Regulatory Flexibility Act (RFA) (September 19, 
1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, 
the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and 
Executive Order 13132.
    Executive Order 12866 (as amended by Executive Order 13258, 
which merely reassigns responsibility of duties) 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 rule is a major rule as defined in 
5 U.S.C. 804(2). We estimate that the proposed changes for FY 2008 
operating and capital payments will redistribute in excess of $100 
million among different types of inpatient cases. The market basket 
update to the IPPS rates required by the statute, in conjunction 
with other proposed payment changes in this proposed rule, would 
result in an approximate $3.3 billion increase in FY 2008 operating 
and capital payments. This amount does not reflect changes in 
hospital admissions or case-mix intensity in operating PPS payments, 
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 
considered to be small entities, either by nonprofit status or by 
having revenues of $31 million in any 1 year. (For details on the 
latest standards for health care providers, we refer readers to the 
Small Business Administration Web site at: http://sba.gov/idc/groups/pubic/documents/sba_homepage/serv_sstd_tablepdf.pdf.) 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. We believe that this 
proposed rule will have a significant impact on small entities as 
explained in this Appendix. Because we acknowledge that many of the 
affected entities are small entities, the analysis discussed 
throughout the preamble of this proposed rule constitutes our 
initial regulatory flexibility analysis. Therefore, we are 
soliciting comments on our estimates and analysis of the impact of 
the proposed rule on those small entities.
    In addition, section 1102(b) of the Act requires us to prepare a 
regulatory impact analysis for any proposed rule that may have a 
significant impact on the operations of a substantial number of 
small rural hospitals. This analysis must conform to the provisions 
of section 603 of the RFA. With the exception of hospitals located 
in certain New England counties, for purposes of section 1102(b) of 
the Act, we previously defined a small rural hospital as a hospital 
with fewer than 100 beds that is located outside of a Metropolitan 
Statistical Area (MSA) or New England County Metropolitan Area 
(NECMA). However, under the current 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 that 
is located outside of an MSA and has fewer than 100 beds. 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 rule whose mandates require spending in 
any 1 year of $100 million in 1995 dollars, updated annually for 
inflation. That threshold level is currently approximately $120 
million. This proposed rule will not mandate any requirements for 
State, local, or tribal governments, nor will it affect private 
sector costs.
    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. As stated above, this proposed rule would 
not have a substantial effect on State and local governments.
    The following analysis, in conjunction with the remainder of 
this document, demonstrates that this rule is consistent with the 
regulatory philosophy and principles identified in Executive Order 
12866, the RFA, and section 1102(b) of the Act. The 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.

[[Page 25115]]

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 
Hospital Insurance Trust Fund.
    We believe the proposed changes in this proposed rule would 
further each of these goals while maintaining the financial 
viability of the hospital industry and ensuring access to high 
quality health care for Medicare beneficiaries. We expect that these 
proposed changes would ensure that the outcomes of this payment 
system are reasonable and equitable while avoiding or minimizing 
unintended adverse consequences.

III. Limitations of Our Analysis

    The following quantitative analysis presents the projected 
effects of our proposed policy changes, as well as statutory changes 
effective for FY 2008, on various hospital groups. We estimate the 
effects of individual proposed policy changes by estimating payments 
per case while holding all other payment policies constant. We use 
the best data available, but, generally, we do not attempt to 
predict behavioral responses to our proposed policy changes, and we 
do not make adjustments for future changes in such variables as 
admissions, lengths of stay, or case-mix. However, we believe that 
adoption of the MS-DRGs proposed in this proposed rule would create 
a risk of increased aggregate levels of payment as a result of more 
comprehensive documentation and coding. As explained earlier in this 
proposed rule, the Secretary has broad discretion under section 
1886(d)(3)(A)(vi) of the Act to adjust the standardized amount so as 
to eliminate the effect of changes in coding or classification of 
discharges that do not reflect real changes in case-mix. Using this 
authority, the Medicare Actuary estimates that an adjustment of 4.8 
percent over 2 years will be necessary to maintain budget neutrality 
for the transition to the MS-DRGs. We are proposing to reduce the 
IPPS standardized amounts by -2.4 percent each year for FY 2008 and 
FY 2009. The payment impacts shown below illustrate the impact of 
changes in hospital payment, including the proposed -2.4 percent 
adjustment to the IPPS standardized amounts both prior to and 
following the assumed growth in case-mix. As we have done in the 
previous rules, we are soliciting comments and information about the 
anticipated effects of these proposed changes on hospitals and our 
methodology for estimating them.

IV. Hospitals Included In and Excluded From the IPPS

    The prospective payment systems for hospital inpatient operating 
and capital-related costs encompass nearly all general short-term, 
acute care hospitals that participate in the Medicare program. There 
were 35 Indian Health Service hospitals in our database, which we 
excluded from the analysis due to the special characteristics of the 
prospective payment methodology for these hospitals. Among other 
short-term, acute care hospitals, only the 45 such hospitals in 
Maryland remain excluded from the IPPS under the waiver at section 
1814(b)(3) of the Act.
    As of March 2007, there are 3,535 IPPS hospitals to be included 
in our analysis. This represents about 59 percent of all Medicare-
participating hospitals. The majority of this impact analysis 
focuses on this set of hospitals. There are also approximately 1,283 
CAHs. These small, limited service hospitals are paid on the basis 
of reasonable costs rather than under the IPPS. There are also 1,186 
specialty hospitals and 2,315 specialty units that are excluded from 
the IPPS. These specialty hospitals include IPFs, IRFs, LTCHs, 
RNHCIs, children's hospitals, and cancer hospitals. Proposed changes 
in payments for IPFs and IRFs are made through other separate 
rulemaking. Payment impacts for these specialty hospitals and units, 
other than the reasonable cost updates for IPFs paid under a blend, 
are not included in this proposed rule. There is also a separate 
rule to update and propose changes to the LTCHs for its July 1 to 
June 30 rate year. However, we have traditionally used the IPPS rule 
to update the LTCH relative weights because the LTCH PPS uses the 
same DRGs as the IPPS, resulting in the LTCH relative weights being 
recalibrated according to the same schedule as the IPPS (that is, 
for each Federal fiscal year). The impacts of our proposed policy 
changes on LTCHs, where applicable, are discussed below.

V. Effects on Excluded Hospitals and Hospital Units

    As of March 2007, there were 1,197 hospitals excluded from the 
IPPS. Of these 1,187 hospitals, 483 IPFs, 6 LTCHs, 81 children's 
hospitals, 11 cancer hospitals, and 16 RNHCIs are either being paid, 
on a reasonable cost basis or have a portion of the PPS payment 
based on a reasonable cost subject to the rate-of-increase ceiling 
under Sec.  413.40. The remaining providers, 216 IRFs and 371 LTCHs, 
are paid 100 percent of the Federal prospective rate under the IRF 
PPS and the LTCH PPS, respectively. As stated above, IRFs and IPFS 
are not affected by this proposed rule. The impacts of the changes 
to LTCHs are discussed separately below. In addition, there are 
1,283 IPFs co-located in hospitals otherwise subject to IPPS, paid 
on a blend of the IPF PPS per diem payment and the reasonable cost-
based payment and 996 IRFs (paid under the IRF PPS) co-located 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 93 IPPS excluded hospitals and units in Maryland that are 
paid in accordance with the waiver at section 1814(b)(3) of the Act.
    In the past, hospitals and units excluded from the IPPS have 
been paid based on their reasonable costs subject to limits as 
established by the Tax Equity and Fiscal Responsibility Act of 1982 
(TEFRA). Hospitals that continue to be paid fully on a reasonable 
cost basis are subject to TEFRA limits for FY 2008. For these 
hospitals (cancer and children's hospitals), consistent with section 
1886(b)(3)(B)(ii) of the Act, the proposed update will be the 
percentage increase in the FY 2008 IPPS operating market basket, 
currently estimated to be 3.3 percent. In addition, in accordance 
with Sec.  403.752(a) of the regulations, RNHCIs are paid under 
Sec.  413.40, which also uses section 1886(b)(3)(B)(ii) of the Act 
to update the percentage increase in the rate-of-increase limits. 
For RNHCIs, the update will be the percentage increase in the FY 
2008 IPPS operating market basket increase, currently estimated to 
be 3.3 percent.
    Effective for cost reporting periods beginning on or after 
October 1, 2002, LTCHs that elected to be paid based on 100 percent 
of the LTCH PPS rule are paid, based on a Federal prospective 
payment amount that is updated annually. Existing LTCHs would 
receive a PPS blended payment that consisted of the Federal 
prospective payment rate and a reasonable cost-based payment rate 
over a 5-year transition period, unless the LTCH elected 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. In accordance with Sec.  412.533, for cost reporting periods 
beginning on or after October 1, 2006, the LTCH PPS transition blend 
percentages are 100 percent of the Federal prospective payment 
amount and zero percent of the PPS amount calculated under 
reasonable cost principles. FY 2007 was the fifth year of the 5-year 
transition period established under Sec.  412.533. Because the 
reasonable cost principles amount is zero percent for cost reporting 
periods beginning during FY 2008, LTCHs no longer receive a portion 
of their payment that is based in part on a reasonable cost subject 
to the rate-of-increase ceiling. Thus, there is no longer a need for 
an update factor for LTCHs' TEFRA target amount for FY 2008.
    The final rule implementing the IPF PPS (69 FR 66922) 
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 3.4 percent.
    The impact on excluded hospitals and hospital units of the 
proposed 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,

[[Page 25116]]

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.

VI. Quantitative Effects of the Proposed Policy Changes Under the IPPS 
for Operating Costs

A. Basis and Methodology of Estimates

    In this proposed rule, we are announcing proposed policy changes 
and proposed payment rate updates for the IPPS for operating costs. 
Proposed 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, we estimate that 
proposed total FY 2008 operating payments would increase 3.3 percent 
compared to FY 2007 largely due to the statutorily mandated update 
to the IPPS rates. This amount reflects an adjustment of -2.4 
percent to the IPPS standardized amounts to offset an anticipated 
increase in payments resulting from improved documentation and 
coding that does not represent real increases in underlying resource 
demands and patient acuity due to the proposed adoption of MS-DRGs. 
The impacts do not illustrate changes in hospital admissions or real 
case-mix intensity, which would also affect overall payment changes.
    We have prepared separate impact analyses of the proposed 
changes to each system. This section deals with proposed changes to 
the operating prospective payment system. Our payment simulation 
model relies on the most recent available data to enable us to 
estimate the impacts on payments per case of certain changes in this 
proposed rule. However, there are other proposed changes for which 
we do not have data available that would allow us to estimate the 
payment impacts using this model. For those proposed changes, we 
have attempted to predict the payment impacts based upon our 
experience and other more limited data.
    The data used in developing the quantitative analyses of 
proposed changes in payments per case presented below are taken from 
the FY 2006 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, in this analysis, we do not make adjustments for future 
changes in such variables as admissions, lengths of stay, or 
underlying growth in real case-mix. Second, due to the 
interdependent nature of the IPPS payment components, it is very 
difficult to precisely quantify the impact associated with each 
proposed change. Third, we use 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 FY 2006 MedPAR file, we simulated payments 
under the operating IPPS given various combinations of payment 
parameters. Any short-term, acute care hospitals not paid under the 
IPPS (Indian Health Service hospitals and hospitals in Maryland) 
were excluded from the simulations. The impact of payments under the 
capital IPPS, or the impact of payments for costs other than 
inpatient operating costs, are not analyzed in this section. 
Estimated payment impacts of proposed FY 2008 changes to the capital 
IPPS are discussed in section VIII of this Appendix. The proposed 
changes discussed separately below are the following:
     The effects of the proposed annual reclassification of 
diagnoses and procedures and the proposed recalibration of the DRG 
relative weights required by section 1886(d)(4)(C) of the Act.
     The effects of the proposed changes in hospitals' wage 
index values reflecting wage data from hospitals' cost reporting 
periods beginning during FY 2004, compared to the FY 2003 wage data.
     The effects of the proposed wage and recalibration 
budget neutrality factors.
     The effects of the expiration of the 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 the expiration of the 3-year provision 
for applying an imputed rural floor to States that have no rural 
areas and to States that have rural areas but no IPPS hospitals are 
located in those areas (69 FR 49109).
     The effects of geographic reclassifications by the 
MGCRB that will be effective in FY 2008.
     The effects of the proposed adjustment to the 
application of the rural floor budget neutrality provision on the 
wage index instead of on the standardized amount.
     The effects of the September 30, 2007 expiration of 
section 508 of Pub. L. 108-173, which allowed qualifying hospitals 
to appeal the wage index classification otherwise 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).
     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 effect of the budget neutrality adjustment being 
made for the adoption of the proposed MS-DRGs under section 
1886(d)(3)(A)(iv) of the Act for the change in aggregate payments 
that is a result of changes in the coding or classification of 
discharges that do not reflect real changes in case-mix.
     The total estimated change in payments based on 
proposed FY 2008 policies relative to payments based on FY 2007 
policies.
    To illustrate the impacts of the proposed FY 2008 changes, our 
analysis begins with a FY 2007 baseline simulation model using: the 
proposed FY 2008 update of 3.3 percent; the FY 2007 DRG GROUPER 
(Version 24.0); the most current CBSA designations for hospitals 
based on OMB's MSA definitions; the FY 2007 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)(viii) of the Act, as added by section 
5001(a) of Pub. L. 109-171, provides that for FY 2007 and subsequent 
years, the update factor will be reduced by 2.0 percentage points 
for any hospital that does not submit quality data in a form and 
manner and at a time specified by the Secretary. At the time this 
impact was prepared, 147 providers did not receive the full market 
basket rate-of-increase for FY 2007 because they failed the quality 
data submission process. For purposes of the simulations shown 
below, we modeled the proposed payment changes for FY 2008 using a 
reduced update for these 147 hospitals. However, we do not have 
enough information to determine which hospitals will not receive the 
full market basket rate-of-increase for FY 2008 at this time.
    Each proposed and statutory policy change is then added 
incrementally to this baseline, finally arriving at an FY 2008 model 
incorporating all of the proposed changes. This simulation allows us 
to isolate the effects of each proposed change.
    Our final comparison illustrates the proposed percent change in 
payments per case from FY 2007 to FY 2008. 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 are updating the standardized 
amounts for FY 2008 using the most recently forecasted hospital 
market basket increase for FY 2008 of 3.3 percent. (Hospitals that 
fail to comply with the quality data submission requirement to 
receive the full update will receive an update reduced by 2.0 
percentage points to 1.3 percent.) Under section 1886(b)(3)(B)(iv) 
of the Act, the updates to the hospital-specific amounts for SCHs 
and for MDHs are also equal to the market basket increase, or 3.3 
percent.
    A second significant factor that affects the proposed changes in 
hospitals' payments per case from FY 2007 to FY 2008 is the change 
in a hospital's geographic reclassification status from one year to 
the next. That is, payments may be reduced for hospitals 
reclassified in FY 2007 that are no longer reclassified in FY 2008. 
Conversely, payments may increase for hospitals not reclassified in 
FY 2007 that are reclassified in FY 2008. Particularly with the 
expiration of section 508 of Pub. L. 108-173, the reclassification 
provision, 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.
    A third significant factor is that we currently estimate that 
actual outlier payments during FY 2007 will be 4.9 percent of total 
DRG payments. When the FY 2007 final rule was published, we 
projected FY 2007 outlier payments would be 5.1 percent

[[Page 25117]]

of total DRG plus outlier payments; the average standardized amounts 
were offset correspondingly. The effects of the lower than expected 
outlier payments during FY 2008 (as discussed in the Addendum to 
this proposed rule) are reflected in the analyses below comparing 
our current estimates of FY 2007 payments per case to estimated FY 
2008 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 the proposed 
changes for FY 2008. 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 3,535 hospitals included 
in the analysis.
    The next four rows of Table I contain hospitals categorized 
according to their geographic location: All urban, which is further 
divided into large urban and other urban; and rural. There are 2,540 
hospitals located in urban areas included in our analysis. Among 
these, there are 1,409 hospitals located in large urban areas 
(populations over 1 million), and 1,131 hospitals in other urban 
areas (populations of 1 million or fewer). In addition, there are 
995 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 2008 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 (including 
reclassifications under section 1886(d)(8)(B) and section 
1886(d)(8)(E) of the Act that have implications for capital 
payments) are 2,619, 1,436, 1,183 and 916, respectively.
    The next three groupings examine the impacts of the proposed 
changes on hospitals grouped by whether or not they have GME 
residency programs (teaching hospitals that receive an IME 
adjustment) or receive DSH payments, or some combination of these 
two adjustments. There are 2,479 nonteaching hospitals in our 
analysis, 816 teaching hospitals with fewer than 100 residents, and 
240 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 together hospitals 
considered urban after geographic reclassification, in terms of 
whether they receive the IME adjustment, the DSH adjustment, both, 
or neither.
    The next five rows examine the impacts of the proposed changes 
on rural hospitals by special payment groups (SCHs, RRCs, and MDHs), 
as well as rural hospitals not receiving a special payment 
designation. There were 59 RRCs, 45 SCHs, 21 MDHs, 17 hospitals that 
are both SCHs and RRCs, and 1 hospital that is both MDH and RRC.
    The next series of groupings concern the geographic 
reclassification status of hospitals. The first grouping displays 
all urban hospitals that were reclassified by the MGCRB for FY 2008. 
The second grouping shows the MGCRB rural reclassifications.
    The final two groupings are based on the type of ownership and 
the hospital's Medicare utilization expressed as a percent of total 
patient days. These data were taken from the FY 2004 Medicare cost 
reports.
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C. Effects of the Proposed Changes to the DRG Reclassifications and 
Relative Cost-Based Weights (Column 2)

    In Column 2 of Table I, we present the combined effects of the 
proposed DRG reclassifications and recalibration, as discussed in 
section II. of the preamble to this proposed rule. Section 
1886(d)(4)(C)(i) of the Act requires us annually to make appropriate 
classification changes in order to reflect changes in treatment 
patterns, technology, and any other factors that may change the 
relative use of hospital resources.
    As discussed in the preamble of this proposed rule, we are 
proposing to continue the 3-year transition from charge-based to 
cost-based relative weights. The proposed relative weights for FY 
2008 will be \2/3\ cost-based and \1/3\ charge-based. Further, we 
are proposing to adopt MS-DRGs that would increase the number of 
DRGs from 538 to 745. In column 2, we compare aggregate payments 
using the proposed FY 2008 MS-DRGS (GROUPER Version 25.0) and 
blended relative weights to the FY 2007 CMS DRG blended relative 
weights (GROUPER Version 24.0). The proposed methods of calculating 
the relative weights and the reclassification changes to the GROUPER 
are described in more detail in section II.H. of the preamble to 
this proposed rule. We note that, consistent with section 
1886(d)(4)(C)(iii) of the Act, we are proposing to apply a budget 
neutrality factor to ensure that the overall payment impact of the 
proposed DRG changes (combined with the proposed wage index changes) 
is budget neutral. This proposed budget neutrality factor of 
0.999317 is applied to payments in Column 4 and not Column 2 because 
it is a combined DRG reclassification and recalibration and wage 
index budget neutrality factor.
    We estimate that proposed changes to the relative weights and 
DRGs will increase payments to hospitals located in large urban 
areas (populations over 1 million) by approximately 0.9 percent. 
These changes generally increase payments to hospitals in all urban 
areas (0.4 percent) and large teaching hospitals (0.7 percent). 
Rural hospitals will generally experience a decrease in payments 
from these changes (-1.8 percent). However, it is important to 
evaluate these changes together with the cost weights that we 
adopted in the FY 2007 IPPS final rule. We are adopting cost weights 
over a transition period from FY 2007 to FY 2009. The cost weights 
generally increased payments to rural hospitals. Column 2 shows the 
changes for the proposed rule only and therefore reflects the full 
payment impact of the MS-DRGs while showing only the FY 2008 portion 
of the transition to cost weights finalized in last year's rule. In 
FY 2007, we are paying hospitals using a blend of \1/3\ cost and \2/
3\ charge relative weights. In FY 2008, we will pay hospitals using 
a blend of \2/3\ cost and \1/3\ charge relative weights. In FY 2009, 
we will pay hospitals using 100 percent cost relative weights. 
Therefore, there will likely be some additional increases in 
payments to rural hospitals from the final year of the transition to 
fully implemented cost weights that are not illustrated in the above 
table. Cardiac specialty hospitals would experience the greatest 
decline in payments (4.0 percent) from the proposed changes to adopt 
MS-DRGs and the blended relative cost weights.

D. Effects of Proposed Wage Index Changes (Column 3)

    Section 1886(d)(3)(E) of the Act requires that, beginning 
October 1, 1993, we annually update the wage data used to calculate 
the wage index. In accordance with this requirement, the proposed 
wage index for FY 2008 is based on data submitted for hospital cost 
reporting periods beginning on or after October 1, 2003 and before 
October 1, 2004.
    The estimated impact of the proposed wage data on hospital 
payments is isolated in Column 3 by holding the other payment 
parameters constant in this simulation. That is, Column 3 shows the 
percentage changes in payments when going from a model using the FY 
2007 wage index, based on FY 2003 wage data and having a 100-percent 
occupational mix adjustment applied, to a model using the FY 2008 
pre-reclassification wage index, adjusted for occupational mix, 
based on FY 2004 wage data. The wage data collected on the FY 2004 
cost report include overhead costs for contract labor that were not 
collected on FY 2003 and earlier cost reports. The impacts below 
incorporate the effects of the FY 2004 wage data collected on 
hospital cost reports, including additional overhead costs for 
contract labor compared to the wage data from FY 2003 cost reports 
that were used to calculate the FY 2007 wage index.
    Column 3 shows the impacts of updating the wage data using FY 
2004 cost reports. Overall, the new wage data will lead to a -0.1 
percent change for all hospitals. This decrease could be attributed 
to fluctuations in the wage data. Among the regions, the largest 
increase is in the rural Pacific region, which experiences a 0.5 
percent increase. The largest decline from updating the wage data is 
seen in the Puerto Rico region (a 0.5 percent decrease).
    In looking at the wage data itself, the national average hourly 
wage increased 4.3 percent compared to FY 2007. Therefore, the only 
manner in which to maintain or exceed the previous year's wage index 
was to match or exceed the national 4.3 percent increase in average 
hourly wage. Of the 3,486 hospitals with wage data for both FYs 2007 
and 2008, 1,709, or 49.0 percent, experienced an average hourly wage 
increase of 4.3 percent or more.
    The following chart compares the shifts in wage index values for 
hospitals for FY 2008 relative to FY 2007. Among urban hospitals, 52 
will experience an increase of more than 5 percent and less than 10 
percent and 6 will experience an increase of more than 10 percent. 
Among rural hospitals, 21 will experience an increase of more than 5 
percent and less than 10 percent, and 4 will experience an increase 
of more than 10 percent. However, 965 rural hospitals will 
experience increases or decreases of less than 5 percent, while 
2,384 urban hospitals will experience increases or decreases of less 
than 5 percent. Thirty-three urban hospitals will experience 
decreases in their wage index values of more than 5 percent and less 
than 10 percent. Twenty-one urban hospitals will experience 
decreases in their wage index values of greater than 10 percent. No 
rural hospitals will experience decreases of more than 5 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.....................          6          4
Increase more than 5 percent and less than 10              52         21
 percent..........................................
Increase or decrease less than 5 percent..........      2,384        965
Decrease more than 5 percent and less than 10              33          0
 percent..........................................
Decrease more than 10 percent.....................         21          0
------------------------------------------------------------------------

E. Combined Effects of Proposed DRG and Wage Index Changes (Column 
4)

    Section 1886(d)(4)(C)(iii) of the Act requires that changes to 
DRG reclassifications and the relative weights cannot increase or 
decrease aggregate payments. In addition, section 1886(d)(3)(E) of 
the Act specifies that any updates or adjustments to the wage index 
are to be budget neutral. As noted in the Addendum to this proposed 
rule, in determining the budget neutrality factor, we equated 
simulated aggregate payments for FY 2007 and FY 2008 using the FY 
2006 Medicare utilization data after applying the proposed changes 
to the DRG relative weights and the wage index.
    We computed a wage and DRG recalibration budget neutrality 
factor of 0.999317. The 0.0 percent impact for all hospitals 
demonstrates that these proposed changes, in combination with the 
proposed budget neutrality factor, are budget neutral. In Table I, 
the combined overall impacts of the effects of both the proposed DRG 
reclassifications and the updated wage index are shown in Column 4. 
The estimated changes shown in this column reflect the combined 
effects of the proposed changes in Columns 2 and 3 and the budget 
neutrality factor for the revised FY 2008 wage index.

[[Page 25125]]

Due to the proposed changes to the application of the rural floor 
budget neutrality, this column does not include the wage index floor 
for urban areas as required by section 4410 of Pub. L. 105-33. The 
effects of that provision are included in Column 7. There also may 
be some variation of plus or minus 0.1 percentage point due to 
rounding.

F. Effects of the Expiration of the 3-Year Provision Allowing Urban 
Hospitals That Were Converted to Rural as a Result of the FY 2005 
Labor Market Area Changes To Maintain the Wage Index of the Urban 
Labor Market Area in Which They Were Formerly Located (Column 5)

    The policy adopted in FY 2005 for urban hospitals that became 
rural under the new labor market area definitions is to expire in FY 
2008. In FY 2005, we adopted a policy that allowed urban hospitals 
that became rural under the new labor market area regions 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. 
Beginning in FY 2008, these hospitals will receive their statewide 
rural wage index or their FY 2008 MGCRB reclassified wage index. 
Column 5 shows the impact of the expiration of the labor market area 
transition for those hospitals that were urban under the old labor 
market area designations and are now considered rural hospitals. 
Currently, the rural hospital row shows a 0.2 percent decrease from 
the end of the provision as these hold harmless hospitals are now 
considered geographically rural and are now receiving the wage index 
of the MSA where they are currently located.

G. Effects of MGCRB Reclassifications (Column 6)

    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 other bases than where they are geographically located). 
The proposed changes in Column 6 reflect the per case payment impact 
of moving from this baseline to a simulation incorporating the MGCRB 
decisions for FY 2008 which 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 proposed FY 2008 wage index values incorporate 
all of the MGCRB's reclassification decisions for FY 2008. The wage 
index values also reflect any decisions made by the CMS 
Administrator through the appeals and review process through 
February 28, 2007.
    The overall effect of geographic reclassification is required by 
section 1886(d)(8)(D) of the Act to be budget neutral. Therefore, we 
are proposing to apply an adjustment of 0.991938 to ensure that the 
effects of the section 1886(d)(10) reclassifications are budget 
neutral. (See section II.A. of the Addendum to this proposed rule.) 
Geographic reclassification generally benefits hospitals in rural 
areas. We estimate that geographic reclassification will increase 
payments to rural hospitals by an average of 1.7 percent.

H. Effects of the Adjustment to the Application of the Rural Floor 
(Column 7)

    As discussed in section III.G. of the preamble of this proposed 
rule, section 4410 of Pub. L. 105-33 established the rural floor by 
requiring that the wage index for a hospital in any urban area 
cannot be less than the area wage index determined for the state's 
rural area. Since FY 1998, we have implemented this provision by 
adjusting the standardized amounts. In this proposed rule, we are 
proposing to change how we apply budget neutrality to the rural 
floor beginning in FY 2008. Rather than applying a budget neutrality 
adjustment to the standardized amount, a uniform budget neutrality 
adjustment would be applied to the wage index. Therefore, we are 
proposing to apply an adjustment to the wage index of 0.997084 (-
0.29 percent) to ensure that the rural floor adjustments are budget 
neutral as indicated by the zero effect on payments to hospitals 
overall.
    Column 7 shows the projected impact of change in the application 
of the rural floor. The column compares the post-reclassification FY 
2008 wage index of providers before the rural floor adjustment and 
the post-reclassification FY 2008 wage index of providers with the 
rural floor adjustment. Only urban hospitals can benefit from the 
rural floor provision. Because the provision is budget neutral, all 
other hospitals (that is, all rural hospitals and those urban 
hospitals to which the adjustment is not made) will experience a 
decrease in payments due to the budget neutrality adjustment. We 
project rural hospitals will experience a 0.1 percent decrease in 
payments. We project hospitals located in other urban areas 
(populations of 1 million or fewer) will experience a 0.1 percent 
increase in payments. The rural floor will benefit 77 percent of the 
hospitals in New Hampshire (10) and 45 percent of the hospitals in 
Connecticut (15), explaining the average increase of 1 percent shown 
in the table for hospitals located in New England. The average 
increase among hospitals in the Pacific region is estimated at 0.4 
percent and is explained by application of the rural floor to 34 
percent of the hospitals in California (114) and 18 percent of the 
hospitals in Washington (9).

I. Effects of the Expiration of the Imputed Rural Floor (Column 8)

    The FY 2005 IPPS final rule (69 FR 49109) established a 
temporary imputed rural floor for all urban States from FY 2005 to 
FY 2007. The rural floor requires that an urban wage index cannot be 
lower than the wage index for any rural hospital in that State. 
Therefore, an imputed rural floor was established for States that do 
not have rural areas or rural IPPS hospitals. The provision will 
expire at the end of FY 2007 unless we were to adopt a change to the 
regulation to continue it for FY 2008.
    Column 8 shows the effects of the expiration of the imputed 
rural floor. Only hospitals located in Massachusetts and New Jersey 
were affected by the provision. However, as explained in section 
III.G. of the preamble of this proposed rule, the imputed rural 
floor will no longer apply in Massachusetts even if it were to be 
continued because one hospital acquired rural status under Sec.  
412.103 of the regulations. Urban providers in New England (MA) and 
the Mid-Atlantic region (NJ) will experience a decrease by 0.1 
percent and by 0.2 percent respectively from the imputed rural floor 
no longer being applied in those States.

J. Effects of the Expiration of Section 508 of Pub. L. 108-173 
(Column 9)

    Section 508 of Pub. L. 108-173 will expire on September 30, 
2007. As stated in the FY 2007 IPPS final rule (71 FR 48333), we 
established procedural rules under section 1886(d)(10)(D)(v) of the 
Act to address specific circumstances where individual and group 
reclassifications involve a section 508 hospital. In the final rule, 
the rules were designed to recognize the special circumstances of 
section 508 hospital reclassifications ending mid-year during FY 
2007 and were intended to allow previously approved 
reclassifications to continue through March 31, 2007, and new 
section 1886(d)(10) reclassifications to begin April 1, 2007, upon 
the conclusion of the section 508 reclassifications. Under these 
procedural rules, some section 1886(d)(10) hospital 
reclassifications are only in effect for the second half of the 
fiscal year. However, Division B, Title I, section 106(a) of the 
MIEA-TRHCA (Pub. L. 109-432) extended any geographic 
reclassifications of hospitals that would expire on March 31, 2007, 
by 6 months until September 30, 2007. For FY 2008, the providers 
that had been reclassified under section 508 in FY 2007 will receive 
payment using the wage index for the area where they are currently 
located. The impact of the expiration of the policy is modeled in 
Column 9 of Table I. Section 508 of Pub. L. 108-173 was not a budget 
neutral provision of statute. Its enactment increased total payments 
for Medicare inpatient hospital services. Therefore, relative to FY 
2007, the expiration of section 508 of Pub. L. 108-173 will reduce 
Medicare inpatient hospital payments by an estimated 0.1 percent.

K. Effects of the Proposed Wage Index Adjustment for Out-Migration 
(Column 10)

    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, post-
reclassification 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. With the out-migration adjustment, rural 
providers will experience a 0.1 percent increase in payments in FY 
2008 relative to

[[Page 25126]]

no adjustment at all. We included these additional payments to 
providers in the impact table shown above, and we estimate the 
impact of these providers receiving the out-migration increase to be 
approximately $15 million.

L. Effects of All Proposed Changes With CMI Adjustment Prior to 
Assumed Growth (Column 11)

    Column 11 compares our estimate of payments per case between FY 
2007 and FY 2008 with all proposed changes reflected in this 
proposed rule for FY 2008 including a 0.976 adjustment to the 
payment rates to account for anticipated improvements in 
documentation and coding that is expected to increase case-mix. We 
generally apply an adjustment to the DRGs to ensure budget 
neutrality assuming constant utilization. However, with the proposed 
adoption of the MS-DRGs, the number of DRGs will expand from 538 to 
745. Therefore, we expect an increase in the CMI due to improved 
coding and have applied an additional adjustment to achieve budget 
neutrality. However, because we modeled the impact, including the 
adjustment for anticipated case-mix increase but not the actual 
case-mix increase itself in column 11, this column illustrates a 
total payment changes that is less than what is anticipated to 
occur.

M. Effects of All Proposed Changes With CMI Adjustment and Assumed 
Growth (Column 12)

    Column 12 compares our estimate of payments per case between FY 
2007 and FY 2008, incorporating all proposed changes reflected in 
this proposed rule for FY 2008 (including statutory changes). This 
column includes all of the proposed policy changes and assumes the 
2.4 percent increase in case-mix from improved documentation and 
coding will occur equally across all hospitals.
    Column 12 reflects the impact of all proposed FY 2008 changes 
relative to FY 2007, including those shown in Columns 2 through 10. 
The average increase for all hospitals is approximately 3.3 percent. 
This increase includes the effects of the proposed 3.3 percent 
market basket update. It also reflects the 0.2 percentage point 
difference between the projected outlier payments in FY 2008 (5.1 
percent of total DRG payments) and the current estimate of the 
percentage of actual outlier payments in FY 2007 (4.9 percent), as 
described in the introduction to this Appendix and the Addendum to 
this proposed rule. As a result, payments are projected to be 0.2 
percentage points lower in FY 2007 than originally estimated, 
resulting in a 0.2 percentage point greater increase for FY 2008 
than would otherwise occur. In addition, the impact of expiration of 
section 508 of Pub. L. 108-173 reclassification accounts for a 0.1 
percent decrease in estimated payments. As stated earlier, section 
1886(d)(13) of the Act 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. This provision of 
the statute is not budget neutral. Although the out-migration 
adjustment will increase payments to some hospitals in FY 2008 
relative to not having an adjustment at all, the total number of 
hospitals receiving the adjustment will be less in FY 2008 than FY 
2007, resulting in a 0.1 percent reduction in total IPPS payments. 
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 product of 
the percentage changes described above.
    The proposed overall change in payments per case for hospitals 
in FY 2008 is estimated to increase by 3.3 percent. Hospitals in 
urban areas would experience an estimated 3.6 percent increase in 
payments per case compared to FY 2007. Hospitals in large urban 
areas would experience an estimated 4.2 percent increase and 
hospitals in other urban areas would experience an estimated 2.8 
percent increase in payments per case in FY 2008. Hospitals' 
payments per case in rural areas are estimated to increase 0.9 
percent.
    Among urban census divisions, the largest estimated payment 
increases would be 4.7 percent in the Pacific region and 4.2 percent 
in the South Atlantic region. The smallest urban increase is 
estimated at 2.6 percent in the New England region.
    Among rural regions in Column 12, the providers in the West 
South Central region experience an estimated decrease in payments by 
0.7 percent. The Pacific and South Atlantic regions would benefit 
the most, with 2.0 and 1.8 percent estimated increases, 
respectively.
    Among special categories of rural hospitals in Column 12, the 
one MDH/RRC provider would experience an estimated decrease in 
payments of 0.8 percent and MDH providers would receive an estimated 
increase of 0.3 percent. RRCs would experience an estimated increase 
in payments by 2.5 percent.
    Urban hospitals reclassified for FY 2008 are anticipated to 
receive an increase of 3.3 percent, while urban hospitals that not 
reclassified for FY 2008 are expected to receive an increase of 3.6 
percent. Rural hospitals reclassifying for FY 2008 are anticipated 
to receive a 1.5 percent payment increase.

N. Effects of Proposed Policy on Payment Adjustments for Low-Volume 
Hospitals

    For FY 2008, we are proposing to continue to apply the volume 
adjustment criteria we specified in the FY 2005 IPPS final rule (69 
FR 49099). We expect that three providers would receive the low-
volume adjustment for FY 2008. We included these additional payments 
to providers in the impact table shown above and we estimate the 
impact of these providers receiving the additional 25-percent 
payment increase to be approximately $50,000.

O. Impact Analysis of Table II

    Table II presents the projected impact of the proposed changes 
for FY 2008 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 2007 with the proposed average estimated 
per case payments for FY 2008, as calculated under our models. Thus, 
this table presents, in terms of the average dollar amounts paid per 
discharge, the combined effects of the proposed changes presented in 
Table I. The proposed percentage changes shown in the last column of 
Table II equal the percentage changes in average payments from 
Column 12 of Table I.

         Table II.--Impact Analysis of Proposed Changes for FY 2008 Operating Prospective Payment System
                                               [Payments per case]
----------------------------------------------------------------------------------------------------------------
                                                                                      Average
                                                                    Average FY      proposed FY    All proposed
                                                     Number of     2007 payment    2008 payment       FY 2008
                                                  hospitals  (1)   per case \1\    per case \1\    changes  (4)
                                                                        (2)             (3)
----------------------------------------------------------------------------------------------------------------
All hospitals...................................            3535            9004            9299             3.3
By Geographic Location:
    Urban hospitals.............................            2540            9343            9678             3.6
    Large urban areas (populations over 1                   1409            9750           10156             4.2
     million)...................................
    Other urban areas (populations of 1 million             1131            8854            9103             2.8
     or fewer)..................................
    Rural hospitals.............................             995            7060            7123             0.9
Bed Size (Urban):
    0-99 beds...................................             632            7236            7263             0.4
    100-199 beds................................             849            7904            8170             3.4
    200-299 beds................................             480            8815            9120             3.5
    300-499 beds................................             412            9749           10136             4.0
    500 or more beds............................             167           11762           12234             4.0

[[Page 25127]]

 
Bed Size (Rural):
    0-49 beds...................................             342            6161            6065            -1.6
    50-99 beds..................................             369            6558            6588             0.5
    100-149 beds................................             172            6867            6960             1.3
    150-199 beds................................              67            7626            7735             1.4
    200 or more beds............................              45            8759            8938             2.0
Urban by Region:
    New England.................................             126            9748           10001             2.6
    Middle Atlantic.............................             350           10243           10529             2.8
    South Atlantic..............................             388            8801            9175             4.2
    East North Central..........................             395            8890            9197             3.4
    East South Central..........................             166            8512            8784             3.2
    West North Central..........................             156            9064            9321             2.8
    West South Central..........................             358            8819            9174             4.0
    Mountain....................................             153            9507            9826             3.3
    Pacific.....................................             395           11136           11657             4.7
    Puerto Rico.................................              53            4368            4525             3.6
Rural by Region:
    New England.................................              19            9675            9714             0.4
    Middle Atlantic.............................              72            7466            7525             0.8
    South Atlantic..............................             173            6579            6700             1.8
    East North Central..........................             124            7521            7574             0.7
    East South Central..........................             177            6400            6479             1.2
    West North Central..........................             115            7743            7792             0.6
    West South Central..........................             194            6381            6339            -0.7
    Mountain....................................              80            7766            7834             0.9
    Pacific.....................................              41            8725            8896             2.0
By Payment Classification:
    Urban hospitals.............................            2619            9298            9629             3.6
    Large urban areas (populations over 1                   1436            9725           10127             4.1
     million)...................................
    Other urban areas (populations of 1 million             1183            8789            9034             2.8
     or fewer)..................................
    Rural areas.................................             916            7175            7242             0.9
Teaching Status:
    Non-teaching................................            2479            7648            7851             2.7
    Fewer than 100 Residents....................             816            9067            9384             3.5
    100 or more Residents.......................             240           13006           13533             4.1
Urban DSH:
    Non-DSH.....................................             879            8146            8307             2.0
    100 or more beds............................            1527            9792           10182             4.0
    Less than 100 beds..........................             359            6574            6697             1.9
Rural DSH:
    SCH.........................................             391            6992            7013             0.3
    RRC.........................................             189            7686            7818             1.7
    100 or more beds............................              36            5902            6028             2.1
    Less than 100 beds..........................             154            5333            5353             0.4
Urban teaching and DSH:
    Both teaching and DSH.......................             805           10750           11185             4.0
    Teaching and no DSH.........................             192            8861            9078             2.5
    No teaching and DSH.........................            1081            7990            8283             3.7
    No teaching and no DSH......................             541            7664            7812             1.9
Rural Hospital Types:
    RRC.........................................              59            8155            8358             2.5
    SCH.........................................              45            9225            9301             0.8
    MDH.........................................              21            6321            6339             0.3
    SCH and RRC.................................              17            9968           10239             2.7
    MDH and RRC.................................               1            9755            9674            -0.8
Type of Ownership:
    Voluntary...................................            2069            9136            9424             3.2
    Proprietary.................................             823            8173            8478             3.7
    Government..................................             598            9270            9593             3.5
Medicare Utilization as a Percent of Inpatient
 Days:
    0-25........................................             230           12731           13443             5.6
    25-50.......................................            1292           10160           10570             4.0
    50-65.......................................            1453            7913            8116             2.6
    Over 65.....................................             441            7240            7331             1.2

[[Page 25128]]

 
Hospitals Reclassified by the Medicare
 Geographic Classification Review Board:
FY 2008 Reclassifications:
    All Reclassified Hospitals FY 2008..........             801            8695            8938             2.8
    All Non-Reclassified Hospitals FY 2008......            2734            9106            9417             3.4
    Urban Reclassified Hospitals FY 2008........             434            9273            9581             3.3
    Urban Non-reclassified Hospitals FY 2008....            2105            9359            9701             3.6
    Rural Reclassified Hospitals FY 2008........             367            7555            7669             1.5
    Rural Nonreclassified Hospitals FY 2008.....             568            6411            6392            -0.3
    All Section 401 Reclassified Hospitals......              31            8647            8799             1.8
    Other Reclassified Hospitals (Section                     61            6635            6729             1.4
     1886(d)(8)(B)).............................
    Former Section 508 Hospitals................             107            9766            9814             0.5
Specialty Hospitals:
    Cardiac Specialty Hospitals.................              22           10736           10676           -0.6
----------------------------------------------------------------------------------------------------------------
\1\ These payment amounts per case do not reflect any estimates of annual case-mix increase.

VII. Effects of Other Proposed Policy Changes

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

A. Effects of Proposed Policy on Hospital-Acquired Conditions, 
Including Infections

    In section II.F. of the preamble of this proposed rule, we 
discuss our proposal to implement section 5001(c) of Pub. L. 109-
171, which requires the Secretary to identify, by October 1, 2007, 
at least two conditions that are (a) high cost or high volume or 
both, (2) result in the assignment of a case to a DRG that has a 
higher payment when present as a secondary diagnosis, and (c) could 
reasonably have been prevented through application of evidence-based 
guidelines. For discharges occurring on or after October 1, 2008, 
hospitals will not receive additional payment for cases in which one 
of the selected conditions was not present on admission. That is, 
the case will be paid as though the secondary diagnosis was not 
present. However, the statute also requires the Secretary to 
continue counting the condition as a secondary diagnosis that 
results in a higher IPPS payment when doing the budget neutrality 
calculations for DRG reclassifications and recalibration. Therefore, 
we do our budget neutrality calculations as though the payment 
provision did not apply but Medicare will make a lower payment to 
the hospital for the specific case that includes the secondary 
diagnosis. Thus, the provision will result in cost savings to the 
Medicare program.
    Although we believe there will be modest savings to the Medicare 
program from implementation of this provision, we cannot estimate 
them at this time. To estimate savings associated with this 
provision, we would need to know the frequency that the selected 
conditions are not present on admission in the Medicare population. 
Medicare will not begin collecting this information from hospitals 
until October 1, 2007. Therefore, there is currently no data upon 
which to estimate the savings of this provision. The provision does 
not go into effect until October 1, 2008. For this reason, there 
will be no savings for FY 2008. Any savings associated with this 
provision will not be realized until FY 2009. Based on the data 
available to us for next year's IPPS rule, we will estimate the 
savings associated with the conditions we selected under this 
provision for FY 2009 and subsequent years.
    We further note that the provision will only apply when the 
selected conditions are the only secondary diagnosis present on the 
claim that will lead to higher payment. Therefore, if a nonselected 
secondary diagnosis that leads to the same higher payment is on the 
claim, the case will continue to be assigned to the higher paying 
DRG and there will be no savings to Medicare from the case. Our 
analysis of the Medicare claims suggests that patients will 
generally have multiple secondary diagnoses during a hospital stay. 
Patients having one MCC or CC will frequently have additional 
conditions that also lead to higher payment. In only a small 
percentage of the cases did we find that a patient had only one 
secondary diagnosis that would lead to higher payment, and in these 
cases, we have no information to suggest whether the condition was 
acquired after admission. Therefore, we believe the savings 
associated with this provision are likely to be very modest. Again, 
once we have data on the frequency of occurrence of the selected 
conditions after admission, we will refine our analysis.

B. Effects of Proposed MS-LTC-DRG Reclassifications and Relative 
Weights for LTCHs

    In section II.I. of the preamble to this final rule, we discuss 
the proposed changes to adopt MS-LTC-DRG relative weights for FY 
2008, which are based on the Version 25.0 of the CMS GROUPER 
(including the changes in the classifications, relative weights, and 
geometric mean length of stay for each proposed MS-LTC-DRG). We 
noted in the same section that, in the FY 2008 LTCH PPS proposed 
rule (72 FR 4784 through 4786), we proposed that, beginning with the 
MS-LTC-DRG update for FY 2008, the annual update to the proposed MS-
LTC-DRG classifications and relative weights would be done in a 
budget neutral manner, such that estimated aggregate LTCH PPS 
payments would be unaffected; that is, they would be neither greater 
than nor less than the estimated aggregate LTCH PPS payments that 
would have been made without the proposed MS-LTC-DRG classification 
and relative weight changes. However, if the budget neutrality 
policy had not been proposed, we are estimating that, under the 
current payment policies (RY 2007), using the most recent available 
claims data (FY 2006 MedPAR files) for the 376 LTCHs in our 
database, the proposed changes to the MS-LTC-DRG classifications and 
relative weights for FY 2008 would have resulted in an aggregate 
decrease in LTCH PPS payments of approximately 1.6 percent. In 
applying the budget neutrality adjustment described above, we 
assumed constant utilization. However, with the proposed adoption of 
the MS-LTC-DRGs, we expect an increase in coding or classification 
of discharges that do not reflect real change in case-mix due to the 
adoption of the new patient classification system. Therefore, we 
have applied an additional adjustment of 0.976 to the proposed MS-
LTC-DRG relative weights for the anticipated increase in case-mix 
due to improved documentation and coding.

[[Page 25129]]

C. Effects of Proposed New Technology Add-On Payments

    In section II.I. of the preamble to this proposed rule, we 
discuss proposed add-on payments for new medical services and 
technologies. As explained in that section, we are not required to 
ensure that any add-on payments for new technology under section 
1886(d)(5)(K) of the Act are budget neutral. As discussed earlier in 
this proposed rule, we have yet to determine whether 
Wingspan[supreg] meets the criteria for new technology add-on 
payments for FY 2008. Therefore, it is premature to estimate the 
potential payment impact in FY 2008 of any potential decision to 
make new technology add-on payments for Wingspan[supreg]. In 
addition, for FY 2008, we have proposed to discontinue new 
technology add-on payments for GORE TAG, Restore[supreg], and X 
STOP. In the FY 2007 IPPS final rule (71 FR 48344), we estimated 
that FY 2007 IPPS new technology add-on payments would be $16.61 
million, $6.01 million, and $9.35 million, respectively, for these 
technologies. We have no additional information to further refine 
these estimates. Therefore, we estimate that Medicare's new 
technology add-on payments will decline by approximately $32 million 
(the sum of our estimates for FY 2007) in FY 2008 compared to FY 
2007.

D. Effects of Requirements for Hospital Reporting of Quality Data 
for Annual Hospital Payment Update

    In section IV.A. of the preamble of this proposed rule, we 
discuss the requirements for hospitals to report quality data in 
order for hospitals to receive the full annual hospital payment 
update for FY 2008 and FY 2009. We also note that, for the FY 2008 
payment update, hospitals must pass our validation requirement of a 
minimum of 80 percent reliability, based upon our chart-audit 
validation process, for the first three quarters of data from CY 
2006. These data were due to the QIO Clinical Warehouse by August 
15, 2006 (first quarter CY 2006 discharges), November 15, 2006 
(second quarter CY 2006 discharges), and February 15, 2007 (third 
quarter CY 2006 discharges). We have continued our efforts to ensure 
that QIOs provide assistance to all hospitals that wish to submit 
data. In the preamble of this proposed 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 21,500 charts per quarter total 
submitted to the agency. We reimburse hospitals for the cost of 
sending charts to the Clinical Data Abstraction Center (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 150 pages. Thus, the agency 
will have expenditures of approximately $473,200 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.

E. Effects of Proposed Policy on Cancellation of Classification of 
Acquired Rural Status and Rural Referral Centers

    In section IV.C.2. of the preamble of this proposed rule, we are 
proposing to revise our regulations to change the effective date of 
cancellation of acquired rural status for rural referral centers 
from ``the hospital's next full cost reporting period following the 
date of its request for cancellation'' to the next cost reporting 
period for hospitals paid on the basis of reasonable costs (such as 
CAHs) and for hospitals under the IPPS, after at least one 12-month 
cost reporting period as rural and not until the beginning of the 
Federal fiscal year following the date of its request for 
cancellation. Currently, there are about 100 IPPS hospitals that 
have acquired rural status. During this fiscal year (FY 2007), we 
have only received requests for cancellations from five hospitals. 
However, this number may increase if the current policy is not 
changed. We anticipate that the proposed policy change would, at a 
minimum, affect these five hospitals. However, we estimate that the 
proposed policy change would not have a significant impact on IPPS 
hospitals.

F. Effects of Proposed Policy on Payment for IME and Direct GME

    In section IV.D.3. of the preamble of this proposed rule, we 
discuss our proposed changes related to whether vacation and sick 
leave as well as orientation should be included in the FTE count for 
IME and direct GME payment purposes. We are proposing, for cost 
reporting periods beginning on or after October, 1, 2007, for direct 
GME and IME, that time spent by residents on vacation or sick leave 
be removed from the total time considered to constitute an FTE 
resident. In addition, we are proposing to continue our existing 
policy to count time spent by residents in orientation activities 
for both IME and direct GME payment purposes. Because we are 
proposing to remove vacation and sick leave from the total time 
considered to constitute an FTE resident, we believe the impact of 
this change would be negligible. In addition, there is no impact 
from the clarification of the policy for orientation time since it 
is not a change in policy.

G. Effects of Proposed Policy Changes Relating to Emergency 
Services Under EMTALA During an Emergency Period

    In section IV.F. of the preamble of this proposed rule, we are 
proposing to amend the EMTALA regulations regarding EMTALA 
implementation in emergency areas during an emergency period. 
Section 1135 of the Act authorizes the Secretary to temporarily 
waive or modify the application of several requirements and their 
implementing regulations as they relate to actions taken in an 
emergency area during an emergency period. The EMTALA regulations 
(Sec.  489.24(a)(2)) now specify that sanctions for inappropriate 
transfer during a national emergency do not apply to a hospital with 
a dedicated emergency department located in an emergency area.
    To make our regulations better reflect the scope of the 
authority under section 1135 of the Act, we are proposing to revise 
them to clarify that such waivers also may apply to sanctions for 
the redirection or relocation of an individual to an alternate 
location to receive a medical screening examination where that 
direction or relocation occurs pursuant to a State emergency 
preparedness plan. We also are proposing to revise the regulations 
to incorporate changes made by the Pandemic and All-Hazards 
Preparedness Act. That legislation amended section 1135 of the Act 
to state that, in the case of a public health emergency that 
involves a pandemic infectious disease, sanctions for the direction 
or relocation of an individual to an alternative location for 
screening may be waived based on either a State emergency 
preparedness plan or a State pandemic preparedness plan, whichever 
applies in the State. In addition, section 1135 of the Act was 
amended to create an exception to the otherwise applicable 72-hour 
limitation on the duration of waivers or modifications of sanctions 
for EMTALA violations in cases where a public health emergency 
involves a pandemic infectious disease (such as pandemic influenza).
    As described more fully earlier in this preamble, these changes 
are not discretionary and do not impose any substantive new 
requirements. On the contrary, they merely update our regulations to 
make them consistent with current statutory requirements. Because of 
this, we are estimating no impact on Medicare expenditures and no 
significant impact on hospitals with emergency departments.

H. Effects of Proposed Policy on Disclosure of Physician Ownership 
in Hospitals and Patient Safety Measures

    In section IV.G. of the preamble of this proposed rule, we 
discuss our proposals to adopt a requirement relating to disclosure 
of physician ownership in hospitals and to increase patient safety 
measures. In the strategic and implementing plan included in our 
``Final Report to the Congress and Strategic and Implementing Plan'' 
required under section 5006 of the Deficit Reduction Act of 2005, we 
stated that we would adopt a disclosure requirement that would 
require hospitals to disclose to patients whether they are 
physician-owned and, if so, the names of the physician-owners. In 
addition, we recognize that patients should be made aware of whether 
or not a physician is present in the hospital at all times, and the 
hospital's plans to address patients' emergency medical conditions 
when a physician is not present.
    We believe this proposed rule would impose minimal additional 
costs on hospitals. We believe the cost of implementing these 
provisions borne by hospitals would be limited to a one-time cost 
associated with completing minor revisions to portions of the 
medical staff bylaws and policies and procedures related to patient 
admission and registration, as well as providing written 
notification to patients and affected staff. In addition, the 
proposed changes concerning disclosure of physician ownership in 
hospitals are consistent with current practices of members of the 
physician-owned specialty hospital associations. Therefore, we do 
not believe that these proposed changes will have any significant 
economic impact on hospitals.

[[Page 25130]]

I. Effects of Implementation of Rural Community Hospital 
Demonstration Program

    In section IV.H. of the preamble to this proposed rule, we 
discuss our implementation of section 410A of Pub. L. 108-173 that 
required the Secretary to establish a demonstration that will modify 
reimbursement for inpatient services for up to 15 small rural 
hospitals. Section 410A(c)(2) requires that ``in conducting the 
demonstration program under this section, the Secretary shall ensure 
that the aggregate payments made by the Secretary do not exceed the 
amount which the Secretary would have paid if the demonstration 
program under this section was not implemented.'' As discussed in 
section IV.H. of the preamble to this proposed rule, we are 
satisfying this requirement by adjusting national IPPS rates by a 
factor that is sufficient to account for the added costs of this 
demonstration. We estimate that the average additional annual 
payment for FY 2008 that would be made to each participating 
hospital under the demonstration would be approximately $1,075,765. 
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 the 9 participating 
hospitals, the total annual impact of the demonstration program is 
estimated to be $9,681,893. The proposed adjustment factor to the 
Federal rate used in calculating Medicare inpatient prospective 
payments as a result of the demonstration is 0.999899.

J. Effects of Proposed Policy on Services Furnished to 
Beneficiaries in Custody of Penal Authorities

    In section VII. of the preamble of this proposed rule, we 
discuss our proposal to revise our regulations relating to the 
special conditions under which Medicare payment may be made for 
services furnished to individuals in custody of penal authorities. 
We are proposing to indicate that, for purposes of Medicare payment, 
individuals who are in custody include, but are not limited to, 
individuals who are under arrest, incarcerated, imprisoned, escaped 
from confinement, under supervised release, required to reside in 
mental health facilities, required to reside in halfway houses, 
required to live under home detention, or confined completely or 
partially in any way under a penal statute or rule. This proposed 
definition is in accordance with how custody has been defined by 
Federal courts for purposes of the habeas corpus protections of the 
Constitution and is consistent with current CMS policy. We 
anticipate that this proposed change would have no measurable impact 
on Medicare expenditures.

VIII. Impact of Proposed Changes in the Capital IPPS

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 V. of the 
preamble of this proposed rule, with the 10-year transition period 
ending with hospital cost reporting periods beginning on or after 
October 1, 2001 (FY 2002), beginning in FY 2002 capital prospective 
payment system payments for most hospitals are based solely on the 
capital Federal rate. Therefore, we no longer include information on 
obligated capital costs or projections of old capital costs and new 
capital costs, which were factors needed to calculate payments 
during the transition period, for our impact analysis.
    In accordance with Sec.  412.312, the basic methodology for 
determining a capital PPS payment includes a large urban add-on 
adjustment. However, as discussed above and in section V. of the 
preamble of this proposed rule, we are proposing to eliminate the 
large urban add-on adjustment to capital IPPS payments in FY 2008. 
The proposed basic methodology for calculating capital IPPS payments 
in FY 2008 would be: (Standard Federal Rate) x (DRG weight) x (GAF) 
x (COLA for hospitals located in Alaska and Hawaii) x (1 + 
Disproportionate Share Adjustment Factor + IME Adjustment Factor, if 
applicable).
    In addition, hospitals may also receive outlier payments for 
those cases that qualify under the threshold established for each 
fiscal year.
    The data used in developing the impact analysis presented below 
are taken from the December 2006 update of the FY 2006 MedPAR file 
and the December 2006 update of the Provider-Specific File that is 
used for payment purposes. Although the analyses of the proposed 
changes to the capital prospective payment system do not incorporate 
cost data, we used the December 2006 update of the most recently 
available hospital cost report data (FYs 2004 and 2005) to 
categorize hospitals. Our analysis has several qualifications. In 
general, we do not make adjustments for behavioral changes that 
hospitals may adopt in response to proposed policy changes. However, 
as discussed in section III. of the Addendum to this proposed rule, 
we proposed that the capital rates would be adjusted to account for 
upcoding under the proposed MS-DRGs. Furthermore, due to the 
interdependent nature of the IPPS, it is very difficult to precisely 
quantify the impact associated with each proposed change. In 
addition, we draw upon various sources for the data used to 
categorize hospitals in the tables. In some cases (for instance, the 
number of beds), there is a fair degree of variation in the data 
from different sources. We have attempted to construct these 
variables with the best available sources overall. However, for 
individual hospitals, some miscategorizations are possible.
    Using cases from the December 2006 update of the FY 2006 MedPAR 
file, we simulated payments under the capital PPS for FY 2007 and FY 
2008 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. of the Addendum to this proposed 
rule, payments are no longer made under the regular exceptions 
provision under Sec. Sec.  412.348(b) through (e). Therefore, we no 
longer use the actuarial capital cost model (described in Appendix B 
of the August 1, 2001 proposed rule (66 FR 40099)). We modeled 
payments for each hospital by multiplying the capital Federal rate 
by the GAF and the hospital's case-mix. We then added estimated 
payments for indirect medical education, disproportionate share, 
large urban add-on, and outliers, if applicable. (We note that, 
consistent with our proposal to eliminate the large urban add-on 
beginning in FY 2008, such estimated payments under this policy are 
only reflected in the payments we modeled for FY 2007 and were not 
included in the payments we modeled for FY 2008.) 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 2007 and 2008. (We note that 
this does not reflect the proposed adjustment to the capital rates 
to account for assumed growth in case mix due to improvement in 
documentation and coding (upcoding) under the proposed MS-DRGs, as 
discussed in section III. of the Addendum of this proposed rule.)
     We estimate that the Medicare discharges will be 12.925 
million in FY 2007 and 12.995 million in FY 2008 for an estimated 
0.54 percent increase from FY 2007 to FY 2008.
     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. As discussed in section V. of the 
preamble and section III.A. of the Addendum to this proposed rule, 
the proposed FY 2008 update for rural hospitals is 0.8 percent. We 
are proposing a 0.0 percent update for urban hospitals in FY 2008.
     In addition to the proposed FY 2008 update factors, the 
proposed FY 2008 capital Federal rate for both urban and rural 
hospitals was calculated based on a proposed GAF/DRG budget 
neutrality factor of 1.0018, a proposed outlier adjustment factor of 
0.9484, and a proposed exceptions adjustment factor of 0.9997.
     For FY 2008, as discussed in section V. of the preamble 
and section III.A. of the Addendum to this proposed rule, the 
proposed FY 2008 capital rates for all hospitals was further 
adjusted by a factor of 0.976 (or -2.4 percent) to maintain budget 
neutrality if the proposed MS-DRGs are implemented by eliminating 
the effect of changes in coding or classification of discharges that 
do not reflect real case mix changes.

[[Page 25131]]

B. Results

    We used the actuarial model described above to estimate the 
potential impact of our proposed changes for FY 2008 on total 
capital payments per case, using a universe of 3,535 hospitals. As 
described above, the individual hospital payment parameters are 
taken from the best available data, including the December 2006 
update of the FY 2006 MedPAR file, the December 2006 update to the 
Provider-Specific File, and the most recent cost report data from 
the December 2006 update of HCRIS. In Table III, we present a 
comparison of total payments per case for FY 2007 compared to 
proposed FY 2008 based on the proposed FY 2008 payment policies. 
Column 2 shows estimates of payments per case under our model for FY 
2007. Column 3 shows estimates of payments per case under our model 
for FY 2008. Column 4 shows the total percentage change in payments 
from FY 2007 to FY 2008. The change represented in Column 4 includes 
the proposed 0.8 percent update to the capital Federal rate for 
rural hospitals and a 0.0 percent update for urban hospitals, a 1.0 
percent increase in case-mix, changes in the adjustments to the 
capital Federal rate (for example, the effect of the hospital wage 
index on the GAF), reclassifications by the MGCRB, and the proposed 
additional 2.4 percent reduction to all of the rates to account for 
upcoding or changes in coding that do not reflect real changes in 
case-mix if the proposed MS-DRGs are implemented. The comparisons 
are provided by: (1) geographic location; (2) region; and (3) 
payment classification.
    The simulation results show that, on average, capital payments 
per case can be expected to decrease 0.7 percent in FY 2008. In 
addition to the proposed 0.0 percent update for urban hospitals, 
this projected decrease in capital payments per case can be 
attributed to the proposed -2.4 percent adjustment to all hospitals 
to account for assumed growth in case mix due to improvements in 
documentation and coding prior to the assumed growth occurring if 
the proposed MS-DRGs are implemented. Although the proposed GAF/DRG 
factor is expected to increase payments slightly (0.18 percent) in 
FY 2008 as compared to FY 2007, the proposed outlier factor is 
expected to contribute to the estimated decrease in capital payments 
from FY 2007 to FY 2008 by 0.88 percent.
    The results of our comparisons by geographic location and by 
region are consistent with the results we expected after proposing 
to eliminate the large urban add-on adjustment, and the proposed 0.0 
percent update for urban hospitals. The geographic comparison shows 
that urban hospitals are expected to experience a 0.6 percent 
decrease in IPPS capital payments per case, while rural hospitals 
are expected to experience a 0.9 percent decrease in capital 
payments per case. This difference is mostly due to the proposed MS-
DRGs. Specifically, based on existing hospital claims data, under 
the proposed MS-DRGs, the better recognition of severity of illness 
is expected to increase payments to urban hospitals that treat a 
more acutely ill mix of patients and improvement in the DRG system 
will increase their payments. Similarly, however, the improved 
recognition of severity of illness will decrease payments to rural 
hospitals because they are treating less severely ill patients. 
Therefore we project a lower increase in estimated payments for 
rural hospitals due to the proposed DRG changes as compared to urban 
hospitals. In addition to the effect of the proposed DRG changes, 
the capital impact is also somewhat affected by the proposed wage-
index changes because the GAF values are derived from the proposed 
wage index. Another factor contributing to the decrease in payments 
for rural hospitals is the expiration of the 3-year hold harmless 
provision for urban hospitals that were converted to rural under the 
new CBSAs in FY 2005. The policy allowed urban hospitals under the 
old labor market area designations that became rural under the CBSAs 
to receive payment using the wage index of the MSA where they were 
previously classified as urban for 3 years: FY 2005 through FY 2007. 
Beginning in FY 2008, these rural hospitals will receive the wage 
index for the area that they are currently located in. As a result, 
rural hospitals will experience a decrease in payments because of 
the addition of these formerly urban hospitals.
    More than half of all regions are estimated to experience a 
decrease in total capital payments per case from FY 2007 to FY 2008. 
These decreases vary by region and range from a -2.3 percent in the 
Middle Atlantic urban region to a -0.7 in the East South Central 
urban region. For most of the regions projected to experience a 
larger than average decrease in capital payments, the difference is 
mostly due to changes in the proposed GAF and the elimination of the 
large urban add-on adjustment. In the regions experiencing an 
increase in total capital payments per case, the range is from 0.7 
in the Pacific rural region to a 0.1 percent increase in the South 
Atlantic rural region. For most of the regions projected to 
experience an increase in capital payments, it is mostly due to 
changes to adopt the proposed MS-DRGs. The change in payments per 
case for all hospitals is -0.7 percent.
    By type of ownership, voluntary hospitals are estimated to 
experience a decrease of -1.0 percent in capital payments per case, 
while proprietary and government hospitals are estimated to 
experience 0.1 percent and 0.2 percent increases in payments, 
respectively. Government hospitals and proprietary hospitals are 
projected to have slight increases in capital payments mostly due to 
a smaller than average estimated decrease in payments due to 
proposed changes in the GAF and a slightly larger than average 
estimated increase in payments due to proposed changes to adopt MS-
DRGs.
    Section 1886(d)(10) of the Act established the MGCRB. Before FY 
2005, hospitals could apply to the MGCRB 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; however, hospitals still may apply for reclassification for 
purposes of the wage index for FY 2008. 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 2008, we show the average payments per case for reclassified 
hospitals for FY 2007. Rural nonreclassified hospitals are expected 
to have the largest decrease in payments (-2.0 percent), as compared 
to the -0.3 percent for rural reclassified hospitals for FY 2008. 
This difference is mostly due to proposed changes in the GAF and 
proposed changes to adopt MS-DRGs. Urban hospitals are expected to 
experience a decrease in payments of 0.9 percent and 0.6 percent, 
respectively, for reclassified and nonreclassified hospitals. This 
difference is mostly due to the proposed elimination of the large 
urban add-on.

                                Table III.--Comparison of Total Payments Per Case
                                 [FY 2007 payments compared to FY 2008 payments]
----------------------------------------------------------------------------------------------------------------
                                                                     Average FY     Average FY
                                                     Number of    2007 payments/  2008 payments/      Change
                                                     hospitals         case            case
----------------------------------------------------------------------------------------------------------------
By Geographic Location:
    All hospitals...............................           3,535             758             753            -0.7
    Large urban areas (populations over 1                  1,409             842             833            -1.1
     million)...................................
    Other urban areas (populations of 1 million            1,131             747             747             0.0
     or fewer)..................................
    Rural areas.................................             995             524             519            -0.9
    Urban hospitals.............................           2,540             799             794            -0.6
    0-99 beds...................................             632             628             618            -1.7
    100-199 beds................................             849             683             677            -0.8
    200-299 beds................................             480             754             748            -0.8
    300-499 beds................................             412             828             824            -0.5

[[Page 25132]]

 
    500 or more beds............................             167           1,002             999            -0.3
    Rural hospitals.............................             995             524             519            -0.9
    0-49 beds...................................             342             430             418            -2.8
    50-99 beds..................................             369             480             473            -1.5
    100-149 beds................................             172             523             521            -0.3
    150-199 beds................................              67             576             573            -0.5
    200 or more beds............................              45             657             656            -0.1
By Region:
    Urban by Region.............................           2,540             799             794            -0.6
    New England.................................             126             847             830            -2.1
    Middle Atlantic.............................             350             875             855            -2.3
    South Atlantic..............................             388             756             759             0.3
    East North Central..........................             395             783             777            -0.8
    East South Central..........................             166             723             718            -0.7
    West North Central..........................             156             780             772            -1.0
    West South Central..........................             358             749             750             0.2
    Mountain....................................             153             797             799             0.2
    Pacific.....................................             395             914             918             0.5
    Puerto Rico.................................              53             348             344            -1.2
    Rural by Region.............................             995             524             519            -0.9
    New England.................................              19             694             683            -1.5
    Middle Atlantic.............................              72             536             531            -0.8
    South Atlantic..............................             173             508             508             0.1
    East North Central..........................             124             557             548            -1.6
    East South Central..........................             177             487             481            -1.2
    West North Central..........................             115             556             550            -1.1
    West South Central..........................             194             478             469            -2.0
    Mountain....................................              80             522             524             0.4
    Pacific.....................................              41             634             639             0.7
By Payment Classification:
    All hospitals...............................           3,535             758             753            -0.7
    Large urban areas (populations over 1                  1,436             840             831            -1.1
     million)...................................
    Other urban areas (populations of 1 million            1,183             742             742             0.1
     or fewer)..................................
    Rural areas.................................             916             527             522            -1.0
Teaching Status:
    Non-teaching................................           2,479             640             636            -0.6
    Fewer than 100 Residents....................             816             770             764            -0.8
    100 or more Residents.......................             240           1,096           1,090            -0.5
Urban DSH:
    100 or more beds............................           1,527             823             820            -0.2
    Less than 100 beds..........................             359             551             542            -1.7
Rural DSH:
    Sole Community (SCH/EACH)...................             391             469             463            -1.3
    Referral Center (RRC/EACH)..................             189             584             583            -0.2
Other Rural:
    100 or more beds............................              36             479             478            -0.2
    Less than 100 beds..........................             154             433             425            -1.8
Urban teaching and DSH:
    Both teaching and DSH.......................             805             902             899            -0.4
    Teaching and no DSH.........................             192             807             788            -2.3
    No teaching and DSH.........................           1,081             672             672            -0.1
    No teaching and no DSH......................             541             704             694            -1.4
Rural Hospital Types:
    Non special status hospitals................           2,477             801             796            -0.6
    RRC/EACH....................................              59             693             692            -0.2
    SCH/EACH....................................              45             633             623            -1.5
    Medicare-dependent hospitals (MDH)..........              21             450             433            -3.7
    SCH, RRC and EACH...........................              17             741             740             0.0
Hospitals Reclassified by the Medicare
 Geographic Classification Review Board:
FY2008 Reclassifications:
    All Urban Reclassified......................             434             793             786            -0.9
    All Urban Non-Reclassified..................           2,105             800             796            -0.6
    All Rural Reclassified......................             367             570             568            -0.3
    All Rural Non-Reclassified..................             568             459             450            -2.0
    Other Reclassified Hospitals (Section                     61             511             501            -2.1
     1886(d)(8)(B)).............................
Type of Ownership:
    Voluntary...................................           2,069             776             768            -1.0
    Proprietary.................................             823             689             690             0.1

[[Page 25133]]

 
    Government..................................             598             745             746             0.2
Medicare Utilization as a Percent of Inpatient
 Days:
    0-25........................................             230           1,001           1,006             0.5
    25-50.......................................           1,292             857             854            -0.4
    50-65.......................................           1,453             672             666            -1.0
    Over 65.....................................             441             605             594            -1.8
----------------------------------------------------------------------------------------------------------------

IX. Alternatives Considered

    This proposed rule contains a range of proposed policies. The 
preamble of this proposed rule provides descriptions of the 
statutory provisions that are addressed, identifies those proposed 
policies when discretion has been exercised, presents rationale for 
our decisions and, where relevant, alternatives that were 
considered.

X. Overall Conclusion

    The changes we are proposing in this proposed rule would affect 
all classes of hospitals. Some hospitals are expected to experience 
significant gains and others less significant gains, but overall 
hospitals are projected to experience positive updates in IPPS 
payments in FY 2008. Table I of section VI of this Appendix 
demonstrates the estimated distributional impact of the IPPS budget 
neutrality requirements for proposed DRG and wage index changes, and 
for the wage index reclassifications under the MGCRB. Table I also 
shows an overall increase of 3.3 percent in operating payments, an 
estimated increase of $3.28 billion, which includes hospital 
reporting of quality data program costs ($1.89 million) and all 
operating payment policies as described in section VI. of this 
Appendix. Capital payments are estimated to decrease by 0.7 percent 
per case, as shown in Table III of section VIII. of this Appendix. 
Therefore, we project that capital payments will decline by $13 
million in FY 2008 compared to FY 2007. The operating and capital 
payments should result in a net increase of $3.269 billion to IPPS 
providers. The discussions presented in the previous pages, in 
combination with the rest of this proposed rule, constitute a 
regulatory impact analysis.

XI. Accounting Statement

    As required by OMB Circular A-4 (available at http://www.whitehousegov/omb/circulars/a004/a-4.pdf), in Table IV below, we 
have prepared an accounting statement showing the classification of 
the expenditures associated with the provisions of this proposed 
rule. This table provides our best estimate of the increase in 
Medicare payments on providers as a result of the proposed changes 
to the IPPS presented in this rule. All expenditures are classified 
as transfers to Medicare providers.

      Table IV.--Accounting Statement: Classification of Estimated
                  Expenditures From FY 2007 to FY 2008
------------------------------------------------------------------------
                 Category                             Transfers
------------------------------------------------------------------------
Annualized Monetized Transfers............  $3.269 Billion.
From Whom to Whom.........................  Federal Government to IPPS
                                             Medicare Providers.
                                           -----------------------------
    Total.................................  $3.269 Billion.
------------------------------------------------------------------------

XII. Executive Order 12866

    In accordance with the provisions of Executive Order 12866, the 
Office of Management and Budget reviewed this proposed rule.

Appendix B: Recommendation of Update Factors for Operating Cost 

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

I. Background

    Section 1886(e)(4)(A) of the Act requires that the Secretary, 
taking into consideration the recommendations of the 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 the proposed and final update 
factors recommended by the Secretary in the proposed and final IPPS 
rules, respectively. Accordingly, this Appendix provides the 
recommendations of appropriate update factors for the IPPS 
standardized amount, the hospital-specific rates for SCHs and MDHs, 
and the rate-of-increase limits for hospitals and hospital units 
excluded from the IPPS, as well as IPFs and IRFs. We also discuss 
our response to MedPAC's recommended update factors for inpatient 
hospital services.

II. Inpatient Hospital Update for FY 2008

    Section 1886(b)(3)(B)(i)(XX) of the Act, as amended by section 
5001(a) of Pub. L. 109-171, sets the FY 2008 percentage increase in 
the operating cost standardized amount equal to the rate-of-increase 
in the hospital market basket for IPPS hospitals in all areas, 
subject to the hospital submitting quality information under rules 
established by the Secretary in accordance with 1886(b)(3)(B)(viii) 
of the Act. For hospitals that do not provide these data, the update 
is equal to the market basket percentage increase less 2.0 
percentage points. Consistent with current law, based on the Office 
of the Actuary's first quarter 2007 forecast of the FY 2008 market 
basket increase, we are estimating that the FY 2008 update to the 
standardized amount will be 3.3 percent (that is, the current 
estimate of the market basket rate-of-increase) for hospitals in all 
areas, provided the hospital submits quality data in accordance with 
our rules. For hospitals that do not submit quality data, we are 
estimating that the update to the standardized amount will be 1.3 
percent (that is, the current estimate of the market basket rate-of-
increase minus 2.0 percentage points).
    Section 1886(b)(3)(B)(iv) of the Act sets the FY 2008 percentage 
increase in the hospital-specific rates applicable to SCHs and MDHs 
equal to the rate set forth in section 1886(b)(3)(B)(i) of the Act 
(that is, the same update factor as for all other hospitals subject 
to the IPPS, or the rate-of-increase in the market basket). 
Therefore, the update to the hospital-specific rates applicable to 
SCHs and MDHs is also estimated to be 3.3 percent.
    Section 1886(b)(3)(B)(ii) of the Act is used for purposes of 
determining the percentage increase in the rate-of-increase limits 
for children's and cancer hospitals. Section 1886(b)(3)(B)(ii) of 
the Act sets the percentage increase in the rate-of-increase limits 
equal to the market basket percentage increase. In accordance with 
Sec.  403.752(a) of the regulations, RNHCIs are paid under Sec.  
413.40, which also uses section 1886(b)(3)(B)(ii) of the Act to 
update the percentage increase in the rate-of-increase limits. 
Section 1886(j)(3)(C) of the Act addresses the increase factor for 
the Federal prospective payment rate of IRFs. Section 123 of Pub. L. 
106-113, as amended by section 307(b) of Pub. L. 106-554, provides 
the statutory authority for updating payment rates under the LTCH 
PPS. As discussed below, for cost reporting periods beginning on or 
after October 1, 2006, LTCHs that are not defined as new under Sec.  
412.23(e)(4), and that had not elected to be paid under 100 percent 
of the Federal rate are paid 100 percent of the adjusted Federal PPS 
rate. Therefore, because no portion of LTCHs' prospective payments 
will be based on reasonable cost concepts for cost reporting periods 
beginning on or after October 1,

[[Page 25134]]

2006, we are not proposing a rate-of-increase percentage for FY 2008 
for LTCHs to be used under Sec.  413.40. In addition, section 124 of 
Pub. L. 106-113 provides the statutory authority for updating all 
aspects of the payment rates for IPFs. Under this broad authority, 
IPFs that are not defined as new under Sec.  412.426(c) will be paid 
under a blend methodology for cost reporting periods beginning on or 
after January 1, 2005, and before January 1, 2008. The methodology 
blends the estimated Federal per diem payment amount and a facility-
specific payment amount. The portion of the IPF PPS payment that is 
based on reasonable cost principles is updated in accordance with 42 
CFR Part 413, which uses section 1886(b)(3)(B)(ii) of the Act to 
determine the percentage increase in the rate-of-increase limits. 
For the reasonable cost-based portion of an IPF's PPS blended 
payments, we are proposing our current estimate of the excluded 
hospital market basket increase (3.4 percent) to update the target 
amounts. New IPFs are paid based on 100 percent of the Federal per 
diem payment amount.
    Currently, children's hospitals, cancer hospitals, and RNHCIs 
are the remaining three types of hospitals still reimbursed under 
the reasonable cost methodology. We are providing our current 
estimate of the FY 2008 IPPS operating market basket percentage 
increase (3.3 percent) to update the target limits for children's 
hospitals, cancer hospitals, and RNHCIs.
    Effective for cost reporting periods beginning on or after 
October 1, 2002, LTCHs have been paid under the LTCH PPS, which was 
implemented with a 5-year transition period for LTCHs not defined as 
new under Sec.  412.23(e)(4) (hereafter referred to as 
``existing''). (See 67 FR 55954.) An existing LTCH could have 
elected to be paid at 100 percent of the adjusted Federal 
prospective rate at the start of any of its cost reporting periods 
during the transition period. During this transition period, if an 
existing LTCH did not elect to be paid at 100 percent of the 
adjusted Federal prospective payment rate, it received a PPS payment 
that consisted of a blend of its reasonable cost-based payment and 
the Federal prospective payment rate. For cost reporting periods 
beginning on or after October 1, 2006, no portion of a LTCH's PPS 
payments can be based on reasonable cost concepts. Consequently, 
there is no need to propose to update the target limit under Sec.  
413.40 effective October 1, 2007 for LTCHs.
    In the RY 2008 LTCH PPS proposed rule (72 FR 4791 through 4792), 
we recommended an update of 0.71 percent (that is, the latest 
estimate of the market basket rate-of-increase of 3.2 percent minus 
an adjustment factor of 2.49 percentage points for case-mix growth 
due to improved coding) to the LTCH PPS Federal rate for RY 2008.
    Effective for cost reporting periods beginning on or after 
January 1, 2005, IPFs are paid under the IPF PPS. IPF PPS payments 
are based on a Federal per diem rate that is derived from 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. For cost reporting periods beginning on or after January 
1, 2005, and before January 1, 2008, existing IPFs (those not 
defined as ``new'' under Sec.  412.426(c)) are paid based on a blend 
of the reasonable cost-based PPS payments and the Federal per diem 
base rate. For cost reporting periods beginning on or after January 
1, 2008, existing IPFs will be paid based on 100 percent of the 
Federal per diem rate. For purposes of the update factor for FY 
2008, the portion of the IPF PPS transitional blend payment based on 
reasonable costs would be determined by updating the IPF's TEFRA 
limit by the current estimate of the excluded hospital market 
basket, which is estimated to be 3.4 percent. The update factor of 
4.3 percent to the Federal per diem rate for July 1, 2006 through 
June 30, 2007 was provided in the rate year (RY) 2007 IPF PPS final 
rule (71 FR 27046). The Federal per diem rate for RY 2008 will be 
updated in the RY 2008 update notice that is scheduled for 
publication in May 2007.
    IRFs are paid under the IRF PPS for cost reporting periods 
beginning on or after January 1, 2002. For cost reporting periods 
beginning on or after October 1, 2002 (FY 2003), and thereafter, the 
Federal prospective payments to IRFs are based on 100 percent of the 
adjusted Federal IRF prospective payment amount, updated annually. 
(See 69 FR 45721). Under section 1886(j)(3)(C) of the Act, the FY 
2008 IRF PPS update will equal 3.3 percent based on the Global 
Insight, Inc.'s first quarter 2007 forecast with historical data 
through the fourth quarter of 2006. We expect that the market basket 
will be updated with more recent data to the extent the data are 
available.

III. Secretary's Recommendation

    MedPAC is recommending an inpatient hospital update equal to the 
market basket rate of increase for FY 2008. MedPAC's rationale for 
this update recommendation is described in more detail below. Using 
the 2007 first quarter forecast from the Office of the Actuary of 
the FY 2008 market basket increase and an adjustment factor based on 
the FY 2008 President's Budget, we are recommending an update to the 
standardized amount of 2.65 percent (that is, the market basket 
rate-of-increase of 3.3 percent minus an adjustment factor of 0.65 
percentage points). We are recommending that this same update factor 
apply to SCHs and MDHs. Our rationale for this recommended update is 
described below.
    In addition to making a recommendation for IPPS hospitals, in 
accordance with section 1886(e)(4)(A) of the Act, we are also 
recommending update factors for all other types of hospitals. 
Consistent with the President's budget, we are recommending an 
update based on the market basket increase for children's hospitals, 
cancer hospitals, and RNHCIs of 3.3 percent. For IPFs that are 
currently paid on a PPS blended payment basis, a portion of which is 
based on reasonable cost-principles and Federal prospective payment 
amounts, we are recommending an update factor of 3.4 percent for the 
portion of the payment that is based on reasonable costs. Consistent 
with the President's Budget, based on Global Insight Inc.'s 1st 
quarter 2007 forecast of the RPL market basket increase, we are 
recommending an update equal to the market basket increase of 3.2 
percent for the Federal per diem payment amount.
    In the RY 2008 LTCH PPS proposed rule (72 FR 4791 through 4792), 
we recommended an update of 0.71 percent (that is, the most recent 
estimate of the market basket rate-of-increase of 3.2 percent minus 
an adjustment factor of 2.49 percentage points for case-mix growth 
due to improved coding) to the Federal rate for RY 2008. We will 
provide the final update in the LTCH final rule. Finally, consistent 
with the President's FY 2008 Budget, we are recommending that the 
Federal rate to the IRF PPS remain unchanged for FY 2008.
    For fiscal years prior to FY 2008, section 1886(e)(3) of the Act 
directed the Secretary to report to the Congress an initial estimate 
of his recommendation of an appropriate payment inflation update for 
inpatient hospital services for the upcoming fiscal year not later 
than March 1. Section 1886(d)(4)(C) of the Act further required the 
Secretary to include recommendations with respect to adjustments to 
the DRG weighting factors in the March 1 Report to Congress. In 
addition, sections 1886(e)(4)(A) and (e)(5)(B) of the Act require 
that the Secretary recommend update factors in each of the IPPS 
proposed and final rules, taking into account MedPAC's 
recommendation. Thus, the statute required the Secretary to make 
update recommendations in both a March 1 Report to Congress, and 
later in the IPPS proposed and final rules. Historically, the only 
difference between the recommendation we provided in the March 1 
Report to Congress and the IPPS proposed rule was the use of a later 
estimate of the market basket increase for the proposed rule. 
Section 106(c) of Pub. L. 109-432 eliminated the requirement to make 
the Report to Congress recommending an update and adjustments to DRG 
weighting factors by March 1. In accordance with section 106(c) of 
Pub. L. 109-432, we are making the Secretary's only recommendation 
for an update factor in the IPPS rules.

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

    In its March 2007 Report to Congress, MedPAC assessed the 
adequacy of current payments and costs, and the relationship between 
payments and an appropriate cost base, utilizing an established 
methodology used by MedPAC in the past several years.
    MedPAC recommended an update to the hospital inpatient rates 
equal to the increase in the hospital market basket in FY 2008, 
concurrent with implementation of a quality incentive payment 
program. MedPAC also recommended that CMS put pressure on hospitals 
to control their costs rather than accommodate the current rate of 
cost growth.
    MedPAC noted that, notwithstanding negative overall Medicare 
margins, most of the indicators of Medicare payment adequacy to 
hospitals are positive, including beneficiaries' access to care, 
increased access to capital, and service volume increases. MedPAC 
also noted that this recommendation ``should have no impact on 
beneficiary access to care and is not expected to affect providers' 
willingness and ability to provide care to Medicare beneficiaries.''

[[Page 25135]]

    Response: We agree with MedPAC that hospitals should control 
costs rather than accommodate the current rate of growth. An update 
equal to less than the market basket will pressure hospitals to 
control their costs, consistent with MedPAC's recommendation. As 
MedPAC noted, rising hospital costs are resulting in margins for 
some hospitals that are below zero. As discussed in section II. of 
the preamble of this proposed rule, CMS is refining the DRGs to 
better account for severity illness and is basing the DRG weights on 
cost rather than charges. We believe that these refinements will 
better match Medicare payments to the cost of care and provide 
incentives for hospitals to be more efficient in controlling costs. 
For these reasons, we are recommending an inpatient hospital update 
equal to the market basket increase minus an adjustment factor of 
0.65 percentage points for hospitals paid under the IPPS for FY 
2008.
    We note that, because the operating and capital prospective 
payment systems remain separate, we are proposing to continue to use 
separate updates for operating and capital payments. The proposed 
update to the capital payment rate is discussed in section III. of 
the Addendum to this proposed rule.

[FR Doc. 07-1920 Filed 4-13-07; 4:15 pm]
BILLING CODE 4120-01-P