Federal Register, Volume 79 Issue 151 (Wednesday, August 6, 2014)

[Federal Register Volume 79, Number 151 (Wednesday, August 6, 2014)]
[Rules and Regulations]
[Pages 45938-46009]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2014-18329]

[[Page 45937]]

Vol. 79

Wednesday,

No. 151

August 6, 2014

Part III

Department of Health and Human Services

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Center for Medicare & Medicaid Services

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42 CFR Part 412

Medicare Program; Inpatient Psychiatric Facilities Prospective Payment
System--Update for Fiscal Year Beginning October 1, 2014 (FY 2015);
Final Rule

Federal Register / Vol. 79 , No. 151 / Wednesday, August 6, 2014 /
Rules and Regulations

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 412

[CMS-1606-F]
RIN 0938-AS08

Medicare Program; Inpatient Psychiatric Facilities Prospective
Payment System--Update for Fiscal Year Beginning October 1, 2014 (FY
2015)

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

ACTION: Final rule.

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SUMMARY: This final rule will update the prospective payment rates for
Medicare inpatient hospital services provided by inpatient psychiatric
facilities (IPFs). These changes will be applicable to IPF discharges
occurring during the fiscal year (FY) beginning October 1, 2014 through
September 30, 2015. This final rule will also address implementation of
ICD-10-CM and ICD-10-PCS codes; finalize a new methodology for updating
the cost of living adjustment (COLA), and finalize new quality measures
and reporting requirements under the IPF quality reporting program.

DATES: These regulations are effective on October 1, 2014.

FOR FURTHER INFORMATION CONTACT:

Dorothy Myrick or Jana Lindquist, (410) 786-4533, for general
information. Hudson Osgood, (410) 786-7897 or Bridget Dickensheets,
(410) 786-8670, for information regarding the market basket and labor-
related share.
Theresa Bean, (410) 786-2287, for information regarding the regulatory
impact analysis. Rebecca Kliman, (410) 786-9723 or Jeffrey Buck, (410)
786-0407, for information regarding the inpatient psychiatric facility
quality reporting program.

SUPPLEMENTARY INFORMATION:

Table of Contents

To assist readers in referencing sections contained in this
document, we are providing the following table of contents.

I. Executive Summary
A. Purpose
B. Summary of the Major Provisions
C. Summary of Transfers
II. Background
A. Annual Requirements for Updating the IPF PPS
B. Overview of the Legislative Requirements of the IPF PPS
C. General Overview of the IPF PPS
III. Provisions of the Proposed Regulations and Responses to Public
Comments
IV. Changing the IPF PPS Payment Rate Update Period From a Rate Year
to a Fiscal Year
V. Market Basket for the IPF PPS
A. Background
B. Development of an IPF-Specific Market Basket
C. FY 2015 Market Basket Update
D. Labor-Related Share
VI. Updates to the IPF PPS for FY Beginning October 1, 2014
A. Determining the Standardized Budget-Neutral Federal Per Diem
Base Rate
B. Update of the Federal Per Diem Base Rate and
Electroconvulsive Therapy Rate
VII. Update of the IPF PPS Adjustment Factors
A. Overview of the IPF PPS Adjustment Factors
B. Patient-Level Adjustments
1. Adjustment for MS-DRG Assignment
2. Payment for Comorbid Conditions
3. Patient Age Adjustments
4. Variable Per Diem Adjustments
C. Facility-Level Adjustments
1. Wage Index Adjustment
a. Background
b. Wage Index for FY 2015
c. OMB Bulletins
2. Adjustment for Rural Location
3. Teaching Adjustment
a. FTE Intern and Resident Cap Adjustment
b. Temporary Adjustment to the FTE Cap To Reflect Residents
Added Due to Hospital Closure
c. Temporary Adjustment to FTE Cap To Reflect Residents Affected
by Residency Program Closure
i. Receiving IPF
ii. IPF That Closed Its Program
4. Cost of Living Adjustment for IPFs Located in Alaska and
Hawaii
5. Adjustment for IPFs With a Qualifying Emergency Department
(ED)
D. Other Payment Adjustments and Policies
1. Outlier Payments
a. Update to the Outlier Fixed Dollar Loss Threshold Amount
b. Update to IPF Cost-to-Charge Ratio Ceilings
2. Future Refinements
VIII. Inpatient Psychiatric Facilities Quality Reporting Program
IX. Provisions of the Final Regulations
X. Collection of Information Requirements
XI. Comments Beyond the Scope of the Final Rule
XII. Regulatory Impact Analysis
Addenda

Acronyms

Because of the many terms to which we refer by acronym in this
final rule, we are listing the acronyms used and their corresponding
meanings in alphabetical order below:

BBRA Medicare, Medicaid and SCHIP [State Children's Health Insurance
Program] Balanced Budget Refinement Act of 1999 (Pub. L. 106-113)
CBSA Core-Based Statistical Area
CCR Cost-to-Charge Ratio
CAH Critical Access Hospital
DSM-IV-TR Diagnostic and Statistical Manual of Mental Disorders
Fourth Edition--Text Revision
DRGs Diagnosis-Related Groups
FY Federal Fiscal Year (October 1 through September 30)
ICD-9-CM International Classification of Diseases, 9th Revision,
Clinical Modification
ICD-10-CM International Classification of Diseases, 10th Revision,
Clinical Modification
ICD-10-PCS International Classification of Diseases, 10th Revision,
Procedure Coding System
IPFs Inpatient Psychiatric Facilities
IPFQR Inpatient Psychiatric Facilities Quality Reporting
IRFs Inpatient Rehabilitation Facilities
LTCHs Long-Term Care Hospitals
MAC Medicare Administrative Contractor
MedPAR Medicare Provider Analysis and Review File
RPL Rehabilitation, Psychiatric, and Long-Term Care
RY Rate Year (July 1 through June 30)
TEFRA Tax Equity and Fiscal Responsibility Act of 1982 (Pub. L. 97-
248)

I. Executive Summary

A. Purpose

This final rule updates the prospective payment rates for Medicare
inpatient hospital services provided by inpatient psychiatric
facilities for discharges occurring during the fiscal year (FY)
beginning October 1, 2014 through September 30, 2015.

B. Summary of the Major Provisions

In this final rule, we update the IPF PPS, as specified in 42 CFR
412.428. The updates include the following:
The FY 2008-based Rehabilitation, Psychiatric, and Long
Term Care (RPL) market basket update (currently estimated to be 2.9
percent) will be adjusted by a 0.3 percentage point reduction as
required by section 1886(s)(2)(A)(ii) of the Social Security Act (the
Act) and a reduction for economy-wide productivity (currently estimated
to be 0.5 percentage point) as required by section 1886(s)(2)(A)(i) of
the Act.
The FY 2015 per diem rate is updated from $713.19 to $728.
31.
The electroconvulsive therapy payment is updated from
$307.04 to $313.55.
The fixed dollar loss threshold amount is updated from
$10,245 to $8,755 in order to maintain outlier payments that are 2
percent of total IPF PPS payments.
The national urban and rural cost-to-charge ratio (CCR)
ceilings for FY 2015 is 1.6582 and 1.8590, respectively, and the
national median CCR will be 0.6220 for rural IPFs and 0.4710 for

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urban IPFs. These amounts are used in the outlier calculation to
determine if an IPF's CCR is statistically accurate and for new
providers without an established CCR.
The cost of living adjustment factors for IPFs located in
Alaska and Hawaii is updated using the approach finalized in the FY
2014 inpatient hospital prospective payment system (IPPS) final rule
(78 FR 50985 through 50987).
In addition:
We identify the ICD-10-CM/PCS codes that will be eligible
for the MS-DRG and comorbidity payment adjustments under the IPF PPS.
The effective date of those changes is October 1, 2015.
We identify the ICD-9-CM/PCS codes that will be eligible
for the MS-DRG and comorbidity payment adjustments under the IPF PPS.
We use the best available hospital wage index and
establish the wage index budget-neutrality adjustment of 1.0002.
We retain the 17 percent payment adjustment for IPFs
located in rural areas, the 1.31 payment adjustment factor for IPFs
with a qualifying emergency department, the coefficient value of 0.5150
for the teaching adjustment, and the MS-DRG adjustment factors and
comorbidity adjustment factors currently being paid to IPFs in FY 2014.

C. Summary of Impacts

------------------------------------------------------------------------
Provision description
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Total transfers
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FY 2015 IPF PPS payment rate update.... The overall economic impact of
this final rule is an
estimated $120 million in
increased payments to IPFs
during FY 2015.
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Costs
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New quality reporting program The total costs in FY 2015 for
requirements. IPFs as a result of the final
new quality reporting
requirements is estimated to
be $33,372,508.
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II. Background

A. Annual Requirements for Updating the IPF PPS

In November 2004, we implemented the inpatient psychiatric
facilities (IPF) prospective payment system (PPS) in a final rule that
appeared in the November 15, 2004 Federal Register (69 FR 66922). In
developing the IPF PPS, to ensure that the IPF PPS is able to account
adequately for each IPF's case-mix, we performed an extensive
regression analysis of the relationship between the per diem costs and
certain patient and facility characteristics to determine those
characteristics associated with statistically significant cost
differences on a per diem basis. For characteristics with statistically
significant cost differences, we used the regression coefficients of
those variables to determine the size of the corresponding payment
adjustments.
In that final rule, we explained that we believe it is important to
delay updating the adjustment factors derived from the regression
analysis until we have IPF PPS data that include as much information as
possible regarding the patient-level characteristics of the population
that each IPF serves. Therefore, we indicated that we did not intend to
update the regression analysis and the patient- and facility-level
adjustments until we complete that analysis. Until that analysis is
complete, we stated our intention to publish a notice in the Federal
Register each spring to update the IPF PPS (71 FR 27041). We have begun
the necessary analysis to make refinements to the IPF PPS using more
current data to set the adjustment factors; however, we did not propose
those refinements in the proposed rule and are not finalizing them in
this final rule. Rather, as explained in section V.D.3 of this final
rule, we expect that in future rulemaking, possibly for Fiscal Year
(FY) 2017, we will be ready to propose potential refinements.
In the May 6, 2011 IPF PPS final rule (76 FR 26432), we changed the
payment rate update period to a rate year (RY) that coincides with a FY
update. Therefore, update notices are now published in the Federal
Register in the summer to be effective on October 1. When proposing
changes in IPF payment policy, a proposed rule would be issued in the
spring and the final rule in the summer in order to be effective on
October 1. For further discussion on changing the IPF PPS payment rate
update period to a RY that coincides with a FY, see the IPF PPS final
rule published in the Federal Register on May 6, 2011 (76 FR 26434
through 26435). For a detailed list of updates to the IPF PPS, see 42
CFR 412.428.
Our most recent IPF PPS annual update occurred in an August 1,
2013, Federal Register notice (78 FR 46734) (hereinafter referred to as
the August 2013 IPF PPS notice) that set forth updates to the IPF PPS
payment rates for FY 2014. That notice updated the IPF PPS per diem
payment rates that were published in the August 2012 IPF PPS notice (77
FR 47224) in accordance with our established policies.

B. Overview of the Legislative Requirements for the IPF PPS

Section 124 of the Medicare, Medicaid, and SCHIP (State Children's
Health Insurance Program) Balanced Budget Refinement Act of 1999 (BBRA)
(Pub. L. 106-113) required the establishment and implementation of an
IPF PPS. Specifically, section 124 of the BBRA mandated that the
Secretary develop a per diem PPS for inpatient hospital services
furnished in psychiatric hospitals and psychiatric units including an
adequate patient classification system that reflects the differences in
patient resource use and costs among psychiatric hospitals and
psychiatric units.
Section 405(g)(2) of the Medicare Prescription Drug, Improvement,
and Modernization Act of 2003 (MMA) (Pub. L. 108-173) extended the IPF
PPS to distinct part psychiatric units of critical access hospitals
(CAHs).
Section 3401(f) of the Patient Protection and Affordable Care Act
(Pub. L. 111-148) as amended by section 10319(e) of that Act and by
section 1105(d) of the Health Care and Education Reconciliation Act of
2010 (Pub. L. 111-152) (hereafter referred to as ``the Affordable Care
Act'') added subsections to section 1886 of the Act.

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Section 1886(s)(1) of the Act titled ``Reference to Establishment
and Implementation of System'' refers to section 124 of the BBRA, which
relates to the establishment of the IPF PPS.
Section 1886(s)(2)(A)(i) of the Act requires the application of the
productivity adjustment described in section 1886(b)(3)(B)(xi)(II) of
the Act to the IPF PPS for the RY beginning in 2012 (that is, a RY that
coincides with a FY) and each subsequent RY. For the RY beginning in
2014 (that is, FY 2015), the current estimate of the productivity
adjustment will be equal to 0.5 percentage point, which we are
finalizing in this FY 2015 final rule.
Section 1886(s)(2)(A)(ii) of the Act requires the application of an
``other adjustment'' that reduces any update to an IPF PPS base rate by
percentages specified in section 1886(s)(3) of the Act for the RY
beginning in 2010 through the RY beginning in 2019. For the RY
beginning in 2014 (that is, FY 2015), section 1886(s)(3)(C) of the Act
requires the reduction to be 0.3 percentage point. We are finalizing
that reduction in this FY 2015 IPF PPS final rule.
Section 1886(s)(4) of the Act requires the establishment of a
quality data reporting program for the IPF PPS beginning in RY 2014. We
proposed and finalized new requirements for quality reporting for IPFs
in the ``Hospital Inpatient Prospective Payment System for Acute Care
Hospitals and the Long Term Care Hospital Prospective Payment System
and Fiscal Year 2014 Rates'' proposed rule published on May 10, 2013
(78 FR 27486, 27734 through 27744) and final rule published on August
19, 2013 (78 FR 50496, 50887 through 50903).
To implement and periodically update these provisions, we have
published various proposed and final rules in the Federal Register. For
more information regarding these rules, see the CMS Web site at http://www.cms.hhs.gov/InpatientPsychFacilPPS/.

C. General Overview of the IPF PPS

The November 2004 IPF PPS final rule (69 FR 66922) established the
IPF PPS, as required by section 124 of the BBRA and codified at subpart
N of part 412 of the Medicare regulations. The November 2004 IPF PPS
final rule set forth the per diem Federal rates for the implementation
year (the 18-month period from January 1, 2005 through June 30, 2006),
and provided payment for the inpatient operating and capital costs to
IPFs for covered psychiatric services they furnish (that is, routine,
ancillary, and capital costs, but not costs of approved educational
activities, bad debts, and other services or items that are outside the
scope of the IPF PPS). Covered psychiatric services include services
for which benefits are provided under the fee-for-service Part A
(Hospital Insurance Program) of the Medicare program.
The IPF PPS established the Federal per diem base rate for each
patient day in an IPF derived from the national average daily routine
operating, ancillary, and capital costs in IPFs in FY 2002. The average
per diem cost was updated to the midpoint of the first year under the
IPF PPS, standardized to account for the overall positive effects of
the IPF PPS payment adjustments, and adjusted for budget-neutrality.
The Federal per diem payment under the IPF PPS is comprised of the
Federal per diem base rate described above and certain patient- and
facility-level payment adjustments that were found in the regression
analysis to be associated with statistically significant per diem cost
differences.
The patient-level adjustments include age, DRG assignment,
comorbidities, and variable per diem adjustments to reflect higher per
diem costs in the early days of an IPF stay. Facility-level adjustments
include adjustments for the IPF's wage index, rural location, teaching
status, a cost-of-living adjustment for IPFs located in Alaska and
Hawaii, and the presence of a qualifying emergency department (ED).
The IPF PPS provides additional payment policies for: outlier
cases; interrupted stays; and a per treatment adjustment for patients
who undergo electroconvulsive therapy (ECT). During the IPF PPS
mandatory 3-year transition period, stop-loss payments were also
provided; however, since the transition ended in 2008, these payments
are no longer available.
A complete discussion of the regression analysis that established
the IPF PPS adjustment factors appears in the November 2004 IPF PPS
final rule (69 FR 66933 through 66936).
Section 124 of the BBRA did not specify an annual rate update
strategy for the IPF PPS and was broadly written to give the Secretary
discretion in establishing an update methodology.
Therefore, in the November 2004 IPF PPS final rule, we implemented
the IPF PPS using the following update strategy:
Calculate the final Federal per diem base rate to be
budget-neutral for the 18-month period of January 1, 2005 through June
30, 2006.
Use a July 1 through June 30 annual update cycle.
Allow the IPF PPS first update to be effective for
discharges on or after July 1, 2006 through June 30, 2007.

III. Provisions of the Proposed Regulations and Responses to Comments

On May 6, 2014, we published a proposed rule in the Federal
Register (79 FR 26040) entitled Medicare Program; Inpatient Psychiatric
Facilities Prospective Payment System--Update for Fiscal Year Beginning
October 1, 2014 (FY 2015). The May 6, 2014 proposed rule (herein
referred to as the FY 2015 IPF PPS proposed rule) set forth the
proposed update to the prospective payment rates for Medicare inpatient
hospital services provided by inpatient psychiatric facilities. In
addition to the update, we proposed to:
Adjust the FY 2008-based Rehabilitation, Psychiatric, and
Long Term Care (RPL) market basket update by 0.3 percentage point
reduction.
Update the FY 2015 per diem rate from $713.19 to $727.67.
Update the electroconvulsive therapy payment from $307.04
to $313.27.
Update the fixed dollar loss threshold amount from $10,245
to $10,125.
Update the cost of living adjustment factors for IPFs
located in Alaska and Hawaii.

In addition, we proposed:
Effective when ICD-10-CM/PCS becomes the required medical
data code set for use on Medicare claims (which we now know will be
October 1, 2015), the ICD-10-CM codes that would be eligible for the
MS-DRG and comorbidity payment adjustments under the IPF PPS.
ICD-9-CM/PCS codes that would be eligible for the MS-DRG
and comorbidity payment adjustments.
To use the best available hospital wage index and
establish the wage index budget-neutrality adjustment.
New Quality Measures for the FY 2016 Payment Determination
and Subsequent Years (Patient Assessment of Experience of Care, Use of
an Electronic Health Record).
New Quality Measures for the FY 2017 Payment Determination
and Subsequent Years (Influenza Immunization, Influenza Vaccination
Coverage Among Healthcare Personnel, Tobacco Use Screening, and Tobacco
Use Treatment Provided or Offered and Tobacco Use Treatment).
Effective with FY 2017 payment determination, a
requirement that facilities submit to CMS aggregate population counts
for Medicare and non-Medicare discharges by age group, diagnostic
group, and quarter, and sample size counts for measures, for which
sampling is performed.

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To solicit recommendations from the public on additions
and changes to the IPF quality reporting program in future years.
We provided for a 60-day comment period on the FY 2015 IPF PPS
proposed rule. We received 28 public comments from hospital and
hospital-based associations. In general, many commenters supported CMS'
efforts to continue researching the possibility of an IPF-specific
market basket and agreed that more work is necessary before any
conclusions can be drawn regarding a proposal to develop an IPF-
specific market basket. The majority of the comments were regarding the
IPF quality reporting program (IPFQR Program). In general, the
commenters varied as to their support for the newly proposed measures
for the FY 2016 and FY 2017 payment determinations. Furthermore, many
commenters offered recommendations on the IPFQR Program additions and
changes for future IPFQR Program years. Summaries of the public
comments received and our responses to those comments are provided in
the appropriate sections in the preamble of this final rule.

IV. Changing the IPF PPS Payment Rate Update Period From a Rate Year to
a Fiscal Year

Prior to RY 2012, the IPF PPS was updated on a July 1 through June
30 annual update cycle. Effective with RY 2012, we switched the IPF PPS
payment rate update from a rate year that begins on July 1 and ends on
June 30 to a period that coincides with a fiscal year. In order to
transition from a RY to a FY, the IPF PPS RY 2012 covered a 15-month
period from July 1 through September 30. As proposed and finalized,
after RY 2012, the rate year update period for the IPF PPS payment
rates and other policy changes begin on October 1 through September 30.
Therefore, the update cycle for FY 2015 will be October 1, 2014 through
September 30, 2015.
For further discussion of the 15-month market basket update for RY
2012 and changing the payment rate update period from a RY to a FY, we
refer readers to the RY 2012 IPF PPS proposed rule (76 FR 4998) and the
RY 2012 IPF PPS final rule (76 FR 26432).

V. Market Basket for the IPF PPS

A. Background

The input price index (that is, the market basket) that was used to
develop the IPF PPS was the Excluded Hospital with Capital market
basket. This market basket was based on 1997 Medicare cost report data
and included data for Medicare participating IPFs, inpatient
rehabilitation facilities (IRFs), long-term care hospitals (LTCHs),
cancer hospitals, and children's hospitals. Although ``market basket''
technically describes the mix of goods and services used in providing
hospital care, this term is also commonly used to denote the input
price index (that is, cost category weights and price proxies combined)
derived from that market basket. Accordingly, the term ``market
basket'' as used in this document refers to a hospital input price
index.
Beginning with the May 2006 IPF PPS final rule (71 FR 27046 through
27054), IPF PPS payments were updated using a FY 2002-based market
basket reflecting the operating and capital cost structures for IRFs,
IPFs, and LTCHs (hereafter referred to as the Rehabilitation,
Psychiatric, and Long-Term Care (RPL) market basket).
We excluded cancer and children's hospitals from the RPL market
basket because these hospitals are not reimbursed through a PPS;
rather, their payments are based entirely on reasonable costs subject
to rate-of-increase limits established under the authority of section
1886(b) of the Act, which are implemented in regulations at Sec.
413.40. Moreover, the FY 2002 cost structures for cancer and children's
hospitals are noticeably different than the cost structures of the
IRFs, IPFs, and LTCHs. A complete discussion of the FY 2002-based RPL
market basket appears in the May 2006 IPF PPS final rule (71 FR 27046
through 27054).
In the RY 2012 IPF PPS proposed rule (76 FR 4998) and final rule
(76 FR 26432), we proposed and finalized the use of a rebased and
revised FY 2008-based RPL market basket to update IPF payments.

B. Development of an IPF-Specific Market Basket

In the May 1, 2009 IPF PPS notice (74 FR 20362), we expressed our
interest in exploring the possibility of creating a stand-alone, or
IPF-specific market basket that reflects the cost structures of only
IPF providers. We noted that, of the available options, one would be to
join the Medicare cost report data from freestanding IPF providers with
data from hospital-based IPF providers. We indicated that an
examination of the Medicare cost report data comparing freestanding and
hospital-based IPFs revealed considerable differences between the two
with respect to cost levels and cost structures. At that time, we
stated that we were unable to fully explain the differences in costs
between freestanding and hospital-based IPF providers. As a result, we
felt that further research was required and we solicited public
comments for additional information that might help explain the reasons
for the variations in costs and cost structures, as indicated by the
cost report data (74 FR 20376). We summarized the public comments we
received and our responses in the April 2010 IPF PPS notice (75 FR
23111 through 23113).
Since the April 2010 IPF PPS notice was published, we have made
significant progress on the development of a stand-alone, or IPF-
specific, market basket. Our research has focused on addressing several
concerns regarding the use of the hospital-based IPF Medicare cost
report data in the calculation of the major market basket cost weights.
As discussed above, one concern is the cost level differences for
hospital-based IPFs relative to freestanding IPFs that were not readily
explained by the specific characteristics of the individual providers
and the patients that they serve (for example, case mix, urban/rural
status, teaching status). Furthermore, we are concerned about the
variability in the cost report data among these hospital-based IPF
providers and the potential impact on the market basket cost weights.
These concerns led us to consider whether it is appropriate to use the
universe of IPF providers to derive an IPF-specific market basket.
Recently, we have investigated the use of regression analysis to
evaluate the effect of including hospital-based IPF Medicare cost
report data in the calculation of cost distributions. We created
preliminary regression models to try to explain variations in costs per
day across both freestanding and hospital-based IPFs. These models were
intended to capture the effects of facility-level and patient-level
characteristics (for example, wage index, urban/rural status, ownership
status, length-of-stay, occupancy rate, case mix, and Medicare
utilization) on IPF costs per day. Using the results from the
preliminary regression analyses, we identified smaller subsets of
hospital-based and freestanding IPF providers where the predicted costs
per day using the regression model closely matched the actual costs per
day for each IPF. We then derived different sets of cost distributions
using (1) these subsets of IPF providers and (2) the entire universe of
freestanding and hospital-based IPF providers (including those IPFs for
which the variability in cost levels remains unexplained). After
comparing these sets of cost distributions, the differences were not
substantial enough for us to conclude that the inclusion of those IPF
providers with unexplained

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variability in costs in the calculation of the cost distributions is a
major cause for concern.
Another concern with incorporating the hospital-based IPF data in
the derivation of an IPF-specific market basket is the complexity of
the Medicare cost report data for these providers. The freestanding
IPFs independently submit a Medicare cost report for their facilities,
making it relatively straightforward to obtain the cost categories
necessary to determine the major market basket cost weights. However,
cost report data submitted for a hospital-based IPF are embedded in the
Medicare cost report submitted for the entire hospital facility in
which the IPF is located. Therefore, adjustments would have to be made
to obtain cost weights that represent just the hospital-based IPF (as
opposed to the hospital as a whole). For example, ancillary costs for
services such as clinic services, drugs charged to patients, and
emergency services for the entire hospital would need to be
appropriately converted to a value that only represents the hospital-
based IPF unit's cost. The preliminary method we have developed to
allocate these costs is complex and still needs to be fully evaluated
before we are ready to propose an IPF-specific market basket that would
reflect both hospital-based and freestanding IPF data.
We would also note that our current preliminary data show higher
labor costs for IPFs than observed for the 2008-based RPL market
basket. This increase is driven primarily by higher compensation cost
as a percent of total costs for IPFs. In our ongoing research, we are
also evaluating the differences in salary costs as a percent of total
costs for both hospital-based and freestanding IPFs. Salary costs are
historically the largest component of the market baskets. Based on our
review of the data reported on the applicable Medicare cost reports,
our initial findings (using the preliminary allocation method as
discussed above) have shown that the hospital-based IPF salary costs as
a percent of total costs tend to be lower than those of freestanding
IPFs. We are still evaluating the methods for deriving salary costs as
a percent of total costs and need to further investigate the percentage
of ancillary costs that should be appropriately allocated to the IPF
salary costs for the hospital-based IPF, as discussed above.
Also, effective for cost reports beginning on or after May 1, 2010,
we finalized a revised Hospital and Hospital Health Care Complex Cost
Report, Form CMS 2552-10, (74 FR 31738). The report is available for
download from the CMS Web site at http://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/CostReports/Hospital-2010-form.html. The revised Hospital and Hospital Health Care Complex Cost
Report includes a new worksheet (Worksheet S-3, part V) that identifies
the contract labor costs and benefit costs for the hospital/hospital
care complex and is applicable to sub-providers and units. Our analysis
of Worksheet S-3, part V shows significant underreporting of this data
with fewer than 20 freestanding IPF providers reporting it. We
encourage providers to submit this data so we can use it to calculate
benefits and contract labor cost weights for the market basket. In the
absence of this data, we will likely use the 2008-based RPL market
basket methodology (76 FR 5003) to calculate the IPF benefit cost
weight. This methodology calculates the ratio of the IPPS benefit cost
weight to the IPPS salary cost weight and applies this ratio to the IPF
salary cost weight in order to estimate the IPF benefit cost weight.
For contract labor, in the absence of IPF-specific data, we will use a
similar methodology.
For the reasons discussed above, while we believe we have made
significant progress on the development of an IPF-specific market
basket, we believe that further research is required at this time. As a
result, we are not finalizing an IPF-specific market basket for FY
2015. We plan to complete our research during the remainder of this
year and, provided that we are prepared to draw conclusions from our
research, may propose an IPF-specific market basket for the FY 2016
rulemaking cycle. Public comments and responses on the IPF-specific
market basket are summarized below.
Comment: Several commenters supported the development of a stand-
alone IPF market basket. In addition, the commenters acknowledged that
further analysis is required and asked that CMS make available the
methodologies and data sources that are under consideration for the
development of the stand-alone IPF market basket.
Response: As the commenters suggested, we will continue to research
and analyze the development of an IPF-specific market basket that uses
the most appropriate and reliable data sources and methods. We
anticipate proposing to use an IPF-specific market basket in the FY
2016 IPF proposed rule and the public will have the opportunity to
comment on our market basket methodology and data sources during the
60-day comment period following the publication of the proposed rule.

C. FY 2015 Market Basket Update

In the FY 2015 IPF PPS proposed rule (76 FR 26044), we proposed a
FY 2015 IPF update of 2.0 percent, reflecting a 2.7 percent market
basket update, less 0.4 percentage point MFP adjustment (as mandated in
section 1886(s)(2)(A)(i) of the Act and further described in section
1886(b)(3)(B)(xi)(II) of the Act)), less 0.3 percentage point
adjustment (as mandated in Section 1886(s)(2)(A)(ii) of the Act).
Furthermore, we also proposed that if more recent data are subsequently
available (for example, a more recent estimate of the market basket and
MFP adjustment), we would use such data, if appropriate, to determine
the FY 2015 market basket update and MFP adjustment in the final rule.
Based on a more recent update for this FY 2015 IPF PPS final rule,
that is, the IHS Global Insight, Inc. (IGI) second quarter 2014
forecast of the FY 2008-based RPL market basket, we are finalizing a
market basket rate-of-increase of 2.9 percent (prior to the application
of statutory adjustments). IGI is a nationally recognized economic and
financial forecasting firm that contracts with CMS to forecast the
components of the market baskets.
As previously described in section I.B, section 1886(s)(2)(A)(i) of
the Act requires the application of the productivity adjustment
described in section 1886(b)(3)(B)(xi)(II) of the Act to the IPF PPS
for the RY beginning in 2012 and each subsequent RY. The statute
defines the productivity adjustment to be equal to the 10-year moving
average of changes in annual economy-wide private nonfarm business
multifactor productivity (MFP) (as projected by the Secretary for the
10-year period ending with the applicable FY, year, cost reporting
period, or other annual period) (the ``MFP adjustment'').
The Bureau of Labor Statistics (BLS) publishes the official measure
of private non-farm business MFP. We refer readers to the BLS Web site
at http://www.bls.gov/mfp to obtain the BLS historical published MFP
data. The MFP adjustment for FY 2015 applicable to the IPF PPS is
derived using a projection of MFP that is currently produced by IGI.
For a detailed description of the model currently used by IGI to
project MFP, as well as a description of how the MFP adjustment is
calculated, we refer readers to the FY 2012 IPPS/LTCH final rule (76 FR
51690 through 51692). Based on the most recent estimate, that is, IGI's
second quarter 2014 forecast, the productivity adjustment for FY 2015
is 0.5 percentage point. Section 1886(s)(2)(A)(ii) of the Act also
requires

[[Page 45943]]

the application of an ``other adjustment'' that reduces any update to
an IPF PPS base rate by percentages specified in section 1886(s)(3) of
the Act for rate years beginning in 2010 through the RY beginning in
2019. For the RY beginning in 2014 (that is, FY 2015), the reduction is
0.3 percentage point. We are implementing the productivity adjustment
and ``other adjustment'' in this FY 2015 IPF PPS final rule.
In summary, we are basing the FY 2015 market basket update, which
is used to determine the applicable percentage increase for the IPF
payments, on the most recent estimate of the FY 2008-based RPL market
basket (2.9 percent based on IGI's second quarter 2014 forecast). We
are then reducing this percentage increase by the current estimate of
the MFP adjustment for FY 2015 of 0.5 percentage point (the 10-year
moving average of MFP for the period ending FY 2015 based on IGI's
second quarter 2014 forecast). Following application of the MFP, we are
further reducing the applicable percentage increase by 0.3 percentage
point, as required by section 1886(s)(3) of the Act. The final FY 2015
IPF update is 2.1 percent (2.9 percent market basket update, less 0.5
percentage point MFP adjustment, less 0.3 percentage point ``other''
adjustment).

D. Labor-Related Share

Due to variations in geographic wage levels and other labor-related
costs, we believe that payment rates under the IPF PPS should continue
to be adjusted by a geographic wage index, which would apply to the
labor-related portion of the Federal per diem base rate (hereafter
referred to as the labor-related share).
The labor-related share is determined by identifying the national
average proportion of total costs that are related to, influenced by,
or vary with the local labor market. We classify a cost category as
labor-related if the costs are labor-intensive and vary with the local
labor market. Based on our definition of the labor-related share, we
include in the labor-related share the sum of the relative importance
of Wages and Salaries, Employee Benefits, Professional Fees: Labor-
related, Administrative and Business Support Services, All Other:
Labor-related Services, and a portion of the Capital-Related cost
weight.
Therefore, to determine the labor-related share for the IPF PPS for
FY 2015, we used the FY 2008-based RPL market basket cost weights
relative importance to determine the labor-related share for the IPF
PPS. This estimate of the FY 2015 labor-related share is based on IGI's
second quarter 2014 forecast, which is the same forecast used to derive
the FY 2015 market basket update.
Table 1 below shows the FY 2015 relative importance labor-related
share using the FY 2008-based RPL market basket along with the FY 2014
relative importance labor-related share.

Table 1--FY 2015 Relative Importance Labor-Related Share and the FY 2014
Relative Importance Labor-Related Share Based on the FY 2008-Based RPL
Market Basket
------------------------------------------------------------------------
FY 2014 relative FY 2015 relative
importance labor- importance labor-
related share \1\ related share \2\
------------------------------------------------------------------------
Wages and Salaries.............. 48.394 48.271
Employee Benefits............... 12.963 12.936
Professional Fees: Labor-Related 2.065 2.058
Administrative and Business 0.415 0.415
Support Services...............
All Other: Labor-Related 2.080 2.061
Services.......................
Subtotal........................ 65.917 65.741
Labor-Related Portion of Capital 3.577 3.553
Costs (46%)....................
---------------------------------------
Total Labor-Related Share... 69.494 69.294
------------------------------------------------------------------------
\1\ Published in the FY 2014 IPF PPS notice (78 FR 46738) and based on
IHS Global Insight, Inc.'s second quarter 2013 forecast of the FY 2008-
based RPL market basket.
\2\ Based on IHS Global Insight, Inc.'s second quarter 2014 forecast of
the FY 2008-based RPL market basket.

The final labor-related share for FY 2015 is the sum of the FY 2015
relative importance of each labor-related cost category, and reflects
the different rates of price change for these cost categories between
the base year (FY 2008) and FY 2015. The sum of the relative importance
for FY 2015 for operating costs (Wages and Salaries, Employee Benefits,
Professional Fees: Labor-Related, Administrative and Business Support
Services, and All Other: Labor-related Services) is 65.741 percent, as
shown in Table 1 above. The portion of Capital-related cost that is
influenced by the local labor market is estimated to be 46 percent.
Since the relative importance for Capital-Related Costs is 7.723
percent of the FY 2008-based RPL market basket in FY 2015, we take 46
percent of 7.723 percent to determine the labor-related share of
Capital-related cost for FY 2015. The result is 3.553 percent, which we
add to 65.741 percent for the operating cost amount to determine the
total labor-related share for FY 2015. Therefore, the labor-related
share for the IPF PPS in FY 2015 is 69.294 percent. This labor-related
share is determined using the same general methodology as employed in
calculating all previous IPF labor-related shares (see, for example, 69
FR 66952 through 66953). The wage index and the labor-related share are
reflected in budget-neutrality adjustments.

VI. Updates to the IPF PPS for FY 2015 (Beginning October 1, 2014)

The IPF PPS is based on a standardized Federal per diem base rate
calculated from the IPF average per diem costs and adjusted for budget-
neutrality in the implementation year. The Federal per diem base rate
is used as the standard payment per day under the IPF PPS and is
adjusted by the patient-level and facility-level adjustments that are
applicable to the IPF stay. A detailed explanation of how we calculated
the average per diem cost appears in the November 2004 IPF PPS final
rule (69 FR 66926).

A. Determining the Standardized Budget-Neutral Federal Per Diem Base
Rate

Section 124(a)(1) of the BBRA required that we implement the IPF
PPS in a budget-neutral manner. In other words, the amount of total
payments under the IPF PPS, including any payment adjustments, must be
projected

[[Page 45944]]

to be equal to the amount of total payments that would have been made
if the IPF PPS were not implemented. Therefore, we calculated the
budget-neutrality factor by setting the total estimated IPF PPS
payments to be equal to the total estimated payments that would have
been made under the Tax Equity and Fiscal Responsibility Act of 1982
(TEFRA) (Pub. L. 97-248) methodology had the IPF PPS not been
implemented. A step-by-step description of the methodology used to
estimate payments under the TEFRA payment system appears in the
November 2004 IPF PPS final rule (69 FR 66926).
Under the IPF PPS methodology, we calculated the final Federal per
diem base rate to be budget-neutral during the IPF PPS implementation
period (that is, the 18-month period from January 1, 2005 through June
30, 2006) using a July 1 update cycle. We updated the average cost per
day to the midpoint of the IPF PPS implementation period (that is,
October 1, 2005), and this amount was used in the payment model to
establish the budget-neutrality adjustment.
Next, we standardized the IPF PPS Federal per diem base rate to
account for the overall positive effects of the IPF PPS payment
adjustment factors by dividing total estimated payments under the TEFRA
payment system by estimated payments under the IPF PPS. Additional
information concerning this standardization can be found in the
November 2004 IPF PPS final rule (69 FR 66932) and the RY 2006 IPF PPS
final rule (71 FR 27045). We then reduced the standardized Federal per
diem base rate to account for the outlier policy, the stop loss
provision, and anticipated behavioral changes. A complete discussion of
how we calculated each component of the budget-neutrality adjustment
appears in the November 2004 IPF PPS final rule (69 FR 66932 through
66933) and in the May 2006 IPF PPS final rule (71 FR 27044 through
27046). The final standardized budget-neutral Federal per diem base
rate established for cost reporting periods beginning on or after
January 1, 2005 was calculated to be $575.95.
The Federal per diem base rate has been updated in accordance with
applicable statutory requirements and 42 CFR 412.428 through
publication of annual notices or proposed and final rules. These
documents are available on the CMS Web site at http://www.cms.hhs.gov/InpatientPsychFacilPPS/. A detailed discussion on the standardized
budget-neutral Federal per diem base rate and the electroconvulsive
therapy (ECT) rate appears in the August 2013 IPF PPS update notice (78
FR 46738 through 46739).

B. FY 2015 Update of the Federal Per Diem Base Rate and
Electroconvulsive Therapy (ECT) Rate

In accordance with section 1886(s)(2)(A)(ii) of the Act, which
requires the application of an ``other adjustment,'' described in
section 1886(s)(3) of the Act (specifically, section 1886(s)(3)(C)) for
FY 2014 that reduces the update to the IPF PPS base rate for the FY
beginning in Calendar Year (CY) 2014, we are adjusting the IPF PPS
update by a 0.3 percentage point reduction for FY 2015. In addition, in
accordance with section 1886(s)(2)(A)(i) of the Act, which requires the
application of the productivity adjustment that reduces the update to
the IPF PPS base rate for the FY beginning in CY 2014, we are adjusting
the IPF PPS update by a 0.5 percentage point reduction for FY 2015.
The current (that is, FY 2014) Federal per diem base rate is
$713.19 and the ECT base rate is $307.04. For FY 2015, we are applying
an update of 2.1 percent (that is the FY 2008-based RPL market basket
increase for FY 2015 of 2.9 percent less the productivity adjustment of
0.5 percentage point less the 0.3 percentage point required under
section1886(s)(3)(C) of the Act), and the wage index budget-neutrality
factor of 1.0002 (as discussed in section VI.C.1. of this final rule)
to the FY 2014 Federal per diem base rate of $713.19, yielding a
Federal per diem base rate of $728.31 for FY 2015. Similarly, we are
applying the 2.1 percent payment update, and the 1.0002 wage index
budget-neutrality factor to the FY 2014 ECT base rate, yielding an ECT
base rate of $313.55 for FY 2015.
As noted above, section 1886(s)(4) of the Act requires the
establishment of a quality data reporting program for the IPF PPS
beginning in FY 2014. We finalized new requirements for quality
reporting for IPFs in the ``Hospital Inpatient Prospective Payment
Systems for Acute Care Hospitals and the Long Term Care Hospital
Prospective Payment System and Fiscal Year 2014 Rates'' proposed rule
published on May 10, 2013 (78 FR 27486, 27734 through 27744) and final
rule published on August 19, 2013 (78 FR 50496, 50887 through 50903).
Section 1886(s)(4)(A)(i) of the Act requires that, for FY 2014 and each
subsequent rate year, the Secretary shall reduce any annual update to a
standard Federal rate for discharges occurring during the rate year by
2.0 percentage points for any IPF that does not comply with the quality
data submission requirements with respect to an applicable year.
Therefore, we are applying a 2.0 percentage point reduction to the
Federal per diem base rate and the ECT base rate as follows:
For IPFs that fail to submit quality reporting data under the IPFQR
program, we are applying a 0.1 percent annual update (that is 2.1
percent reduced by 2 percentage points in accordance with section
1886(s)(4)(A)(ii) of the Act) and the wage index budget-neutrality
factor of 1.0002 to the FY 2014 Federal per diem base rate of $713.19,
yielding a Federal per diem base rate of $714.05 for FY 2015.
Similarly, we are applying the 0.1 percent annual update and the
1.0002 wage index budget-neutrality factor to the FY 2014 ECT base rate
of $307.04, yielding an ECT base rate of $ 307.41 for FY 2015.
In the FY 2014 IPPS/LTCH PPS final rule (78 FR50496), we adopted
two new measures for the FY 2016 payment determination and subsequent
years for the IPFQR Program. We also finalized a request for voluntary
information whereby IPFs will be asked to provide information on the
patient experience of care survey. For the FY 2016 payment
determination and subsequent years, we are adding two new measures to
those already adopted for the FY 2016 payment determination and
subsequent years. For the FY 2017 payment determination and subsequent
years, we are adopting four new measures. Public comments and responses
on the FY 2015 updates to the IPF PPS are summarized below.
Comment: One commenter did not believe the proposed FY 2015 update
and its associated projected payments to Michigan IPFs was an adequate
increase as it failed to cover the cost of medical inflation.
Response: CMS proposed applying an update of 2.0 percent (79 FR
26044) to the FY 2014 Federal per diem base rate of $713.19, as well as
a 1.0003 wage index budget-neutrality factor, yielding a proposed
Federal per diem base rate of $727.67 for FY 2015 (79 FR 26046). The
proposed 2.0 percent update reflected the proposed increase in the
FY2008-based RPL market basket for FY 2015, as required by statute, of
2.7 percent less the proposed productivity adjustment of 0.4 percentage
point (as mandated in section 1886(s)(2)(A)(i) of the Act and further
described in section 1886(b)(3)(B)(xi)(II) of the Act)) and less the
0.3 percentage point adjustment (as mandated in Section
1886(s)(2)(A)(ii) of the Act).
As discussed in section III.C and section VI.C.1 of this final
rule, we are

[[Page 45945]]

finalizing an update of 2.1 percent to the FY 2014 Federal per diem
base rate as well as a 1.0002 wage index budget-neutrality factor for
FY 2015. The final 2.1 percent FY 2015 update reflects the 2.9 percent
market basket update less the productivity adjustment of 0.5 percentage
point (as mandated in section 1886(s)(2)(A)(i) of the Act and further
described in section 1886(b)(3)(B)(xi)(II) of the Act)) and less the
0.3 percentage point adjustment (as mandated in Section
1886(s)(2)(A)(ii) of the Act).

VII. Update of the IPF PPS Adjustment Factors

A. Overview of the IPF PPS Adjustment Factors

The IPF PPS payment adjustments were derived from a regression
analysis of 100 percent of the FY 2002 MedPAR data file, which
contained 483,038 cases. For a more detailed description of the data
file used for the regression analysis, see the November 2004 IPF PPS
final rule (69 FR 66935 through 66936). While we have since used more
recent claims data to simulate payments to set the fixed dollar loss
threshold amount for the outlier policy and to assess the impact of the
IPF PPS updates, we continue to use the regression-derived adjustment
factors established in 2005 for FY 2015.
As we stated previously, we have begun an analysis of more current
IPF claims and cost report data; however, as we stated in the FY 2015
IPF PPS proposed rule, we are not making refinements to the IPF PPS in
this final rule. Once our analysis is complete, we will propose to
update the adjustment factors in a future notice of proposed
rulemaking. However, we continue to monitor claims and payment data
independently from cost report data to assess issues, to determine
whether changes in case-mix or payment shifts have occurred among
freestanding governmental, non-profit and private psychiatric
hospitals, and psychiatric units of general hospitals, and CAHs and
other issues of importance to IPFs.
On April 1, 2014, the Protecting Access to Medicare Act of 2014
(PAMA) (Pub. L. 113-93) was enacted. Section 212 of PAMA, titled
``Delay in Transition from ICD-9 to ICD-10 Code Sets,'' provides that
``[t]he Secretary of Health and Human Services may not, prior to
October 1, 2015, adopt ICD-10 code sets as the standard for code sets
under section 1173(c) of the Social Security Act (42 U.S.C. 1320d-2(c))
and section 162.1002 of title 45, Code of Federal Regulations.'' At the
time we sent the proposed rule to the Federal Register for publication,
the Secretary had not yet announced when the new ICD-10 compliance date
would be. Therefore we indicated that, in light of PAMA, the effective
date of changes from ICD-9 to ICD-10 for the IPF PPS would be the date
when ICD-10 becomes the required medical data code set for use on
Medicare claims, whenever that date may be.
On May 1, 2014, the Department announced that, in light of section
212 of PAMA, ``the U.S. Department of Health and Human Services expects
to release an interim final rule in the near future that will include a
new compliance date that would require the use of ICD-10 beginning
October 1, 2015. The rule will also require HIPAA covered entities to
continue to use ICD-9-CM through September 30, 2015.'' Therefore, in
light of this announcement, we will continue to require use of the ICD-
9-CM codes for reporting the MS-DRG and comorbidity adjustment factors
for IPF services through FY 2015 and we will require the use of ICD-10
codes beginning October 1, 2015.

B. Patient-Level Adjustments

The IPF PPS includes payment adjustments for the following patient-
level characteristics: Medicare Severity diagnosis related groups (MS-
DRGs) assignment of the patient's principal diagnosis, selected
comorbidities, patient age, and the variable per diem adjustments.
1. Adjustment for MS-DRG Assignment
We believe it is important to maintain the same diagnostic coding
and DRG classification for IPFs that are used under the IPPS for
providing psychiatric care. For this reason, when the IPF PPS was
implemented for cost reporting periods beginning on or after January 1,
2005, we adopted the same diagnostic code set (ICD-9-CM) and DRG
patient classification system (that is, the CMS DRGs) that were
utilized at the time under the IPPS. In the May 2008 IPF PPS notice (73
FR 25709), we discussed CMS's effort to better recognize resource use
and the severity of illness among patients. CMS adopted the new MS-DRGs
for the IPPS in the FY 2008 IPPS final rule with comment period (72 FR
47130). In the 2008 IPF PPS notice (73 FR 25716) we provided a
crosswalk to reflect changes that were made under the IPF PPS to adopt
the new MS-DRGs. For a detailed description of the mapping changes from
the original DRG adjustment categories to the current MS-DRG adjustment
categories, we refer readers to the May 2008 IPF PPS notice (73 FR
25714).
The IPF PPS includes payment adjustments for designated psychiatric
DRGs assigned to the claim based on the patient's principal diagnosis.
The DRG adjustment factors were expressed relative to the most
frequently reported psychiatric DRG in FY 2002, that is, DRG 430
(psychoses). The coefficient values and adjustment factors were derived
from the regression analysis. Mapping the DRGs to the MS-DRGs resulted
in the current 17 IPF-MS-DRGs, instead of the original 15 DRGs, for
which the IPF PPS provides an adjustment. For FY 2015, as we did in FY
2013 (77 FR 47231) and FY 2014 (78 FR 46741 through 46741), we proposed
to make a payment adjustment for psychiatric diagnoses that group to
one of the 17 MS-IPF-DRGs listed in Table 2. Psychiatric principal
diagnoses that do not group to one of the 17 designated DRGs would
still receive the Federal per diem base rate and all other applicable
adjustments, but the payment would not include a DRG adjustment.
In the Standards for Electronic Transaction final rule, published
in the Federal Register on August 17, 2000 (65 FR 50312), the
Department adopted the International Classification of Diseases, 9th
Revision, Clinical Modification (ICD-9-CM) as the HIPAA designated code
set for reporting diseases, injuries, impairments, other health related
problems, their manifestations, and causes of injury. Therefore, on
January 1, 2005 when the IPF PPS began, we used ICD-9-CM as the
designated code set for the IPF PPS. IPF claims with a principal
diagnosis included in Chapter Five of the ICD-9-CM are paid the Federal
per diem base rate and all other applicable adjustments, including any
applicable DRG adjustment. However, as we indicated in the FY 2014 IPF
PPS notice (78 FR 46741), in accordance with the requirements of the
final rule that delayed the ICD-10 compliance date from October 1,
2014, published in the Federal Register on September 5, 2012 (77 FR
54664), we will be discontinuing the use of ICD-9-CM codes. In the FY
2015 IPF PPS proposed rule we proposed the conversion of ICD-9-CM to
ICD-10-CM/PCS codes. In light of PAMA, we proposed the effective date
would be when ICD-10 becomes the required medical data code set for use
on Medicare claims. Now that the Secretary has announced October 1,
2015 as the new compliance date for ICD-10, we will continue to require
the use of the ICD-9-CM codes for reporting the MS-DRGs for IPF
services through FY 2015, and we will require the use of ICD-10 codes
beginning October 1, 2015.

[[Page 45946]]

The ICD-10-CM/PCS coding guidelines are available through the CMS
Web site at: www.cms.gov/Medicare/Coding/ICD10/downloads/pcs_2012_guidelines.pdf and http://www.cms.gov/Medicare/Coding/ICD10/index.html?redirect=/ICD10 or on the Center for Disease Control and
Prevention (CDC's) Web site at www.cdc.gov/nchs/data/icd10/10cmguidelines2012.pdf.
Every year, changes to the ICD-10-CM and the ICD-10-PCS coding
system will be addressed in the IPPS proposed and final rules. The
changes to the codes are effective October 1 of each year and must be
used by acute care hospitals as well as other providers to report
diagnostic and procedure information. The IPF PPS has always
incorporated ICD-9-CM coding changes made in the annual IPPS update and
will continue to do so for the ICD-10-CM and ICD-10-PCS coding changes.
We will continue to publish coding changes in a Transmittal/Change
Request, similar to how coding changes are announced by the IPPS and
LTCH PPS. The coding changes relevant to the IPF PPS are also published
in the IPF PPS proposed and final rules, or in IPF PPS update notices.
In 42 CFR 412.428(e), we indicate that CMS will publish information
pertaining to the annual update for the IPF PPS, which includes
describing the ICD-9-CM coding changes and DRG classification changes
discussed in the annual update to the hospital IPPS regulations. We
proposed to update Sec. 412.428(e) to indicate that we will describe
the ICD-10-CM coding changes and DRG classification changes discussed
in the annual update to the hospital IPPS regulations when ICD-10-CM/
PCS becomes the required medical data code set for use on Medicare
claims. Now that we know the ICD-10 compliance date will be October 1,
2015, we will include revised Sec. 412.428(e) in the FY 2016 IPF PPS
update, which will be effective on October 1, 2015.
The ICD-9-CM coding changes are reflected in the FY 2015 GROUPER,
Version 32.0, effective for IPPS discharges occurring on or after
October 1, 2014 through September 30, 2015. The GROUPER Version 32.0
software package assigns each case to an MS-DRG on the basis of the
diagnosis and procedure codes and demographic information (that is,
age, sex, and discharge status). The Medicare Code Editor (MCE) version
32.0 has also been updated for IPPS discharges on or after October 1,
2014.
The IPF PPS has always used the same GROUPER and MCE as the IPPS.
We have posted a Definitions Manual of the ICD-10 MS-DRGs Version 31.0-
R (an updated ICD-10 MS-DRGs version 31.0) on the ICD-10 MS-DRG
Conversion Project Web site at: http://www.cms.hhs.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html. We also prepared a
document that describes changes made from Version 31.0 to Version 31.0-
R. We will continue to share ICD-10-MS-DRG conversion activities with
the public through this Web site.
The MS-DRGs were converted so that the MS-DRG assignment logic uses
ICD-10-CM/PCS codes directly. When a provider submits a claim for
discharges, the ICD-10-CM/PCS diagnosis and procedure codes will be
assigned to the correct MS-DRG. The MS-DRGs were converted with a
single overarching goal: That MS-DRG assignment for a given patient
record is the same after ICD-10-CM implementation as it would be if the
same record had been coded in ICD-9-CM and submitted prior to ICD-10-
CM/PCS implementation. This goal is referred to as replication, and
every effort was made to achieve this goal.
The General Equivalence Mappings (GEMs) were used to assist in
converting the ICD-9-CM-based MS-DRGs to ICD-10-CM/PCS. The majority of
ICD-9-CM codes (greater than 80 percent) have straightforward
translation alternative(s) in ICD-10-CM/PCS, where the diagnoses or
procedures classified to a given ICD-9-CM code are replaced by a number
of (typically more specific) ICD-10-CM/PCS codes and assigned to the
same MS-DRG as the ICD-9-CM code they are replacing. Further
information on the assessment of ICD-10-CM/PCS MS-DRGs and financial
impact can be found on the CMS ICD-10 Web site at: http://www.cms.hhs.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html.
Questions concerning the MS-DRGs should be directed to Patricia E.
Brooks, Co-Chairperson, ICD-10-CM Coordination and Maintenance
Committee, CMS, Center for Medicare Management, Hospital and Ambulatory
Policy Group, Division of Acute Care, [email protected],
Mailstop C4-08-06, 7500 Security Boulevard, Baltimore, Maryland 21244-
1850.

Use of the General Equivalence Mappings To Assist in Direct Conversion

For the FY 2015 update, we are not making changes to the MS-IPF-DRG
adjustment factors. That is, we do not intend to re-run the regression
analysis to update the 17 IPF MS-DRG adjustment factors. The General
Equivalence Mappings (GEMs) were used to assist in converting the ICD-
9-CM-based MS-DRGs to ICD-10-CM/PCS. For this update, we are using the
ICD-10-CM/PCS codes that will be used for the MS-DRG payment
adjustment. Further information for the ICD-10-CM/PCS MS-DRG conversion
project can be found on the CMS ICD-10-CM Web site at http://www.cms.hhs.gov/Medicare/Coding/ICD10/ICD-10-MS-DRG-Conversion-Project.html.
Final Rule Action: The MS-IPF-DRG adjustment factors (as shown in
Table 2) will continue to be paid for discharges occurring in FY 2015.
The MS-IPF-DRG adjustment factors will be updated on October 1, 2014,
using the ICD-9-CM/PCS code set. The conversion of ICD-9-CM/PCS codes
to ICD-10-CM/PCS codes for the IPF PPS in this final rule will go into
effect on October 1, 2015.

Table 2--FY 2015 Current MS-IPF-DRGS Applicable for the Principal
Diagnosis Adjustment
------------------------------------------------------------------------
Adjustment
MS-DRG MS-DRG descriptions factor
------------------------------------------------------------------------
056.......... Degenerative nervous system disorders w 1.05
MCC.
057.......... Degenerative nervous system disorders w/o 1.05
MCC.
080.......... Nontraumatic stupor & coma w MCC......... 1.07
081.......... Nontraumatic stupor & coma w/o MCC....... 1.07
876.......... O.R. Procedure w principal diagnoses of 1.22
mental illness.
880.......... Acute adjustment reaction & psychosocial 1.05
dysfunction.
881.......... Depressive neuroses...................... 0.99
882.......... Neuroses except depressive............... 1.02
883.......... Disorders of personality & impulse 1.02
control.
884.......... Organic disturbances & mental retardation 1.03

[[Page 45947]]

885.......... Psychoses................................ 1.00
886.......... Behavioral & developmental disorders..... 0.99
887.......... Other mental disorder diagnoses.......... 0.92
894.......... Alcohol/drug abuse or dependence, left 0.97
AMA.
895.......... Alcohol/drug abuse or dependence w 1.02
rehabilitation therapy.
896.......... Alcohol/drug abuse or dependence w/o 0.88
rehabilitation therapy w MCC.
897.......... Alcohol/drug abuse or dependence w/o 0.88
rehabilitation therapy w/o MCC.
------------------------------------------------------------------------

2. Payment for Comorbid Conditions
The intent of the comorbidity adjustments is to recognize the
increased costs associated with comorbid conditions by providing
additional payments for certain concurrent medical or psychiatric
conditions that are expensive to treat. In the May 2011 IPF PPS final
rule (76 FR 26451 through 26452), we explained that the IPF PPS
includes 17 comorbidity categories and identified the new, revised, and
deleted ICD-9-CM diagnosis codes that generate a comorbid condition
payment adjustment under the IPF PPS for RY 2012 (76 FR 26451).
Comorbidities are specific patient conditions that are secondary to
the patient's principal diagnosis and that require treatment during the
stay. Diagnoses that relate to an earlier episode of care and have no
bearing on the current hospital stay are excluded and must not be
reported on IPF claims. Comorbid conditions must exist at the time of
admission or develop subsequently, and affect the treatment received,
length of stay (LOS), or both treatment and LOS.
For each claim, an IPF may receive only one comorbidity adjustment
within a comorbidity category, but it may receive an adjustment for
more than one comorbidity category. Current billing instructions
require IPFs to enter the full, that is, the complete ICD-9-CM codes
for up to 24 additional diagnoses if they co-exist at the time of
admission or develop subsequently and impact the treatment provided.
Billing instructions will require that IPFs enter the full ICD-10-CM/
PCS codes. The effective date of this change will be October 1, 2015.
The comorbidity adjustments were determined based on the regression
analysis using the diagnoses reported by IPFs in FY 2002. The principal
diagnoses were used to establish the DRG adjustments and were not
accounted for in establishing the comorbidity category adjustments,
except where ICD-9-CM ``code first'' instructions apply. As we
explained in the May 2011 IPF PPS final rule (76 FR 265451), the ``code
first'' rule applies when a condition has both an underlying etiology
and a manifestation due to the underlying etiology. For these
conditions, ICD-9-CM has a coding convention that requires the
underlying conditions to be sequenced first followed by the
manifestation. Whenever a combination exists, there is a ``use
additional code'' note at the etiology code and a ``code first'' note
at the manifestation code.
The same principle holds for ICD-10-CM as for ICD-9-CM. Whenever a
combination exists, there is a ``use additional code'' note in the ICD-
10-CM codebook pertaining to the etiology code, and a ``code first''
code pertaining to the manifestation code. We provide a ``code first''
table in Addendum C of this final rule for reference that highlights
the same or similar manifestation codes where the ``code first''
instructions apply in ICD-10-CM that were present in ICD-9-CM. In the
``code first'' table, pertaining to ICD-10-CM codes F02.80, F02.81 and
F05, where individual examples of possible etiologies are listed in the
codebook, in the interest of inclusiveness, all ICD-10-CM examples are
included in addition to the comparable ICD-10-CM translations of
examples listed in the ICD-9-CM codebook for the same manifestations.
Also, in the interest of inclusiveness, an ICD-10-CM manifestation code
F45.42 ``Pain disorder with related psychological factors,'' is
included in the IPF PPS ``code first'' table even though it contains a
``code also'' instruction rather than a ``code first'' instruction, but
is included in this version of the table for information purposes only.
The list of ICD-10-CM codes that we identified as ``code first'' can be
located in Addendum C in this final rule.
As discussed in the MS-DRG section, it is our policy to maintain
the same diagnostic coding set for IPFs that is used under the IPPS for
providing the same psychiatric care. The 17 comorbidity categories
formerly defined using ICD-9-CM codes have been converted to ICD-10-CM/
PCS. The goal for converting the comorbidity categories is referred to
as replication, meaning that the payment adjustment for a given patient
encounter is the same after ICD-10-CM implementation as it will be if
the same record had been coded in ICD-9-CM and submitted prior to ICD-
10-CM/PCS implementation. All conversion efforts were made with the
intent of achieving this goal. The effective date of this change is
October 1 2015.

Direct Conversion of Comorbidity Categories

We converted the ICD-9-CM codes for the IPF PPS Comorbidity Payment
Adjustment Categories to ICD-10-CM/PCS codes. When an IPF submits a
claim for discharges the ICD-10-CM/PCS codes will be assigned to the
correct comorbidity categories. The same method of direct conversion to
ICD-10-CM/PCS for replication of ICD-9-CM based payment applications
has been implemented by policy groups throughout CMS to convert
applications to ICD-10-CM/PCS, including the MS-DRGs.

Use of the General Equivalence Mappings to Assist in Direct Conversion

As with the other policy groups mentioned above, the General
Equivalence Mappings (GEMs) were used to assist in converting ICD-9-CM-
based applications to ICD-10-CM/PCS. Further information concerning the
GEMs can be found on the CMS ICD-10 Web site at: http://www.cms.gov/Medicare/Coding/ICD10/2014-ICD-10-CM-and-GEMs.html.
The majority of ICD-9-CM codes (greater than 80 percent) have
straightforward translation alternative(s) in ICD-10-CM/PCS, where the
diagnoses or procedures classified to a given ICD-9-CM code are
replaced by a number of possibly more specific ICD-10-CM/PCS codes, and
those ICD-10-CM/PCS codes capture the intent of the payment policy.
In rare instances, ICD-10-CM has discontinued an area of detail in
the classification. For example, this is the case with the concept of
``malignant

[[Page 45948]]

hypertension'' in the Cardiac Conditions comorbidity category.
Malignant hypertension is no longer classified separately in codes that
specify heart failure, such as ICD-9-CM code 404.03 Hypertensive heart
and chronic kidney disease, malignant, with heart failure and with
chronic kidney disease stage V or end-stage renal disease. This code,
in the Cardiac Conditions comorbidity category, has no corresponding
code in the ICD-10-CM Cardiac Conditions comorbidity category. Instead,
all sub-types of hypertension in the presence of heart disease or
chronic kidney disease are classified to a single code in ICD-10-CM
that specifies the level of heart and kidney function, such as I13.2
Hypertensive heart and chronic kidney disease with heart failure and
with stage 5 chronic kidney disease, or end stage renal disease.
Discussed below are the comorbidity categories where the crosswalk
between ICD-9-CM and ICD-10-CM diagnosis codes is less than
straightforward. For instance, in some cases, the use of combination
codes in one code set is represented as two separate codes in the other
code set.

Conversion of Gangrene and Uncontrolled Diabetes Mellitus With or
Without Complications Comorbidity Categories

In the Gangrene comorbidity category, there are new ICD-10-CM
combination codes not present in ICD-9-CM. Therefore, we are including
many more ICD-10-CM codes in the comorbidity definitions than were
included using ICD-9-CM codes so that the comorbidity category using
ICD-10-CM codes is a complete and accurate replication of the category
using ICD-9-CM codes.
The ICD-9-CM version of the comorbidity category Uncontrolled
Diabetes Mellitus With or Without Complications contains combination
codes with extra information that is not relevant to the clinical
intent of the category. All patients with uncontrolled diabetes are
eligible for the payment adjustment, regardless of whether they have
additional diabetic complications. The diagnosis of uncontrolled
diabetes is coded separately in ICD-10-CM. As a result, only two ICD-
10-CM codes are needed to achieve complete and accurate replication of
the comorbidity category definition using ICD-9-CM codes.

Conversion of the Gangrene Comorbidity Category

Currently, two ICD-9-CM codes are used for the Gangrene comorbidity
category: 440.24 Atherosclerosis of native arteries of the extremities
with gangrene and 785.4 Gangrene.
The first code, 440.24, is a combination code and specifies
patients with underlying peripheral vascular disease and a current
acute manifestation of gangrene. This is the only ICD-9-CM combination
code that specifies gangrene in addition to the underlying cause. Also,
a number of ICD-10-CM codes exist for gangrene and they are all
included in the ICD-10-CM comorbidity category. The ICD-10-CM codes
specify anatomic site in more detail. An example is given below:

I70.261 Atherosclerosis of native arteries of extremities with
gangrene, right leg
I70.262 Atherosclerosis of native arteries of extremities with
gangrene, left leg
I70.263 Atherosclerosis of native arteries of extremities with
gangrene, bilateral legs
I70.268 Atherosclerosis of native arteries of extremities with
gangrene, other extremity

In addition, many ICD-10-CM codes specify gangrene in combination
with diabetes. We are including these codes in the comorbidity category
to ensure that a patient with diabetes complicated by gangrene receives
the same payment adjustment for the condition when it is coded in ICD-
10 as if it had been coded in ICD-9-CM.

Conversion of the Uncontrolled Diabetes Mellitus With or Without
Complications Comorbidity Category

Where ICD-9-CM uses combination codes for uncontrolled diabetes,
ICD-10-CM classifies diabetes that is out of control in a separate,
standalone code. Unlike ICD-9-CM, ICD-10-CM does not have additional
codes that specify out of control diabetes in combination with a
complication such as, for example, diabetic chronic kidney disease. The
result is that the comorbidity category Uncontrolled Diabetes Mellitus
With or Without Complications is simpler to define using ICD-10-CM
codes than ICD-9-CM codes.
ICD-10-CM has changed the classification of a diagnosis of
uncontrolled diabetes in two ways that affect conversion of the
Uncontrolled Diabetes comorbidity category:
1. ICD-10-CM no longer uses the term ``uncontrolled'' in reference
to diabetes.
2. ICD-10-CM classifies diabetes that is poorly controlled in a
separate, standalone code.
ICD-10-CM does not use the term ``uncontrolled'' in codes that
classify diabetes patients. Instead, ICD-10-CM codes specify diabetes
``with hyperglycemia'' as the new terminology for classifying patients
whose diabetes is ``poorly controlled'' or ``inadequately controlled''
or ``out of control.'' We believe these are appropriate codes to
capture the intent of the Uncontrolled Diabetes comorbidity category.
Therefore, to ensure that all patients who qualified for the
Uncontrolled Diabetes comorbidity payment adjustment using ICD-9-CM
codes will also qualify for the payment adjustment using ICD-10-CM
codes, we propose that two ICD-10-CM codes specifying diabetes with
hyperglycemia will be used for the payment adjustment for Uncontrolled
Diabetes Mellitus With or Without Complications: E10.65 Type 1 diabetes
mellitus with hyperglycemia, and E11.65 Type 2 diabetes mellitus with
hyperglycemia.

Other Differences between ICD-9-CM and ICD-10-CM Affecting Conversion
of Comorbidity Categories

Two other comorbidity categories in the IPF PPS required careful
review and additional formatting of the corresponding ICD-10-CM codes
in order to replicate the clinical intent of the comorbidity category.
In the Drug and/or Alcohol Induced Mental Disorders comorbidity
category and the Poisoning comorbidity category, significant structural
changes in the way that comparable codes are classified in ICD-10-CM
made it more difficult to list the diagnoses in ICD-10-CM code ranges,
as was possible in ICD-9-CM. Because comparable codes are not
classified contiguously in the ICD-10-CM classification scheme, the
resulting list of codes for this comorbidity category is much longer
than the comorbidity category using ICD-9-CM codes.

Conversion of the Drug and/or Alcohol Induced Mental Disorders
Comorbidity Category

ICD-10-CM has changed the classification of applicable conditions
in two ways that affect conversion of the Drug and/or Alcohol Induced
Mental Disorders comorbidity category:
1. ICD-10-CM does not use the term ``pathological'' in reference to
drug or alcohol intoxication, rather it only uses the phrase ``with
intoxication.''
2. ICD-10-CM contains separate, detailed codes for specific drug-
induced manifestations of mental disorder. ICD-10-CM codes specify the
particular drug and whether the pattern of use is documented as use,
abuse, or dependence.
First, this comorbidity category currently contains ICD-9-CM code
292.2 Pathological drug intoxication. To

[[Page 45949]]

ensure that all patients who qualified for the comorbidity payment
adjustment under ICD-9-CM code 292.2 will also qualify under the ICD-
10-CM version of the same comorbidity category, the 89 ICD-10-CM codes
specifying ``with intoxication'' will qualify for the payment
adjustment. An example of the ICD-10-CM codes for a diagnosis of
cocaine abuse with current intoxication is provided below. All of these
codes are eligible for the payment adjustment.

F14.120 Cocaine abuse with intoxication, uncomplicated
F14.121 Cocaine abuse with intoxication with delirium
F14.122 Cocaine abuse with intoxication with perceptual
disturbance
F14.129 Cocaine abuse with intoxication, unspecified

Next, ICD-10-CM contains separate, detailed codes by drug for
specific drug-induced manifestations of mental disorder, such as drug-
induced psychotic disorder with hallucinations. What was a single code
in ICD-9-CM, 292.12 Drug-induced psychotic disorder with
hallucinations, maps to 24 comparable codes in ICD-10-CM. We will
include all of these more specific ICD-10-CM codes in the comorbidity
category. We believe they are necessary for replication of the clinical
intent of the comorbidity category so that all patients with a drug-
induced psychotic disorder with hallucinations coded on the claim are
eligible for the payment adjustment. Because the ICD-10-CM codes are
not listed contiguously in the classification, they cannot be formatted
as a range of codes and therefore must be listed as single codes in the
comorbidity category definition.
The situation described above is similar for ICD-9-CM code 292.0
Drug withdrawal. ICD-10-CM contains separate, detailed codes by drug
specifying that the patient is in withdrawal. We include all of these
more specific ICD-10-CM codes in the comorbidity category. We believe
they are necessary for replication of the clinical intent of the
comorbidity category, so that all patients with a drug withdrawal code
on the claim are eligible for the payment adjustment. Likewise, because
the ICD-10-CM drug withdrawal codes are not listed contiguously in the
classification, they cannot be formatted as a range of codes and so
must be listed as single codes in the comorbidity category definition.

Conversion of the Poisoning Comorbidity Category

In ICD-10-CM, the Injury and Poisoning chapter has added an axis of
classification for every injury or poisoning diagnosis code, which
specifies additional information about the current encounter. This
creates three unique codes for each injury or poisoning diagnosis,
marked by a different letter in the seventh character of the code:
1. The seventh character ``A'' in the code indicates that the
poisoning is a current diagnosis in its ``acute phase.''
2. The seventh character ``D'' in the code indicates that the
poisoning is no longer in its ``acute phase,'' but that the patient is
receiving aftercare for the earlier poisoning.
3. The seventh character ``S'' in the code indicates that the
patient no longer requires care for any aspect of the poisoning itself,
but that the patient is receiving care for a late effect of the
poisoning.
The intent of the Poisoning comorbidity category is to include only
those patients with a current diagnosis of poisoning. If the intent had
been to include patients requiring only aftercare for an earlier,
resolved case of poisoning, or for care associated with late effects of
poisoning that occurred sometime in the past, the comorbidity category
would have included ICD-9-CM aftercare codes or late effect codes, but
it does not. Only acute poisoning codes from the ICD-9-CM
classification are included. Therefore, the Poisoning comorbidity
category will only include ICD-10-CM poisoning codes with a seventh
character extension ``A,'' to indicate that the poisoning is documented
as a current diagnosis.
In addition, ICD-10-CM poisoning codes specify the circumstances of
the poisoning, whether documented as accidental, self-harm, assault, or
undetermined, as shown in the heroin poisoning example below. We
include all of these more specific ICD-10-CM codes in the comorbidity
category for replication of the clinical intent of the comorbidity
category so that all patients with a current diagnosis of poisoning
coded on the claim would be eligible for the payment adjustment, as
shown in the heroin poisoning example below:

T40.1X1A Poisoning by heroin, accidental (unintentional),
initial encounter
T40.1X2A Poisoning by heroin, intentional self-harm, initial
encounter
T40.1X3A Poisoning by heroin, assault, initial encounter
T40.1X4A Poisoning by heroin, undetermined, initial encounter

ICD-10-CM classifies poisoning by substance, alongside separate
codes for adverse effect or underdosing of the same substance. Because
the poisoning codes are not listed contiguously in the classification,
they cannot be formatted as a range of codes and therefore must be
listed as single codes in the comorbidity category definition.

Proposed Elimination of Codes for Nonspecific Conditions Based on Side
of the Body (Laterality)

We believe that highly descriptive coding provides the best and
clearest way to document a patient's condition and the appropriateness
of the admission and treatment in an IPF. Therefore, whenever possible,
we believe that the most specific code that describes a medical
disease, condition, or injury should be used to document the patient's
diagnoses. Generally, ``unspecified'' codes are used when they most
accurately reflect what is known about the patient's condition at the
time of that particular encounter (for example, there is a lack of
information about a specific type of organism causing an illness).
However, site of illness at the time of the medical encounter is an
important determinant in assessing a patient's principal or secondary
diagnosis. For this reason, we believe that specific diagnosis codes
that narrowly identify anatomical sites where disease, injury, or
condition exist should be used when coding patients' diagnoses whenever
these codes are available. Furthermore, on the same note, we believe
that one should also code to the highest specificity (use the full ICD-
10-CM/PCS code).
In accordance with these principles, we remove site unspecified
codes from the IPF PPS ICD-10-CM/PCS codes in instances in which more
specific codes are available as the clinician should be able to
identify a more specific diagnosis based on clinical assessment at the
medical encounter. For example, the initial GEMS translation included
non-specific codes such as ICD-10-CM code C44.111 ``Basal Cell
carcinoma of skin of unspecified eyelid, including canthus.'' Under our
rule:

C44.111 Basal Cell Carcinoma of skin of unspecified eyelid
will not be accepted.
C44.112 Basal Cell Carcinoma of skin right eyelid will be
accepted.
C44.119 Basal Cell Carcinoma of skin left eyelid will be
accepted.

We are removing these non-specific codes whenever a more specific
diagnosis could be identified by the clinician performing the
assessment. For example code C44.111, we are deleting this code because
the clinician should be able to identify which eye had the basal cell
carcinoma, and therefore will

[[Page 45950]]

report the condition using the code that specifies the right or left
eye.
We are removing a total of 156 ICD-10-CM site unspecified codes
involving the following comorbidity categories: Oncology-93 ICD-10-CM
codes, Gangrene-6 ICD-10-CM codes and Severe Musculoskeletal and
Connective Tissue--57 ICD-10-CM codes. The site unspecified IPF PPS
ICD-10-CM codes being removed are listed below in Tables 3 through 5.

Table 3--Site Unspecified ICD-10-CM Codes To Be Removed From the
Oncology Treatment Comorbidity Category
------------------------------------------------------------------------
ICD-10-CM
diagnosis Code title
------------------------------------------------------------------------
C40.00............ Malignant neoplasm of scapula and long bones of
unspecified upper limb.
C40.10............ Malignant neoplasm of short bones of unspecified
upper limb.
C40.20............ Malignant neoplasm of long bones of unspecified
lower limb.
C40.30............ Malignant neoplasm of short bones of unspecified
lower limb.
C40.80............ Malignant neoplasm of overlapping sites of bone and
articular cartilage of unspecified limb.
C40.90............ Malignant neoplasm of unspecified bones and
articular cartilage of unspecified limb.
C43.10............ Malignant melanoma of unspecified eyelid, including
canthus.
C43.20............ Malignant melanoma of unspecified ear and external
auricular canal.
C43.60............ Malignant melanoma of unspecified upper limb,
including shoulder.
C43.70............ Malignant melanoma of unspecified lower limb,
including hip.
C44.101........... Unspecified malignant neoplasm of skin of
unspecified eyelid, including canthus.
C44.111........... Basal cell carcinoma of skin of unspecified eyelid,
including canthus.
C44.121........... Squamous cell carcinoma of skin of unspecified
eyelid, including canthus.
C44.191........... Other specified malignant neoplasm of skin of
unspecified eyelid, including canthus.
C44.201........... Unspecified malignant neoplasm of skin of
unspecified ear and external auricular canal.
C44.211........... Basal cell carcinoma of skin of unspecified ear and
external auricular canal.
C44.221........... Squamous cell carcinoma of skin of unspecified ear
and external auricular canal.
C44.601........... Unspecified malignant neoplasm of skin of
unspecified upper limb, including shoulder.
C44.611........... Basal cell carcinoma of skin of unspecified upper
limb, including shoulder.
C44.621........... Squamous cell carcinoma of skin of unspecified upper
limb, including shoulder.
C44.691........... Other specified malignant neoplasm of skin of
unspecified upper limb, including shoulder.
C44.701........... Unspecified malignant neoplasm of skin of
unspecified lower limb, including hip.
C44.711........... Basal cell carcinoma of skin of unspecified lower
limb, including hip.
C44.721........... Squamous cell carcinoma of skin of unspecified lower
limb, including hip.
C44.791........... Other specified malignant neoplasm of skin of
unspecified lower limb, including hip.
C47.10............ Malignant neoplasm of peripheral nerves of
unspecified upper limb, including shoulder.
C47.20............ Malignant neoplasm of peripheral nerves of
unspecified lower limb, including hip.
C49.10............ Malignant neoplasm of connective and soft tissue of
unspecified upper limb, including shoulder.
C49.20............ Malignant neoplasm of connective and soft tissue of
unspecified lower limb, including hip.
C4A.10............ Merkel cell carcinoma of unspecified eyelid,
including canthus.
C4A.20............ Merkel cell carcinoma of unspecified ear and
external auricular canal.
C4A.60............ Merkel cell carcinoma of unspecified upper limb,
including shoulder.
C4A.70............ Merkel cell carcinoma of unspecified lower limb,
including hip.
C50.019........... Malignant neoplasm of nipple and areola, unspecified
female breast.
C50.029........... Malignant neoplasm of nipple and areola, unspecified
male breast.
C50.119........... Malignant neoplasm of central portion of unspecified
female breast.
C50.129........... Malignant neoplasm of central portion of unspecified
male breast.
C50.219........... Malignant neoplasm of upper-inner quadrant of
unspecified female breast.
C50.229........... Malignant neoplasm of upper-inner quadrant of
unspecified male breast.
C50.319........... Malignant neoplasm of lower-inner quadrant of
unspecified female breast.
C50.329........... Malignant neoplasm of lower-inner quadrant of
unspecified male breast.
C50.419........... Malignant neoplasm of upper-outer quadrant of
unspecified female breast.
C50.429........... Malignant neoplasm of upper-outer quadrant of
unspecified male breast.
C50.519........... Malignant neoplasm of lower-outer quadrant of
unspecified female breast.
C50.529........... Malignant neoplasm of lower-outer quadrant of
unspecified male breast.
C50.619........... Malignant neoplasm of axillary tail of unspecified
female breast.
C50.629........... Malignant neoplasm of axillary tail of unspecified
male breast.
C50.819........... Malignant neoplasm of overlapping sites of
unspecified female breast.
C50.829........... Malignant neoplasm of overlapping sites of
unspecified male breast.
C50.919........... Malignant neoplasm of unspecified site of
unspecified female breast.
C50.929........... Malignant neoplasm of unspecified site of
unspecified male breast.
C69.00............ Malignant neoplasm of unspecified conjunctiva.
C69.10............ Malignant neoplasm of unspecified cornea.
C69.50............ Malignant neoplasm of unspecified lacrimal gland and
duct.
C69.60............ Malignant neoplasm of unspecified orbit.
C69.80............ Malignant neoplasm of overlapping sites of
unspecified eye and adnexa.
C69.90............ Malignant neoplasm of unspecified site of
unspecified eye.
C76.40............ Malignant neoplasm of unspecified upper limb.
C76.50............ Malignant neoplasm of unspecified lower limb.
D03.10............ Melanoma in situ of unspecified eyelid, including
canthus.
D03.20............ Melanoma in situ of unspecified ear and external
auricular canal.
D03.60............ Melanoma in situ of unspecified upper limb,
including shoulder.
D03.70............ Melanoma in situ of unspecified lower limb,
including hip.
D04.10............ Carcinoma in situ of skin of unspecified eyelid,
including canthus.
D04.20............ Carcinoma in situ of skin of unspecified ear and
external auricular canal.

[[Page 45951]]

D04.60............ Carcinoma in situ of skin of unspecified upper limb,
including shoulder.
D04.70............ Carcinoma in situ of skin of unspecified lower limb,
including hip.
D05.00............ Lobular carcinoma in situ of unspecified breast.
D05.10............ Intraductal carcinoma in situ of unspecified breast.
D05.80............ Other specified type of carcinoma in situ of
unspecified breast.
D05.90............ Unspecified type of carcinoma in situ of unspecified
breast.
D09.20............ Carcinoma in situ of unspecified eye.
D16.00............ Benign neoplasm of scapula and long bones of
unspecified upper limb.
D16.10............ Benign neoplasm of short bones of unspecified upper
limb.
D16.20............ Benign neoplasm of long bones of unspecified lower
limb.
D16.30............ Benign neoplasm of short bones of unspecified lower
limb.
D17.20............ Benign lipomatous neoplasm of skin and subcutaneous
tissue of unspecified limb.
D21.10............ Benign neoplasm of connective and other soft tissue
of unspecified upper limb, including shoulder.
D21.20............ Benign neoplasm of connective and other soft tissue
of unspecified lower limb, including hip.
D22.10............ Melanocytic nevi of unspecified eyelid, including
canthus.
D22.20............ Melanocytic nevi of unspecified ear and external
auricular canal.
D22.60............ Melanocytic nevi of unspecified upper limb,
including shoulder.
D22.70............ Melanocytic nevi of unspecified lower limb,
including hip.
D23.10............ Other benign neoplasm of skin of unspecified eyelid,
including canthus.
D23.20............ Other benign neoplasm of skin of unspecified ear and
external auricular canal.
D23.60............ Other benign neoplasm of skin of unspecified upper
limb, including shoulder.
D23.70............ Other benign neoplasm of skin of unspecified lower
limb, including hip.
D24.9............. Benign neoplasm of unspecified breast.
D31.00............ Benign neoplasm of unspecified conjunctiva.
D31.50............ Benign neoplasm of unspecified lacrimal gland and
duct.
D31.60............ Benign neoplasm of unspecified site of unspecified
orbit.
D31.90............ Benign neoplasm of unspecified part of unspecified
eye.
D48.60............ Neoplasm of uncertain behavior of unspecified
breast.
------------------------------------------------------------------------

Table 4--Site Unspecified ICD-10-CM Codes To Be Removed From the
Gangrene Comorbidity Category
------------------------------------------------------------------------
ICD10 ICD10 description
------------------------------------------------------------------------
I70269............ Atherosclerosis of native arteries of extremities
with gangrene, unspecified extremity.
I70369............ Atherosclerosis of unspecified type of bypass
graft(s) of the extremities with gangrene,
unspecified extremity.
I70469............ Atherosclerosis of autologous vein bypass graft(s)
of the extremities with gangrene, unspecified
extremity.
I70569............ Atherosclerosis of nonautologous biological bypass
graft(s) of the extremities with gangrene,
unspecified extremity.
I70669............ Atherosclerosis of nonbiological bypass graft(s) of
the extremities with gangrene, unspecified
extremity.
I70769............ Atherosclerosis of other type of bypass graft(s) of
the extremities with gangrene, unspecified
extremity.
------------------------------------------------------------------------

Table 5--Site Unspecified ICD-10-CM Codes To Be Removed From the Severe
Musculoskeletal and Connective Tissue Diseases Category
------------------------------------------------------------------------
ICD10 ICD10 description
------------------------------------------------------------------------
M8600............. Acute hematogenous osteomyelitis, unspecified site.
M86019............ Acute hematogenous osteomyelitis, unspecified
shoulder.
M86029............ Acute hematogenous osteomyelitis, unspecified
humerus.
M86039............ Acute hematogenous osteomyelitis, unspecified radius
and ulna.
M86049............ Acute hematogenous osteomyelitis, unspecified hand.
M86059............ Acute hematogenous osteomyelitis, unspecified femur.
M86069............ Acute hematogenous osteomyelitis, unspecified tibia
and fibula.
M86079............ Acute hematogenous osteomyelitis, unspecified ankle
and foot.
M8610............. Other acute osteomyelitis, unspecified site.
M86119............ Other acute osteomyelitis, unspecified shoulder.
M86129............ Other acute osteomyelitis, unspecified humerus.
M86139............ Other acute osteomyelitis, unspecified radius and
ulna.
M86149............ Other acute osteomyelitis, unspecified hand.
M86159............ Other acute osteomyelitis, unspecified femur.
M86169............ Other acute osteomyelitis, unspecified tibia and
fibula.
M86179............ Other acute osteomyelitis, unspecified ankle and
foot.
M8620............. Subacute osteomyelitis, unspecified site.
M86219............ Subacute osteomyelitis, unspecified shoulder.
M86229............ Subacute osteomyelitis, unspecified humerus.
M86239............ Subacute osteomyelitis, unspecified radius and ulna.
M86249............ Subacute osteomyelitis, unspecified hand.
M86259............ Subacute osteomyelitis, unspecified femur.
M86269............ Subacute osteomyelitis, unspecified tibia and
fibula.

[[Page 45952]]

M86279............ Subacute osteomyelitis, unspecified ankle and foot.
M8630............. Chronic multifocal osteomyelitis, unspecified site.
M86319............ Chronic multifocal osteomyelitis, unspecified
shoulder.
M86329............ Chronic multifocal osteomyelitis, unspecified
humerus.
M86339............ Chronic multifocal osteomyelitis, unspecified radius
and ulna.
M86349............ Chronic multifocal osteomyelitis, unspecified hand.
M86359............ Chronic multifocal osteomyelitis, unspecified femur.
M86369............ Chronic multifocal osteomyelitis, unspecified tibia
and fibula.
M86379............ Chronic multifocal osteomyelitis, unspecified ankle
and foot.
M8640............. Chronic osteomyelitis with draining sinus,
unspecified site.
M86419............ Chronic osteomyelitis with draining sinus,
unspecified shoulder.
M86429............ Chronic osteomyelitis with draining sinus,
unspecified humerus.
M86439............ Chronic osteomyelitis with draining sinus,
unspecified forearm.
M86449............ Chronic osteomyelitis with draining sinus,
unspecified hand.
M86459............ Chronic osteomyelitis with draining sinus,
unspecified femur.
M86469............ Chronic osteomyelitis with draining sinus,
unspecified lower leg.
M86479............ Chronic osteomyelitis with draining sinus,
unspecified ankle and foot.
M8650............. Other chronic hematogenous osteomyelitis,
unspecified site.
M86519............ Other chronic hematogenous osteomyelitis,
unspecified shoulder.
M86529............ Other chronic hematogenous osteomyelitis,
unspecified humerus.
M86539............ Other chronic hematogenous osteomyelitis,
unspecified forearm.
M86549............ Other chronic hematogenous osteomyelitis,
unspecified hand.
M86559............ Other chronic hematogenous osteomyelitis,
unspecified femur.
M86569............ Other chronic hematogenous osteomyelitis,
unspecified lower leg.
M86579............ Other chronic hematogenous osteomyelitis,
unspecified ankle and foot.
M8660............. Other chronic osteomyelitis, unspecified site.
M86619............ Other chronic osteomyelitis, unspecified shoulder.
M86629............ Other chronic osteomyelitis, unspecified upper arm.
M86639............ Other chronic osteomyelitis, unspecified forearm.
M86649............ Other chronic osteomyelitis, unspecified hand.
M86659............ Other chronic osteomyelitis, unspecified thigh.
M86669............ Other chronic osteomyelitis, unspecified tibia and
fibula.
M86679............ Other chronic osteomyelitis, unspecified ankle and
foot.
M868x9............ Other osteomyelitis, unspecified sites.
------------------------------------------------------------------------

There are some site unspecified ICD-10-CM codes that we are not
removing. In the case where the site unspecified code is the only
available ICD-10-CM code, that is when a laterality code (site specific
code) is not available, the site unspecified code will not be removed
and it would be appropriate to submit that code.
Currently, IPFs are receiving the comorbidity adjustment using the
ICD-9-CM diagnosis codes for the comorbidity categories shown in Table
6 below.

Table 6--FY 2014 Current Diagnosis Codes and Adjustment Factors for Comorbidity Categories
----------------------------------------------------------------------------------------------------------------
Adjustment
Description of comorbidity ICD-9-CM diagnoses codes factor
----------------------------------------------------------------------------------------------------------------
Developmental Disabilities............... 317, 3180, 3181, 3182, and 319....................... 1.04
Coagulation Factor Deficits.............. 2860 through 2864.................................... 1.13
Tracheostomy............................. 51900 through 51909 and V440......................... 1.06
Renal Failure, Acute..................... 5845 through 5849, 63630, 63631, 63632, 63730, 63731, 1.11
63732, 6383, 6393, 66932, 66934, 9585.
Renal Failure, Chronic................... 40301, 40311, 40391, 40402, 40412, 40413, 40492, 1.11
40493, 5853, 5854, 5855, 5856, 5859, 586, V4511,
V4512, V560, V561, and V562.
Oncology Treatment....................... 1400 through 2399 with a radiation therapy code 92.21- 1.07
92.29 or chemotherapy code 99.25.
Uncontrolled Diabetes-Mellitus with or 25002, 25003, 25012, 25013, 25022, 25023, 25032, 1.05
without complications. 25033, 25042, 25043, 25052, 25053, 25062, 25063,
25072, 25073, 25082, 25083, 25092, and 25093.
Severe Protein Calorie Malnutrition...... 260 through 262...................................... 1.13
Eating and Conduct Disorders............. 3071, 30750, 31203, 31233, and 31234................. 1.12
Infectious Disease....................... 01000 through 04110, 042, 04500 through 05319, 05440 1.07
through 05449, 0550 through 0770, 0782 through
07889, and 07950 through 07959.
Drug and/or Alcohol Induced Mental 2910, 2920, 29212, 2922, 30300, and 30400............ 1.03
Disorders.
Cardiac Conditions....................... 3910, 3911, 3912, 40201, 40403, 4160, 4210, 4211, and 1.11
4219.
Gangrene................................. 44024 and 7854....................................... 1.10
Chronic Obstructive Pulmonary Disease.... 49121, 4941, 5100, 51883, 51884, V4611, V4612, V4613 1.12
and V4614.
Artificial Openings--Digestive and 56960 through 56969, 9975, and V441 through V446..... 1.08
Urinary.

[[Page 45953]]

Severe Musculoskeletal and Connective 6960, 7100, 73000 through 73009, 73010 through 73019, 1.09
Tissue Disease. and 73020 through 73029.
Poisoning................................ 96500 through 96509, 9654, 9670 through 9699, 9770, 1.11
9800 through 9809, 9830 through 9839, 986, 9890
through 9897.
----------------------------------------------------------------------------------------------------------------

Final Rule Action: For FY 2015, we are applying the 17 comorbidity
categories for which we provide an adjustment as shown in Table 6
above. Also, the ICD-10-CM/PCS codes and adjustment factors shown in
Table 7 below, as well as, the removal of 153 site unspecified ICD-10-
CM codes in Tables 3 through 5 above will go into effect October 1,
2015.

Table 7--FY 2015 Diagnosis Codes and Adjustment Factors for Comorbidity Categories
----------------------------------------------------------------------------------------------------------------
Adjustment
Description of comorbidity ICD-10-CM diagnoses codes factor
----------------------------------------------------------------------------------------------------------------
Developmental Disabilities.................... F70 through F79................................. 1.04
Coagulation Factor Deficits................... D66 through D682................................ 1.13
Tracheostomy.................................. J9500 through J9509, and Z930................... 1.06
Renal Failure, Acute.......................... N170 through N179, O0482, O0732, O084 O904, and 1.11
T795XXA.
Renal Failure, Chronic........................ I120, I1311 through I132, N183 through N19, 1.11
Z4901 through Z4931, Z9115, and Z992.
Oncology Treatment............................ C000 through C4002, C4011, C4012 C4021, C4022, 1.07
C4031, C4032, C4081, C4082, C4091 through C430,
C4311, C4312 , C4321, C4322, C4361, C4362,
C4371, C4372 though C4409, C44102, C44109,
C44112, C44119, C44122, C44129, C44191, C44192,
C44202, C44209, C44212, C44219, C44222, C44229
through C44599, C44602, C44609, C44612, C44619,
C44622, C44629, C44692, C44699, C44702, C44709,
C44712, C44719, C44722, C44729, C44792, C44799
through C470, C4711, C4712, C4721, C4722
through C490, C4911, C4912, C4921, C4922
through C4A0, C4A11, C4A12, C4A21, C4A22
through C4A59, C4A61, C4A62, C4A71, C4A72
through C50012, C50021, C50022, C50111, C50112,
C50121, C50122, C50211, C50212, C50221, C50222,
C50311, C50312, C50321, C50322, C50411, C50412,
C50421, C50422, C50511, C50512, C50521, C50522,
C50611, C50612, C50621, C50622, C50811, C50812,
C50821, C50822, C50911, C50912, C50921, C50922,
C510 through C689, C6901, C6902, C6911, C6912
through C6942, C6951, C6952, C6961, C6962,
C6981, C6982, C6991, C6992 through C763, C7641,
C7642, C7651, C7652 through C866, C882 through
C964, C96A, C96Z, C969 through D030, D0311,
D0312, D0321, D0322 through D0359, D0361,
D0362, D0371, D0372 through D040, D0411, D0412,
D0421, D0422 through D045, D0461, D0462, D0471,
D0472 through D049, D0501, D0502, D0511, D0512,
D0581, D0582, D0591, D0592 through D0919, D0921
through D159, D1601, D1602, D1611, D1612,
D1621, D1622, D1631, D1632 through D171, D1721
through D210, D2111, D2112, D2121, D2122
through D220, D2211, D2212, D2221, D2222, D225
through D2261, D2262, D2271, D2272 through
D230, D2311, D2312, D2321, D2322 through D235,
D2361, D2362, D2371, D2372 through D242, D250
through D309, D3101 through D3142, D3151,
D3152, D3161, D3162, D3191, D3192 through D485,
D4861 through D471, D473, D47Z1 through D47Z9,
D479 through D499, K317, K635, Q8500, and Q8501
through Q8509 with a radiation therapy code
from ICD-10-PCS tables 08H through 0YH with a
sixth character device value 1 Radioactive
Element, ICD-10-PCS table CW7, ICD-10-PCS
tables D00 through DW0, ICD-10-PCS tables D01
through DW1, tables D0Y through DWY, or a
chemotherapy code from ICD-10-PCS table 3E0
with a sixth character substance value 0
Antineoplastic and a seventh character
qualifier 5 Other Antineoplastic.
Uncontrolled Diabetes-Mellitus with or without E1065 and E1165................................. 1.05
complications.
Severe Protein Calorie Malnutrition........... E40 through E43................................. 1.13
Eating and Conduct Disorders.................. F5000 through F5002, F509, F631, F6381, and F911 1.12

[[Page 45954]]

Infectious Disease............................ A150 through A269, A280 through A329, A35 1.07
through A439, A46 through A480, A482 through
A488, A491, A70 through A740, A7489, A800
through A99, B0050 through B0059, B010 through
B0229, B03 through B069, B08010 through B0809,
B0820 through B2799, B330 through B333, B338,
B341, B471 through B479, B950 through B955,
B958, B9730 through B9739, G032, I673, J020,
J0300, J0301, J202, K9081, L081, L444, M60009,
and R1111.
Drug and/or Alcohol Induced Mental Disorders.. Alcohol dependence with intoxication and/or 1.03
withdrawal.
F10121, F10220 through F10229, F10231, and ..............
F10921.
Drug withdrawal................................. ..............
F1193, F1123, F13230 through F13239, F13930 ..............
through F13939, F1423, F1523, F1593, F17203,
F17213, F17223, F17293, F19230 through F19239,
and F19930 through F19939.
Drug-induced psychotic disorder with ..............
hallucinations.
F11251, F11151, F11951, F12151, F12251, F13151, ..............
F12951, F13251, F13951, F14151, F14251, F14951,
F15151, F15251, F15951, F16151, F16251, F16951,
F18151, F18251, F18951, F19151, F19251, and
F19951.
Drug intoxication............................... ..............
F11220 through F11229, F11920 through F11929, ..............
F12120 through F12129, F12220 through F12229,
F12920 through F12929, F13120 through F13129,
F13220 through F13229, F13920 through F13929,
F14120 through F14129, F14220 through F14229,
F14920 through F14929, F15120 through F15129,
F15220 through F15229, F15920 through F15929,
F16120 through F16129, F16220 through F16229,
F16920 through F16929, F18120 through F18129,
F18220 through F18229, F18920 through F18929,
F19120 through F19129, F19220 through F19229,
F19230 through F19239, and F19920 through
F19929.
Opioid dependence not listed above.............. ..............
F1120, F1124, F11250, F11259, F11281 through ..............
F11288, F1129.
Cardiac Conditions............................ I010 through I012, I110, I270, I330 through 1.11
I339, and I39.
Gangrene...................................... E0852, E0952, E1052, E1152, E1352, I70261 1.10
through I70268, I70361 through I70368, I70461
through I70468, I70561 through I70568, I70661
through I70668, I70761 through I70768, I7301,
and I96.
Chronic Obstructive Pulmonary Disease......... J441, J470 through J471, J860, J95850, J9610 1.12
through J9622, and Z9911 through Z9912.
Artificial Openings--Digestive and Urinary.... K9400 through K9419, N990, N99520 through 1.08
N99538, N9981, N9989, and Z931 through Z936.
Severe Musculoskeletal and Connective Tissue L4050 through L4059, M320 through M329, M4620 1.09
Diseases. through M4628, M86011, M86012, M86021, M86022,
M86031, M86032, M86041, M86042, M86051, M86052,
M86061, M86062, M86071, M86072, M8608, M8609,
M86111, M86112, M86121, M86122, M86131, M86132,
M86141, M86142, M86151, M86152, M86161, M86162,
M86171, M86172, M8618, M8619, M86211, M86212,
M86221, M86222, M86231, M86232, M86241, M86242,
M86251, M86252, M86261, M86262, M86271, M86272,
M8628, M8629, M86311, M86312, M86321, M86322,
M86331, M86332, M86341, M86342, M86351, M86352,
M86361, M86362, M86371, M86372, M8638, M8639,
M86411, M86412, M86421, M86422, M86431, M86432,
M86441, M86442, M86451, M86452, M86461, M86462,
M86471, M86472, M8648, M8649, M86511, M86512,
M86521, M86522, M86531, M86532, M86541, M86542,
M86551, M86552, M86561, M86562, M86571, M86572,
M8658, M8659, M86611, M86612, M86621, M86622,
M86631, M86632, M86641, M86642, M86651, M86652,
M86661, M86662, M86671, M86672, M8668, M8669,
M868X0, M868X1, M868X2, M868X3, M868X4, M868X5,
M868X6, M868X7, M868X8, and M869.
Poisoning..................................... Note: Only includes the codes below with seventh 1.11
character A specifying initial encounter.

[[Page 45955]]

T391X1 through T391X4, T400X1 through T400X4, ..............
T401X1 through T401X4, T402X1 through T402X4,
T403X1 through T403X4, T404X1 through T404X4,
T40601 through T40604, T40691 through T40694,
T407X1 through T407X4, T408X1 through T408X4,
T40901 through T40904, T40991 through T40994,
T410X1 through T410X4, T411X1 through T411X4,
T41201 through T41204, T41291 through T41294,
T413X1 through T413X4, T4141X through T4144X,
T423X1 through T423X4, T424X1 through T424X4,
T426X1 through T426X4, T4271X through T4274X,
T428X1 through T428X4, T43011 through T43014,
T43021 through T43024, T431X1 through T431X4,
T43201 through T43204, T43211 through T43214,
T43221 through T43224, T43291 through T43294,
T433X1 through T433X4, T434X1 through T434X4,
T43501 through T43504, T43591 through T43594,
T43601 through T43604, T43611 through T43614,
T43621 through T43624, T43631 through T43634,
T43691 through T43694, T438X1 through T438X4,
T4391X through T4394X, T505X1 through T505X4,
T510X1 through T5194X, T510X1 through T510X4,
T5391X through T5394X, T540X1 through T5494X,
T550X1 through T551X4, T560X1 through T560X4,
T571X1 through T571X4, T5801X through T5804X,
T5811X through T5814X, T582X1 through T582X4,
T588X1 through T588X4, T5891X through T5894X,
T600X1 through T600X4, T601X1 through T601X4,
T602X1 through T602X4, T6041X through T6094X,
T63001 through T6394X, T6401X through T6484X,
T650X1 through T650X4, T651X1 through T651X4.
----------------------------------------------------------------------------------------------------------------

3. Patient Age Adjustments
As explained in the November 2004 IPF PPS final rule (69 FR 66922),
we analyzed the impact of age on per diem cost by examining the age
variable (that is, the range of ages) for payment adjustments.
In general, we found that the cost per day increases with age. The
older age groups are more costly than the under 45 age group, the
differences in per diem cost increase for each successive age group,
and the differences are statistically significant.
For FY 2015, we will to continue to use the patient age adjustments
currently in effect as shown in Table 8 below.

Table 8--Age Groupings and Adjustment Factors
------------------------------------------------------------------------
Adjustment
Age factor
------------------------------------------------------------------------
Under 45................................................ 1.00
45 and under 50......................................... 1.01
50 and under 55......................................... 1.02
55 and under 60......................................... 1.04
60 and under 65......................................... 1.07
65 and under 70......................................... 1.10
70 and under 75......................................... 1.13
75 and under 80......................................... 1.15
80 and over............................................. 1.17
------------------------------------------------------------------------

Final Rule Action: We received no comments on the FY 2015 IPF PPS
proposed rule concerning the age adjustment. We are adopting the age
adjustments currently in effect and as shown in Table 8 above for FY
2015.
4. Variable Per Diem Adjustments
We explained in the November 2004 IPF PPS final rule (69 FR 66946)
that the regression analysis indicated that per diem cost declines as
the LOS increases. The variable per diem adjustments to the Federal per
diem base rate account for ancillary and administrative costs that
occur disproportionately in the first days after admission to an IPF.
We used a regression analysis to estimate the average differences
in per diem cost among stays of different lengths. As a result of this
analysis, we established variable per diem adjustments that begin on
day 1 and decline gradually until day 21 of a patient's stay. For day
22 and thereafter, the variable per diem adjustment remains the same
each day for the remainder of the stay. However, the adjustment applied
to day 1 depends upon whether the IPF has a qualifying emergency
department (ED). If an IPF has a qualifying ED, it receives a 1.31
adjustment factor for day 1 of each stay. If an IPF does not have a
qualifying ED, it receives a 1.19 adjustment factor for day 1 of the
stay. The ED adjustment is explained in more detail in section VII.C.5
of this final rule.
For FY 2015, we will continue to use the variable per diem
adjustment factors currently in effect as shown in Table 9 below. A
complete discussion of the variable per diem adjustments appears in the
November 2004 IPF PPS final rule (69 FR 66946).

Table 9--Variable Per Diem Adjustments
------------------------------------------------------------------------
Adjustment
Day-of-stay factor
------------------------------------------------------------------------
Day 1- IPF Without a Qualifying ED...................... 1.19
Day 1- IPF With a Qualifying ED......................... 1.31
Day 2................................................... 1.12
Day 3................................................... 1.08
Day 4................................................... 1.05
Day 5................................................... 1.04
Day 6................................................... 1.02
Day 7................................................... 1.01
Day 8................................................... 1.01
Day 9................................................... 1.00
Day 10.................................................. 1.00
Day 11.................................................. 0.99
Day 12.................................................. 0.99
Day 13.................................................. 0.99
Day 14.................................................. 0.99
Day 15.................................................. 0.98
Day 16.................................................. 0.97
Day 17.................................................. 0.97
Day 18.................................................. 0.96
Day 19.................................................. 0.95
Day 20.................................................. 0.95
Day 21.................................................. 0.95
After Day 21............................................ 0.92
------------------------------------------------------------------------

Final Rule Action: In response to the FY 2015 IPF PPS proposed
rule, we received no public comments concerning the variable per diem
adjustment. We are adopting the variable per diem adjustments currently
in effect and as shown in Table 9 above for FY 2015.

[[Page 45956]]

C. Facility-Level Adjustments

The IPF PPS includes facility-level adjustments for the wage index,
IPFs located in rural areas, teaching IPFs, cost of living adjustments
for IPFs located in Alaska and Hawaii, and IPFs with a qualifying ED.
1. Wage Index Adjustment
a. Background
As discussed in the May 2006 IPF PPS final rule (71 FR 27061) and
in the May 2008 (73 FR 25719) and May 2009 IPF PPS notices (74 FR
20373), in order to provide an adjustment for geographic wage levels,
the labor-related portion of an IPF's payment is adjusted using an
appropriate wage index. Currently, an IPF's geographic wage index value
is determined based on the actual location of the IPF in an urban or
rural area as defined in Sec. 412.64(b)(1)(ii)(A) and (C).
b. Wage Index for FY 2015
Since the inception of the IPF PPS, we have used the pre-
reclassified, pre-floor hospital wage index in developing a wage index
to be applied to IPFs because there is not an IPF-specific wage index
available and we believe that IPFs generally compete in the same labor
market as acute care hospitals so the pre-reclassified, pre-floor
inpatient acute care hospital wage index should be reflective of labor
costs of IPFs. As discussed in the May 2006 IPF PPS final rule for FY
2007 (71 FR 27061 through 27067), under the IPF PPS, the wage index is
calculated using the IPPS wage index for the labor market area in which
the IPF is located, without taking into account geographic
reclassifications, floors, and other adjustments made to the wage index
under the IPPS. For a complete description of these IPPS wage index
adjustments, please see the CY 2013 IPPS/LTCH PPS final rule (77 FR
53365 through 53374). We will continue that practice for FY 2015.
We apply the wage index adjustment to the labor-related portion of
the Federal rate, which is currently estimated to be 69.294 percent.
This percentage reflects the labor-related relative importance of the
FY 2008-based RPL market basket for FY 2015 (see section V.C. of this
final rule).
Changes to the wage index are made in a budget-neutral manner so
that updates do not increase expenditures. For FY 2015, we are applying
the most recent hospital wage index (that is, the FY 2014 pre-floor,
pre-reclassified hospital wage index which is the most appropriate
index as it best reflects the variation in local labor costs of IPFs in
the various geographic areas) using the most recent hospital wage data
(that is, data from hospital cost reports for the cost reporting period
beginning during FY 2010), and applying an adjustment in accordance
with our budget-neutrality policy. This policy requires us to estimate
the total amount of IPF PPS payments for FY 2014 using the labor-
related share and the wage indices from FY 2014 divided by the total
estimated IPF PPS payments for FY 2015 using the labor-related share
and wage indices from FY 2015. The estimated payments are based on FY
2013 IPF claims, inflated to the appropriate FY. This quotient is the
wage index budget-neutrality factor, and it is applied in the update of
the Federal per diem base rate for FY 2015 in addition to the market
basket described in section VI.B. of this final rule. The wage index
budget-neutrality factor for FY 2015 is 1.0002. The wage index
applicable for FY 2015 appears in Table 1 and Table 2 in Addendum B of
this final rule.
In the May 2006 IPF PPS final rule for RY 2007 (71 FR 27061-27067),
we adopted the changes discussed in the Office of Management and Budget
(OMB) Bulletin No. 03-04 (June 6, 2003), which announced revised
definitions for Metropolitan Statistical Areas (MSAs), and the creation
of Micropolitan Statistical Areas and Combined Statistical Areas. In
adopting the OMB Core-Based Statistical Area (CBSA) geographic
designations, we did not provide a separate transition for the CBSA-
based wage index since the IPF PPS was already in a transition period
from TEFRA payments to PPS payments.
As was the case in FY 2014, for FY 2015, we will continue to use
the CBSA geographic designations. The updated FY 2015 CBSA-based wage
index values are presented in Tables 1 and 2 in Addendum B of this
final rule. A complete discussion of the CBSA labor market definitions
appears in the May 2006 IPF PPS final rule (71 FR 27061 through 27067).
In keeping with established IPF PPS wage index policy, we are using
the FY 2014 pre-floor, pre-reclassified hospital wage index (which is
based on data collected from hospital cost reports submitted by
hospitals for cost reporting periods beginning during FY 2010) to
adjust IPF PPS payments beginning October 1, 2014.
c. OMB Bulletins
OMB publishes bulletins regarding CBSA changes, including changes
to CBSA numbers and titles. In the May 2008 IPF PPS notice, we
incorporated the CBSA nomenclature changes published in the most recent
OMB bulletin that applies to the hospital wage index used to determine
the current IPF PPS wage index and stated that we expect to continue to
do the same for all the OMB CBSA nomenclature changes in future IPF PPS
rules and notices, as necessary (73 FR 25721). The OMB bulletins may be
accessed online at http://www.whitehouse.gov/omb/bullentins/index.html.
In accordance with our established methodology, we have
historically adopted any CBSA changes that are published in the OMB
bulletin that corresponds with the hospital wage index used to
determine the IPF PPS wage index. For FY 2015, we use the FY 2014 pre-
floor, pre-reclassified hospital wage index to adjust the IPF PPS
payments. On February 28, 2013, OMB issued OMB Bulletin No. 13-01,
which establishes revised delineations of statistical areas based on
OMB standards published in the Federal Register on June 28, 2010 and
2010 Census Bureau data. Because the FY 2014 pre-floor, pre-
reclassified hospital wage index was finalized prior to the issuance of
this Bulletin, the FY 2014 pre-floor, pre-reclassified hospital wage
index does not reflect OMB's new area delineations based on the 2010
Census and, thus, the FY 2015 IPF PPS wage index will not reflect the
OMB changes.
CMS will use the hospital wage index based on the OMB Bulletin in
the FY 2015 IPPS/LTCH PPS final rule. Therefore, the OMB Bulletin
changes are reflected in the FY 2015 hospital wage index. Because we
base the IPF PPS wage index on the hospital wage index from the prior
year, we anticipate that the OMB Bulletin changes will be reflected in
the FY 2016 IPPS wage index.
Final Rule Action: In response to the FY 2015 IPF PPS proposed
rule, we received no comments concerning the wage adjustment. We are
adopting the FY 2014 pre-floor, pre-reclassified hospital wage index
for FY 2015.
2. Adjustment for Rural Location
In the November 2004 IPF PPS final rule, we provided a 17 percent
payment adjustment for IPFs located in a rural area. This adjustment
was based on the regression analysis, which indicated that the per diem
cost of rural facilities was 17 percent higher than that of urban
facilities after accounting for the influence of the other variables
included in the regression. For FY 2015, we are applying a 17 percent
payment adjustment for IPFs located in a rural area as defined at Sec.
412.64(b)(1)(ii)(C). A complete discussion of the adjustment for rural
locations appears in the

[[Page 45957]]

November 2004 IPF PPS final rule (69 FR 66954).
Final Rule Action: In response to the FY 2015 IPF PPS proposed
rule, we received no comments concerning the rural adjustment. We are
adopting the rural adjustments currently in effect for FY 2015.
3. Teaching Adjustment
In the November 2004 IPF PPS final rule, we implemented regulations
at Sec. 412.424(d)(1)(iii) to establish a facility-level adjustment
for IPFs that are, or are part of, teaching hospitals. The teaching
adjustment accounts for the higher indirect operating costs experienced
by hospitals that participate in graduate medical education (GME)
programs. The payment adjustments are made based on the ratio of the
number of full-time equivalent (FTE) interns and residents training in
the IPF and the IPF's average daily census.
Medicare makes direct GME payments (for direct costs such as
resident and teaching physician salaries, and other direct teaching
costs) to all teaching hospitals including those paid under a PPS, and
those paid under the TEFRA rate-of-increase limits. These direct GME
payments are made separately from payments for hospital operating costs
and are not part of the IPF PPS. The direct GME payments do not address
the estimated higher indirect operating costs teaching hospitals may
face.
The results of the regression analysis of FY 2002 IPF data
established the basis for the payment adjustments included in the
November 2004 IPF PPS final rule. The results showed that the indirect
teaching cost variable is significant in explaining the higher costs of
IPFs that have teaching programs. We calculated the teaching adjustment
based on the IPF's ``teaching variable,'' which is one plus the ratio
of the number of FTE residents training in the IPF (subject to
limitations described below) to the IPF's average daily census (ADC).
We established the teaching adjustment in a manner that limited the
incentives for IPFs to add FTE residents for the purpose of increasing
their teaching adjustment. We imposed a cap on the number of FTE
residents that may be counted for purposes of calculating the teaching
adjustment. The cap limits the number of FTE residents that teaching
IPFs may count for the purpose of calculating the IPF PPS teaching
adjustment, not the number of residents teaching institutions can hire
or train. We calculated the number of FTE residents that trained in the
IPF during a ``base year'' and used that FTE resident number as the
cap. An IPF's FTE resident cap is ultimately determined based on the
final settlement of the IPF's most recent cost report filed before
November 15, 2004 (that is, the publication date of the IPF PPS final
rule).
In the regression analysis, the logarithm of the teaching variable
had a coefficient value of 0.5150. We converted this cost effect to a
teaching payment adjustment by treating the regression coefficient as
an exponent and raising the teaching variable to a power equal to the
coefficient value. We note that the coefficient value of 0.5150 was
based on the regression analysis holding all other components of the
payment system constant. A complete discussion of how the teaching
adjustment was calculated appears in the November 2004 IPF PPS final
rule (69 FR 66954 through 66957) and the May 2008 IPF PPS notice (73 FR
25721).
Final Rule Action: As with other adjustment factors derived through
the regression analysis, we do not plan to rerun the regression
analysis until we analyze IPF PPS data. Therefore, in this final rule,
for FY 2015, we are retaining the coefficient value of 0.5150 for the
teaching adjustment to the Federal per diem base rate.
a. FTE Intern and Resident Cap Adjustment
CMS had been asked by the IPF industry to reconsider the original
IPF teaching policy and permit a temporary increase in the FTE resident
cap when an IPF increases the number of FTE residents it trains due to
the acceptance of displaced residents (residents that are training in
an IPF or a program before the IPF or program closed) when another IPF
closes or closes its medical residency training program.
To help us assess how many IPFs had been, or were expected to be
adversely affected by their inability to adjust their caps under Sec.
412.424(d)(1)(iii) and under these situations, we specifically
requested public comment from IPFs in the May 1, 2009 IPF PPS notice
(74 FR 20376 through 20377). A summary of the comments and our
responses can be reviewed in the April 30, 2010 IPF PPS notice (75 FR
23106 through 23117). All of the commenters recommended that CMS modify
the IPF PPS teaching adjustment policy, supporting a policy change that
would permit the IPF PPS residency cap to be temporarily adjusted when
that IPF trains displaced residents due to closure of an IPF or closure
of an IPF's medical residency training program(s). The commenters
recommended a temporary resident cap adjustment policy similar to the
policies applied in similar contexts for acute care hospitals.
We agreed with the commenters therefore, in the May 6, 2011 IPF PPS
final rule (76 FR 26455), we adopted the temporary resident cap
adjustment policies described below, similar to the temporary
adjustments to the FTE cap used for acute care hospitals.
b. Temporary Adjustment to the FTE Cap To Reflect Residents Added Due
to Hospital Closure
In the May 6, 2011 IPF PPS final rule (76 FR 26455), we added a new
Sec. 412.424(d)(1)(iii)(F)(1) to allow a temporary adjustment to an
IPF's FTE cap to reflect residents added because of another IPF's
closure on or after July 1, 2011, to be effective for cost reporting
periods beginning on or after July 1, 2011. For purposes of this
policy, we adopted the IPPS definition of ``closure of a hospital'' in
42 CFR 413.79(h) to mean the IPF terminates its Medicare provider
agreement as specified in 42 CFR 489.52. The regulations permit an
adjustment to an IPF's FTE cap if the IPF meets the following criteria:
(1) The IPF is training displaced residents from another IPF that
closed on or after July 1, 2011; and (2) no later than 60 days after
the hospital first begins training the displaced residents, the IPF
that is training the displaced residents from the closed IPF submits a
request for a temporary adjustment to its FTE cap to its Medicare
Administrative Contractor (MAC), and documents that the IPF is eligible
for this temporary adjustment to its FTE cap by identifying the
residents who have come from the closed IPF and have caused the
requesting IPF to exceed its cap, (or the IPF may already be over its
cap) and specifies the length of time that the adjustment is needed.
After the displaced residents leave the IPF's training program or
complete their residency program, the IPF's cap would revert to its
original level. Further, the total amount of temporary cap adjustments
that can be distributed to all receiving hospitals cannot exceed the
cap amount of the IPF that closed.
c. Temporary Adjustment to FTE Cap To Reflect Residents Affected by
Residency Program Closure
In the May 6, 2011 final rule (76 FR 26455), we added a new Sec.
412.424(d)(1)(iii)(F)(2) providing that if an IPF that ceases training
residents in a residency training program(s) agrees to temporarily
reduce its FTE cap, we would allow another IPF to receive a temporary
adjustment to its FTE cap to reflect residents added because of the
closure of another IPF's residency training program. For purposes of
this

[[Page 45958]]

policy on closed residency programs, we apply the IPPS definition of
``closure of a hospital residency training program'' to mean that the
hospital ceases to offer training for residents in a particular
approved medical residency training program as specified in Sec.
413.79(h). The methodology for adjusting the caps for the ``receiving
IPF'' and the ``IPF that closed its program'' is described below.
i. Receiving IPF
The regulations at Sec. 412.424(d)(1)(iii)(F)(2)(i) allow an IPF
to receive a temporary adjustment to its FTE cap to reflect residents
added because of the closure of another IPF's residency training
program for cost reporting periods beginning on or after July 1, 2011
if--
The IPF is training additional residents from the
residency training program of an IPF that closed its program on or
after July 1, 2011.
No later than 60 days after the IPF begins to train the
residents, the IPF submits to its MAC a request for a temporary
adjustment to its FTE cap, documents that the IPF is eligible for this
temporary adjustment by identifying the residents who have come from
another IPF's closed program and have caused the IPF to exceed its cap
(or the IPF may already be in excess of its cap), specifies the length
of time the adjustment is needed, and submits to its MAC a copy of the
FTE cap reduction statement by the IPF closing the residency training
program.
ii. IPF That Closed Its Program
The regulations at Sec. 412.424(d)(1)(iii)(F)(2)(ii) provide that
an IPF that agrees to train residents who have been displaced by the
closure of another IPF's resident teaching program may receive a
temporary FTE cap adjustment only if the IPF that closed a program:
Temporarily reduces its FTE cap based on the number of FTE
residents in each program year, training in the program at the time of
the program's closure.
No later than 60 days after the residents who were in the
closed program begin training at another IPF, submits to its MAC a
statement signed and dated by its representative that specifies that it
agrees to the temporary reduction in its FTE cap to allow the IPF
training the displaced residents to obtain a temporary adjustment to
its cap; identifies the residents who were training at the time of the
program's closure; identifies the IPFs to which the residents are
transferring once the program closes; and specifies the reduction for
the applicable program years.
A complete discussion on the temporary adjustment to the FTE cap to
reflect residents added due to hospital closure and by residency
program appears in the January 27, 2011 IPF PPS proposed rule (76 FR
5018 through 5020) and the May 6, 2011 IPF PPS final rule (76 FR 26453
through 26456).
4. Cost of Living Adjustment for IPFs Located in Alaska and Hawaii
The IPF PPS includes a payment adjustment for IPFs located in
Alaska and Hawaii based upon the county in which the IPF is located. As
we explained in the November 2004 IPF PPS final rule, the FY 2002 data
demonstrated that IPFs in Alaska and Hawaii had per diem costs that
were disproportionately higher than other IPFs. Other Medicare PPSs
(for example, the IPPS and LTCH PPS) adopted a cost of living
adjustment (COLA) to account for the cost differential of care
furnished in Alaska and Hawaii.
We analyzed the effect of applying a COLA to payments for IPFs
located in Alaska and Hawaii. The results of our analysis demonstrated
that a COLA for IPFs located in Alaska and Hawaii would improve payment
equity for these facilities. As a result of this analysis, we provided
a COLA in the November 2004 IPF PPS final rule.
A COLA for IPFs located in Alaska and Hawaii is made by multiplying
the nonlabor-related portion of the Federal per diem base rate by the
applicable COLA factor based on the COLA area in which the IPF is
located.
The COLA factors are published on the Office of Personnel
Management (OPM) Web site (http://www.opm.gov/oca/cola/rates.asp).
We note that the COLA areas for Alaska are not defined by county as
are the COLA areas for Hawaii. In 5 CFR 591.207, the OPM established
the following COLA areas:
City of Anchorage, and 80-kilometer (50-mile) radius by
road, as measured from the Federal courthouse;
City of Fairbanks, and 80-kilometer (50-mile) radius by
road, as measured from the Federal courthouse;
City of Juneau, and 80-kilometer (50-mile) radius by road,
as measured from the Federal courthouse;
Rest of the State of Alaska.
As stated in the November 2004 IPF PPS final rule, we update the
COLA factors according to updates established by the OPM. However,
sections 1911 through 1919 of the Nonforeign Area Retirement Equity
Assurance Act, as contained in subtitle B of title XIX of the National
Defense Authorization Act (NDAA) for Fiscal Year 2010 (Pub. L. 111-84,
October 28, 2009), transitions the Alaska and Hawaii COLAs to locality
pay. Under section 1914 of Pub. L. 111-84, locality pay is being phased
in over a 3-year period beginning in January 2010, with COLA rates
frozen as of the date of enactment, October 28, 2009, and then
proportionately reduced to reflect the phase-in of locality pay.
When we published the proposed COLA factors in the January 2011 IPF
PPS proposed rule (76 FR 4998), we inadvertently selected the FY 2010
COLA rates which had been reduced to account for the phase-in of
locality pay. We did not intend to propose the reduced COLA rates
because that would have understated the adjustment.
Since the 2009 COLA rates did not reflect the phase-in of locality
pay, we finalized the FY 2009 COLA rates for RY 2010 through RY 2014
and indicated our intent to address the COLA in FY 2015. Currently,
IPFs located in Alaska and Hawaii receive the updated COLA factors
based on the COLA area in which the IPF is located as shown in Table 10
below.

Table 10--COLA Factors for Alaska and Hawaii IPFs
------------------------------------------------------------------------
Cost of living
Area adjustment
factor
------------------------------------------------------------------------
Alaska:
City of Anchorage and 80-kilometer (50-mile) radius 1.23
by road............................................
City of Fairbanks and 80-kilometer (50-mile) radius 1.23
by road............................................
City of Juneau and 80-kilometer (50-mile) radius by 1.23
road...............................................
Rest of Alaska...................................... 1.25
Hawaii:

[[Page 45959]]

City and County of Honolulu......................... 1.25
County of Hawaii.................................... 1.18
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 Web site at: http://www.opm.gov/oca/cola/rates.asp.)

In the FY 2013 IPPS/LTCH final rule (77 FR 53700 through 53701),
CMS established a methodology for FY 2014 to update the COLA factors
for Alaska and Hawaii. Under that methodology, we use a comparison of
the growth in the Consumer Price Indices (CPIs) in Anchorage, Alaska
and Honolulu, Hawaii relative to the growth in the overall CPI as
published by the Bureau of Labor Statistics (BLS) to update the COLA
factors for all areas in Alaska and Hawaii, respectively. As discussed
in the FY 2013 IPPS/LTCH proposed rule (77 FR 28145), because BLS
publishes CPI data for only Anchorage, Alaska and Honolulu, Hawaii, our
methodology for updating the COLA factors uses a comparison of the
growth in the CPIs for those cities relative to the growth in the
overall CPI to update the COLA factors for all areas in Alaska and
Hawaii, respectively. We believe that the relative price differences
between these cities and the United States (as measured by the CPIs
mentioned above) are generally appropriate proxies for the relative
price differences between the ``other areas'' of Alaska and Hawaii and
the United States.
The CPIs for ``All Items'' that BLS publishes for Anchorage,
Alaska, Honolulu, Hawaii, and for the average U.S. city are based on a
different mix of commodities and services than is reflected in the
nonlabor-related share of the IPPS market basket. As such, under the
methodology we established to update the COLA factors, we calculated a
``reweighted CPI'' using the CPI for commodities and the CPI for
services for each of the geographic areas to mirror the composition of
the IPPS market basket nonlabor-related share. The current composition
of BLS' CPI for ``All Items'' for all of the respective areas is
approximately 40 percent commodities and 60 percent services. However,
the nonlabor-related share of the IPPS market basket is comprised of 60
percent commodities and 40 percent services. Therefore, under the
methodology established for FY 2014 in the FY 2013 IPPS/LTCH PPS final
rule, we created reweighted indexes for Anchorage, Alaska, Honolulu,
Hawaii, and the average U.S. city using the respective CPI commodities
index and CPI services index and applying the approximate 60/40 weights
from the IPPS market basket. This approach is appropriate because we
continue to make a COLA for hospitals located in Alaska and Hawaii by
multiplying the nonlabor-related portion of the standardized amount by
a COLA factor.
Under the COLA factor update methodology established in the FY 2014
IPPS/LTCH final rule, we adjust payments made to hospitals located in
Alaska and Hawaii by incorporating a 25-percent cap on the CPI-updated
COLA factors. We note that OPM's COLA factors were calculated with a
statutorily mandated cap of 25 percent, and since at least 1984, we
have exercised our discretionary authority to adjust Alaska and Hawaii
payments by incorporating this cap. In keeping with this historical
policy, we continue to use such a cap, as our rule is based on OPM's
COLA factors. We believe this approach is appropriate because our CPI-
updated COLA factors use the 2009 OPM COLA factors as a basis.
We believe it is appropriate to adopt the same methodology for the
COLA factors applied under the IPPS because IPFs are hospitals with a
similar mix of commodities and services. In addition, we think it is
appropriate to have a consistent policy approach with that of other
hospitals in Alaska and Hawaii. Therefore, we are adopting the cost of
living adjustment factors shown in Table 11 below for IPFs located in
Alaska and Hawaii. We are adopting the COLA rates, which were published
in the FY 2014 IPPS/LTCH final rule (78 FR 50986) using the new update
methodology.

Table 11--Cost-of-Living Adjustment Factors--Alaska and Hawaii Hospitals
Area COLA Factor
------------------------------------------------------------------------
Cost of living
Area adjustment
factor
------------------------------------------------------------------------
Alaska:
City of Anchorage and 80-kilometer (50-mile) radius 1.23
by road............................................
City of Fairbanks and 80-kilometer (50-mile) radius 1.23
by road............................................
City of Juneau and 80-kilometer (50-mile) radius by 1.23
road...............................................
Rest of Alaska...................................... 1.25
Hawaii:
City and County of Honolulu......................... 1.25
County of Hawaii.................................... 1.19
County of Kauai..................................... 1.25
County of Maui and County of Kalawao................ 1.25
------------------------------------------------------------------------

Final Rule Action: We did not receive any public comments on the
proposed COLA methodology and adjustment factors for IPFs in Alaska and
Hawaii. We are adopting the update

[[Page 45960]]

methodology and adjustment factors shown in Table 11 above.
5. Adjustment for IPFs With a Qualifying Emergency Department (ED)
The IPF PPS includes a facility-level adjustment for IPFs with
qualifying EDs. We provide an adjustment to the Federal per diem base
rate to account for the costs associated with maintaining a full-
service ED. The adjustment is intended to account for ED costs incurred
by a freestanding psychiatric hospital with a qualifying ED or a
distinct part psychiatric unit of an acute care hospital or a CAH for
preadmission services otherwise payable under the Medicare Outpatient
Prospective Payment System (OPPS) furnished to a beneficiary on the
date of the beneficiary's admission to the hospital and during the day
immediately preceding the date of admission to the IPF (see Sec.
413.40(c)(2)) and the overhead cost of maintaining the ED. This payment
is a facility-level adjustment that applies to all IPF admissions (with
one exception described below), regardless of whether a particular
patient receives preadmission services in the hospital's ED.
The ED adjustment is incorporated into the variable per diem
adjustment for the first day of each stay for IPFs with a qualifying
ED. That is, IPFs with a qualifying ED receive an adjustment factor of
1.31 as the variable per diem adjustment for day 1 of each stay. If an
IPF does not have a qualifying ED, it receives an adjustment factor of
1.19 as the variable per diem adjustment for day 1 of each patient
stay.
The ED adjustment is made on every qualifying claim except as
described below. As specified in Sec. 412.424(d)(1)(v)(B), the ED
adjustment is not made when a patient is discharged from an acute care
hospital or CAH and admitted to the same hospital's or CAH's
psychiatric unit. We clarified in the November 2004 IPF PPS final rule
(69 FR 66960) that an ED adjustment is not made in this case because
the costs associated with ED services are reflected in the DRG payment
to the acute care hospital or through the reasonable cost payment made
to the CAH.
Therefore, when patients are discharged from an acute care hospital
or CAH and admitted to the same hospital or CAH's psychiatric unit, the
IPF receives the 1.19 adjustment factor as the variable per diem
adjustment for the first day of the patient's stay in the IPF.
Final Rule Action: For FY 2015, we are retaining the 1.31
adjustment factor for IPFs with qualifying EDs. A complete discussion
of the steps involved in the calculation of the ED adjustment factor
appears in the November 2004 IPF PPS final rule (69 FR 66959 through
66960) and the May 2006 IPF PPS final rule (71 FR 27070 through 27072).

D. Other Payment Adjustments and Policies

1. Outlier Payments
The IPF PPS includes an outlier adjustment to promote access to IPF
care for those patients who require expensive care and to limit the
financial risk of IPFs treating unusually costly patients. In the
November 2004 IPF PPS final rule, we implemented regulations at Sec.
412.424(d)(3)(i) to provide a per-case payment for IPF stays that are
extraordinarily costly. Providing additional payments to IPFs for
extremely costly cases strongly improves the accuracy of the IPF PPS in
determining resource costs at the patient and facility level. These
additional payments reduce the financial losses that would otherwise be
incurred in treating patients who require more costly care and,
therefore, reduce the incentives for IPFs to under-serve these
patients.
We make outlier payments for discharges in which an IPF's estimated
total cost for a case exceeds a fixed dollar loss threshold amount
(multiplied by the IPF's facility-level adjustments) plus the Federal
per diem payment amount for the case.
In instances when the case qualifies for an outlier payment, we pay
80 percent of the difference between the estimated cost for the case
and the adjusted threshold amount for days 1 through 9 of the stay
(consistent with the median LOS for IPFs in FY 2002), and 60 percent of
the difference for day 10 and thereafter. We established the 80 percent
and 60 percent loss sharing ratios because we were concerned that a
single ratio established at 80 percent (like other Medicare PPSs) might
provide an incentive under the IPF per diem payment system to increase
LOS in order to receive additional payments.
After establishing the loss sharing ratios, we determined the
current fixed dollar loss threshold amount of $10,245 through payment
simulations designed to compute a dollar loss beyond which payments are
estimated to meet the 2 percent outlier spending target. Each year when
we update the IPF PPS, we simulate payments using the latest available
data to compute the fixed dollar loss threshold so that outlier
payments represent 2 percent of total projected IPF PPS payments.
a. Update to the Outlier Fixed Dollar Loss Threshold Amount
In accordance with the update methodology described in Sec.
412.428(d), we will update the fixed dollar loss threshold amount used
under the IPF PPS outlier policy. Based on the regression analysis and
payment simulations used to develop the IPF PPS, we established a 2
percent outlier policy which strikes an appropriate balance between
protecting IPFs from extraordinarily costly cases while ensuring the
adequacy of the Federal per diem base rate for all other cases that are
not outlier cases.
Based on an analysis of the latest available data (that is, FY 2013
IPF claims) and rate increases, we believe it is necessary to update
the fixed dollar loss threshold amount in order to maintain an outlier
percentage that equals 2 percent of total estimated IPF PPS payments.
In the May 2006 IPF PPS final rule (71 FR 27072), we describe the
process by which we calculate the outlier fixed dollar loss threshold
amount. We are not changing this process for FY 2015. We begin by
simulating aggregate payments with and without an outlier policy, and
applying an iterative process to determine an outlier fixed dollar loss
threshold amount that will result in estimated outlier payments being
equal to 2 percent of total estimated payments under the simulation.
Based on this process, using the FY 2013 claims data, we estimate that
IPF outlier payments as a percentage of total estimated payments are
approximately 1.6 percent in FY 2014. Thus, we updated the FY 2015 IPF
outlier threshold amount to ensure that estimated FY 2015 outlier
payments are approximately 2 percent of total estimated IPF payments.
The outlier fixed dollar loss threshold amount of $10,245 for FY 2014
changed to $8,755 for FY 2015 to increase estimated outlier payments
and thereby maintain estimated outlier payments at 2 percent of total
estimated aggregate IPF payments for FY 2015.
Final Rule Action: In this final rule, we are adopting $8,755 as
the fixed dollar loss threshold amount for FY 2015.
b. Update to IPF Cost-to-Charge Ratio Ceilings
Under the IPF PPS, an outlier payment is made if an IPF's cost for
a stay exceeds a fixed dollar loss threshold amount plus the IPF PPS
amount. In order to establish an IPF's cost for a particular case, we
multiply

[[Page 45961]]

the IPF's reported charges on the discharge bill by its overall cost-
to-charge ratio (CCR). This approach to determining an IPF's cost is
consistent with the approach used under the IPPS and other PPSs. In the
June 2003 IPPS final rule (68 FR 34494), we implemented changes to the
IPPS policy used to determine CCRs for acute care hospitals because we
became aware that payment vulnerabilities resulted in inappropriate
outlier payments. Under the IPPS, we established a statistical measure
of accuracy for CCRs in order to ensure that aberrant CCR data did not
result in inappropriate outlier payments.
As we indicated in the November 2004 IPF PPS final rule (69 FR
66961), because we believe that the IPF outlier policy is susceptible
to the same payment vulnerabilities as the IPPS, we adopted a method to
ensure the statistical accuracy of CCRs under the IPF PPS.
Specifically, we adopted the following procedure in the November 2004
IPF PPS final rule: We calculated two national ceilings, one for IPFs
located in rural areas and one for IPFs located in urban areas. We
computed the ceilings by first calculating the national average and the
standard deviation of the CCR for both urban and rural IPFs using the
most recent CCRs entered in the CY 2014 Provider Specific File.
To determine the rural and urban ceilings, we multiplied each of
the standard deviations by 3 and added the result to the appropriate
national CCR average (either rural or urban). The upper threshold CCR
for IPFs in FY 2015 is 1.8590 for rural IPFs, and 1.6582 for urban
IPFs, based on CBSA-based geographic designations. If an IPF's CCR is
above the applicable ceiling, the ratio is considered statistically
inaccurate and we assign the appropriate national (either rural or
urban) median CCR to the IPF.
We apply the national CCRs to the following situations:
++ New IPFs that have not yet submitted their first Medicare cost
report. We continue to use these national CCRs until the facility's
actual CCR can be computed using the first tentatively or final settled
cost report.
++ IPFs whose overall CCR is in excess of 3 standard deviations
above the corresponding national geometric mean (that is, above the
ceiling).
++ Other IPFs for which the MAC obtains inaccurate or incomplete
data with which to calculate a CCR.
We are not making any changes to the application of the national
CCRs or to the procedures for updating the CCR ceilings in FY 2015.
However, we are updating the FY 2015 national median and ceiling CCRs
for urban and rural IPFs based on the CCRs entered in the latest
available IPF PPS Provider Specific File. Specifically, for FY 2015,
and to be used in each of the three situations listed above, using the
most recent CCRs entered in the CY 2014 Provider Specific File, we
estimate the national median CCR of 0.6220 for rural IPFs and the
national median CCR of 0.4710 for urban IPFs. These calculations are
based on the IPF's location (either urban or rural) using the CBSA-
based geographic designations.
A complete discussion regarding the national median CCRs appears in
the November 2004 IPF PPS final rule (69 FR 66961 through 66964).
2. Future Refinements
For RY 2012, we identified several areas of concern for future
refinement and we invited comments on these issues in our RY 2012
proposed and final rules. For further discussion of these issues and to
review the public comments, we refer readers to the RY 2012 IPF PPS
proposed rule (76 FR 4998) and final rule (76 FR 26432).
As we have indicated throughout this final rule, we have delayed
making refinements to the IPF PPS until we have completed a thorough
analysis of IPF PPS data on which to base those refinements.
Specifically, we explained that we will delay updating the adjustment
factors derived from the regression analysis until we have IPF PPS data
that include as much information as possible regarding the patient-
level characteristics of the population that each IPF serves. We have
begun the necessary analysis to better understand IPF industry
practices so that we may refine the IPF PPS as appropriate. Using more
recent data, we plan to re-run the regression analyses and the patient-
and facility-level adjustments. While we are not implementing
refinements in this final rule, we expect that in the rulemaking for FY
2017 we will be ready to present the results of our analysis.

VIII. Inpatient Psychiatric Facilities Quality Reporting (IPFQR)
Program

1. Statutory Authority

Section 1886(s)(4) of the Act, as added and amended by sections
3401(f) and 10322(a) of the Affordable Care Act, requires the Secretary
to implement a quality reporting program for inpatient psychiatric
hospitals and psychiatric units. Section 1886(s)(4)(A)(i) of the Act
requires that, for rate year (RY) 2014 and each subsequent rate year,
the Secretary shall reduce any annual update to a standard Federal rate
for discharges occurring during the rate year by 2.0 percentage points
for any inpatient psychiatric hospital or psychiatric unit that does
not comply with quality data submission requirements with respect to an
applicable rate year.
As noted above, section 1886(s)(4)(A)(i) of the Act uses the term
``rate year.'' Beginning with the annual update of the inpatient
psychiatric facility prospective payment system (IPF PPS) that took
effect on July 1, 2011 (RY 2012), we aligned the IPF PPS update with
the annual update of the ICD-9-CM codes, which are effective on October
1 of each year. The change allows for annual payment updates and the
ICD-9-CM coding update to occur on the same schedule and appear in the
same Federal Register document, thus making rule updates more
administratively efficient. To reflect the change to the annual payment
rate update cycle, we revised the regulations at Sec. 412.402 to
specify that, beginning October 1, 2012, the rate year update period
would be the 12-month period of October 1 through September 30, which
we refer to as a fiscal year (FY) (76 FR 26435). For more information
regarding this terminology change, we refer readers to section III. of
the RY 2012 IPF PPS final rule (76 FR 26434 through 26435).
As provided in section 1886(s)(4)(A)(ii) of the Act, the
application of the reduction for failure to report under section
1886(s)(4)(A)(i) of the Act may result in an annual update of less than
0.0 percent for a fiscal year, and may result in payment rates under
section 1886(s)(1) of the Act being less than the payment rates for the
preceding year. In addition, section 1886(s)(4)(B) of the Act requires
that the application of the reduction to a standard Federal rate update
be noncumulative across fiscal years. Thus, any reduction applied under
section 1886(s)(4)(A) of the Act will apply only with respect to the
fiscal year rate involved and the Secretary shall not take into account
the reduction in computing the payment amount under the system
described in section 1886(s)(1) of the Act for subsequent years.
Section 1886(s)(4)(C) of the Act requires that, for FY 2014
(October 1, 2013, through September 30, 2014) and each subsequent year,
each psychiatric hospital and psychiatric unit shall submit to the
Secretary data on quality measures as specified by the Secretary. The
data shall be submitted in a form and manner, and at a time, specified
by the Secretary. Under section 1886(s)(4)(D)(i) of the Act, measures

[[Page 45962]]

selected for the quality reporting program must have been endorsed by
the entity with a contract under section 1890(a) of the Act. The
National Quality Forum (NQF) currently holds this contract.
Section 1886(s)(4)(D)(ii) of the Act provides that, in the case of
a specified area or medical topic determined appropriate by the
Secretary for which a feasible and practical measure has not been
endorsed by the entity with a contract under section 1890(a) of the
Act, the Secretary may specify a measure that is not so endorsed as
long as due consideration is given to measures that have been endorsed
or adopted by a consensus organization identified by the Secretary.
Pursuant to section 1886(s)(4)(D)(iii) of the Act, the Secretary shall
publish the measures applicable to the FY 2014 IPFQR Program no later
than October 1, 2012.
Section 1886(s)(4)(E) of the Act requires the Secretary to
establish procedures for making public the data submitted by inpatient
psychiatric hospitals and psychiatric units under the IPFQR Program.
These procedures must ensure that a facility has the opportunity to
review its data prior to the data being made public. The Secretary must
report quality measures that relate to services furnished by the
psychiatric hospitals and units on the CMS Web site.

2. Application of the Payment Update Reduction for Failure to Report
for the FY 2015 Payment Determination and Subsequent Years

Beginning in FY 2014, section 1886(s)(4)(A)(i) of the Act requires
the application of a 2.0 percentage point reduction to the applicable
annual update to a Federal standard rate for those psychiatric
hospitals and psychiatric units that fail to comply with the quality
reporting requirements implemented in accordance with section
1886(s)(4)(C) of the Act, as detailed below. The application of the
reduction may result in an annual update for a fiscal year that is less
than 0.0 percent and in payment rates for a fiscal year being less than
the payment rates for the preceding fiscal year. Pursuant to section
1886(s)(4)(B) of the Act, any such reduction is not cumulative and will
apply only to the fiscal year involved. In the FY 2013 IPPS/LTCH PPS
final rule (77 FR 53678), we adopted requirements regarding the
application of the payment reduction to the annual update of the
standard Federal rate for failure to report data on measures selected
for the FY 2014 payment determination and subsequent years, and added
new regulatory text at 42 CFR 412.424 to codify these requirements.

3. Covered Entities

In the FY 2013 IPPS/LTCH PPS final rule (77 FR 53645), we
established that the IPFQR Program's quality reporting requirements
cover those psychiatric hospitals and psychiatric units paid under
Medicare's IPF PPS (42 CFR 412.404(b)). Generally, psychiatric
hospitals and psychiatric units within acute care and critical access
hospitals that treat Medicare patients are paid under the IPF PPS. For
more information on the application of, and exceptions to, payments
under the IPF PPS, we refer readers to section IV. of the November 15,
2004 IPF PPS final rule (69 FR 66926). As we noted in the FY 2013 IPPS/
LTCH PPS final rule (77 FR 53645), we use the term ``inpatient
psychiatric facility'' (IPF) to refer to both inpatient psychiatric
hospitals and psychiatric units. This usage follows the terminology in
our IPF PPS regulations (42 CFR 412.402).

4. Considerations in Selecting Quality Measures

In implementing the IPFQR Program, our overarching objective is to
support the HHS National Quality Strategy (NQS) and CMS Quality
Strategy's goal for better health care for individuals, better health
for populations, and lower costs for health care services. More
information on the CMS Quality Strategy can be found at http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/CMS-Quality-Strategy.html.
Implementation of the IPFQR Program works to achieve the goals of the
CMS Quality Strategy by promoting transparency around the quality of
care provided at IPFs to support patient decision-making and drive
quality improvement, as well as to further the alignment of quality
measurement and improvement goals at IPFs with those of other health
care providers.
For purposes of the IPFQR Program, section 1886(s)(4)(D)(i) of the
Act requires that any measure specified by the Secretary must have been
endorsed by the entity with a contract under section 1890(a) of the
Act. However, the statutory requirements under section
1886(s)(4)(D)(ii) of the Act provide an exception that, in the case of
a specified area or medical topic determined appropriate by the
Secretary for which a feasible and practical measure has not been
endorsed by the entity with a contract under section 1890(a) of the
Act, the Secretary may specify a measure that is not so endorsed,
provided that due consideration is given to measures that have been
endorsed or adopted by a consensus organization identified by the
Secretary.
We seek to collect data in a manner that balances the need for
information related to the full spectrum of quality performance and the
need to minimize the burden of data collection and reporting. We have
focused on measures that have high impact and support CMS and HHS
priorities for improved quality and efficiency of care provided by
IPFs. We refer readers to the FY 2013 IPPS/LTCH PPS final rule (77 FR
53645 through 53646) for a detailed discussion of the considerations
taken into account for measure development and selection.
Prior to being proposed in the proposed rule, we place our measures
on a measure under consideration list, which is made public by December
1 of each year. Measures proposed for the Program were included in a
publicly available document entitled ``List of Measures under
Consideration for December 1, 2013'' in compliance with section
1890A(a)(2) of the Act. The Measure Application Partnership (MAP), a
multi-stakeholder group convened by the NQF, then reviews the measures
being proposed for Federal programs and provides input on those
measures to the Secretary, as captured in its ``MAP Pre-Rulemaking
Report: 2014 Recommendations on Measures for More than 20 Federal
Programs,'' which is available on the NQF Web site at http://www.qualityforum.org/Setting_Priorities/Partnership/Measure_Applications_Partnership.aspx. We considered the input and
recommendations provided by the MAP in selecting measures for the
Program.

4. Considerations in Selecting Quality Measures

[[Page 45963]]

improvement goals at IPFs with those of other health care providers.
For purposes of the IPFQR Program, section 1886(s)(4)(D)(i) of the
Act requires that any measure specified by the Secretary must have been
endorsed by the entity with a contract under section 1890(a) of the
Act. However, the statutory requirements under section
1886(s)(4)(D)(ii) of the Act provide an exception that, in the case of
a specified area or medical topic determined appropriate by the
Secretary for which a feasible and practical measure has not been
endorsed by the entity with a contract under section 1890(a) of the
Act, the Secretary may specify a measure that is not so endorsed,
provided that due consideration is given to measures that have been
endorsed or adopted by a consensus organization identified by the
Secretary.
We seek to collect data in a manner that balances the need for
information related to the full spectrum of quality performance and the
need to minimize the burden of data collection and reporting. We have
focused on measures that have high impact and support CMS and HHS
priorities for improved quality and efficiency of care provided by
IPFs. We refer readers to the FY 2013 IPPS/LTCH PPS final rule (77 FR
53645 through 53646) for a detailed discussion of the considerations
taken into account for measure development and selection.
Prior to being proposed in the proposed rule, we place our measures
on a measure under consideration list, which is made public by December
1 of each year. Measures proposed for the Program were included in a
publicly available document entitled ``List of Measures under
Consideration for December 1, 2013'' in compliance with section
1890A(a)(2) of the Act. The Measure Application Partnership (MAP), a
multi-stakeholder group convened by the NQF, then reviews the measures
being proposed for Federal programs and provides input on those
measures to the Secretary, as captured in its ``MAP Pre-Rulemaking
Report: 2014 Recommendations on Measures for More than 20 Federal
Programs,'' which is available on the NQF Web site at http://www.qualityforum.org/Setting_Priorities/Partnership/Measure_Applications_Partnership.aspx. We considered the input and
recommendations provided by the MAP in selecting measures for the
Program.

5. Quality Measures

a. Quality Measures for the FY 2016 Payment Determination and
Subsequent Years
In the FY 2013 IPPS/LTCH PPS final rule (77 FR 53646 through
53652), we adopted six chart-abstracted IPF quality measures for the FY
2014 payment determination and subsequent years.
We note that, at the time that we adopted the measures in the FY
2013 IPPS/LTCH PPS final rule (77 FR 53258), providers were using ICD-
9-CM codes. The conversion of ICD-9-CM to ICD-10-CM/PCS codes for the
IPF PPS will become effective on October 1, 2015. We do not anticipate
that this change will have substantive effects on any Program measures
at this time. CMS will update the user manual, discussed further in
section V below, to reflect any necessary measure updates. Generally,
measures adopted for the IPFQR Program will remain in the Program for
all subsequent years, unless and until specifically stated otherwise
(for example, through removal or replacement).
In the FY 2014 IPPS/LTCH PPS final rule (78 FR 50890 through
50895), we added one new chart-abstracted measure for the IPFQR
Program: Alcohol Use Screening (SUB-1) (NQF #1661). We also
added one new claims-based measure: Follow-Up After Hospitalization for
Mental Illness (FUH) (NQF #0576). Both measures apply to the FY
2016 payment determination and subsequent years, unless and until we
change them through future rulemaking.
The table below sets out the previously adopted measures.

Table 12--Previously Adopted Quality Measures for the IPFQR Program
----------------------------------------------------------------------------------------------------------------
National quality strategy priority NQF # Measure ID Measure description
----------------------------------------------------------------------------------------------------------------
Patient Safety......................... 0640 HBIPS-2.................... Hours of Physical
Restraint Use.*
0641 HBIPS-3.................... Hours of Seclusion Use.*
Clinical Quality of Care............... *** 0552 HBIPS-4.................... Patients Discharged on
Multiple Antipsychotic
Medications.*
0560 HBIPS-5.................... Patients Discharged on
Multiple Antipsychotic
Medications with
Appropriate
Justification.*
1661 SUB-1...................... Alcohol Use Screening.**
0576 FUH........................ Follow-Up After
Hospitalization for
Mental Illness.**
Care Coordination...................... 0557 HBIPS-6.................... Post-Discharge Continuing
Care Plan Created.*
0558 HBIPS-7.................... Post-Discharge Continuing
Care Plan Transmitted to
Next Level of Care
Provider Upon Discharge.*
----------------------------------------------------------------------------------------------------------------
* Quality measures adopted in the FY 2013 IPPS/LTCH PPS final rule for the FY 2014 payment determination and
subsequent years.
** Quality measures adopted in the FY 2014 IPPS/LTCH PPS final rule for the FY 2016 payment determination and
subsequent years.
*** Measure 0552 is no longer endorsed by the NQF.

We note that in the FY 2014 IPPS/LTCH PPS final rule (78 FR 50896
through 50897 and 50900), we also adopted for the FY 2016 payment
determination and subsequent years a voluntary collection of
information, IPF Assessment of Patient Experience of Care (now renamed
Assessment of Patient Experience of Care), which was to be collected
using a Web-Based Measures Tool and would not affect an IPF's FY 2016
payment determination. We also noted that we intended to propose to
make this a mandatory measure in future rulemaking (78 FR 50897), which
we proposed in the FY 2015 IPF PPS proposed rule.
In the FY 2015 proposed rule (79 FR 26063 through 26065), we
proposed two new measures to the IPFQR Program to those already adopted
for the FY 2016 payment determination and subsequent years: (1)
Assessment of Patient Experience of Care; and (2) use of an Electronic
Health Record. We are not removing or replacing any of the previously
adopted measures from the IPFQR Program for FY 2016. These two new
measures will be captured in the IPF Web-Based Measures Tool, which

[[Page 45964]]

can be accessed through the QualityNet home page at: http://www.qualitynet.org/dcs/ContentServer?pagename=QnetPublic/Page/QnetHomepage. The Tool will be updated, so that when IPFs submit their
data for FY 2016 (between July 1, 2015, and August 15, 2015) there will
be a place to provide responses for these two structural measures.
1. Assessment of Patient Experience of Care
Improvement of experience of care for patients, families, and
caregivers is one of our objectives within the CMS Quality Strategy and
is not currently addressed in the IPFQR Program. Surveys of individuals
about their experience in all health care settings provide important
information as to whether or not high-quality, person-centered care is
actually provided, and address elements of service delivery that matter
most to recipients of care.
We included the measure ``Inpatient Consumer Survey (ICS) Consumer
Evaluation of Inpatient Behavioral Healthcare Services'' (NQF
#0726) in our ``List of Measures under Consideration for
December 1, 2012.'' The measure would gather clients' evaluation of
their inpatient care based on six domains--outcome, dignity, rights,
treatment, environment, and empowerment. The MAP provided input on the
measure and supported its inclusion in the IPFQR Program. However, we
did not propose to adopt the measure in the FY 2014 IPPS/LTCH PPS
proposed rule for several reasons, including potential reporting and
information collection burdens in a new program, and compatibility with
the content and format of other similar CMS beneficiary surveys (78 FR
27740 and 78 FR 50896). We also recognized the challenges of measuring
patient experience of care, particularly for involuntary cases and
geriatric psychiatric patients suffering from dementia. In addition, we
recognized that IPFs may have developed their own survey instruments,
which we wanted to learn more about prior to requiring collection of a
patient experience of care survey for the Program (78 FR 50897). We
also indicated our intention to pursue the adoption of a standardized
measure of patient experience of care for the IPFQR program in the near
future for public reporting and consumer decision making purposes.
In the final rule (78 FR 50896), in an effort to proceed cautiously
with the selection of an assessment instrument and collection protocol,
and as an intermediate measure, we implemented a voluntary collection
of information on whether IPFs administer a detailed assessment of
patient experience of care using a standardized collection protocol and
a structured instrument. If the IPFs answered ``Yes,'' we also asked
them to indicate the name of the survey that they administer. We
indicated our intention to propose to change this request for voluntary
information into a mandatory measure in future rulemaking. We are now
requiring this request to be a structural measure for the FY 2016
payment determination.
The measure ``Inpatient Psychiatric Facility Routinely Assesses
Patient Experience of Care'' (now, ``Assessment of Patient Experience
of Care'') was included on our ``List of Measures under Consideration
for December 1, 2013.'' The measure asks IPFs whether they routinely
assess patient experience of care using a standardized collection
protocol and a structured instrument. The MAP supported this measure,
but encouraged its eventual replacement with a robust survey of patient
experience and a measure based on consumer-reported information, such
as a Consumer Assessment of Healthcare Providers and Systems
(CAHPS[supreg]) tool. We believe that the reporting of this measure
will begin to provide information on a priority area of the HHS
National Quality Strategy that is currently unaddressed in the IPFQR
Program, that of patient and family engagement and experience of care.
Further, the information gathered through the collection of this
measure will be helpful in the development of a standardized survey of
patient assessment of care that we intend to develop as a successor to
this measure.
Because this is a structural measure that does not depend on
systems for collecting and abstracting individual patient information,
only requires simple attestation, and does not require extended time to
prepare to report, we believe that it will not be burdensome to IPFs.
Accordingly, we are proposing to include it as a mandatory measure for
the FY 2016 payment determination, a year earlier than for other
measures proposed in this rule that are dependent on these systems.
The measure is currently not NQF-endorsed. Section
1886(s)(4)(D)(ii) of the Act authorizes the Secretary to specify a
measure that is not endorsed by the NQF as long as due consideration is
given to measures that have been endorsed or adopted by a consensus
organization identified by the Secretary. We attempted to find
available measures that have been endorsed or adopted by a consensus
organization and found no other feasible and practical measures on the
topic of patient experience of care for the IPF setting. Therefore, we
believe that the Assessment of Patient Experience of Care proposed
measure meets the measure selection exception requirement under section
1886(s)(4)(D)(ii) of the Act. Public comments and responses on the
Patient Experience of Care Measure are summarized below.
Comment: Some commenters stated that inclusion of this structural
measure was not appropriate because it was not endorsed by the NQF and
not supported for use in the Program by the MAP.
Response: We believe that inclusion of this measure without NQF
endorsement meets the statutory requirements under section
1886(s)(4)(D)(ii) of the Act. Under that section, the Secretary is
authorized to specify a measure that is not endorsed by the NQF as long
as due consideration is given to measures that have been endorsed or
adopted by a consensus organization identified by the Secretary. We
attempted to find available measures that had been endorsed or adopted
by a consensus organization, and found no other feasible and practical
measures on the topic of patient experience of care for the IPF
setting. In addition, this measure was proposed to collect data that
will aid in the development of a future instrument that is more
compatible with the content and format of other similar CMS beneficiary
surveys than the Inpatient Consumer Survey (ICS) Consumer Evaluation of
Inpatient Behavioral Healthcare Services.
We disagree with the commenters' assessment that the MAP did not
support inclusion of this measure. The MAP did support the measure, but
encouraged its eventual replacement with a robust survey of patient
experience and a measure based on consumer-reported information. As we
stated in the proposed rule, we intend to develop a successor to this
measure that will be specified and tested in the inpatient psychiatric
setting, and that will be informed by the collection of information
associated with the Assessment of Patient Experience of Care measure.
Comment: One commenter sought clarification on whether an IPF will
be penalized if it does not collect patient experience of care data.
Response: An IPF will not be penalized for not collecting patient
experience of care data. CMS credits IPFs for reporting this measure in
the IPFQR Program applicable FY if they successfully report by the
deadline whether they collect these data.
Comment: Some commenters stated that, because this measure is an

[[Page 45965]]

attestation measure only, it is not a quality of care measure that
should be part of a requirement that affects payment and that is
publicly reported. Similarly, some commenters stated that this measure
would provide very limited insight to patients on the actual experience
of care in IPFs.
Response: We disagree with the commenters. We believe that the
potential value of a quality measure is primarily in the information
that it provides, and is not necessarily limited by how it is collected
or reported. CMS credits IPFs for reporting this measure in the IPFQR
Program applicable FY if they successfully report by the deadline
whether they collect these data. We believe that the data collected
through reporting of this measure will begin to provide information on
a priority area of the HHS National Quality Strategy, patient and
family engagement and experience of care, which is currently
unaddressed in the Program. Collection of this information will further
enable the development of a successor to this measure that will provide
valuable, actionable information for patients, and their families and
caregivers, on the quality of care provided in IPFs.
Comment: Some commenters suggested that, instead of implementing
this measure, CMS should continue its efforts to develop a standardized
patient assessment survey for IPFs. In particular, some commenters
suggested that CMS undertake an in-depth study of IPFs to identify not
only which survey instruments are currently in use, but also the
potential costs of and operational barriers to implementing such a
standardized survey.
Response: We thank the commenters for their support for development
of a standardized patient assessment survey for IPFs. However, we
believe that implementing this Assessment of Patient Experience of Care
measure at this time will significantly enhance our ability to develop
such a standardized survey by providing useful information to aid in
the development process. As previously stated, we are committed to
developing a standardized patient assessment survey instrument for
IPFs.
Comment: One commenter stated that the proposed rule does not
specify what constitutes the routine assessment of patient experience
of care using a standardized collection protocol and a structured
instrument.
Response: By ``routine assessment'' we mean that administration of
an experience of care instrument occurs as a regular, commonplace
activity of the facility. By ``standardized collection protocol'' we
mean that the administration of the instrument occurs under rules or
guidelines that ensure or promote comparability of individual
responses. By ``structured instrument'' we mean that oral or written
questions constituting the instrument are the same for all respondents
and follow consistent rules for administration.
Comment: One commenter expressed support for this measure, but
stated that IPFs should not be required to report the name of the
instrument because there currently is no nationally utilized, industry
standard tool. Instead, the commenter stated, it should be sufficient
that an IPF demonstrate that the instrument utilized is standardized in
delivery, and structured in formatting and scoring.
Response: We disagree with the commenter. We believe that reporting
the name of the instrument utilized by the IPF will provide more
accurate information through collecting specific survey names, as well
as aiding in the process of developing a future instrument that is more
compatible with the content and format of other similar CMS beneficiary
surveys.
Final Rule Action: After consideration of the public comments, we
are finalizing the Assessment of Patient Experience of Care measure as
proposed for the FY 2016 payment determination and subsequent years.
2. Use of an Electronic Health Record
In 2009, as part of the Health Information Technology for Economic
and Clinical Health (HITECH) Act, incentives were provided to encourage
eligible hospitals and eligible professionals to adopt electronic
health record (EHR) systems. The widespread adoption of these systems
holds the potential to support multiple goals of CMS' quality strategy,
including making care safer and more affordable, and promoting
coordination of care. One review of over a hundred studies of the
effects of EHRs showed that nearly all demonstrated positive overall
results.\1\ These results were most frequently demonstrated in the
areas of efficiency and effectiveness of care, patient safety and
satisfaction, and process of care.\2\
---------------------------------------------------------------------------

\1\ M.B. Buntin, M.F. Burke, M.C. Hoaglin, et al., ``The
Benefits of Health Information Technology: A Review of the Recent
Literature Shows Predominantly Positive Results,'' Health Affairs,
March 2011 30(3):464-71.
\2\ Ibid.
---------------------------------------------------------------------------

Positive results such as these depend in part on the ways in which
an EHR system is used. EHRs can facilitate the use of clinical decision
support tools, physician order entry systems, and health information
exchange. The concept of ``meaningful use'' of EHRs captures the goals
for which incentive payments are made. These goals include, among
others: Quality improvement, safety, and efficiency; health disparities
reduction; patient and family engagement; care coordination improvement
and population health; and maintenance of the privacy and security of
patient health information.\3\
---------------------------------------------------------------------------

\3\ HealthIT.gov, ``EHR Incentives & Certification: Meaningful
Use Definition & Objectives.'' [Internet Cited 2014 February 11].
Available from http://www.healthit.gov/providers-professionals/meaningful-use-definition-objectives.
---------------------------------------------------------------------------

We believe that a measure of the degree of EHR implementation
provides important information about an element of health care service
delivery shown to be associated with the delivery of quality care.
Further, we believe that it provides useful information to consumers
and others in choosing among different facilities.
A key issue in EHR adoption and implementation is the use of this
technology to support health information exchange. HHS has a number of
initiatives designed to encourage and support the adoption of health
information technology and promote nationwide health information
exchange to improve health care. The Office of the National Coordinator
for Health Information Technology (ONC) and CMS work to promote the
adoption of health information technology. Through a number of
activities, HHS is promoting the adoption of ONC-certified EHRs
developed to support secure, interoperable health information exchange.
While available ONC-certified EHRs are not specifically certified for
IPFs and other providers who are not eligible for the Medicare and
Medicaid EHR Incentive Programs, ONC has requested that the HIT Policy
Committee (a Federal Advisory Committee) explore the expansion of EHR
certification under the ONC HIT Certification Program, focusing on EHR
certification criteria needed for long-term and post-acute care
(including LTCHs), and behavioral health care providers. ONC has also
proposed a Voluntary 2015 Edition EHR Certification rule (79 FR 10880)
that would increase the flexibility in ONC's regulatory structure to
more easily accommodate health IT certification for other types of
health care settings where individual or institutional health care
providers are not typically eligible to qualify for the Medicare and
Medicaid EHR Incentive Programs.
While certified EHRs are not specifically certified for IPFs, we
believe that many of the core functions of clinical care that are
captured in EHRs are common across care settings. We believe that the
use of certified EHRs by

[[Page 45966]]

IPFs (and other providers ineligible for the Medicare and Medicaid EHR
Incentive Programs) can effectively and efficiently help providers
improve internal care delivery practices, support the exchange of
important information across care partners and during transitions of
care, and could enable the reporting of electronically specified
clinical quality measures (eCQMs) (as described elsewhere in this
rule). More information on the proposed rule on voluntary 2015 Edition
EHR Certification, identification of EHR certification criteria and
development of standards applicable to IPFQRs can be found at:

http://www.healthit.gov/policy-researchers-implementers/standards-and-certification-regulations
http://www.healthit.gov/facas/FACAS/health-it-policy-committee/hitpc-workgroups/certificationadoption
http://wiki.siframework.org/LCC+LTPAC+Care+Transition+SWG
http://wiki.siframework.org/Longitudinal+Coordination+of+Care

We included the measure, ``IPF Use of an Electronic Health Record
Meeting Stage 1 or Stage 2 Meaningful Use Criteria'' (now, ``Use of an
Electronic Health Record'') in the ``List of Measures under
Consideration for December 1, 2013.'' The measure will assess the
degree to which facilities employ EHR systems in their service program
and use such systems to support health information exchange at times of
transitions in care. It is a structural measure that only requires the
facility to attest to which one of the following statements best
describes the facility's highest level typical use of an EHR system
(excluding the billing system) during the reporting period, and whether
this use includes the exchange of interoperable health information with
a health information service provider:
a. The facility most commonly used paper documents or other forms
of information exchange (for example, email) not involving the transfer
of health information using EHR technology at times of transitions in
care.
b. The facility most commonly exchanged health information using
non-certified EHR technology (that is, not certified under the ONC HIT
Certification Program) at times of transitions in care.
c. The facility most commonly exchanged health information using
certified EHR technology (certified under the ONC HIT Certification
Program) at times of transitions in care.
We will also ask IPFs to indicate whether transfers of health
information at times of transitions in care included the exchange of
interoperable health information with a health information service
provider (HISP).
In its 2014 report, available at https://www.qualityforum.org/WorkArea/linkit.aspx?LinkIdentifier=id&ItemID=74634, the MAP concluded
that it does not support this measure because it does not adequately
address any current needs of the Program. The MAP noted that
psychiatric hospitals were excluded from the EHR Incentive Programs and
imposing the measure criteria is not realistic. The MAP also expressed
concerns about using quality reporting programs to collect data on
systems and infrastructure, and suggested that the American Hospital
Association's survey of hospitals may be a better source for this type
of data.
We disagree with the MAP's contention that the purpose of this
measure is to collect data on systems and infrastructure. The purpose
of the measure is to assess the use of processes for the collection,
use, and transmission of medical information that have been
demonstrated to impact the quality of care, rather than to collect data
on systems and infrastructure. As we have described above, many studies
document the benefits of EHR use on multiple dimensions related to
health care quality, and to multiple goals of CMS' quality strategy.
Additionally, this is a structural measure that does not depend on
systems for collecting and abstracting individual patient information
and, therefore, is not burdensome on IPFs. Accordingly, we are adopting
it as a measure for FY 2016 payment determination, a year earlier than
for other measures we proposed in the FY 2015 IPF PPS proposed rule.
The Use of an Electronic Health Record proposed measure is not NQF-
endorsed. Section 1886(s)(4)(D)(ii) of the Act authorizes the Secretary
to specify a measure that is not endorsed by the NQF as long as due
consideration is given to measures that have been endorsed or adopted
by a consensus organization identified by the Secretary. We attempted
to find available measures that have been endorsed or adopted by a
consensus organization and found no other feasible and practical
measures on the topic of the degree to which facilities employ an EHR
system in their program. Therefore, we believe that the Use of an
Electronic Health Record proposed measure meets the measure selection
exception requirement under section 1886(s)(4)(D)(ii) of the Act.
Public comments and responses to comments on the Electronic Health
Record measure are summarized below.
Comment: Some commenters stated that inclusion of this structural
measure was not appropriate because it was not endorsed by the NQF and
not supported for use in the Program by the MAP.
Response: As outlined in the proposed rule, we believe that
inclusion of this measure without NQF-endorsement meets the statutory
requirements under section 1886(s)(4)(D)(ii) of the Act. Under that
section, the Secretary is authorized to specify a measure that is not
endorsed by the NQF insofar as due consideration is given to measures
that have been endorsed or adopted by a consensus organization
identified by the Secretary. We attempted to find available measures
that had been endorsed or adopted by a consensus organization and found
no other feasible and practical measures on the topic of EHR use in the
IPF setting.
While the MAP did not support inclusion of this measure, we
disagreed with its interpretation of the purpose of this measure. The
purpose of the measure is to assess the use of processes for the
collection, use, and transmission of medical information that have been
demonstrated to impact the quality of care, rather than to collect data
on systems and infrastructure. Many studies document the benefits of
EHR use on multiple dimensions related to health care quality, and to
multiple goals of CMS' quality strategy.
Comment: Some commenters stated that IPFs are currently excluded
from the Medicare EHR Incentive Program and, therefore, it is
inappropriate to subject IPFs to the statutory 2.0 percentage point
reduction for failure to report the measure without also permitting
them to avail themselves of associated incentives. Some commenters
indicated their support of this measure if CMS and the Office of the
National Coordinator for Health Information Technology plan to expand
the EHR Incentive Program to include IPFs.
Response: We believe that the evidence demonstrating the positive
effects of EHR use on multiple aspects of medical care supports its
adoption as a quality measure independent of a facility's possible
eligibility for incentives promoting such use. Further, even though
current certification requirements have not explicitly considered the
needs of IPFs, much of the care process in IPFs is common with that of
eligible hospitals, meaning that use of existing certified EHRs can
effectively and efficiently improve care.
Comment: Some commenters stated that, because this measure is an
attestation only measure, it is not a quality of care measure that
should be

[[Page 45967]]

part of a requirement that affects payment and that is publicly
reported.
Response: We disagree with the commenters. CMS credits IPFs for
reporting any response category indicating their current EHR use
status. We believe that the potential value of a quality measure is
primarily in the information that it provides, and is not necessarily
limited by how it is collected or reported. Further, information
collected through reporting of this measure will provide valuable
information on EHR use in IPFs, which is tied to the provision of high
quality care. Therefore, we believe that public reporting of this
measure would provide significant insight to patients, and their
families and caregivers, on the quality of care provided in IPFs.
Comment: Some commenters stated that the proposed rule does not
present sufficient empirical evidence to support the conclusion that
the use of currently available EHR technology platforms facilitates the
delivery of a high quality of care.
Response: The use of EHRs in hospitals has proven over the years to
be effective in reducing medication errors, supporting timely exchange
of patient information to the next level of provider (for example, the
provider who will care for the patient after discharge), and improving
communication among the health care team.\4\ \5\ In 2008, the Substance
Abuse and Mental Health Services Administration (SAMHSA) conducted a
study of state mental health facilities and found that five states
already have a complete EHR system in their state psychiatric hospitals
and 18 states have incorporated some parts of EHRs. The study found
that these systems improved the communication of information and
patient safety.\6\
---------------------------------------------------------------------------

\4\ Institute of Medicine. Preventing Medication Errors: Quality
Chasm Series. Washington, DC: The National Academies Press, 2007.
\5\ Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, et
al. Systematic Review: Impact of Health Information Technology on
Quality, Efficiency, and Costs of Medical Care. Ann Intern Med.
2006;144:742-752.
\6\ Lutterman, T., Phelan, B., Berhane, A., Shaw, R., Rana, V.
(2008). Characteristics of State Mental Health Agency Data Systems.
DHHS Pub. No. (SMA) 08-4361. Rockville, MD: Center for Mental Health
Services, Substance Abuse and Mental Health Services Administration.
Report can be accessed at: http://store.samhsa.gov/shin/content/SMA08-4361/SMA08-4361.pdf.
---------------------------------------------------------------------------

Final Rule Action: After consideration of the public comments, we
are finalizing the Use of an Electronic Health Record measure as
proposed for the FY 2016 payment determination and subsequent years.
b. Quality Measures for the FY 2017 Payment Determination and
Subsequent Years
In the FY 2015 proposed rule (78 FR 26065 through 26068), we
proposed four quality measures to the IPFQR Program for the FY 2017
payment determination and subsequent years: (1) Influenza Immunization
(IMM-2); (2) Influenza Vaccination Coverage Among Healthcare Personnel;
(3) Tobacco Use Screening (TOB-1); and (4) Tobacco Use Treatment
Provided or Offered (TOB-2) and Tobacco Use Treatment (TOB-2a).
1. Influenza Immunization (IMM-2) (NQF #1659)
Increasing influenza (flu) vaccination can reduce unnecessary
hospitalizations and secondary complications, particularly among high
risk populations such as the elderly.\7\ Each year, approximately
226,000 people in the U.S. are hospitalized with complications from
influenza, and between 3,000 and 49,000 die from the disease and its
complications.\8\
---------------------------------------------------------------------------

\7\ Centers for Disease Control and Prevention. ``People at High
Risk of Developing Flu-Related Complications.'' [Internet Cited 2014
February 11]. Available from http://www.cdc.gov/flu/about/disease/high_risk.htm.
\8\ Thompson WW, Shay DK, Weintraub E, Brammer L, Cox N,
Anderson LJ, Fukuda. ``Mortality associated with influenza and
respiratory syncytial virus in the United States.'' JAMA. 2003
January 8; 289 (2): 179-186.
---------------------------------------------------------------------------

Vaccination is the most effective method for preventing influenza
virus infection and its potentially severe complications, and
vaccination is associated with reductions in influenza among all age
groups.\9\ The Advisory Committee on Immunization Practices (ACIP)
recommends seasonal influenza vaccination for all persons 6 months of
age and older, thereby stressing the importance of influenza
prevention. Evidence from a Veteran's Affairs locked behavioral
psychiatric unit with 26 patients and 40 staff during an influenza
outbreak demonstrates significant room for improvement in vaccination
rates among IPFs.\10\ In this study, 54 percent of the patients had not
been vaccinated, and 36 percent of non-vaccinated patients manifested
symptoms as compared with 25 percent of vaccinated patients.\11\ We
believe that the adoption of a measure that assesses influenza
immunization in the IPF setting not only works toward reducing the rate
of influenza infection, but also affords consumers and others useful
information in choosing among different facilities.
---------------------------------------------------------------------------

\9\ Centers for Disease Control and Prevention. Newsroom press
release February 24, 2010. ``CDC's Advisory Committee on
Immunization Practices (ACIP) Recommends Universal Annual Influenza
Vaccination.'' [Internet Cited 2010 March 3]. Available from http://www.cdc/media/pressrel/2010/r100224.htm.
\10\ Risa KJ, et al. ``In[fllig]uenza outbreak management on a
locked behavioral health unit.'' Am J Infect Control 2009;37:76-8.
\11\ Ibid.
---------------------------------------------------------------------------

We included the Influenza Immunization (NQF #1659) measure
in the ``List of Measures under Consideration for December 1, 2013.''
The Influenza Immunization (IMM-2) chart-abstracted measure assesses
inpatients, age 6 months and older, discharged during October,
November, December, January, February, or March, who are screened for
influenza vaccination status and vaccinated prior to discharge, if
indicated. The numerator includes discharges that were screened for
influenza vaccine status and were vaccinated prior to discharge, if
indicated. The denominator includes inpatients, age 6 months and older,
discharged during October, November, December, January, February, or
March. The measure excludes patients who: expire prior to hospital
discharge or have an organ transplant during the current
hospitalization; have a length of stay greater than 120 days; are
transferred or discharged to another acute care hospital; or leave
Against Medical Advice (AMA). We refer readers to https://www.qualityforum.org/QPS/1659 for further technical specifications.
The MAP gave conditional support for the measure, concluding that
it is not ready for implementation because it needs more experience or
testing. In its 2014 final report, the MAP recognized that influenza
immunization is important for healthcare personnel and patients, but
cautioned that CDC and CMS need to collaborate on adjusting
specifications for reporting from psychiatric units before the measure
can be included in the IPFQR Program. CMS does not agree with this
recommendation. Given previous experience with the use of this measure
in inpatient settings and the clarity of specifications for it, CMS
does not believe that additional experience or testing is needed before
implementing this measure in IPFs, or that specifications need to be
further adjusted for these facilities. We also believe that comments
concerning collaboration with CDC largely apply to the subsequent
measure for influenza vaccination among healthcare personnel, which is
explained in the discussion for that measure.
We believe that the IMM-2 measure meets the measure selection
criterion under section 1886(s)(4)(D)(ii) of the Act. This section
provides that, in the case of a specified area or medical topic

[[Page 45968]]

determined appropriate by the Secretary for which a feasible and
practical measure has not been endorsed by the entity with a contract
under section 1890(a) of the Act, the Secretary may specify a measure
that is not so endorsed as long as due consideration is given to
measures that have been endorsed or adopted by a consensus organization
identified by the Secretary.
This measure is not NQF-endorsed in the IPF setting and we could
not find any other comparable measure that is specifically endorsed for
the IPF setting. However, we believe that this measure is appropriate
for the assessment of the quality of care furnished by IPFs for the
reasons discussed above. Further, this measure has been endorsed by NQF
for the ``Hospital/Acute care facility'' setting. Although not
explicitly endorsed for use in the IPF setting, we believe that the
characteristics of IPFs as distinct part units of hospitals or
freestanding hospitals are similar enough to hospitals/acute care
facilities that this measure may be appropriately used in such
facilities. Finally, the adoption of this measure in the IPFQR Program
aligns with the Hospital Inpatient Quality Reporting (HIQR) Program,
which also includes this measure in its measure set. Public comments
and responses to comments on the IMM-2 measure are summarized below.
Comment: Multiple commenters expressed support for inclusion of
this measure. Some commenters stated that it is ready to be
implemented, and that further testing or experience is not required. In
addition, one commenter also stated that inclusion of this measure
would further alignment with similar measures collected across multiple
types of acute and post-acute care settings.
Response: We thank the commenters for their support.
Comment: Some commenters stated that this measure is not relevant
to the quality of care in IPFs. In particular, some commenters stated
that there is no empirically demonstrated direct, or indirect,
relationship between this measure and the delivery of high quality
behavioral health care in the IPF setting. Therefore, according to some
commenters, this measure only provides public health value and is not
an appropriate addition to the Program.
Response: We disagree with the commenters. While this measure does
not speak directly to specific behavioral health care services, it
provides meaningful information on the overall quality of care provided
in IPFs by addressing an area directly tied to improving patient
health. Accordingly, this measure not only provides value from a public
health standpoint, but speaks directly to the overall quality of care
that IPFs are able to provide.
Comment: Some commenters recommended that this measure should first
be pilot-tested in the IPF setting before it is proposed for adoption
into the Program. The commenters stated that this measure had been
adequately tested in the acute care setting, but expressed concern as
to the potential for negative unintended consequences in the IPF
setting without further testing.
Response: We disagree with the need to pilot test this measure in
the IPF setting before adoption. We believe that the challenges
associated with this measure in the acute care setting are not
sufficiently distinguishable from those present in the IPF setting such
that they would warrant delaying adoption at this time.
Comment: One commenter stated that adopting influenza vaccination
measures for both patients and personnel may create double-reporting
for facilities that have distinct inpatient units for patients and
staff.
Response: We believe that simultaneous adoption of the IMM-2 and
Influenza Vaccination Coverage Among HealthCare Personnel measures is
appropriate because only through both can potential influenza exposure
for the patient population be fully assessed. We do not perceive a
potential for double-reporting in the use of the measures.
Final Rule Action: After consideration of the public comments, we
are finalizing the IMM-2 measure as proposed for the FY 2017 payment
determination and subsequent years.
2. Influenza Vaccination Coverage Among HealthCare Personnel (NQF
#0431)
Healthcare personnel (HCP) can serve as vectors for influenza
transmission because they are at risk for both acquiring influenza from
patients and transmitting it to patients, and HCP often come to work
when ill.\12\ An early report of HCP influenza infections during the
2009 H1N1 influenza pandemic estimated that 50 percent of infected HCP
had contracted the influenza virus from patients or coworkers in the
health care setting.\13\ Influenza virus infection is common among HCP,
with evidence suggesting that nearly one-quarter of HCP were infected
during influenza season, but few recalled having influenza.\14\ While
it is difficult to precisely assess HCP influenza vaccination rates
among IPFs because of varying state policies requiring hospitals to
collect and report HCP vaccination coverage rates, evidence from a
Veterans Affairs locked behavioral psychiatric unit with 26 patients
and 40 staff during an influenza outbreak demonstrates significant room
for improvement.\15\ In this study, only 55 percent of all staff had
been vaccinated, and 22 percent of non-vaccinated staff manifested
symptoms as compared with 18 percent of vaccinated staff.\16\ We
believe that the adoption of a measure that assesses influenza
vaccination among HCP in the IPF setting not only works toward
improving the rate at which non-vaccinated HCP manifest symptoms as
compared with vaccinated HCP, but also affords consumers and others
useful information in choosing among different facilities.
---------------------------------------------------------------------------

\12\ Wilde JA, McMillan JA, Serwint J, et al. ``Effectiveness of
influenza vaccine in healthcare professionals: a randomized trial.''
JAMA 1999; 281: 908-913.
\13\ Harriman K, Rosenberg J, Robinson S, et al. ``Novel
influenza A (H1N1) virus infections among health-care personnel--
United States, April-May 2009.'' Morb Mortal Wkly Rep. 2009; 58(23):
641-645.
\14\ Elder AG, O'Donnell B, McCruden EA, et al. ``Incidence and
recall of influenza in a cohort of Glasgow health-care workers
during the 1993-4 epidemic: results of serum testing and
questionnaire.'' BMJ. 1996; 313:1241-1242.
\15\ Risa KJ, et al. ``Influenza outbreak management on a locked
behavioral health unit.'' Am J Infect Control 2009;37:76-8.
\16\ Ibid.
---------------------------------------------------------------------------

We included the Influenza Vaccination Coverage Among Healthcare
Personnel (NQF #0431) measure in the ``List of Measures under
Consideration for December 1, 2013.'' The measure assesses the
percentage of HCP who receive the influenza vaccination. The measure is
designed to ensure that reported HCP influenza vaccination percentages
are consistent over time within a single healthcare facility, as well
as comparable across facilities. The numerator includes HCP in the
denominator population who, during the time from October 1 (or when the
vaccine became available) through March 31 of the following year:
a. Received an influenza vaccination administered at the healthcare
facility, or reported in writing (paper or electronic) or provided
documentation that influenza vaccination was received elsewhere;
b. Were determined to have a medical contraindication/condition of
severe allergic reaction to eggs or to other component(s) of the
vaccine, or history of Guillain-Barre Syndrome within 6 weeks after a
previous influenza vaccination;
c. Declined influenza vaccination; or

[[Page 45969]]

d. Had an unknown vaccination status or did not otherwise fall
under any of the abovementioned numerator categories.
The denominator includes the number of HCP working in the
healthcare facility for at least one working day between October 1 and
March 31 of the following year, regardless of clinical responsibility
or patient contact, and is calculated separately for employees,
licensed independent practitioners, and adult students/trainees and
volunteers. The measure has no exclusions. We refer readers to https://www.qualityforum.org/QPS/0431 and the CDC Web site ( http://www.cdc.gov/nhsn/PDFs/HPS-manual/vaccination/HPS-flu-vaccine-protocol.pdf) for further technical specifications.
The MAP gave conditional support for the measure, concluding that
it is not ready for implementation because it needs more experience or
testing. In its 2014 report, the MAP recognized that influenza
immunization is important for healthcare personnel and patients, but
cautioned that CDC and CMS need to collaborate on adjusting
specifications for reporting from psychiatric units before the measure
can be included in the IPFQR Program. CMS does not agree with this
recommendation. As explained for the IMM-2 measure, given previous
experience with the use of this measure and the clarity of its
specifications, CMS does not believe that additional experience or
testing is needed before implementing this measure in IPFs, or that
specifications need to be further adjusted for these facilities. In
response to comments concerning collaboration with CDC, CDC and CMS
have conferred on this issue and language has been added to the
description of this measure below that clarifies that IPFs will use the
CDC National Healthcare Safety Network (NHSN) infrastructure and
protocol to report the measure for IPFQR Program purposes. Neither CMS
nor CDC believes that there are any coordination issues remaining for
the implementation of this measure.
We believe that the Influenza Vaccination Coverage Among Health
Care Personnel proposed measure meets the measure selection criterion
under section 1886(s)(4)(D)(ii) of the Act. This section provides that,
in the case of a specified area or medical topic determined appropriate
by the Secretary for which a feasible and practical measure has not
been endorsed by the entity with a contract under section 1890(a) of
the Act, the Secretary may specify a measure that is not so endorsed as
long as due consideration is given to measures that have been endorsed
or adopted by a consensus organization identified by the Secretary.
This measure is not NQF-endorsed in the IPF setting and we could
not find any other comparable measure that is specifically endorsed for
the IPF setting. However, we believe that this measure is appropriate
for the assessment of the quality of care furnished by IPFs for the
reasons discussed above. Further, this measure has been endorsed by NQF
for the ``Hospital/Acute care facility'' setting. Although not
explicitly endorsed for use in IPF settings, we believe that the
characteristics of IPFs as distinct part units of hospitals or
freestanding hospitals mean that this measure may be appropriately used
in such facilities.
IPFs will use the CDC National Healthcare Safety Network (NHSN)
infrastructure and protocol to report the measure for IPFQR Program
purposes. The IPF reporting of HCP influenza vaccination summary data
to NHSN will begin for the 2015-2016 influenza season, from October 1,
2015, to March 31, 2016, with a reporting deadline of May 15, 2016.
Although the collection period for this measure extends into the first
quarter of the following calendar year, this measure data will be
included with other measures that will be required for FY 2017 payment
determination. Similarly, reporting for subsequent years will include
results for the influenza season that begins in the last quarter of the
applicable calendar year's reporting.
The adoption of this measure in the IPFQR Program will align with
the HIQR, the Hospital Outpatient Quality Reporting (HOQR), and the
Ambulatory Surgical Center Quality Reporting (ASCQR) Programs. The
Influenza Vaccination Coverage Among Healthcare Personnel (HCP) (NQF
#0431) measure was finalized for the HIQR Program in the FY
2012 IPPS/LTCH PPS final rule (76 FR 51636), and the HOQR Program in
the CY 2014 OPPS/ASC final rule (78 FR 75099), and the ASCQR Program in
the CY 2013 Hospital Outpatient Prospective Payment final rule (77 FR
68495).
We are aware of public concerns about the burden of separately
collecting healthcare personnel (HCP) influenza vaccination status
across inpatient and outpatient settings, in particular, distinguishing
between the inpatient and outpatient setting personnel for reporting
purposes. We also understand that some are unclear about how the
measure will be reported to CDC's NHSN.
We believe reporting a single vaccination count for each healthcare
facility by each individual facility's CMS Certification Number (CCN)
will be less burdensome to IPFs than requiring them to distinguish
between their inpatient and outpatient personnel. Therefore, beginning
with the 2015-2016 influenza season, IPFs will collect and report all
HCP under each individual IPF's CCN and submit this single number to
CDC's NHSN. For each CMS CCN, a percentage of the HCP who received an
influenza vaccination will be calculated and publically reported, so
that the public will know what percentage of the HCP have been
vaccinated in each IPF. We believe this will provide meaningful data
that would help inform the public and healthcare facilities, while
improving the quality of care. Specific details on data submission for
this measure can be found in an Operational Guidance available at:
http://www.cdc.gov/nhsn/acute-care-hospital/hcp-vaccination/ and at
http://www.cdc.gov/nhsn/acute-care-hospital/index.html.
Public comments and responses to comments on the Influenza
Vaccination Coverage Among Healthcare Personnel measure are summarized
below.
Comment: Multiple commenters supported the adoption of this
measure. Some commenters stated that its proposed timeline promotes
alignment across quality reporting programs and that the public
reporting of an overall vaccination rate for a facility will provide
meaningful data to inform the public on the quality of care provided by
the IPF. Some commenters also expressed support for CMS' intention to
allow reporting as a single vaccination count for each healthcare
facility by each individual facility CCN because it will simplify data
collection for facilities with multiple care settings. In addition,
some commenters stressed that inclusion of this measure would further
alignment with similar measures collected across multiple types of
acute and post-acute care settings.
Response: We thank the commenters for their support.
Comment: Some commenters expressed concern over the burden on
facilities to require documentation of vaccination status for
volunteers at their facilities. One commenter stated that the measure
should either exclude volunteers from its requirements or be limited
only to volunteers who spend a substantial portion of time at a
facility over the course of a year.
Response: We understand the commenters' concern and are cognizant
of the burden associated with reporting on this measure. However,
because of

[[Page 45970]]

the known benefits of vaccination and the fact that adoption of this
measure furthers alignment across quality reporting programs, we
believe that its inclusion in the Program is appropriate. Furthermore,
we believe that limiting the scope of this measure with regard to
volunteers would undercut the purpose of the measure. By being present
in facilities, and interacting with patients and other personnel, the
vaccination status of volunteers is effectively as important as that of
other healthcare personnel, regardless of the amount of time spent in
the facility.
Comment: Some commenters stated that this measure is not pertinent
to the quality of care in IPFs. In particular, some commenters stated
that there is no empirically demonstrated direct, or indirect,
relationship between this measure and the delivery of high quality
behavioral health care in the IPF setting. Therefore, according to some
commenters, this measure only provides public health value and is not
an appropriate addition to the Program.
Response: We disagree with the commenters. While this measure does
not speak directly to specific behavioral health care services, it
provides meaningful information on the overall quality of care provided
at IPFs by addressing an area tied directly to improving patient
health. Accordingly, this measure not only provides value from a public
health standpoint, but speaks directly to the overall quality of care
that any given IPF is able to provide.
Comment: Some commenters sought clarification on which individuals
were considered `healthcare personnel' for purposes of reporting on
this measure.
Response: Clarification as to which individuals are considered
healthcare personnel for purposes of this measure can be found at:
http://www.cdc.gov/nhsn/PDFs/HPS-manual/vaccination/HPS-flu-vaccine-protocol.pdf.
Comment: Some commenters recommended that this measure should first
be pilot-tested in the IPF setting before adoption into the Program.
Response: We disagree with the need to first pilot-test this
measure in the IPF setting before adoption. We believe that the
challenges associated with this measure in the acute care setting are
not sufficiently distinguishable from those present in the IPF setting
such that they would warrant delaying adoption at this time.
Comment: Some commenters stated that, while reporting this measure
under IPFs' CCN to the CDC's NHSN may simplify reporting, reporting
will depend on how the facility chooses to bill for the services. For
instance, an acute care hospital with an IPF unit may choose to bill
under one CCN, or have one CCN for the acute care hospital and another
CCN for the IPF. Therefore, commenters suggested, CMS should make both
values available through QualityNet prior to public reporting, so that
facilities can reconcile any differences.
Response: We understand the commenters' concerns. However, we
believe that reporting this measure under IPFs' CCN to the CDC's NHSN
best promotes efficiency and accuracy of data collection.
Final Rule Action: After consideration of the public comments, we
are finalizing the Influenza Vaccination Coverage Among HealthCare
Personnel measure as proposed for the FY 2017 payment determination and
subsequent years.
3. Tobacco Use Screening (TOB-1) (NQF #1651)
Tobacco use is currently the single greatest cause of disease in
the U.S., accounting for more than 435,000 deaths annually.\17\ Smoking
is a known cause of multiple cancers, heart disease, stroke,
complications of pregnancy, chronic obstructive pulmonary disease,
other respiratory problems, poorer wound healing, and many other
diseases.\18\ This health issue is especially important for persons
with mental illness and substance use disorders. One study has
estimated that these individuals are twice as likely to smoke as the
rest of the population.\19\ Tobacco use also creates a heavy cost to
both individuals and society. Smoking-attributable health care
expenditures are estimated at $96 billion per year in direct medical
expenses and $97 billion in lost productivity.\20\
---------------------------------------------------------------------------

\17\ Centers for Disease Control and Prevention. ``Annual
Smoking-Attributable Mortality, Years of Potential Life Lost, and
Productivity Losses--United States, 2000-2004.'' Morb Mortal Wkly
Rep. 2008. 57(45): 1226-1228. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5745a3.htm.
\18\ U.S. Department of Health and Human Services. ``The health
consequences of smoking: a report of the Surgeon General.'' Atlanta,
GA, U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health, 2004.
\19\ Lasser K, Boyd JW, Woolhandler S, Himmelstein, DU,
McCormick D, Bor DH. Smoking and mental illness: A population-based
prevalence study. JAMA. 2000;284(20):2606-2610.
\20\ Centers for Disease Control and Prevention. ``Best
Practices for Comprehensive Tobacco Control Programs--2007.''
Atlanta, GA, Department of Health and Human Services, Centers for
Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health, 2007.
---------------------------------------------------------------------------

Strong and consistent evidence demonstrates that timely tobacco
dependence interventions for patients using tobacco can significantly
reduce the risk of suffering from tobacco-related disease, as well as
provide improved health outcomes for those already suffering from a
tobacco-related disease.\21\ Research demonstrates that tobacco users
hospitalized with psychiatric illnesses who enter into treatment can
successfully overcome their tobacco dependence.\22\ Evidence also
suggests that tobacco cessation treatment does not increase, and may
even decrease, the risk of rehospitalization for tobacco users
hospitalized with psychiatric illnesses.\23\ Research further
demonstrates that effective tobacco cessation support across the care
continuum can be provided with only a minimal additional effort and
without harm to the mental health recovery process.\24\ We believe that
the adoption of a measure that assesses tobacco use screening among
patients of IPFs encourages the uptake of tobacco cessation treatment
and its attendant benefits. We further believe that the reporting of
this measure will afford consumers and others useful information in
choosing among different facilities.
---------------------------------------------------------------------------

\21\ U.S. Department of Health and Human Services. ``The health
consequences of smoking: a report of the Surgeon General.'' Atlanta,
GA, U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health, 2004.
\22\ Prochaska, JJ, et al. ``Efficacy of Initiating Tobacco
Dependence Treatment in Inpatient Psychiatry: A Randomized
Controlled Trial.'' Am. J. Pub. Health. 2013 August 15; e1-e9.
\23\ Ibid.
\24\ Ibid.
---------------------------------------------------------------------------

The Tobacco Use Screening (TOB-1) chart-abstracted measure assesses
hospitalized patients who are screened within the first three days of
admission for tobacco use (cigarettes, smokeless tobacco, pipe, and
cigar) within the previous 30 days. The numerator includes the number
of patients who were screened for tobacco use status within the first 3
days of admission. The denominator includes the number of hospitalized
inpatients 18 years of age and older. The measure excludes patients
who: Are less than 18 years of age; are cognitively impaired; have a
duration of stay less than or equal to 3 days, or greater than 120
days; or have Comfort Measures Only documented.
We refer readers to http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx for
further details on measure specifications.

[[Page 45971]]

In the ``List of Measure under Consideration for December 1,
2013,'' we originally proposed a similar measure to that finalized
here, which was ``Preventive Care & Screening: Tobacco Use: Screening &
Cessation Intervention (NQF 0028).'' However, the MAP determined that
this measure did not meet the needs of the program and instead
recommended that we adopt an alternate measure from the Joint
Commission's suite of measures for inpatient settings, which we are now
finalizing. This measure, and the following one (TOB-2 and 2a), best
reflect the activities encompassed by the original NQF 0028 measure.
The measure was NQF-endorsed on March 7, 2014, and meets the
measure selection criterion under section 1886(s)(4)(D)(i) of the Act.
Public comments and responses to comments on the TOB-1 measure are
summarized below.
Comment: One commenter stated that this measure requires labor-
intensive manual chart abstraction, does not permit sampling, and does
not benefit from data validation of aggregately submitted data. Without
sampling, the commenter further stated that facilities will have to
invest valuable resources abstracting data that has not been validated
for accuracy for public reporting and possible future payment penalty.
Response: We understand the commenter's concern with regard to the
burden associated with reporting on this measure. We believe, however,
that this measure strikes an appropriate balance between encouraging
the uptake of tobacco cessation treatment and its documented benefits
without unnecessarily burdening facilities. We also understand the
commenter's concern with regard to the unavailability of validation. We
are aware of this issue and currently are working toward developing a
validation methodology for future use in the Program.
Comment: Some commenters stated that this measure does not provide
meaningful information on the quality of care provided in IPFs.
Similarly, some commenters stated that screening for tobacco use is
important for the IPF patient population, but asserted that this should
be an individualized part of a patient's care. One commenter also
stated that this measure has limitations, such as not being developed
and tested in the IPF setting and only applying to patients 18 years
old and older, that affect its utility.
Response: We disagree with the commenters. We believe that
reporting of this measure will yield information that provides
meaningful distinctions in the quality of care provided across IPFs and
address an important health behavior for persons with mental illness.
Precisely because tobacco use screening is considered an essential step
in the care process for IPF patients, we believe that it is critical
for patients, and their families and caregivers, to have accurate
available information on whether IPFs integrate this into their care
processes. Moreover, we do not believe that the limitations that the
commenter noted substantially discount the value of this measure for
the Program.
Comment: Some commenters stated that, while screening for tobacco
use in the IPF setting is important, the HBIPS-1 measure is a better
alternative because it is already collected by most IPFs, captures much
of the information on tobacco use that CMS seeks to collect, and
facilitates a more holistic approach to addressing tobacco use.
Response: We disagree with the commenters. The HBIPS-1 measure does
not explicitly provide for tobacco screening and intervention. Please
refer to the following link http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx for further details on HBIPS-1 measure specifications.
Comment: One commenter stated that the burden for reporting this
measure is too great because documenting a generic assessment of
whether a patient uses smokeless tobacco or cigarettes should be enough
of an assessment to determine if counseling or treatment for cessation
should be provided.
Response: We disagree with the commenter. We believe that the
requirements associated with reporting on this measure strike a
reasonable balance between provider burden and providing useful
information to the public on the quality of care provided in IPFs.
Final Rule Action: After consideration of the public comments, we
are finalizing the TOB-1 measure as proposed for the FY 2017 payment
determination and subsequent years.
4. Tobacco Use Treatment Provided or Offered (TOB-2) and Tobacco Use
Treatment (TOB-2a) (NQF #1654)
As stated in our discussion of the proposed TOB-1 measure, tobacco
use is currently the single greatest cause of disease in the U.S. We
also indicated that research demonstrates that timely tobacco cessation
treatment for hospitalized tobacco users with psychiatric illnesses may
decrease the risk of rehospitalization, have only a minimal additional
effort, and not harm the mental health recovery process. We believe
that the adoption of a measure that assesses tobacco use screening
treatment among IPFs encourages the uptake of tobacco cessation
treatment and its attendant benefits. We further believe that the
reporting of this measure will afford consumers and others useful
information in choosing among different facilities.
The Tobacco Use Treatment Provided or Offered (TOB-2) and Tobacco
Use Treatment (TOB-2a) chart-abstracted measure is reported as an
overall rate that includes all patients to whom tobacco use treatment
was provided, or offered and refused, and a second rate, a subset of
the first, which includes only those patients who received tobacco use
treatment. The overall rate, TOB-2, assesses patients identified as
tobacco product users within the past 30 days who receive or refuse
practical counseling to quit, and receive or refuse Food and Drug
Administration (FDA)-approved cessation medications during the first 3
days following admission. The numerator includes the number of patients
who received or refused practical counseling to quit, and received or
refused FDA-approved cessation medications during the first 3 days
after admission.
The second rate, TOB-2a, assesses patients who received counseling
and medication, as well as those who received counseling and had reason
for not receiving the medication during the first 3 days following
admission. The numerator includes the number of patients who received
practical counseling to quit and received FDA-approved cessation
medications during the first 3 days after admission.
The denominator for both TOB-2 and TOB-2a includes the number of
hospitalized inpatients 18 years of age and older identified as current
tobacco users. The measure excludes patients who: Are less than 18
years of age; are cognitively impaired; are not current tobacco users;
refused or were not screened for tobacco use during the hospital stay;
have a duration of stay less than or equal to 3 days, or greater than
120 days; or have Comfort Measures Only documented.
We refer readers to http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx for
further details on measure specifications.
The measure was NQF-endorsed on March 7, 2014, and meets the
measure selection criteria under section 1886(s)(4)(D)(i) of the Act.
We also note that at this time we are not adopting two

[[Page 45972]]

other tobacco treatment measures that are part of the set from which
TOB-1, TOB-2 and TOB2a are taken. We believe that the two measures we
are finalizing best encompass the activities that we originally
proposed to measure through the use of the NQF 0028 measure, and best
assess activities demonstrated to produce positive results in tobacco
use reduction. Additionally, we believe that the other measure
represents a significantly greater collection and reporting burden.
Public comments and responses to comments on the TOB-2 and TOB-2a
measures are summarized below.
Comment: One commenter stated that this measure requires labor-
intensive manual chart abstraction, does not permit sampling, and does
not benefit from data validation of aggregately submitted data. Without
sampling, the commenter further argued, facilities will have to invest
valuable resources abstracting data that has not been validated for
accuracy for public reporting and possible future payment penalty.
Response: We understand the commenter's concern with regard to the
burden associated with reporting on this measure. However, we believe
that this measure strikes an appropriate balance between encouraging
the uptake of tobacco cessation treatment, providing consumers with
relevant and actionable information about this aspect of quality, and
its documented benefits without unnecessarily burdening facilities.
Comment: Some commenters stated that this measure does not provide
meaningful information on the quality of care provided in IPFs.
Similarly, some commenters stated that tobacco use treatment is
important for the IPF patient population, but asserted that this should
be an individualized part of a patient's care. One commenter also
stated that this measure has limitations, such as not being developed
and tested in the IPF setting and applying only to patients 18 years
old and older, that affect its utility.
Response: We disagree with the commenters. We believe that
reporting of this measure will yield information that provides
meaningful distinctions in the quality of care provided across IPFs and
does not conflict with the inclusion of cessation treatment within an
individualized plan of care. Precisely because tobacco use cessation
treatment is considered an essential step in the care process for IPF
patients, we believe that it is critical for patients, and their
families and caregivers, to have accurate available information on
whether IPFs integrate this into their care processes. Moreover, we do
not believe that the limitations that the commenter noted substantially
discount the value of this measure for the Program.
Comment: Some commenters stated that, while tobacco use treatment
in the IPF setting is important, the HBIPS-1 measure is a better
alternative because it is already collected by most IPFs, captures much
of the information on tobacco use that CMS seeks to collect, and
facilitates a more holistic approach to addressing tobacco use.
Response: We disagree with the commenters. Importantly, the HBIPS-1
measure does not explicitly provide for tobacco screening and
intervention. Therefore, we believe that the TOB-2 and TOB-2a measures
more adequately align with the Program's reporting goals. Please refer
to the following link: http://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx for
further details on HBIPS-1 measure specifications.
Comment: One commenter stated that the abstraction burden for
reporting this measure is too great because documenting a generic
assessment of whether a patient uses smokeless tobacco or cigarettes
should be enough of an assessment to determine if counseling or
treatment for cessation should be provided.
Response: We disagree with the commenter. We believe that the
requirements associated with reporting on this measure strike a
reasonable balance between provider burden and providing useful
information to the public on the quality of care provided in IPFs.
Final Rule Action: After consideration of the public comments, we
are finalizing the TOB-2 and TOB-2a measure as proposed for the FY 2017
payment determination and subsequent years.
c. Summary of Measures
In addition to the eight measures that we previously finalized for
the IPFQR Program, we are adding two new measures for reporting for the
FY 2016 payment determination and subsequent years. We are also adding
four new measures for the FY 2017 payment determination and subsequent
years. The tables below list the new measures for the FY 2016 and FY
2017 payment determinations and subsequent years.

Table 13--New Quality Measures for the IPFQR Program for FY 2016 Payment Determination and Subsequent Years
----------------------------------------------------------------------------------------------------------------
National quality strategy priority NQF # Measure ID Measure description
----------------------------------------------------------------------------------------------------------------
Patient- and Caregiver-Centered N/A N/A........................ Assessment of Patient
Experience of Care. Experience of Care.
Effective Communication and N/A N/A........................ Use of an Electronic
Coordination of Care. Health Record.
----------------------------------------------------------------------------------------------------------------

Table 14--New Quality Measures for the IPFQR Program for FY 2017 Payment Determination and Subsequent Years
----------------------------------------------------------------------------------------------------------------
National quality strategy priority NQF # Measure ID Measure description
----------------------------------------------------------------------------------------------------------------
Population/Community Health............ 1659 IMM-2...................... Influenza Immunization.
Population/Community Health............ 0431 N/A........................ Influenza Vaccination
Coverage Among Healthcare
Personnel.
Clinical Quality of Care............... 1651 TOB-1...................... Tobacco Use Screening.
Clinical Quality of Care............... 1654 TOB-2 Tobacco Use Treatment
TOB-2a..................... Provided or Offered and
Tobacco Use Treatment.
----------------------------------------------------------------------------------------------------------------

Public comments and responses to comments on the new measures for
FY 2016 and FY 2017 payment determinations and subsequent years are
summarized below.
Comment: Some commenters expressed concern that CMS has proposed
too many process measures at

[[Page 45973]]

the expense of outcome measures. One commenter recommended that CMS
should evaluate critically the extent to which potential measures will
contribute to meaningful differences in the health outcomes achieved by
IPF patients. This commenter further noted that CMS should be mindful
of the burden associated with proposing new measures for the Program.
Response: We agree with the commenter that concern for measuring
health outcomes should play an important role in measure development.
To this end, as we stated in the proposed rule, we intend to propose
the addition of a readmissions measure to the Program through future
rulemaking. Further, we continue to welcome recommendations for the
adoption of other outcome measures for inpatient psychiatric care.
We also understand the commenter's concern regarding the reporting
burden associated with complying with the Program's requirements. We
are mindful that the reporting burden can be particularly acute for the
many small IPFs that participate in the Program. Accordingly, we have
endeavored to keep the number of measures in the Program at a
manageable number that is far fewer than is required for many other
quality reporting programs. In considering how to expand the Program's
measure set in future years, we intend to strike a balance between
developing a measure set that adequately assesses the quality of care
provided in IPFs, while not requiring IPFs to report on unnecessary or
duplicative measures.
Comment: Some commenters requested that more time be afforded to
IPFs before data collection on new measures is required.
Response: The Program's data collection requirements for new
measures are consistent with policies adopted in other quality
reporting programs. The period from the adoption of final measures to
the beginning of the applicable reporting period typically exceeds four
months. Depending on the individual facility's practices, actual data
collection may take place significantly after this period.
d. Additional Procedural Requirements for the FY 2017 Payment
Determination and Subsequent Years
In addition to the quality measures that we have described above,
IPFs must, when they begin reporting for the FY 2017 payment
determination, submit to CMS aggregate population counts for Medicare
and non-Medicare discharges by age group, diagnostic group, and
quarter, and sample size counts for measures, for which sampling is
performed (as is allowed for in HBIPS-4-7, and SUB-1). These
requirements are separate from those described under subsection (c) of
the section entitled ``Form, Manner, and Timing of Quality Data
Submission.'' That subsection describes the population, sample size,
and minimum reporting case threshold requirements for individual
measures, while this section describes the collection of general
population and sampling data that will assist in determining compliance
with those requirements. We believe that it is vital for IPFs to
accurately determine and submit to CMS their population and sampling
size data in order for CMS to assess IPFs' data reporting completeness
for their total population, both Medicare and non-Medicare. In addition
to helping to better assess the quality and completeness of measure
data, we expect that this information will improve our ability to
assess the relevance and impact of potential future measures. For
example, understanding that the size of subgroups of patients addressed
by a particular measure varies greatly over time could be helpful in
assessing the stability of reported measure values, and subsequent
decisions concerning measure retention. Similarly, better understanding
of the size of particular subgroups in the overall population will
assist us in making choices among potential future measures specific to
a particular subgroup (e.g., those with depression).
Furthermore, the form, manner, and timing of this submission will
follow the policies discussed at section VIII of this preamble, and
that failure to provide this information will be subject to the 2.0
percentage point reduction in the annual update for any IPF that does
not comply with quality data submission requirements, pursuant to
section 1886(s)(4)(A)(i) of the Act. Public comments and responses to
comments on the additional procedural requirements for the FY 2017
payment determination and subsequent years are summarized below.
Comment: Some commenters expressed support for the adoption of the
requirement that IPFs must submit to CMS aggregate population counts
for Medicare and non-Medicare discharges by age group, diagnostic
group, and quarter, and sample size counts for measures for which
sampling is performed.
Response: We thank the commenters for their support.
Comment: Some commenters stated that the requirement for IPFs to
submit to CMS aggregate population counts for Medicare and non-Medicare
discharges by age group, diagnostic group, and quarter, and sample size
counts for measures for which sampling is performed is an inefficient
use of a quality reporting program and, instead, this information would
be more properly gathered through other means not tied to public
reporting and under the Program's statutory penalty for failure to
report IPFQR quality measure data and meet other program requirements.
Similarly, some commenters further stated that this requirement would
be unique among quality reporting programs.
Response: We disagree with the commenters. We believe that
collection of this information will not only work to better assess the
quality and completeness of measure data, but also improve our ability
to assess the relevance and impact of potential future measures.
Moreover, collection of this type of information is not unprecedented
among quality reporting programs. For instance, the PPS-Exempt Cancer
Hospital Quality Reporting (PCHQR) made a similar proposal in the FY
2015 IPPS proposed rule (79 FR 28259).
Comment: Some commenters recommended that the specifications for
this data submission should mirror the same elements collected by The
Joint Commission (TJC).
Response: We do not have plans at this time to align our data
submission with that of TJC, but will consider their requirements in
providing direction concerning these submissions.
Comment: Due to the Program's statutory penalty for failure to
report IPFQR quality measure data and meet other program requirements,
some commenters stated that CMS should specify its data validation
approach before requiring submission of this information. The
commenters further stated that the results of a validation methodology
should be a factor in determining whether a statutory penalty should be
assessed.
Response: We disagree with the commenters. While we are working
toward developing a validation methodology for use in future Program
years, we do not believe that submission of these data warrants being
delayed until implementation of such a methodology.
Final Rule Action: After consideration of the public comments, we
are finalizing the requirement for IPFs to submit to CMS aggregate
population counts for Medicare and non-Medicare discharges by age
group, diagnostic group, and quarter, and sample size counts for
measures for which sampling is performed as proposed for the FY

[[Page 45974]]

2017 payment determination and subsequent years.
e. Maintenance of Technical Specifications for Quality Measures
We will provide a user manual that will contain links to measure
specifications, data abstraction information, data submission
information, a data submission mechanism known as the Web-based
Measures Tool, and other information necessary for IPFs to participate
in the IPFQR Program. This manual will be posted on the QualityNet Web
site at: https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1228772250192. We will maintain the technical specifications for the quality
measures by updating this manual periodically and including detailed
instructions for IPFs to use when collecting and submitting data on the
required measures. These updates will be accompanied by notifications
to IPFQR Program participants, providing sufficient time between the
change and effective dates in order to allow users to incorporate
changes and updates to the measure specifications into data collection
systems.
Many of the quality measures used in different Medicare and
Medicaid reporting programs are endorsed by the National Quality Forum
(NQF). As part of its regular maintenance process for endorsed
performance measures, the NQF requires measure stewards to submit
annual measure maintenance updates and undergo maintenance of
endorsement review every 3 years. In the measure maintenance process,
the measure steward (owner/developer) is responsible for updating and
maintaining the currency and relevance of the measure and will confirm
existing or minor specification changes with NQF on an annual basis.
NQF solicits information from measure stewards for annual reviews, and
it reviews measures for continued endorsement in a specific 3-year
cycle.
We note that NQF's annual or triennial maintenance processes for
endorsed measures may result in the NQF requiring updates to the
measures in order to maintain endorsement status. We believe that it is
important to have in place a subregulatory process to incorporate non-
substantive updates required by the NQF into the measure specifications
we have adopted for the IPFQR Program, so that these measures remain
up-to-date.
We also recognize that some changes the NQF might require to its
endorsed measures are substantive in nature and might not be
appropriate for adoption using a subregulatory process. Therefore, in
the FY 2013 IPPS/LTCH PPS final rule (77 FR 53503 through 53505), we
finalized a policy under which we will use a subregulatory process to
make only non-substantive updates to measures used for the IPFQR
Program (77 FR 53653). With respect to what constitutes substantive
versus non-substantive changes, we expect to make this determination on
a case-by-case basis. Examples of non-substantive changes to measures
might include updates to diagnosis or procedure codes, medication
updates for categories of medications, broadening of age ranges, and
exclusions for a measure. We believe that non-substantive changes may
include updates to NQF-endorsed measures based upon changes to
guidelines upon which the measures are based. As stated in the FY 2013
IPPS/LTCH PPS final rule, we will revise the manual, so that it clearly
identifies the updates and provides links to where additional
information on the updates can be found. We will also post the updates
on the QualityNet Web site at https://www.QualityNet.org. We will
provide 6 months for facilities to implement changes where changes to
the data collection systems are necessary.
We will continue to use rulemaking to adopt substantive updates
required by the NQF to the endorsed measures that we have adopted for
the IPFQR Program. Examples of changes that we might consider to be
substantive are those in which the changes are so significant that the
measure is no longer the same measure, or when a standard of
performance assessed by a measure becomes more stringent (for example,
changes in acceptable timing of medication, procedure/process, or test
administration). Another example of a substantive change would be where
the NQF has extended its endorsement of a previously endorsed measure
to a new setting, such as extending a measure from the inpatient
setting to hospice. These policies regarding what is considered
substantive versus non-substantive would apply to all measures in the
IPFQR Program. We also note that the NQF process incorporates an
opportunity for public comment and engagement in the measure
maintenance process.
We believe that this policy adequately balances our need to
incorporate technical updates to all Program measures in the most
expeditious manner possible, while preserving the public's ability to
comment on updates that so fundamentally change an endorsed measure
that it is no longer the same measure that we originally adopted.
Public comments and our responses are summarized below.
Comment: One commenter expressed support for use of the
Specifications Manual in the Program.
Response: We thank the commenter for its support.
Comment: One commenter recommended that CMS provide a more detailed
Specifications Manual that would, for instance, include more robust
definitions, and explanations of measures and data requirements.
Response: We thank the commenter for its recommendation. Once
finalized, CMS will review the Specifications Manual on a regular basis
and make updates as necessary.
6. New Quality Measures for Future Years
As we have previously indicated, we seek to develop a comprehensive
set of quality measures to be available for widespread use for informed
decision-making and quality improvement in the IPF setting. Therefore,
through future rulemaking, we intend to propose new measures that will
help further our goal of achieving better health care and improved
health for Medicare beneficiaries who obtain inpatient psychiatric
services through the widespread dissemination and use of quality
information.
As part of the 2013 Measures under Consideration (http://www.qualityforum.org/Setting_Priorities/Partnership/Measures_Under_Consideration_List.aspx), we identified 10 possible measures for the
IPFQR Program. We are finalizing four of these measures for adoption in
this final rule. Five of the measures are currently undergoing testing,
and we anticipate that one or more would be adopted in the near future.
These measures are:

Suicide Risk Screening completed within one day of admission
Violence Risk Screening completed within one day of admission
Drug Use Screening completed within one day of admission
Alcohol Use Screening completed within one day of admission
Metabolic Screening

We also are currently planning to develop a 30-day psychiatric
readmission measure. Similar to readmission measures currently in use
for other CMS quality reporting programs, such as the HIQR Program, we
envision that this measure will encompass all 30-day readmissions for
discharges from IPFs, including readmissions for non-psychiatric
diagnoses. Additionally, we intend to develop a standardized survey of
patient

[[Page 45975]]

experience of care tailored for use in inpatient psychiatric settings,
but also sharing elements with similar surveys in use in other CMS
reporting programs.
We further anticipate that we will recommend additional measures
for development or adoption in the future. We intend to develop a
measure set that effectively assesses IPF quality across the range of
services and diagnoses, encompasses all of the goals of the CMS quality
strategy, addresses measure gaps identified by the MAP and others, and
minimizes collection and reporting burden. Finally, we may propose the
removal of some measures in the future, should one or more no longer
reflect significant variation in quality among IPFs, or prove to be
less effective than alternative measures in measuring the intended
focus area. Public comments and responses to comments on new quality
measures for future years are summarized below.
Comment: CMS received several comments in response to our proposal
for new quality measures for future years. Some commenters stated that
a number of the measures noted as currently undergoing testing address
areas included in the HBIPS-1 measure and; therefore, would be
unnecessarily duplicative. One commenter asserted that HBIPS-1 also
contains additional areas of screening that are important for all
patients and, as an integrated, comprehensive set of screens, would
provide a clinical picture of the patient that any individual screen by
itself could not provide. Disaggregating this measure into separate
measures, according to the commenter, would introduce the potential for
weakening the screening process. In addition, the commenter noted that
HBIPS-1 provides very similar screenings to the measures currently
undergoing testing, but within 3 days of admission, which is more
appropriate for the IPF setting. In addition, the commenter stated that
the metabolic screening measure that is currently undergoing testing
should be limited to anthropomorphic screening.
Some commenters recommended that CMS should not include the five
measures currently undergoing testing in the Program until they have
been approved by the MAP and endorsed by the NQF. Another commenter
stated that adopting the measures that are currently undergoing testing
may result in unnecessary laboratory work for IPFs and; therefore,
would increase the cost of health care services. One commenter
recommended that, with regard to the measures that are currently
undergoing testing, CMS consider a three-day timeframe for assessment,
as opposed to a one-day timeframe, as part of the measure
specifications.
We also received a comment supporting the inclusion of a
readmissions measure that focuses on those readmissions that are
clinically related to the index admission and are potentially
preventable by the IPF. The commenter also suggested that readmissions
measures should be risk-adjusted to account for differences across
patients in the likelihood of readmission, and stated that appropriate
risk adjustment should include patient assessment data. Other
commenters stated that a readmissions measure for the IPF setting may
not be a true assessment of the quality of inpatient psychiatric care
because IPF patients tend to exhibit characteristics that the available
literature associates as risk factors for hospital readmissions. One
commenter further stated that, while quality measures and care pathways
aimed at improving medical care for heart attacks, heart failure, and
pneumonia have been in place for more than a decade, psychiatric
measures and care pathways for treating chronic psychiatric diseases
are in their early stages of development, suggesting that a readmission
to IPF care may not indicate anything meaningful about the quality and
extent of care provided during an initial stay. In addition, we
received a comment recommending that CMS consider a number of issues as
it develops a readmissions measure for the Program. First, the
commenter asked whether such a measure would include only Medicare
patients or all IPF admissions because providers do not have access to
the databases required to report or track readmissions across all
payers. Second, the commenter expressed concern that there may be no
relationship between a psychiatric hospital admission and a subsequent
medical or surgical admission within 30 days, but that consumers will
not have access to this level of information. Third, the commenter
expressed concern that there are presently no published studies on the
current readmission rate for IPFs. Fourth, the commenter expressed
concern that there is no risk-adjustment proposed. Fifth, the commenter
argued that there is currently no NQF endorsement of the measure being
developed. Other commenters stated that a future readmissions measure
should be limited to psychiatric readmission to the same facility. One
commenter expressed support for a readmissions measure in future
Program years, but recommended that CMS remove the unrelated acute
medical admissions from the definition of an unplanned 30-day IPF
readmission because such a readmission is not a reflection on the
quality of care provided at the index IPF admission. Another commenter
recommended that, with regard to a potential readmissions measure, an
exception should be made for dementia-related behavior disorders
because these are by nature frequently repeating and heavily dependent
on factors beyond the control of acute psychiatry.
In addition, we received several comments recommending that CMS
engage the IPF technical expert panel for its guidance and advice on
the challenges associated with implementing many of the measures under
consideration for proposal for inclusion in future Program years. We
also received comments recommending the following areas for further
development and testing of potential measures: Readmission to the same
IPF within 30 days of discharge; improved functioning or stabilization
of functioning as measured through clinical assessment, patient self-
assessment, or discharge to a lower level of care; receiving best-
practices specific to the conditions noted in the treatment plan (for
example, depression, bipolar, and schizophrenia), as well as acuity of
illness; and scheduled appointment for aftercare within 7 days of
discharge, controlling for urban/rural area and type of provider, at a
minimum.
Lastly, one commenter recommended that CMS propose the adoption of
Tobacco Use Treatment Management at Discharge measure (TOB-3; NQF
# 1656) in future program years.
Response: We thank the commenters for their recommendations on
potential measures and related issues for the IPFQR Program. We will
take these recommendations into consideration as we continue to develop
and propose measures for future program years.
7. Public Display and Review Requirements
Section 1886(s)(4)(E) of the Act requires the Secretary to
establish procedures for making the data submitted under the IPFQR
Program available to the public. The statute also requires that these
procedures shall ensure that an IPF has the opportunity to review the
data that is to be made public with respect to the IPF prior to the
data being made public.
In the FY 2014 IPPS/LTCH PPS final rule (78 FR 50897 through
50898), we adopted our proposal to change our policies to better align
the IPFQR Program preview and display periods with those under the HIQR
Program. For the FY 2014 payment determination and

[[Page 45976]]

subsequent years, we adopted our proposed policy to publicly display
the submitted data on a CMS Web site in April of each calendar year
following the start of the respective payment determination year. In
other words, the public display period for the FY 2014 payment
determination would be April 2014; the public display periods for the
FY 2015 and FY 2016 payment determinations would be April 2015 and
April 2016, respectively; and so forth. We also adopted our proposed
policy that the preview period for the FY 2014 payment determination
and subsequent years be modified from September 20 through October 19
(78 FR 50898) to 30 days, approximately twelve weeks prior to the
public display of the data. The table below sets out the public display
timeline.

Table 15--Public Display Timeline
----------------------------------------------------------------------------------------------------------------
Public display (calendar
Payment determination (fiscal year) Reporting period (calendar year) year)
----------------------------------------------------------------------------------------------------------------
2015.................................. Q2 2013 (April 1, 2013-June 30, 2013)........ April 2015.
Q3 2013 (July 1, 2013-September 30, 2013)....
Q4 2013 (October 1, 2013-December 31, 2013)..
2016.................................. Q1 2014 (January 1, 2014-March 31, 2014)..... April 2016.
Q2 2014 (April 1, 2014-June 30, 2014)........
Q3 2014 (July 1, 2014-September 30, 2014)....
Q4 2014 (October 1, 2014-December 31, 2014)..
2017.................................. Q1 2015 (January 1, 2015-March 31, 2015)..... April 2017.
Q2 2015 (April 1, 2015-June 30, 2015)........
Q3 2015 (July 1, 2015-September 30, 2015)....
Q4 2015 (October 1, 2015-December 31, 2015)..
----------------------------------------------------------------------------------------------------------------

Although we have listed the public display timeline only for the FY
2015 through FY 2017 payment determinations, we wish to clarify that
this policy applies to the FY 2015 payment determination and subsequent
years.

We did not propose any changes to these policies in the FY 2015
proposed rule. Therefore, we are finalizing these policies in this
final rule.
8. Form, Manner, and Timing of Quality Data Submission
a. Procedural and Submission Requirements
Section 1886(s)(4)(C) of the Act requires that, for the FY 2014
payment determination and subsequent years, each IPF shall submit to
the Secretary data on quality measures as specified by the Secretary.
Such data shall be submitted in a form and manner, and at a time,
specified by the Secretary. As required by section 1886(s)(4)(A) of the
Act, for any IPF that fails to submit quality data in accordance with
section 1886(s)(4)(C) of the Act, the Secretary will reduce the annual
update to a standard Federal rate for discharges occurring in such
fiscal year by 2.0 percentage points. In the FY 2013 IPPS/LTCH PPS
final rule (77 FR 53655 through 53656), we finalized a policy requiring
that IPFs submit aggregate data on measures on an annual basis via the
Web-Based Measures Tool found in the IPF section on the QualityNet Web
site. The complete data submission requirements, submission deadlines,
and data submission mechanism, known as the Web-Based Measures Tool,
are posted on the QualityNet Web site at: http://www.qualitynet.org/.
The data input forms on the QualityNet Web site for submission require
aggregate data for each separate quarter. Therefore, IPFs need to track
and maintain quarterly records for their data. In that final rule, we
also clarified that this policy applies to all subsequent years, unless
and until we change our policy through future rulemaking.
To participate in the IPFQR Program, in the FY 2013 IPPS/LTCH PPS
final rule (77 FR 53654 through 53655) and in the FY 2014 IPPS/LTCH PPS
final rule (77 FR 50898 through 50899), we required IPFs to comply with
certain procedural requirements. We refer readers to the FY 2014 IPPS/
LTCH PPS final rule (77 FR 50898 through 50899) for further details on
specific procedural requirements.
We did not propose any changes to these policies in the FY 2015
proposed rule. Therefore, we are finalizing these policies in this
final rule.
b. Reporting Periods and Submission Timeframes
In the FY 2013 IPPS/LTCH PPS final rule (77 FR 53655 through
53657), we established reporting periods and submission timeframes for
the FY 2014, FY 2015, and FY 2016 payment determinations, but we did
not require any data validation approach. However, as we stated in that
final rule, we encourage IPFs to use a validation method and conduct
their own analysis. In that final rule, we also explained that the
reporting periods for the FY 2014 and FY 2015 payment determinations
were 6 and 9 months, respectively, to allow us to achieve a 12-month
(calendar year) reporting period for the FY 2016 payment determination.
In the FY 2014 IPPS/LTCH PPS final rule (78 FR 50901), we clarified
that the policy we adopted for the FY 2016 payment determination also
applies to the FY 2017 payment determination and subsequent years,
unless we change it through rulemaking. We also indicated that the
submission timeframe is between July 1 and August 15 of the calendar
year in which the applicable payment determination year begins.
We did not propose any changes to this submission timeframe in 79
FR 26040, which we finalized in the FY 2014 IPPS/LTCH PPS final rule
for all future payment determinations. IPFs will have the opportunity
to review and correct data that they have submitted during the entirety
of July 1 through August 15. We have summarized this information in the
table below.

[[Page 45977]]

Table 16--Quality Reporting Periods and Submission Timeframes for the FY 2015 Payment Determination and
Subsequent Years
----------------------------------------------------------------------------------------------------------------
Payment determination (fiscal Reporting period for services
year) provided (calendar year) Data submission timeframe
----------------------------------------------------------------------------------------------------------------
Quality Reporting Periods and Submission Timeframes for the FY 2015 Payment Determination and Subsequent Years
----------------------------------------------------------------------------------------------------------------
FY 2015.......................... Q2 2013 (April 1, 2013-June July 1, 2014-August 15, 2014.
30, 2013).
Q3 2013 (July 1, 2013-
September 30, 2013).
Q4 2013 (October 1, 2013-
December 31, 2013).
FY 2016.......................... Q1 2014 (January 1, 2014-March July 1, 2015-August 15, 2015.
31, 2014).
Q2 2014 (April 1, 2014-June
30, 2014).
Q3 2014 July 1, 2014-September
30, 2014).
Q4 2014 (October 1, 2014-
December 31, 2014).
FY 2017.......................... Q1 2015 (January 1, 2015-March July 1, 2016-August 15, 2016.
31, 2015).
Q2 2015 (April 1, 2015-June
30, 2015).
Q3 2015 (July 1, 2015-
September 30, 2015).
Q4 2015(October 1, 2015-
December 31, 2015).
----------------------------------------------------------------------------------------------------------------

We have adopted the timeframes discussed above for all future
payment years of the program, and these timeframes will remain in
place, unless and until we change them through future rulemaking.
Therefore, our policy with respect to reporting timeframes is that the
reporting period is the calendar year preceding the calendar year in
which the payment determination year begins. The data submission
timeframe is between July 1 and August 15 of the calendar year in which
the applicable payment determination year begins. We will continue to
provide charts with the specific reporting and data submission
timeframes for future years as we approach those years.
We did not propose any changes to these policies in the FY 2015
proposed rule.
c. Population, Sampling, and Minimum Case Threshold
In the FY 2013 IPPS/LTCH PPS final rule (77 FR 53657 through
53658), for the FY 2014 payment determination and subsequent years, we
finalized our proposed policy that participating IPFs must meet
specific population, sample size, and minimum reporting case threshold
requirements as specified in TJC's Specifications Manual. We refer
readers to the FY 2014 IPPS/LTCH PPS final rule (78 FR 58901 through
58902). We are not proposing any changes to this policy. We refer
participating IPFs to TJC's Specifications Manual (https://manual.jointcommission.org/bin/view/Manual/WebHome) for measure-
specific population, sampling, and minimum case threshold requirements.
We did not propose any changes to these policies in the FY 2015
proposed rule. Therefore, we are finalizing these policies in this
final rule.
d. Data Accuracy and Completeness Acknowledgement (DACA) Requirements
In the FY 2013 IPPS/LTCH PPS final rule (77 FR 53658), we finalized
our proposed DACA policy for the FY 2014 payment determination and
subsequent years. We refer readers to that final rule for further
details on DACA policies.
We are not changing the quarterly reporting periods or DACA
deadline. Therefore, we will continue our adopted policy that the
deadline for submission of the DACA form is no later than August 15
prior to the applicable IPFQR Program payment determination year. The
table below summarizes these policies and timeframes.

Table 17--DACA Submission Deadline
--------------------------------------------------------------------------------------------------------------------------------------------------------
Reporting period for services
Payment determination (fiscal year) provided (calendar year) Submission timeframe DACA deadline Public display
--------------------------------------------------------------------------------------------------------------------------------------------------------
2015............................... Q2 2013 (April 1, 2013-June 30, 2013) July 1, 2014-August 15, August 15, 2014....... April 2015.
2014.
Q3 2013 (July 1, 2013-September 30,
2013).
Q4 2013 (October 1, 2013-December 31,
2013).
2016............................... Q1 2014 (January 1, 2014-March 31, July 1, 2015-August 15, August 15, 2015....... April 2016.
2014). 2015.
Q2 2014 (April 1, 2014-June 30, 2014)
Q3 2014 (July 1, 2014-September 30,
2014).
Q4 2014 (October 1, 2014-December 31,
2014).
2017............................... Q1 2015 (January 1, 2015-March 31, July 1, 2016-August 15, August 15, 2016....... April 2017.
2015). 2016.
Q2 2015 (April 1, 2015-June 30, 2015)
Q3 2015 (July 1, 2015-September 30,
2015).
Q4 2015 (October 1, 2015-December 31,
2015).
--------------------------------------------------------------------------------------------------------------------------------------------------------

We once again clarify that the DACA policies adopted in the FY 2013
IPPS/LTCH PPS final rule will continue to apply for the FY 2014 payment
determination and subsequent years, unless and until we change these
policies through our rulemaking process.
We did not propose any changes to these policies in the FY 2015
proposed rule. Therefore, we are finalizing these policies in this
final rule.

[[Page 45978]]

9. Reconsideration and Appeals Procedures
In the FY 2013 IPPS/LTCH PPS final rule (77 FR 53658 through
53659), we adopted a reconsideration process, later codified at 42 CFR
412.434, whereby IPFs can request a reconsideration of their payment
update reduction in the event that an IPF believes that its annual
payment update has been incorrectly reduced for failure to report
quality data under the IPFQR Program. We refer readers to that final
rule, as well as the FY 2014 IPPS/LTCH PPS final rule (78 FR 50903),
for further details on the reconsideration process.
We did not propose any changes to these policies in the FY 2015
proposed rule. Therefore, we are finalizing these policies in this
final rule.
10. Exceptions to Quality Reporting Requirements
In our experience with other quality reporting and performance
programs, we have noted occasions where participants have been unable
to submit required quality data due to extraordinary circumstances that
are not within their control (for example, natural disasters). It is
our goal to avoid penalizing IPFs in these circumstances or unduly
increasing their burden during these times. Therefore, in the FY 2013
IPPS/LTCH PPS final rule (77 FR 53659 through 53660), we adopted a
policy where, for the FY 2014 payment determination and subsequent
years, IPFs may request, and we may grant, an exception with respect to
the reporting of required quality data where extraordinary
circumstances beyond the control of the IPF may warrant. We wish to
clarify that use of the term ``exception'' in this final rule is
synonymous with the term ``waiver'' as used in previous rules. We are
in the process of revising the Extraordinary Circumstances/Disaster
Extension or Waiver Request form (CMS-10432), approved under OMB
control number 0938-1171. Revisions to the form are being addressed in
the FY 2015 Inpatient Prospective Payment System (IPPS) rule (RIN 0938-
AS11; CMS-1607-P) in the section entitled ``Hospital IQR Program
Extraordinary Circumstances Extensions or Exemptions''. These efforts
will work to facilitate alignment across CMS quality reporting
programs.
When an exception is granted, IPFs will not incur payment
reductions for failure to comply with IPFQR Program requirements. This
process does not preclude us from granting exceptions, including
extensions, to IPFs that have not requested them, should we determine
that an extraordinary circumstance affects an entire region or locale.
We refer readers to the FY 2013 IPPS/LTCH PPS final rule (77 FR 53659
through 53660), as well as the FY 2014 IPPS/LTCH PPS final rule (78 FR
50903), for further details on this process. We are not changing this
process.
In the FY 2015 proposed rule (78 FR 26072 through 26073), we
proposed to add an Extraordinary Circumstances Exception to the IPFQR
Program, effective for the FY 2016 payment determination and subsequent
years, to align with similar exceptions provided for in other CMS
quality reporting programs. Under this exception, we may grant a waiver
or extension to IPFs if we determine that a systemic problem with one
of our data collection systems directly affects the ability of the IPFs
to submit data. Because we do not anticipate that these types of
systemic errors will occur often, we do not anticipate granting a
waiver or extension on this basis frequently. If we make the
determination to grant a waiver or extension, we will communicate this
decision through routine communication channels to IPFs, vendors, and
quality improvement organizations (QIOs) by means of, for example,
memoranda, emails, and notices on the QualityNet Web site. Public
comments and responses to comments on the exceptions to quality
reporting requirements are summarized below.
Comment: Some commenters expressed support for inclusion of an
Extraordinary Circumstances Exception in the Program.
Response: We thank the commenters for their support.
Final Rule Action: After consideration of the public comments, we
are finalizing the Extraordinary Circumstances Exception as proposed
for the FY 2016 payment determination and subsequent years.

IX. Provisions of the Final Regulations

This final rule essentially incorporates the provisions of the
proposed rule set forth in the FY 2015 IPF PPS proposed rule (79 FR
26040), in which we proposed to update the IPF PPS for FY 2015
applicable to IPF discharges occurring during the FY beginning October
1, 2014 through September 30, 2015. In addition, we proposed to update
the COLA adjustment factors for IPFs located in Alaska and Hawaii using
the approach finalized in the FY 2014 IPPS final rule (FR 50985 through
50987). This final rule will also address implementation of ICD-10-CM
and ICD-9-PCS codes and finalize new quality measures and quality
reporting requirements under the quality reporting program.

X. Collection of Information Requirements

Under the Paperwork Reduction Act of 1995, 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 Paperwork Reduction Act
of 1995 requires that we solicit comment on the following issues:
The need for the information collection and its usefulness
in carrying out the proper functions of our agency
The accuracy of our estimate of the information collection
burden
The quality, utility, and clarity of the information to be
collected
Recommendations to minimize the information collection
burden on the affected public, including automated collection
techniques.
In the May 6, 2014 (79 FR 26040) proposed rule, we solicited public
comment on each of the section 3506(c)(2)(A)-required issues for the
following information collection requirements (ICRs). However, we did
not receive any public comments on these ICRs and are adopting the
policies as proposed.

A. ICRs Regarding the Inpatient Psychiatric Facilities Quality
Reporting (IPFQR) Program

The following sets out the estimated burden (hours and cost) for
inpatient psychiatric facilities (IPFs) to comply with the reporting
requirements under section VIII of this rule.
In the FY 2013 IPPS/LTCH PPS final rule (77 FR 53644), we finalized
policies implementing the IPFQR Program. The Program implements the
statutory requirements of section 1886(s)(4) of the Social Security
Act, as added by sections 3401(f) and 10322(a) of the Affordable Care
Act. One program priority is to help achieve better health and better
health care for individuals through the collection of valid, reliable,
and relevant measures of quality health care data. The data are
publicly available for use in improving health care quality which, in
turn, works to further Program goals. IPFs can use this quality data
for many purposes, including in their risk management programs, patient
safety and quality improvement initiatives, and research

[[Page 45979]]

and development of mental health programs, among others.
As clarified throughout the FY 2014 IPPS/LTCH PPS final rule (78 FR
50887), policies finalized in prior rules will apply to FY 2015, unless
and until we change them through future rulemaking. The burden on IPFs
includes the time used for chart abstraction and for personnel training
on the collection of chart-abstracted data, the aggregation of data,
and training for the submission of aggregate-level data through
QualityNet. We note that, beginning in the FY 2016 payment
determination, we have adopted the Assessment of Patient Experience of
Care measure, thereby removing the request for voluntary information
adopted in the FY 2014 IPPS/LTCH PPS final rule.
Based on current participation rates, we estimate that there will
be approximately 574 fewer IPF facilities, or 1,626 facilities
nationwide eligible to participate in the IPFQR Program. Based on
previous measure data submission, we further estimate that the average
facility submits measure data on 556 cases per year. In total, this
calculates to 904,056 cases (aggregate) per year.
In section V of this preamble, we are finalizing our proposals
that, for the FY 2016 payment determination and subsequent years, IPFs
must submit data on the following new measures: Assessment of Patient
Experience of Care, and Use of an Electronic Health Record. Because
both of these measures require only an annual acknowledgement, we
anticipate a negligible additional burden on IPFs.
In the same section of this preamble, we are finalizing our
proposals that, for the FY 2017 payment determination and subsequent
years, IPFs must submit aggregate data on the following new measures:
Influenza Immunization (IMM-2), Influenza Vaccination Coverage Among
Healthcare Personnel, Tobacco Use Screening (TOB-1), and Tobacco Use
Treatment Provided or Offered (TOB-2) and Tobacco Use Treatment (TOB-
2a).
We estimate that the average time spent for chart abstraction per
patient for each of these measures is approximately 15 minutes.
Assuming an approximately uniform sampling methodology, we estimate
(based on prior Program data) that the annual burden for reporting the
IMM-2 measure is 139 hours per year of annual effort per facility (556
x 0.25). This same calculation also applies to the TOB-1, and TOB-2 and
TOB-2a measures. The Influenza Vaccination Coverage Among Healthcare
Personnel measure does not allow sampling; therefore, we anticipate
that the average facility would be required to abstract approximately
40 healthcare personnel, totaling an annual effort per facility of 10
hours (40 x 0.25). We anticipate no measurable burden for the Inpatient
Psychiatric Facility Routinely Assesses Patient Experience of Care
measure and the Use of an Electronic Health Record measure because both
require only attestation.
In total, we estimate an additional 427 hours of annual effort per
facility for the FY 2017 payment determination and subsequent years.
The following table summarizes the estimated hours (per facility) for
each measure.

Table 18--Estimated Annual Effort Per Facility
----------------------------------------------------------------------------------------------------------------
Estimated cases Annual effort
Measure (per facility) Effort (per case) (per facility)
----------------------------------------------------------------------------------------------------------------
Assessment of Patient Experience of Care..... *0 n/a *........................ *0
Use of an Electronic Health Record........... *0; a *.......................... *0
IMM-2........................................ 556 \1/4\ hour................... 139
Influenza Vaccination Coverage Among 40 \1/4\ hour................... 10
Healthcare Personnel.
TOB-1........................................ 556 \1/4\ hour................... 139
TOB-2, TOB-2a................................ 556 \1/4\ hour................... 139
------------------------------------------------------------------
Total.................................... ................ ............................. 427
----------------------------------------------------------------------------------------------------------------
* New non-measurable attestation burden.

The Bureau of Labor Statistics wage estimate for health care
workers that are known to engage in chart abstraction is $31.71/hour.
To account for overhead and fringe benefits we have doubled this
estimate to $63.42/hour. Considering the 427 hours of annual effort
(per facility) for the FY 2017 payment determination and subsequent
years, the annual cost is approximately $27,080.34 (63.42 x 427).
Across all 1,626 IPFs, the aggregate total is $44,032,632.84 (1,626 x
27,080.34).
The estimated burden for training personnel for data collection and
submission for current and future measures is 2 hours per facility. The
cost for this training, based on an hourly rate of $63.42, is $126.84
training costs for each IPF (63.42 x 2), which totals $206,241.84 for
all facilities (1,626 x 126.84).
Using an estimated 1,626 IPFs nationwide eligible for participation
in the IPFQR Program, we estimate that the annual hourly burden for the
collection, submission, and training of personnel for submitting all
quality measures is approximately 429 hours (per IPF) or 697,554
(aggregate) per year. The all-inclusive measure cost for each facility
is approximately $27,207.18 (27,080.34 + 126.84) and for all facilities
we estimate a cost of $44,238,874.68 (44,032,632.84 + 206,241.84).
In section V of this preamble, for the FY 2017 payment
determination, we finalized our proposal that IPFs must submit to CMS
aggregate population counts for Medicare and non-Medicare discharges by
age group, diagnostic group, and quarter, and sample size counts for
measures for which sampling is performed (as is allowed for in HBIPS-4
through -7, and SUB-1). We estimate that it will take each facility
approximately 2.5 hours to comply with this requirement. The burden
across all 1,626 IPFs calculates to 4,065 hours annually (2.5 x 1,626)
at a total of $257,802.30 (4,065 x 63.42) or $158.55 per IPF (2.5 x
63.42).
The following tables set out the total estimated burden that IPFs
will incur to comply with the reporting requirements for both measure
and non-measure data for the FY 2016 and FY 2017 payment
determinations.

[[Page 45980]]

Table 19--Summary of Burden Estimates (OCN 0938-1171, CMS-10432) for the FY 2016 Payment Determination
--------------------------------------------------------------------------------------------------------------------------------------------------------
Labor cost of
Fiscal year 2016 Number of measures Respondents Facility Total annual reporting ($/ Total cost ($)
burden (hours) burden (hours) hr)
--------------------------------------------------------------------------------------------------------------------------------------------------------
From this FY 2015 rule................. 2 (attestation only)........... 1,626 0 0 0 0
training....................... 1,626 0 0 0 0
-------------------------------------------------------------------------------
Total.............................. ............................... 1,626 0 0 0 0
--------------------------------------------------------------------------------------------------------------------------------------------------------

Table 20--Summary of Burden Estimates (OCN 0938-1171, CMS-10432) for the FY 2017 Payment Determination
--------------------------------------------------------------------------------------------------------------------------------------------------------
Labor cost of
Fiscal year 2017 Number of measures Respondents Facility burden Total annual reporting ($/ Total cost ($)
(hours) burden (hours) hr)
--------------------------------------------------------------------------------------------------------------------------------------------------------
From this FY 2015 rule................... 4.......................... 1,626 427 694,302 63.42 44,032,632.84
(139 x 3 + 10)
2 (attestation only)....... .............. ................ 0 .............. ..............
training................... .............. 2 3,252 .............. 206,241.84
---------------------------------------------------------------------------------
Subtotal............................. ........................... 1,626 429 697,554 63.42 44,238,874.68
From this FY 2015 rule................... Non-measure data........... 1,626 2.50 4,065 63.42 257,802.30
---------------------------------------------------------------------------------
Total............................ ........................... 1,626 431.50 701,619 63.42 44,496,676.98
--------------------------------------------------------------------------------------------------------------------------------------------------------

We are not changing any of the administrative, reporting, or
submission requirements for the measures previously finalized in the FY
2013 IPPS/LTCH PPS final rule (77 FR 53654 through 53657) and the FY
2014 IPPS/LTCH PPS final rule (78 FR 50898 through 50903), except that
we are removing the Request for Voluntary Information--IPF Assessment
of Patient Experience of Care section because of the Assessment of
Patient Experience of Care measure.

B. FY 2014 and FY 2015 Burden Adjustments (OCN 0938-1171, CMS-10432)

In the FY 2014 final rule (78 FR 50964), we estimated that the
annual hourly burden per IPF for the collection, submission, and
training of personnel for submitting all quality measures was
approximately 761 hours. This figure represented an estimate for all
measures, both previously and newly finalized, in the Program. We
further stated that because we were unable to estimate how many IPFs
will participate, we could not estimate the aggregate impact.
Because the estimates we present herein, including the estimated
annual burden of 431.5 hours per IPF, represent estimates only for
measure and non-measure data collection and submission requirements, an
accurate comparison with estimates presented in the FY 2014 final rule
is not possible.

C. ICRs Regarding the Hospital and Health Care Complex Cost Report
(CMS-2552-10)

This final rule would not impose any new or revised collection of
information requirements associated with CMS-2552-10 (as discussed
under preamble section IV.B.). Consequently, the cost report does not
require additional OMB review under the authority of the Paperwork
Reduction Act of 1995 (44 U.S.C. 3501 et seq.). The report's
information collection requirements and burden estimates have been
approved by OMB under OCN 0938-0052.

D. ICRs Regarding Exceptions to Quality Reporting Requirements

As discussed in section VII.10, we are in the process of revising
the Extraordinary Circumstances/Disaster Extension or Waiver Request
form, currently approved under OMB control number 0938-1171. Revisions
to the form are being addressed in the FY 2015 Inpatient Prospective
Payment System rule (RIN 0938-AS11, CMS-1607-F). In that rule we update
the form's instructions and simplify the form so that a hospital or
facility may apply for an extension for all applicable quality
reporting programs at the same time.

E. Submission of PRA-Related Comments

We have submitted a copy of this rule to OMB for its review of the
rule's information collection and recordkeeping requirements. These
requirements are not effective until they have been approved by the
OMB.
When commenting on the stated information collections, please
reference the document identifier or OMB control number. To be assured
consideration, comments and recommendations must be received by the OMB
desk officer via one of the following transmissions:

Mail: OMB, Office of Information and Regulatory Affairs Attention: CMS
Desk Officer
Fax: (202) 395-5806 OR
Email: [email protected].

PRA-related comments must be received on/by September 2, 2014.

XI. Comments Beyond the Scope of the Final Rule

In response to the proposed rule, a few commenters chose to raise
issues that are beyond the scope of our proposals. In this final rule,
we are not summarizing or responding to those comments in this
document.

XII. Regulatory Impact Analysis

A. Statement of Need

This final rule updates the prospective payment rates for Medicare
inpatient hospital services provided by IPFs for discharges occurring
during the FY beginning October 1, 2014, through September 30, 2015. We
are applying the FY 2008-based RPL market basket increase of 2.9
percent, less the productivity adjustment of 0.5

[[Page 45981]]

percentage point as required by section 1886(s)(2)(A)(i) of the Act,
and less the 0.3 percentage point required by sections
1886(s)(2)(A)(ii) and 1886(s)(3)(C) of the Act. In this final rule, we
also address the implementation of the International Classification of
Diseases, 10th Revision, Clinical Modification (ICD-10-CM/PCS) for the
IPF prospective payment system, and describe new quality reporting
requirements for the IPFQR Program.

B. Overall Impact

We have examined the impact of this final rule as required by
Executive Order 12866 on Regulatory Planning and Review (September 30,
1993), Executive Order 13563 on Improving Regulation and Regulatory
Review (January 18, 2011), the Regulatory Flexibility Act (RFA)
(September 19, 1980, Pub.L. 96-354), section 1102(b) of the Social
Security Act, section 202 of the Unfunded Mandates Reform Act of 1995
(March 22, 1995; Pub. L. 104-4), Executive Order 13132 on Federalism
(August 4, 1999) and the Congressional Review Act (5 U.S.C. 804(2)).
Executive Orders 12866 and 13563 direct 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).
This final rule is designated as economically ``significant'' under
section 3(f)(1) of Executive Order 12866.
We estimate that the total impact of these changes for FY 2015
payments compared to FY 2014 payments will be a net increase of
approximately $120 million. This reflects a $100 million increase from
the update to the payment rates, as well as a $20 million increase as a
result of the update to the outlier threshold amount. Outlier payments
are estimated to increase from 1.6 percent in FY 2014 to 2.0 percent in
FY 2015.
The RFA requires agencies to analyze options for regulatory relief
of small entities if a rule has a significant impact on a substantial
number of small entities. For purposes of the RFA, small entities
include small businesses, nonprofit organizations, and small
governmental jurisdictions. Most IPFs and most other providers and
suppliers are small entities, either by nonprofit status or having
revenues of $7 million to $35.5 million or less in any 1 year,
depending on industry classification (for details, refer to the SBA
Small Business Size Standards found at http://www.sba.gov/sites/default/files/files/Size_Standards_Table.pdf), or being nonprofit
organizations that are not dominant in their markets.
Because we lack data on individual hospital receipts, we cannot
determine the number of small proprietary IPFs or the proportion of
IPFs' revenue derived from Medicare payments. Therefore, we assume that
all IPFs are considered small entities. The Department of Health and
Human Services generally uses a revenue impact of 3 to 5 percent as a
significance threshold under the RFA.
As shown in Table 21, we estimate that the overall revenue impact
of this proposed rule on all IPFs is to increase Medicare payments by
approximately 2.5 percent. As a result, since the estimated impact of
this final rule is a net increase in revenue across all categories of
IPFs, the Secretary has determined that this final rule will have a
positive revenue impact on a substantial number of small entities. MACs
are not considered to be small entities. Individuals and States are not
included in the definition of a small entity.
In addition, section 1102(b) of the Social Security Act requires us
to prepare a regulatory impact analysis if a rule may have a
significant impact on the operations of a substantial number of small
rural hospitals. This analysis must conform to the provisions of
section 604 of the RFA. For purposes of section 1102(b) of the Act, we
define a small rural hospital as a hospital that is located outside of
a metropolitan statistical area and has fewer than 100 beds. As
discussed in detail below, the rates and policies set forth in this
final rule will not have an adverse impact on the rural hospitals based
on the data of the 309 rural units and 75 rural hospitals in our
database of 1,626 IPFs for which data were available. Therefore, the
Secretary has determined that this final rule will not have a
significant impact on the operations of a substantial number of small
rural hospitals.
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) 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. In 2014, that
threshold is approximately $141 million. This final rule will not
impose spending costs on state, local, or tribal governments in the
aggregate, or by the private sector, of $141 million.
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 final rule will not have a
substantial effect on state and local governments.

C. Anticipated Effects

We discuss the historical background of the IPF PPS and the impact
of this final rule on the Federal Medicare budget and on IPFs.
1. Budgetary Impact
As discussed in the November 2004 and May 2006 IPF PPS final rules,
we applied a budget neutrality factor to the Federal per diem and ECT
base rates to ensure that total estimated payments under the IPF PPS in
the implementation period would equal the amount that would have been
paid if the IPF PPS had not been implemented. The budget neutrality
factor includes the following components: Outlier adjustment, stop-loss
adjustment, and the behavioral offset. As discussed in the May 2008 IPF
PPS notice (73 FR 25711), the stop-loss adjustment is no longer
applicable under the IPF PPS.
In accordance with Sec. 412.424(c)(3)(ii), we indicated that we
will evaluate the accuracy of the budget neutrality adjustment within
the first 5 years after implementation of the payment system. We may
make a one-time prospective adjustment to the Federal per diem and ECT
base rates to account for differences between the historical data on
cost-based TEFRA payments (the basis of the budget neutrality
adjustment) and estimates of TEFRA payments based on actual data from
the first year of the IPF PPS. As part of that process, we will
reassess the accuracy of all of the factors impacting budget
neutrality. In addition, as discussed in section VII.C.1 of this final
rule, we are using the wage index and labor-related share in a budget
neutral manner by applying a wage index budget neutrality factor to the
Federal per diem and ECT base rates. Therefore, the budgetary impact to
the Medicare program of this final rule will be due to the market
basket update for FY 2015 of 2.9 percent (see section V.B. of this
final rule) less the productivity adjustment of 0.5 percentage point
required by section 1886 (s)(2)(A)(i) of the Act, less the ``other
adjustment'' of 0.3 percentage point under sections 1886(s)(2)(A)(ii)
and 1886 (s)(3)(C) of the Act, and the

[[Page 45982]]

update to the outlier fixed dollar loss threshold amount.
We estimate that the FY 2015 impact will be a net increase of $120
million in payments to IPF providers. This reflects an estimated $100
million increase from the update to the payment rates and a $20 million
increase due to the update to the outlier threshold amount to increase
outlier payments from approximately 1.6 percent in FY 2014 to 2.0
percent in FY 2015. This estimate does not include the implementation
of the required 2 percentage point reduction of the market basket
increase factor for any IPF that fails to meet the IPF quality
reporting requirements (as discussed in section 4 below).
2. Impact on Providers
To understand the impact of the changes to the IPF PPS on
providers, discussed in this final rule, it is necessary to compare
estimated payments under the IPF PPS rates and factors for FY 2015
versus those under FY 2014. The estimated payments for FY 2014 and FY
2015 will be 100 percent of the IPF PPS payment, since the transition
period has ended and stop-loss payments are no longer paid. We
determined the percent change of estimated FY 2015 IPF PPS payments to
FY 2014 IPF PPS payments for each category of IPFs. In addition, for
each category of IPFs, we have included the estimated percent change in
payments resulting from the update to the outlier fixed dollar loss
threshold amount, the labor-related share and wage index changes for
the FY 2015 IPF PPS, and the market basket update for FY 2015, as
adjusted by the productivity adjustment according to section
1886(s)(2)(A)(i), and the ``other adjustment'' according to sections
1886(s)(2)(A)(ii) and 1886(s)(3)(C) of the Act.
To illustrate the impacts of the FY 2015 changes in this final
rule, our analysis begins with a FY 2014 baseline simulation model
based on FY 2013 IPF payments inflated to the midpoint of FY 2014 using
IHS Global Insight Inc.'s most recent forecast of the market basket
update (see section IV.C. of this final rule); the estimated outlier
payments in FY 2014; the CBSA designations for IPFs based on OMB's MSA
definitions after June 2003; the FY 2013 pre-floor, pre-reclassified
hospital wage index; the FY 2014 labor-related share; and the FY 2014
percentage amount of the rural adjustment. During the simulation, the
total estimated outlier payments are maintained at 2 percent of total
IPF PPS payments.
Each of the following changes is added incrementally to this
baseline model in order for us to isolate the effects of each change:
The update to the outlier fixed dollar loss threshold
amount.
The FY 2014 pre-floor, pre-reclassified hospital wage
index and FY 2015 labor-related share.
The market basket update for FY 2015 of 2.9 percent less
the productivity adjustment of 0.5 percentage point reduction in
accordance with section 1886(s)(2)(A)(i) of the Act and less the
``other adjustment'' of 0.3 percentage point in accordance with
sections 1886(s)(2)(A)(ii) and 1886(s)(3)(C) of the Act.
Our final comparison illustrates the percent change in payments
from FY 2014 (that is, October 1, 2013, to September 30, 2014) to FY
2015 (that is, October 1, 2014, to September 30, 2015) including all
the changes in this final rule.

Table 21--IPF Impact Table for FY 2015
[Projected impacts (% change in columns 3-6)]
----------------------------------------------------------------------------------------------------------------
CBSA wage Adjusted
Facility by type Number of Outlier index & labor market basket Total percent
facilities share update \1\ change \2\
(1) (2) (3) (4) (5) (6)
----------------------------------------------------------------------------------------------------------------
All Facilities:................. 1,626 0.4 0.0 2.1 2.5
Total Urban................. 1,242 0.4 0.0 2.1 2.5
Total Rural................. 384 0.3 -0.1 2.1 2.3
Urban unit...................... 827 0.6 0.1 2.1 2.7
Urban hospital.................. 415 0.2 0.0 2.1 2.2
Rural unit...................... 309 0.4 -0.1 2.1 2.4
Rural hospital.................. 75 0.2 -0.3 2.1 2.0
By Type of Ownership:
Freestanding IPFs:
Urban Psychiatric Hospitals:
Government.............. 129 0.4 -0.1 2.1 2.4
Non-Profit.............. 99 0.3 0.2 2.1 2.6
For-Profit.............. 187 0.0 -0.2 2.1 2.0
Rural Psychiatric Hospitals:
Government.............. 37 0.3 0.2 2.1 2.7
Non-Profit.............. 13 0.2 -0.1 2.1 2.2
For-Profit.............. 25 0.0 -0.7 2.1 1.4
IPF Units:
Urban:
Government.............. 125 0.8 0.1 2.1 3.0
Non-Profit.............. 546 0.6 0.1 2.1 2.8
For-Profit.............. 156 0.3 -0.1 2.1 2.3
Rural:
Government.............. 76 0.3 -0.1 2.1 2.3
Non-Profit.............. 168 0.4 -0.1 2.1 2.4
For-Profit.............. 65 0.4 0.0 2.1 2.6
By Teaching Status:
Non-teaching................ 1,426 0.3 0.0 2.1 2.4
Less than 10% interns and 109 0.5 0.2 2.1 2.8
residents to beds..........
10% to 30% interns and 65 0.8 -0.1 2.1 2.9
residents to beds..........
More than 30% interns and 26 1.0 0.5 2.1 3.7
residents to beds..........
By Region:

[[Page 45983]]

New England................. 109 0.6 0.1 2.1 2.8
Mid-Atlantic................ 250 0.4 0.6 2.1 3.1
South Atlantic.............. 235 0.3 -0.3 2.1 2.1
East North Central.......... 260 0.4 -0.2 2.1 2.3
East South Central.......... 165 0.3 -0.3 2.1 2.2
West North Central.......... 144 0.4 -0.3 2.1 2.3
West South Central.......... 238 0.2 -0.4 2.1 1.9
Mountain.................... 103 0.3 -0.3 2.1 2.1
Pacific..................... 122 0.6 0.9 2.1 3.7
By Bed Size:
Psychiatric Hospitals:
Beds: 0-24.............. 88 0.1 -0.3 2.1 2.0
Beds: 25-49............. 67 0.1 -0.1 2.1 2.1
Beds: 50-75............. 87 0.2 -0.1 2.1 2.2
Beds: 76 +.............. 248 0.2 0.0 2.1 2.2
Psychiatric Units:
Beds: 0-24.............. 677 0.6 0.0 2.1 2.7
Beds: 25-49............. 298 0.5 -0.1 2.1 2.6
Beds: 50-75............. 102 0.4 0.0 2.1 2.6
Beds: 76 +.............. 59 0.6 0.4 2.1 3.1
----------------------------------------------------------------------------------------------------------------
\1\ This column reflects the payment update impact of the RPL market basket update for FY 2015 of 2.9 percent, a
0.5 percentage point reduction for the productivity adjustment as required by section 1886(s)(2)(A)(i) of the
Act, and a 0.3 percentage point reduction in accordance with sections 1886(s)(2)(A)(ii) and 1886(s)(3)(C) of
the Act.
\2\ Percent changes in estimated payments from FY 2014 to FY 2015 include all of the changes presented in this
proposed rule. Note, the products of these impacts may be different from the percentage changes shown here due
to rounding effects.

3. Results
Table 21 above displays the results of our analysis. The table
groups IPFs into the categories listed below based on characteristics
provided in the Provider of Services (POS) file, the IPF provider
specific file, and cost report data from HCRIS:

Facility Type
Location
Teaching Status Adjustment
Census Region
Size

The top row of the table shows the overall impact on the 1,626 IPFs
included in this analysis.
In column 3, we present the effects of the update to the outlier
fixed dollar loss threshold amount. We estimate that IPF outlier
payments as a percentage of total IPF payments are 1.6 percent in FY
2014. Thus, we are adjusting the outlier threshold amount in this final
rule to set total estimated outlier payments equal to 2 percent of
total payments in FY 2015. The estimated change in total IPF payments
for FY 2015, therefore, includes an approximate 0.4 percent increase in
payments because the outlier portion of total payments is expected to
increase from approximately 1.6 percent to 2 percent.
The overall impact of this outlier adjustment update (as shown in
column 3 of table 21), across all hospital groups, is to increase total
estimated payments to IPFs by 0.4 percent. We do not estimate that any
group of IPFs will experience a decrease in payments from this update.
The largest increase in payments is estimated to reflect a 1 percent
increase in payments for IPFs located in teaching hospitals with an
intern and resident ADC ratio greater than 30 percent.
In column 4, we present the effects of the budget-neutral update to
the labor-related share and the wage index adjustment under the CBSA
geographic area definitions announced by OMB in June 2003. This is a
comparison of the simulated FY 2015 payments under the FY 2014 hospital
wage index under CBSA classification and associated labor-related share
to the simulated FY 2014 payments under the FY 2013 hospital wage index
under CBSA classifications and associated labor-related share. We note
that there is no projected change in aggregate payments to IPFs, as
indicated in the first row of column 4. However, there will be small
distributional effects among different categories of IPFs. For example,
we estimate the largest increase in payments to be a 0.9 percent
increase for IPFs in the Pacific region and the largest decrease in
payments to be a 0.7 percent decrease for rural for-profit IPFs.
Column 5 shows the estimated effect of the update to the IPF PPS
payment rates, which includes a 2.9 percent market basket update less
the productivity adjustment of 0.5 percentage point in accordance with
section 1886(s)(2)(A)(i), and less the 0.3 percentage point in
accordance with section 1886(s)(2)(A)(ii) and 1886(s)(3)(C).
Column 6 compares our estimates of the total changes reflected in
this final rule for FY 2015, to our payments for FY 2014 (without these
changes). This column reflects all FY 2015 changes relative to FY 2014.
The average estimated increase for all IPFs is approximately 2.5
percent. This estimated net increase includes the effects of the 2.9
percent market basket update adjusted by the productivity adjustment of
minus 0.5 percentage point, as required by section 1886(s)(2)(A)(i) of
the Act and the ``other adjustment'' of minus 0.3 percentage point, as
required by sections 1886(s)(2)(A)(ii) and 1886(s)(3)(C) of the Act. It
also includes the overall estimated 0.4 percent increase in payments
from the update to the outlier fixed dollar loss threshold amount.
Since we are making the updates to the IPF labor-related share and wage
index in a budget-neutral manner, they will not affect total

[[Page 45984]]

estimated IPF payments in the aggregate. However, they will affect the
estimated distribution of payments among providers.
Overall, no IPFs are estimated to experience a net decrease in
payments as a result of the updates in this final rule. IPFs in urban
areas will experience a 2.5 percent increase and IPFs in rural areas
will experience a 2.3 percent increase. The largest payment increase is
estimated at 3.7 percent for IPFs located in teaching hospitals with an
intern and resident ADC ratio greater than 30 percent and IPFs in the
Pacific region. This is due to the larger than average positive effect
of the CBSA wage index and labor-related share updates and the higher
volume of outlier payments for IPFs in these categories.
4. Effects of Updates to the IPF QRP
As discussed in section V.B. of this final rule and in accordance
with section 1886(s)(4)(A)(ii) of the Act, we will implement a 2
percentage point reduction in the FY 2015 increase factor for IPFs that
have failed to report the required quality reporting data to us during
the most recent IPF quality reporting period. In section V.B. of this
final rule, we discuss how the 2 percentage point reduction will be
applied. Only a few IPFs received the 2 percentage point reduction in
the FY 2014 increase factor for failure to meet program requirements,
and we will anticipate that even fewer IPFs would receive the reduction
for FY 2015 as IPFs become more familiar with the requirements. Thus,
we estimate that this policy will have a negligible impact on overall
IPF payments for FY 2015.
For the FY 2016 payment determination, we estimate no additional
burden on IPFs as a result of changes in reporting requirements. For
the FY 2017 payment determination, we estimate an additional annual
burden across all 1,626 IPFs of 701,619 hours, with a total Program
cost of $44,496,677. This estimate includes an estimated 3,252 hours
annually for training, at an estimated annual cost of $206,241. It also
includes an estimated 4,065 hours annually, at an estimated annual cost
of $257,802, for IPFs to submit to CMS aggregate population counts for
Medicare and non-Medicare discharges by age group, diagnostic group,
and quarter, and sample size counts for measures for which sampling is
performed. Further discussion of these figures can be found in section
IX.
For the FY 2017 payment determination, the applicable reporting
period is calendar year (CY) 2015. Assuming that reporting costs are
uniformly distributed across the year, three-quarters of those costs
would have been incurred in FY 2015, which ends on September 30, 2015.
Therefore, the estimated FY 2015 burden for IPFs will be three-quarters
of $44,496,677, or approximately $33,372,508.
We intend to closely monitor the effects of this new quality
reporting program on IPF providers and help facilitate successful
reporting outcomes through ongoing stakeholder education, national
trainings, and a technical help desk.
5. Effect on Beneficiaries
Under the IPF PPS, IPFs will receive payment based on the average
resources consumed by patients for each day. We do not expect changes
in the quality of care or access to services for Medicare beneficiaries
under the FY 2015 IPF PPS but we continue to expect that paying
prospectively for IPF services would enhance the efficiency of the
Medicare program.

D. Alternatives Considered

The statute does not specify an update strategy for the IPF PPS and
is broadly written to give the Secretary discretion in establishing an
update methodology. Therefore, we are updating the IPF PPS using the
methodology published in the November 2004 IPF PPS final rule. No
alternative policy options were considered in this final rule since
this final rule simply provides an update to the rates for FY 2015 and
transition ICD-9-CM codes to ICD-10-CM codes. Additionally, for the
IPFQR Program, alternatives were not considered because the Program, as
designed, best achieves quality reporting goals for the inpatient
psychiatric care setting, while minimizing associated reporting burdens
on IPFs. Lastly, sections VIII.1. and VIII.4. discuss other benefits
and objectives of the Program.

E. Accounting Statement

As required by OMB Circular A-4 (available at http://www.whitehouse.gov/omb/circulars_a004_a-4), in Table 22 below, we
have prepared an accounting statement showing the classification of the
expenditures associated with the provisions of this final rule. The
costs for data submission presented in Table 22 are calculated in
section IX, which also discusses the benefits of data collection. This
table provides our best estimate of the increase in Medicare payments
under the IPF PPS as a result of the changes presented in this final
rule and based on the data for 1,626 IPFs in our database. Furthermore,
we present the estimated costs associated with updating the IPFQR
program. The increases in Medicare payments are classified as Federal
transfers to IPF Medicare providers.

Table 22--Accounting Statement--Classification of Estimated Expenditures
----------------------------------------------------------------------------------------------------------------
Category Transfers
----------------------------------------------------------------------------------------------------------------
Change in Estimated Transfers from FY 2014 IPF PPS to FY 2015 IPF PPS
----------------------------------------------------------------------------------------------------------------
Annualized Monetized Transfers............................... $120 million.
From Whom to Whom?........................................... Federal Government to IPF Medicare providers.
----------------------------------------------------------------------------------------------------------------
FY 2015 Costs to updating the Quality Reporting Program for IPFs
----------------------------------------------------------------------------------------------------------------
Category Costs
----------------------------------------------------------------------------------------------------------------
Annualized Monetized Costs for IPFs to Submit Data (Quality 33,372,508.
Reporting Program).
----------------------------------------------------------------------------------------------------------------

[[Page 45985]]

In accordance with the provisions of Executive Order 12866, this
final rule was reviewed by the Office of Management and Budget.

Dated: July 24, 2014
Marilyn Tavenner,
Administrator, Centers for Medicare & Medicaid Services.
Approved: July 30, 2014.
Sylvia M. Burwell,
Secretary.

Note: The following Addenda will not appear in the Code of
Federal Regulations.

Addendum A--Rate and Adjustment Factors

Per Diem Rate
------------------------------------------------------------------------

------------------------------------------------------------------------
Federal Per Diem Base Rate................................... $728.31
Labor Share (0.69294)........................................ 504.68
Non-Labor Share (0.30706).................................... 223.63
------------------------------------------------------------------------

Per Diem Rate Applying the 2 Percentage Point Reduction
------------------------------------------------------------------------

------------------------------------------------------------------------
Federal Per Diem Base Rate................................... $714.05
Labor Share (0.69294)........................................ 494.79
Non-Labor Share (0.30706).................................... 219.26
------------------------------------------------------------------------

Fixed Dollar Loss Threshold Amount: $8,755
Wage Index Budget-Neutrality Factor: 1.0002

Facility Adjustments
----------------------------------------------------------------------------------------------------------------

----------------------------------------------------------------------------------------------------------------
Rural Adjustment Factor.................... 1.17.
Teaching Adjustment Factor................. 0.5150.
Wage Index................................. Pre-reclass Hospital Wage Index (FY2014).
----------------------------------------------------------------------------------------------------------------

Cost of Living Adjustments (COLAs)
------------------------------------------------------------------------
Cost of
living
Area adjustment
factor
------------------------------------------------------------------------
Alaska:
City of Anchorage and 80-kilometer (50-mile) radius by 1.23
road....................................................
City of Fairbanks and 80-kilometer (50-mile) radius by 1.23
road....................................................
City of Juneau and 80-kilometer (50-mile) radius by road. 1.23
Rest of Alaska........................................... 1.25
Hawaii:
City and County of Honolulu............................ 1.25
County of Hawaii....................................... 1.19
County of Kauai........................................ 1.25
County of Maui and County of Kalawao................... 1.25
------------------------------------------------------------------------

Patient Adjustments
------------------------------------------------------------------------

------------------------------------------------------------------------
ECT--Per Treatment......................................... $313.55
ECT--Per Treatment Applying the 2 Percentage Point 307.41
Reduction.................................................
------------------------------------------------------------------------

Variable Per Diem Adjustments
------------------------------------------------------------------------
Adjustment
factor
------------------------------------------------------------------------
Day 1--Facility Without a Qualifying Emergency Department. 1.19
Day 1--Facility With a Qualifying Emergency Department.... 1.31
Day 2..................................................... 1.12
Day 3..................................................... 1.08
Day 4..................................................... 1.05
Day 5..................................................... 1.04
Day 6..................................................... 1.02
Day 7..................................................... 1.01
Day 8..................................................... 1.01
Day 9..................................................... 1.00
Day 10.................................................... 1.00
Day 11.................................................... 0.99
Day 12.................................................... 0.99
Day 13.................................................... 0.99
Day 14.................................................... 0.99
Day 15.................................................... 0.98
Day 16.................................................... 0.97
Day 17.................................................... 0.97
Day 18.................................................... 0.96
Day 19.................................................... 0.95
Day 20.................................................... 0.95
Day 21.................................................... 0.95
After Day 21.............................................. 0.92
------------------------------------------------------------------------

Age Adjustments
------------------------------------------------------------------------
Adjustment
Age (in years) factor
------------------------------------------------------------------------
Under 45.................................................. 1.00
45 and under 50........................................... 1.01
50 and under 55........................................... 1.02
55 and under 60........................................... 1.04
60 and under 65........................................... 1.07
65 and under 70........................................... 1.10
70 and under 75........................................... 1.13
75 and under 80........................................... 1.15
80 and over............................................... 1.17
------------------------------------------------------------------------

DRG Adjustments
------------------------------------------------------------------------
Adjustment
MS-DRG MS-DRG descriptions factor
------------------------------------------------------------------------
056........... Degenerative nervous system disorders w 1.05
MCC.
057........... Degenerative nervous system disorders w/ ..............
o MCC.
080........... Nontraumatic stupor & coma w MCC........ 1.07
081........... Nontraumatic stupor & coma w/o MCC...... ..............
876........... O.R. procedure w principal diagnoses of 1.22
mental illness.
880........... Acute adjustment reaction & psychosocial 1.05
dysfunction.
881........... Depressive neuroses..................... 0.99
882........... Neuroses except depressive.............. 1.02
883........... Disorders of personality & impulse 1.02
control.
884........... Organic disturbances & mental 1.03
retardation.
885........... Psychoses............................... 1.00
886........... Behavioral & developmental disorders.... 0.99
887........... Other mental disorder diagnoses......... 0.92
894........... Alcohol/drug abuse or dependence, left 0.97
AMA.
895........... Alcohol/drug abuse or dependence w 1.02
rehabilitation therapy.
896........... Alcohol/drug abuse or dependence w/o 0.88
rehabilitation therapy w MCC.

[[Page 45986]]

897........... Alcohol/drug abuse or dependence w/o ..............
rehabilitation therapy w/o MCC.
------------------------------------------------------------------------

Comorbidity Adjustments
------------------------------------------------------------------------
Adjustment
Comorbidity factor
------------------------------------------------------------------------
Developmental Disabilities.............................. 1.04
Coagulation Factor Deficit.............................. 1.13
Tracheostomy............................................ 1.06
Eating and Conduct Disorders............................ 1.12
Infectious Diseases..................................... 1.07
Renal Failure, Acute.................................... 1.11
Renal Failure, Chronic.................................. 1.11
Oncology Treatment...................................... 1.07
Uncontrolled Diabetes Mellitus.......................... 1.05
Severe Protein Malnutrition............................. 1.13
Drug/Alcohol Induced Mental Disorders................... 1.03
Cardiac Conditions...................................... 1.11
Gangrene................................................ 1.10
Chronic Obstructive Pulmonary Disease................... 1.12
Artificial Openings--Digestive & Urinary................ 1.08
Severe Musculoskeletal & Connective Tissue Diseases..... 1.09
Poisoning............................................... 1.11
------------------------------------------------------------------------

Addendum B--FY 2015 CBSA Wage Index Tables

In this addendum, we provide the wage index tables referred to
in the preamble to this final rule. The tables presented below are
as follows:
Table 1-FY 2015 Wage Index For Urban Areas Based on CBSA Labor
Market Areas.
Table 2-FY 2015 Wage Index Based On CBSA Labor Market Areas For
Rural Areas.

Table 1--FY 2015 Wage Index for Urban Areas Based on CBSA Labor Market
Areas
------------------------------------------------------------------------
Urban area (constituent Wage
CBSA Code counties) index
------------------------------------------------------------------------
10180........................ Abilene, TX................... 0.8225
Callahan County, TX...........
Jones County, TX..............
Taylor County, TX.............
10380........................ Aguadilla-Isabela-San 0.3647
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..................... 0.8521
Portage County, OH............
Summit County, OH.............
10500........................ Albany, GA.................... 0.8713
Baker County, GA..............
Dougherty County, GA..........
Lee County, GA................
Terrell County, GA............
Worth County, GA..............
10580........................ Albany-Schenectady-Troy, NY... 0.8600
Albany County, NY.............
Rensselaer County, NY.........
Saratoga County, NY...........
Schenectady County, NY........
Schoharie County, NY..........
10740........................ Albuquerque, NM............... 0.9663
Bernalillo County, NM.........
Sandoval County, NM...........
Torrance County, NM...........
Valencia County, NM...........

[[Page 45987]]

10780........................ Alexandria, LA................ 0.7788
Grant Parish, LA..............
Rapides Parish, LA............
10900........................ Allentown-Bethlehem-Easton, PA- 0.9215
NJ.
Warren County, NJ.............
Carbon County, PA.............
Lehigh County, PA.............
Northampton County, PA........
11020........................ Altoona, PA................... 0.9101
Blair County, PA..............
11100........................ Amarillo, TX.................. 0.8302
Armstrong County, TX..........
Carson County, TX.............
Potter County, TX.............
Randall County, TX............
11180........................ Ames, IA...................... 0.9425
Story County, IA..............
11260........................ Anchorage, AK................. 1.2221
Anchorage Municipality, AK....
Matanuska-Susitna Borough, AK.
11300........................ Anderson, IN.................. 0.9654
Madison County, IN............
11340........................ Anderson, SC.................. 0.8766
Anderson County, SC...........
11460........................ Arbor, MI..................... 1.0086
Washtenaw County, MI..........
11500........................ Anniston-Oxford, AL........... 0.7402
Calhoun County, AL............
11540........................ Appleton, WI.................. 0.9445
Calumet County, WI............
Outagamie County, WI..........
11700........................ Asheville, NC................. 0.8511
Buncombe County, NC...........
Haywood County, NC............
Henderson County, NC..........
Madison County, NC............
12020........................ Athens-Clarke County, GA...... 0.9244
Clarke County, GA.............
Madison County, GA............
Oconee County, GA.............
Oglethorpe County, GA.........
12060........................ Atlanta-Sandy Springs- 0.9452
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-Hammonton, NJ... 1.2258

[[Page 45988]]

Atlantic County, NJ...........
12220........................ Auburn-Opelika, AL............ 0.7771
Lee County, AL................
12260........................ Augusta-Richmond County, GA-SC 0.9150
Burke County, GA..............
Columbia County, GA...........
McDuffie County, GA...........
Richmond County, GA...........
Aiken County, SC..............
Edgefield County, SC..........
12420........................ Austin-Round Rock-San Marcos, 0.9576
TX.
Bastrop County, TX............
Caldwell County, TX...........
Hays County, TX...............
Travis County, TX.............
Williamson County, TX.........
12540........................ Bakersfield-Delano, CA........ 1.1579
Kern County, CA...............
12580........................ Baltimore-Towson, MD.......... 0.9873
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.................... 0.9710
Penobscot County, ME..........
12700........................ Barnstable Town, MA........... 1.3007
Barnstable County, MA.........
12940........................ Baton Rouge, LA............... 0.8078
Ascension Parish, LA..........
East Baton Rouge Parish, LA...
East Feliciana Parish, LA.....
Iberville Parish, LA..........
Livingston Parish, LA.........
Pointe Coupee Parish, LA......
St. Helena Parish, LA.........
West Baton Rouge Parish, LA...
West Feliciana Parish, LA.....
12980........................ Battle Creek, MI.............. 0.9915
Calhoun County, MI............
13020........................ Bay City, MI.................. 0.9486
Bay County, MI................
13140........................ Beaumont-Port Arthur, TX...... 0.8598
Hardin County, TX.............
Jefferson County, TX..........
Orange County, TX.............
13380........................ Bellingham, WA................ 1.1890
Whatcom County, WA............
13460........................ Bend, OR...................... 1.1807
Deschutes County, OR..........
13644........................ Bethesda-Rockville-Frederick, 1.0319
MD.
Frederick County, MD..........
Montgomery County, MD.........
13740........................ Billings, MT.................. 0.8691
Carbon County, MT.............
Yellowstone County, MT........
13780........................ Binghamton, NY................ 0.8602
Broome County, NY.............
Tioga County, NY..............
13820........................ Birmingham-Hoover, AL......... 0.8367
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.................. 0.7282
Burleigh County, ND...........

[[Page 45989]]

Morton County, ND.............
13980........................ Blacksburg-Christiansburg- 0.8319
Radford, VA.
Giles County, VA..............
Montgomery County, VA.........
Pulaski County, VA............
Radford City, VA..............
14020........................ Bloomington, IN............... 0.9304
Greene County, IN.............
Monroe County, IN.............
Owen County, IN...............
14060........................ Bloomington-Normal, IL........ 0.9310
McLean County, IL.............
14260........................ Boise City-Nampa, ID.......... 0.9259
Ada County, ID................
Boise County, ID..............
Canyon County, ID.............
Gem County, ID................
Owyhee County, ID.............
14484........................ Boston-Quincy, MA............. 1.2453
Norfolk County, MA............
Plymouth County, MA...........
Suffolk County, MA............
14500........................ Boulder, CO................... 0.9850
Boulder County, CO............
14540........................ Bowling Green, KY............. 0.8573
Edmonson County, KY...........
Warren County, KY.............
14740........................ Bremerton-Silverdale, WA...... 1.0268
Kitsap County, WA.............
14860........................ Bridgeport-Stamford-Norwalk, 1.3252
CT.
Fairfield County, CT..........
15180........................ Brownsville-Harlingen, TX..... 0.8179
Cameron County, TX............
15260........................ Brunswick, GA................. 0.8457
Brantley County, GA...........
Glynn County, GA..............
McIntosh County, GA...........
15380........................ Buffalo-Niagara Falls, NY..... 1.0045
Erie County, NY...............
Niagara County, NY............
15500........................ Burlington, NC................ 0.8529
Alamance County, NC...........
15540........................ Burlington-South Burlington, 1.0130
VT.
Chittenden County, VT.........
Franklin County, VT...........
Grand Isle County, VT.........
15764........................ Cambridge-Newton-Framingham, 1.1146
MA.
Middlesex County, MA..........
15804........................ Camden, NJ.................... 1.0254
Burlington County, NJ.........
Camden County, NJ.............
Gloucester County, NJ.........
15940........................ Canton-Massillon, OH.......... 0.8730
Carroll County, OH............
Stark County, OH..............
15980........................ Cape Coral-Fort Myers, FL..... 0.8683
Lee County, FL................
16020........................ Cape Girardeau-Jackson, MO-IL. 0.9174
Alexander County, IL..........
Bollinger County, MO..........
Cape Girardeau County, MO.....
16180........................ Carson City, NV............... 1.0721
Carson City, NV...............
16220........................ Casper, WY.................... 1.0111
Natrona County, WY............
16300........................ Cedar Rapids, IA.............. 0.8964
Benton County, IA.............
Jones County, IA..............
Linn County, IA...............
16580........................ Champaign-Urbana, IL.......... 0.9416
Champaign County, IL..........

[[Page 45990]]

Ford County, IL...............
Piatt County, IL..............
16620........................ Charleston, WV................ 0.8119
Boone County, WV..............
Clay County, WV...............
Kanawha County, WV............
Lincoln County, WV............
Putnam County, WV.............
16700........................ Charleston-North Charleston- 0.8972
Summerville, SC.
Berkeley County, SC...........
Charleston County, SC.........
Dorchester County, SC.........
16740........................ Charlotte-Gastonia-Rock Hill, 0.9447
NC[dash]SC.
Anson County, NC..............
Cabarrus County, NC...........
Gaston County, NC.............
Mecklenburg County, NC........
Union County, NC..............
York County, SC...............
16820........................ Charlottesville, VA........... 0.9209
Albemarle County, VA..........
Fluvanna County, VA...........
Greene County, VA.............
Nelson County, VA.............
Charlottesville City, VA......
16860........................ Chattanooga, TN-GA............ 0.8783
Catoosa County, GA............
Dade County, GA...............
Walker County, GA.............
Hamilton County, TN...........
Marion County, TN.............
Sequatchie County, TN.........
16940........................ Cheyenne, WY.................. 0.9494
Laramie County, WY............
16974........................ Chicago-Naperville-Joliet, IL. 1.0418
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........................ Chico, CA..................... 1.1616
Butte County, CA..............
17140........................ Cincinnati-Middletown, OH-KY- 0.9470
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............ 0.7802
Christian County, KY..........
Trigg County, KY..............
Montgomery County, TN.........
Stewart County, TN............
17420........................ Cleveland, TN................. 0.7496
Bradley County, TN............
Polk County, TN...............
17460........................ Cleveland-Elyria-Mentor, OH... 0.9303
Cuyahoga County, OH...........

[[Page 45991]]

Geauga County, OH.............
Lake County, OH...............
Lorain County, OH.............
Medina County, OH.............
17660........................ Coeur d'Alene, ID............. 0.9064
Kootenai County, ID...........
17780........................ College Station-Bryan, TX..... 0.9497
Brazos County, TX.............
Burleson County, TX...........
Robertson County, TX..........
17820........................ Colorado Springs, CO.......... 0.9282
El Paso County, CO............
Teller County, CO.............
17860........................ Columbia, MO.................. 0.8196
Boone County, MO..............
Howard County, MO.............
17900........................ Columbia, SC.................. 0.8601
Calhoun County, SC............
Fairfield County, SC..........
Kershaw County, SC............
Lexington County, SC..........
Richland County, SC...........
Saluda County, SC.............
17980........................ Columbus, GA-AL............... 0.8170
Russell County, AL............
Chattahoochee County, GA......
Harris County, GA.............
Marion County, GA.............
Muscogee County, GA...........
18020........................ Columbus, IN.................. 0.9818
Bartholomew County, IN........
18140........................ Columbus, OH.................. 0.9803
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............ 0.8433
Aransas County, TX............
Nueces County, TX.............
San Patricio County, TX.......
18700........................ Corvallis, OR................. 1.0596
Benton County, OR.............
18880........................ Crestview-Fort Walton Beach- 0.8911
Destin, FL.
Okaloosa County, FL...........
19060........................ Cumberland, MD-WV............. 0.8054
Allegany County, MD...........
Mineral County, WV............
19124........................ Dallas-Plano-Irving, TX....... 0.9831
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.................... 0.8625
Murray County, GA.............
Whitfield County, GA..........
19180........................ Danville, IL.................. 0.9460
Vermilion County, IL..........
19260........................ Danville, VA.................. 0.7888
Pittsylvania County, VA.......
Danville City, VA.............
19340........................ Davenport-Moline-Rock Island, 0.9306
IA-IL.
Henry County, IL..............
Mercer County, IL.............

[[Page 45992]]

Rock Island County, IL........
Scott County, IA..............
19380........................ Dayton, OH.................... 0.9034
Greene County, OH.............
Miami County, OH..............
Montgomery County, OH.........
Preble County, OH.............
19460........................ Decatur, AL................... 0.7165
Lawrence County, AL...........
Morgan County, AL.............
19500........................ Decatur, IL................... 0.8151
Macon County, IL..............
19660........................ Deltona-Daytona Beach-Ormond 0.8560
Beach, FL.
Volusia County, FL............
19740........................ Denver-Aurora-Broomfield, CO.. 1.0395
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, IA 0.9393
Dallas County, IA.............
Guthrie County, IA............
Madison County, IA............
Polk County, IA...............
Warren County, IA.............
19804........................ Detroit-Livonia-Dearborn, MI.. 0.9237
Wayne County, MI..............
20020........................ Dothan, AL.................... 0.7108
Geneva County, AL.............
Henry County, AL..............
Houston County, AL............
20100........................ Dover, DE..................... 0.9939
Kent County, DE...............
20220........................ Dubuque, IA................... 0.8790
Dubuque County, IA............
20260........................ Duluth, MN-WI................. 1.0123
Carlton County, MN............
St. Louis County, MN..........
Douglas County, WI............
20500........................ Durham-Chapel Hill, NC........ 0.9669
Chatham County, NC............
Durham County, NC.............
Orange County, NC.............
Person County, NC.............
20740........................ Eau Claire, WI................ 1.0103
Chippewa County, WI...........
Eau Claire County, WI.........
20764........................ Edison-New Brunswick, NJ...... 1.0985
Middlesex County, NJ..........
Monmouth County, NJ...........
Ocean County, NJ..............
Somerset County, NJ...........
20940........................ El Centro, CA................. 0.8848
Imperial County, CA...........
21060........................ Elizabethtown, KY............. 0.7894
Hardin County, KY.............
Larue County, KY..............
21140........................ Elkhart-Goshen, IN............ 0.9337
Elkhart County, IN............
21300........................ Elmira, NY.................... 0.8725
Chemung County, NY............
21340........................ El Paso, TX................... 0.8404
El Paso County, TX............
21500........................ Erie, PA...................... 0.7940
Erie County, PA...............

[[Page 45993]]

21660........................ Eugene-Springfield, OR........ 1.1723
Lane County, OR...............
21780........................ Evansville, IN-KY............. 0.8381
Gibson County, IN.............
Posey County, IN..............
Vanderburgh County, IN........
Warrick County, IN............
Henderson County, KY..........
Webster County, KY............
21820........................ Fairbanks, AK................. 1.0997
Fairbanks North Star Borough,
AK.
21940........................ Fajardo, PR................... 0.3728
Ceiba Municipio, PR...........
Fajardo Municipio, PR.........
Luquillo Municipio, PR........
22020........................ Fargo, ND-MN.................. 0.7802
Cass County, ND...............
Clay County, MN...............
22140........................ Farmington, NM................ 0.9735
San Juan County, NM...........
22180........................ Fayetteville, NC.............. 0.8601
Cumberland County, NC.........
Hoke County, NC...............
22220........................ Fayetteville-Springdale- 0.8955
Rogers, AR-MO.
Benton County, AR.............
Madison County, AR............
Washington County, AR.........
McDonald County, MO...........
22380........................ Flagstaff, AZ................. 1.2786
Coconino County, AZ...........
22420........................ Flint, MI..................... 1.1238
Genesee County, MI............
22500........................ Florence, SC.................. 0.7999
Darlington County, SC.........
Florence County, SC...........
22520........................ Florence-Muscle Shoals, AL.... 0.7684
Colbert County, AL............
Lauderdale County, AL.........
22540........................ Fond du Lac, WI............... 0.9477
Fond du Lac County, WI........
22660........................ Fort Collins-Loveland, CO..... 0.9704
Larimer County, CO............
22744........................ Fort Lauderdale-Pompano Beach- 1.0378
Deerfield, FL.
Broward County, FL............
22900........................ Fort Smith, AR-OK............. 0.7561
Crawford County, AR...........
Franklin County, AR...........
Sebastian County, AR..........
Le Flore County, OK...........
Sequoyah County, OK...........
23060........................ Fort Wayne, IN................ 0.9010
Allen County, IN..............
Wells County, IN..............
Whitley County, IN............
23104........................ Fort Worth-Arlington, TX...... 0.9535
Johnson County, TX............
Parker County, TX.............
Tarrant County, TX............
Wise County, TX...............
23420........................ Fresno, CA.................... 1.1768
Fresno County, CA.............
23460........................ Gadsden, AL................... 0.7983
Etowah County, AL.............
23540........................ Gainesville, FL............... 0.9710
Alachua County, FL............
Gilchrist County, FL..........
23580........................ Gainesville, GA............... 0.9253
Hall County, GA...............
23844........................ Gary, IN...................... 0.9418
Jasper County, IN.............
Lake County, IN...............

[[Page 45994]]

Newton County, IN.............
Porter County, IN.............
24020........................ Glens Falls, NY............... 0.8367
Warren County, NY.............
Washington County, NY.........
24140........................ Goldsboro, NC................. 0.8550
Wayne County, NC..............
24220........................ Grand Forks, ND-MN............ 0.7290
Polk County, MN...............
Grand Forks County, ND........
24300........................ Grand Junction, CO............ 0.9270
Mesa County, CO...............
24340........................ Grand Rapids-Wyoming, MI...... 0.9091
Barry County, MI..............
Ionia County, MI..............
Kent County, MI...............
Newaygo County, MI............
24500........................ Great Falls, MT............... 0.9235
Cascade County, MT............
24540........................ Greeley, CO................... 0.9653
Weld County, CO...............
24580........................ Green Bay, WI................. 0.9587
Brown County, WI..............
Kewaunee County, WI...........
Oconto County, WI.............
24660........................ Greensboro-High Point, NC..... 0.8320
Guilford County, NC...........
Randolph County, NC...........
Rockingham County, NC.........
24780........................ Greenville, NC................ 0.9343
Greene County, NC.............
Pitt County, NC...............
24860........................ Greenville-Mauldin-Easley, SC. 0.9604
Greenville County, SC.........
Laurens County, SC............
Pickens County, SC............
25020........................ Guayama, PR................... 0.3707
Arroyo Municipio, PR..........
Guayama Municipio, PR.........
Patillas Municipio, PR........
25060........................ Gulfport-Biloxi, MS........... 0.8575
Hancock County, MS............
Harrison County, MS...........
Stone County, MS..............
25180........................ Hagerstown-Martinsburg, MD-WV. 0.9234
Washington County, MD.........
Berkeley County, WV...........
Morgan County, WV.............
25260........................ Hanford-Corcoran, CA.......... 1.1124
Kings County, CA..............
25420........................ Harrisburg-Carlisle, PA....... 0.9533
Cumberland County, PA.........
Dauphin County, PA............
Perry County, PA..............
25500........................ Harrisonburg, VA.............. 0.9090
Rockingham County, VA.........
Harrisonburg City, VA.........
25540........................ Hartford-West Hartford-East 1.1050
Hartford, CT.
Hartford County, CT...........
Middlesex County, CT..........
Tolland County, CT............
25620........................ Hattiesburg, MS............... 0.7938
Forrest County, MS............
Lamar County, MS..............
Perry County, MS..............
25860........................ Hickory-Lenoir-Morganton, NC.. 0.8492
Alexander County, NC..........
Burke County, NC..............
Caldwell County, NC...........
Catawba County, NC............
25980........................ Hinesville-Fort Stewart, GA 0.8700
\1\.

[[Page 45995]]

Liberty County, GA............
Long County, GA...............
26100........................ Holland-Grand Haven, MI....... 0.8016
Ottawa County, MI.............
26180........................ Honolulu, HI.................. 1.2321
Honolulu County, HI...........
26300........................ Hot Springs, AR............... 0.8474
Garland County, AR............
26380........................ Houma-Bayou Cane-Thibodaux, LA 0.7525
Lafourche Parish, LA..........
Terrebonne Parish, LA.........
26420........................ Houston-Sugar Land-Baytown, TX 0.9915
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-OH.. 0.8944
Boyd County, KY...............
Greenup County, KY............
Lawrence County, OH...........
Cabell County, WV.............
Wayne County, WV..............
26620........................ Huntsville, AL................ 0.8455
Limestone County, AL..........
Madison County, AL............
26820........................ Idaho Falls, ID............... 0.9312
Bonneville County, ID.........
Jefferson County, ID..........
26900........................ Indianapolis-Carmel, IN....... 1.0108
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................. 0.9854
Johnson County, IA............
Washington County, IA.........
27060........................ Ithaca, NY.................... 0.9326
Tompkins County, NY...........
27100........................ Jackson, MI................... 0.8944
Jackson County, MI............
27140........................ Jackson, MS................... 0.8162
Copiah County, MS.............
Hinds County, MS..............
Madison County, MS............
Rankin County, MS.............
Simpson County, MS............
27180........................ Jackson, TN................... 0.7729
Chester County, TN............
Madison County, TN............
27260........................ Jacksonville, FL.............. 0.8956
Baker County, FL..............
Clay County, FL...............
Duval County, FL..............
Nassau County, FL.............
St. Johns County, FL..........
27340........................ Jacksonville, NC.............. 0.7861
Onslow County, NC.............
27500........................ Janesville, WI................ 0.9071
Rock County, WI...............

[[Page 45996]]

27620........................ Jefferson City, MO............ 0.8465
Callaway County, MO...........
Cole County, MO...............
Moniteau County, MO...........
Osage County, MO..............
27740........................ Johnson City, TN.............. 0.7226
Carter County, TN.............
Unicoi County, TN.............
Washington County, TN.........
27780........................ Johnstown, PA................. 0.8450
Cambria County, PA............
27860........................ Jonesboro, AR................. 0.7983
Craighead County, AR..........
Poinsett County, AR...........
27900........................ Joplin, MO.................... 0.7983
Jasper County, MO.............
Newton County, MO.............
28020........................ Kalamazoo-Portage, MI......... 0.9959
Kalamazoo County, MI..........
Van Buren County, MI..........
28100........................ Kankakee-Bradley, IL.......... 0.9657
Kankakee County, IL...........
28140........................ Kansas City, MO-KS............ 0.9447
Franklin County, KS...........
Johnson County, KS............
Leavenworth County, KS........
Linn County, KS...............
Miami County, KS..............
Wyandotte County, KS..........
Bates County, MO..............
Caldwell County, MO...........
Cass County, MO...............
Clay County, MO...............
Clinton County, MO............
Jackson County, MO............
Lafayette County, MO..........
Platte County, MO.............
Ray County, MO................
28420........................ Kennewick-Pasco-Richland, WA.. 0.9459
Benton County, WA.............
Franklin County, WA...........
28660........................ Killeen-Temple-Fort Hood, TX.. 0.8925
Bell County, TX...............
Coryell County, TX............
Lampasas County, TX...........
28700........................ Kingsport-Bristol-Bristol, TN- 0.7192
VA.
Hawkins County, TN............
Sullivan County, TN...........
Bristol City, VA..............
Scott County, VA..............
Washington County, VA.........
28740........................ Kingston, NY.................. 0.9066
Ulster County, NY.............
28940........................ Knoxville, TN................. 0.7432
Anderson County, TN...........
Blount County, TN.............
Knox County, TN...............
Loudon County, TN.............
Union County, TN..............
29020........................ Kokomo, IN.................... 0.9061
Howard County, IN.............
Tipton County, IN.............
29100........................ La Crosse, WI-MN.............. 1.0205
Houston County, MN............
La Crosse County, WI..........
29140........................ Lafayette, IN................. 0.9954
Benton County, IN.............
Carroll County, IN............
Tippecanoe County, IN.........
29180........................ Lafayette, LA................. 0.8231
Lafayette Parish, LA..........

[[Page 45997]]

St. Martin Parish, LA.........
29340........................ Lake Charles, LA.............. 0.7765
Calcasieu Parish, LA..........
Cameron Parish, LA............
29404........................ Lake County-Kenosha County, IL- 1.0658
WI.
Lake County, IL...............
Kenosha County, WI............
29420........................ Lake Havasu City-Kingman, AZ.. 0.9912
Mohave County, AZ.............
29460........................ Lakeland-Winter Haven, FL..... 0.8283
Polk County, FL...............
29540........................ Lancaster, PA................. 0.9695
Lancaster County, PA..........
29620........................ Lansing-East Lansing, MI...... 1.0618
Clinton County, MI............
Eaton County, MI..............
Ingham County, MI.............
29700........................ Laredo, TX.................... 0.7586
Webb County, TX...............
29740........................ Las Cruces, NM................ 0.9265
Dona Ana County, NM...........
29820........................ Las Vegas-Paradise, NV........ 1.1627
Clark County, NV..............
29940........................ Lawrence, KS.................. 0.8664
Douglas County, KS............
30020........................ Lawton, OK.................... 0.7893
Comanche County, OK...........
30140........................ Lebanon, PA................... 0.8157
Lebanon County, PA............
30300........................ Lewiston, ID-WA............... 0.9215
Nez Perce County, ID..........
Asotin County, WA.............
30340........................ Lewiston-Auburn, ME........... 0.9048
Androscoggin County, ME.......
30460........................ Lexington-Fayette, KY......... 0.8902
Bourbon County, KY............
Clark County, KY..............
Fayette County, KY............
Jessamine County, KY..........
Scott County, KY..............
Woodford County, KY...........
30620........................ Lima, OH...................... 0.9158
Allen County, OH..............
30700........................ Lincoln, NE................... 0.9465
Lancaster County, NE..........
Seward County, NE.............
30780........................ Little Rock-North Little Rock- 0.8632
Conway, AR.
Faulkner County, AR...........
Grant County, AR..............
Lonoke County, AR.............
Perry County, AR..............
Pulaski County, AR............
Saline County, AR.............
30860........................ Logan, UT-ID.................. 0.8754
Franklin County, ID...........
Cache County, UT..............
30980........................ Longview, TX.................. 0.8933
Gregg County, TX..............
Rusk County, TX...............
Upshur County, TX.............
31020........................ Longview, WA.................. 1.0460
Cowlitz County, WA............
31084........................ Los Angeles-Long Beach- 1.2417
Glendale, CA.
Los Angeles County, CA........
31140........................ Louisville-Jefferson County, 0.8852
KY-IN.
Clark County, IN..............
Floyd County, IN..............
Harrison County, IN...........
Washington County, IN.........
Bullitt County, KY............
Henry County, KY..............

[[Page 45998]]

Meade County, KY..............
Nelson County, KY.............
Oldham County, KY.............
Shelby County, KY.............
Spencer County, KY............
Trimble County, KY............
31180........................ Lubbock, TX................... 0.8956
Crosby County, TX.............
Lubbock County, TX............
31340........................ Lynchburg, VA................. 0.8771
Amherst County, VA............
Appomattox County, VA.........
Bedford County, VA............
Campbell County, VA...........
Bedford City, VA..............
Lynchburg City, VA............
31420........................ Macon, GA..................... 0.9014
Bibb County, GA...............
Crawford County, GA...........
Jones County, GA..............
Monroe County, GA.............
Twiggs County, GA.............
31460........................ Madera-Chowchilla, CA......... 0.8317
Madera County, CA.............
31540........................ Madison, WI................... 1.1414
Columbia County, WI...........
Dane County, WI...............
Iowa County, WI...............
31700........................ Manchester-Nashua, NH......... 1.0057
Hillsborough County, NH.......
31740........................ Manhattan, KS................. 0.7843
Geary County, KS..............
Pottawatomie County, KS.......
Riley County, KS..............
31860........................ Mankato-North Mankato, MN..... 0.9277
Blue Earth County, MN.........
Nicollet County, MN...........
31900........................ Mansfield, OH................. 0.8509
Richland County, OH...........
32420........................ Mayag[uuml]ez, PR............. 0.3762
Hormigueros Municipio, PR.....
Mayag[uuml]ez Municipio, PR...
32580........................ McAllen-Edinburg-Mission, TX.. 0.8393
Hidalgo County, TX............
32780........................ Medford, OR................... 1.0690
Jackson County, OR............
32820........................ Memphis, TN-MS-AR............. 0.9038
Crittenden County, AR.........
DeSoto County, MS.............
Marshall County, MS...........
Tate County, MS...............
Tunica County, MS.............
Fayette County, TN............
Shelby County, TN.............
Tipton County, TN.............
32900........................ Merced, CA.................... 1.2734
Merced County, CA.............
33124........................ Miami-Miami Beach-Kendall, FL. 0.9870
Miami-Dade County, FL.........
33140........................ Michigan City-La Porte, IN.... 0.9216
LaPorte County, IN............
33260........................ Midland, TX................... 1.0049
Midland County, TX............
33340........................ Milwaukee-Waukesha-West Allis, 0.9856
WI.
Milwaukee County, WI..........
Ozaukee County, WI............
Washington County, WI.........
Waukesha County, WI...........
33460........................ Minneapolis-St. Paul- 1.1213
Bloomington, MN-WI.
Anoka County, MN..............
Carver County, MN.............

[[Page 45999]]

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.................. 0.9142
Missoula County, MT...........
33660........................ Mobile, AL.................... 0.7507
Mobile County, AL.............
33700........................ Modesto, CA................... 1.3629
Stanislaus County, CA.........
33740........................ Monroe, LA.................... 0.7530
Ouachita Parish, LA...........
Union Parish, LA..............
33780........................ Monroe, MI.................... 0.8718
Monroe County, MI.............
33860........................ Montgomery, AL................ 0.7475
Autauga County, AL............
Elmore County, AL.............
Lowndes County, AL............
Montgomery County, AL.........
34060........................ Morgantown, WV................ 0.8339
Monongalia County, WV.........
Preston County, WV............
34100........................ Morristown, TN................ 0.6861
Grainger County, TN...........
Hamblen County, TN............
Jefferson County, TN..........
34580........................ Mount Vernon-Anacortes, WA.... 1.0652
Skagit County, WA.............
34620........................ Muncie, IN.................... 0.8743
Delaware County, IN...........
34740........................ Muskegon-Norton Shores, MI.... 1.1076
Muskegon County, MI...........
34820........................ Myrtle Beach-North Myrtle 0.8700
Beach-Conway, SC.
Horry County, SC..............
34900........................ Napa, CA...................... 1.5375
Napa County, CA...............
34940........................ Naples-Marco Island, FL....... 0.9108
Collier County, FL............
34980........................ Nashville-Davidson-- 0.9141
Murfreesboro-Franklin, TN.
Cannon County, TN.............
Cheatham County, TN...........
Davidson County, TN...........
Dickson County, TN............
Hickman County, TN............
Macon County, TN..............
Robertson County, TN..........
Rutherford County, TN.........
Smith County, TN..............
Sumner County, TN.............
Trousdale County, TN..........
Williamson County, TN.........
Wilson County, TN.............
35004........................ Nassau-Suffolk, NY............ 1.2755
Nassau County, NY.............
Suffolk County, NY............
35084........................ Newark-Union, NJ-PA........... 1.1268
Essex County, NJ..............
Hunterdon County, NJ..........
Morris County, NJ.............
Sussex County, NJ.............
Union County, NJ..............
Pike County, PA...............
35300........................ New Haven-Milford, CT......... 1.1883

[[Page 46000]]

New Haven County, CT..........
35380........................ New Orleans-Metairie-Kenner, 0.8752
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........................ New York-White Plains-Wayne, 1.3089
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....... 0.8444
Berrien County, MI............
35840........................ North Port-Bradenton-Sarasota- 0.9428
Venice, FL.
Manatee County, FL............
Sarasota County, FL...........
35980........................ Norwich-New London, CT........ 1.1821
New London County, CT.........
36084........................ Oakland-Fremont-Hayward, CA... 1.7048
Alameda County, CA............
Contra Costa County, CA.......
36100........................ Ocala, FL..................... 0.8425
Marion County, FL.............
36140........................ Ocean City, NJ................ 1.0584
Cape May County, NJ...........
36220........................ Odessa, TX.................... 0.9661
Ector County, TX..............
36260........................ Ogden-Clearfield, UT.......... 0.9170
Davis County, UT..............
Morgan County, UT.............
Weber County, UT..............
36420........................ Oklahoma City, OK............. 0.8879
Canadian County, OK...........
Cleveland County, OK..........
Grady County, OK..............
Lincoln County, OK............
Logan County, OK..............
McClain County, OK............
Oklahoma County, OK...........
36500........................ Olympia, WA................... 1.1601
Thurston County, WA...........
36540........................ Omaha-Council Bluffs, NE-IA... 0.9756
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........................ Orlando-Kissimmee-Sanford, FL. 0.9063
Lake County, FL...............
Orange County, FL.............
Osceola County, FL............
Seminole County, FL...........
36780........................ Oshkosh-Neenah, WI............ 0.9398
Winnebago County, WI..........
36980........................ Owensboro, KY................. 0.7790
Daviess County, KY............
Hancock County, KY............
McLean County, KY.............

[[Page 46001]]

37100........................ Oxnard-Thousand Oaks-Ventura, 1.3113
CA.
Ventura County, CA............
37340........................ Palm Bay-Melbourne-Titusville, 0.8790
FL.
Brevard County, FL............
37380........................ Palm Coast, FL................ 0.8174
Flagler County, FL............
37460........................ Panama City-Lynn Haven-Panama 0.7876
City Beach, FL.
Bay County, FL................
37620........................ Parkersburg-Marietta-Vienna, 0.7569
WV-OH.
Washington County, OH.........
Pleasants County, WV..........
Wirt County, WV...............
Wood County, WV...............
37700........................ Pascagoula, MS................ 0.7542
George County, MS.............
Jackson County, MS............
37764........................ Peabody, MA................... 1.0553
Essex County, MA..............
37860........................ Pensacola-Ferry Pass-Brent, FL 0.7767
Escambia County, FL...........
Santa Rosa County, FL.........
37900........................ Peoria, IL.................... 0.8434
Marshall County, IL...........
Peoria County, IL.............
Stark County, IL..............
Tazewell County, IL...........
Woodford County, IL...........
37964........................ Philadelphia, PA.............. 1.0849
Bucks County, PA..............
Chester County, PA............
Delaware County, PA...........
Montgomery County, PA.........
Philadelphia County, PA.......
38060........................ Phoenix-Mesa-Scottsdale, AZ... 1.0465
Maricopa County, AZ...........
Pinal County, AZ..............
38220........................ Pine Bluff, AR................ 0.8069
Cleveland County, AR..........
Jefferson County, AR..........
Lincoln County, AR............
38300........................ Pittsburgh, PA................ 0.8669
Allegheny County, PA..........
Armstrong County, PA..........
Beaver County, PA.............
Butler County, PA.............
Fayette County, PA............
Washington County, PA.........
Westmoreland County, PA.......
38340........................ Pittsfield, MA................ 1.0920
Berkshire County, MA..........
38540........................ Pocatello, ID................. 0.9754
Bannock County, ID............
Power County, ID..............
38660........................ Ponce, PR..................... 0.4594
Juana D[iacute]az Municipio,
PR.
Ponce Municipio, PR...........
Villalba Municipio, PR........
38860........................ Portland-South Portland- 0.9981
Biddeford, ME.
Cumberland County, ME.........
Sagadahoc County, ME..........
York County, ME...............
38900........................ Portland-Vancouver-Hillsboro, 1.1766
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............ 0.9352
Martin County, FL.............

[[Page 46002]]

St. Lucie County, FL..........
39100........................ Poughkeepsie-Newburgh- 1.1544
Middletown, NY.
Dutchess County, NY...........
Orange County, NY.............
39140........................ Prescott, AZ.................. 1.0161
Yavapai County, AZ............
39300........................ Providence-New Bedford-Fall 1.0539
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................ 0.9461
Juab County, UT...............
Utah County, UT...............
39380........................ Pueblo, CO.................... 0.8215
Pueblo County, CO.............
39460........................ Punta Gorda, FL............... 0.8734
Charlotte County, FL..........
39540........................ Racine, WI.................... 0.8903
Racine County, WI.............
39580........................ Raleigh-Cary, NC.............. 0.9304
Franklin County, NC...........
Johnston County, NC...........
Wake County, NC...............
39660........................ Rapid City, SD................ 0.9568
Meade County, SD..............
Pennington County, SD.........
39740........................ Reading, PA................... 0.9220
Berks County, PA..............
39820........................ Redding, CA................... 1.4990
Shasta County, CA.............
39900........................ Reno-Sparks, NV............... 1.0326
Storey County, NV.............
Washoe County, NV.............
40060........................ Richmond, VA.................. 0.9723
Amelia County, VA.............
Caroline County, VA...........
Charles City County, VA.......
Chesterfield County, VA.......
Cumberland County, VA.........
Dinwiddie County, VA..........
Goochland County, VA..........
Hanover County, VA............
Henrico County, VA............
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........................ Riverside-San Bernardino- 1.1497
Ontario, CA.
Riverside County, CA..........
San Bernardino County, CA.....
40220........................ Roanoke, VA................... 0.9195
Botetourt County, VA..........
Craig County, VA..............
Franklin County, VA...........
Roanoke County, VA............
Roanoke City, VA..............
Salem City, VA................
40340........................ Rochester, MN................. 1.1662
Dodge County, MN..............
Olmsted County, MN............
Wabasha County, MN............

[[Page 46003]]

40380........................ Rochester, NY................. 0.8749
Livingston County, NY.........
Monroe County, NY.............
Ontario County, NY............
Orleans County, NY............
Wayne County, NY..............
40420........................ Rockford, IL.................. 0.9751
Boone County, IL..............
Winnebago County, IL..........
40484........................ Rockingham County-Strafford 1.0172
County, NH.
Rockingham County, NH.........
Strafford County, NH..........
40580........................ Rocky Mount, NC............... 0.8750
Edgecombe County, NC..........
Nash County, NC...............
40660........................ Rome, GA...................... 0.8924
Floyd County, GA..............
40900........................ Sacramento-Arden-Arcade- 1.5498
Roseville, CA.
El Dorado County, CA..........
Placer County, CA.............
Sacramento County, CA.........
Yolo County, CA...............
40980........................ Saginaw-Saginaw Township 0.8849
North, MI.
Saginaw County, MI............
41060........................ St. Cloud, MN................. 1.0658
Benton County, MN.............
Stearns County, MN............
41100........................ St. George, UT................ 0.9345
Washington County, UT.........
41140........................ St. Joseph, MO-KS............. 0.9834
Doniphan County, KS...........
Andrew County, MO.............
Buchanan County, MO...........
DeKalb County, MO.............
41180........................ St. Louis, MO-IL.............. 0.9336
Bond County, IL...............
Calhoun County, IL............
Clinton County, IL............
Jersey County, IL.............
Macoupin County, IL...........
Madison County, IL............
Monroe County, IL.............
St. Clair County, IL..........
Crawford County, MO...........
Franklin County, MO...........
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..................... 1.1148
Marion County, OR.............
Polk County, OR...............
41500........................ Salinas, CA................... 1.5820
Monterey County, CA...........
41540........................ Salisbury, MD................. 0.8948
Somerset County, MD...........
Wicomico County, MD...........
41620........................ Salt Lake City, UT............ 0.9350
Salt Lake County, UT..........
Summit County, UT.............
Tooele County, UT.............
41660........................ San Angelo, TX................ 0.8169
Irion County, TX..............
Tom Green County, TX..........
41700........................ San Antonio-New Braunfels, TX. 0.8911
Atascosa County, TX...........
Bandera County, TX............
Bexar County, TX..............

[[Page 46004]]

Comal County, TX..............
Guadalupe County, TX..........
Kendall County, TX............
Medina County, TX.............
Wilson County, TX.............
41740........................ San Diego-Carlsbad-San Marcos, 1.2213
CA.
San Diego County, CA..........
41780........................ Sandusky, OH.................. 0.7788
Erie County, OH...............
41884........................ San Francisco-San Mateo- 1.6743
Redwood City, CA.
Marin County, CA..............
San Francisco County, CA......
San Mateo County, CA..........
41900........................ San Germ[aacute]n-Cabo Rojo, 0.4550
PR.
Cabo Rojo Municipio, PR.......
Lajas Municipio, PR...........
Sabana Grande Municipio, PR...
San Germ[aacute]n Municipio,
PR.
41940........................ San Jose-Sunnyvale-Santa 1.7086
Clara, CA.
San Benito County, CA.........
Santa Clara County, CA........
41980........................ San Juan-Caguas-Guaynabo, PR.. 0.4356
Aguas Buenas Municipio, PR....
Aibonito Municipio, PR........
Arecibo Municipio, PR.........
Barceloneta Municipio, PR.....
Barranquitas Municipio, PR....
Bayam[oacute]n Municipio, PR..
Caguas Municipio, PR..........
Camuy Municipio, PR...........
Can[oacute]vanas Municipio, PR
Carolina Municipio, PR........
Cata[ntilde]o Municipio, PR...
Cayey Municipio, PR...........
Ciales Municipio, PR..........
Cidra Municipio, PR...........
Comer[iacute]o Municipio, PR..
Corozal Municipio, PR.........
Dorado Municipio, PR..........
Florida Municipio, PR.........
Guaynabo Municipio, PR........
Gurabo Municipio, PR..........
Hatillo Municipio, PR.........
Humacao Municipio, PR.........
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 Robles, 1.3036
CA.
San Luis Obispo County, CA....
42044........................ Santa Ana-Anaheim-Irvine, CA.. 1.2111
Orange County, CA.............
42060........................ Santa Barbara-Santa Maria- 1.2825
Goleta, CA.
Santa Barbara County, CA......
42100........................ Santa Cruz-Watsonville, CA.... 1.7937
Santa Cruz County, CA.........

[[Page 46005]]

42140........................ Santa Fe, NM.................. 1.0136
Santa Fe County, NM...........
42220........................ Santa Rosa-Petaluma, CA....... 1.6679
Sonoma County, CA.............
42340........................ Savannah, GA.................. 0.8757
Bryan County, GA..............
Chatham County, GA............
Effingham County, GA..........
42540........................ Scranton-Wilkes-Barre, PA..... 0.8331
Lackawanna County, PA.........
Luzerne County, PA............
Wyoming County, PA............
42644........................ Seattle-Bellevue-Everett, WA.. 1.1733
King County, WA...............
Snohomish County, WA..........
42680........................ Sebastian-Vero Beach, FL...... 0.8760
Indian River County, FL.......
43100........................ Sheboygan, WI................. 0.9203
Sheboygan County, WI..........
43300........................ Sherman-Denison, TX........... 0.8723
Grayson County, TX............
43340........................ Shreveport-Bossier City, LA... 0.8262
Bossier Parish, LA............
Caddo Parish, LA..............
De Soto Parish, LA............
43580........................ Sioux City, IA-NE-SD.......... 0.9163
Woodbury County, IA...........
Dakota County, NE.............
Dixon County, NE..............
Union County, SD..............
43620........................ Sioux Falls, SD............... 0.8275
Lincoln County, SD............
McCook County, SD.............
Minnehaha County, SD..........
Turner County, SD.............
43780........................ South Bend-Mishawaka, IN-MI... 0.9425
St. Joseph County, IN.........
Cass County, MI...............
43900........................ Spartanburg, SC............... 0.8782
Spartanburg County, SC........
44060........................ Spokane, WA................... 1.1174
Spokane County, WA............
44100........................ Springfield, IL............... 0.9165
Menard County, IL.............
Sangamon County, IL...........
44140........................ Springfield, MA............... 1.0383
Franklin County, MA...........
Hampden County, MA............
Hampshire County, MA..........
44180........................ Springfield, MO............... 0.8440
Christian County, MO..........
Dallas County, MO.............
Greene County, MO.............
Polk County, MO...............
Webster County, MO............
44220........................ Springfield, OH............... 0.8447
Clark County, OH..............
44300........................ State College, PA............. 0.9575
Centre County, PA.............
44600........................ Steubenville-Weirton, OH-WV... 0.7598
Jefferson County, OH..........
Brooke County, WV.............
Hancock County, WV............
44700........................ Stockton, CA.................. 1.3734
San Joaquin County, CA........
44940........................ Sumter, SC.................... 0.7594
Sumter County, SC.............
45060........................ Syracuse, NY.................. 0.9897
Madison County, NY............
Onondaga County, NY...........
Oswego County, NY.............

[[Page 46006]]

45104........................ Tacoma, WA.................... 1.1574
Pierce County, WA.............
45220........................ Tallahassee, FL............... 0.8391
Gadsden County, FL............
Jefferson County, FL..........
Leon County, FL...............
Wakulla County, FL............
45300........................ Tampa-St. Petersburg- 0.9075
Clearwater, FL.
Hernando County, FL...........
Hillsborough County, FL.......
Pasco County, FL..............
Pinellas County, FL...........
45460........................ Terre Haute, IN............... 0.9706
Clay County, IN...............
Sullivan County, IN...........
Vermillion County, IN.........
Vigo County, IN...............
45500........................ Texarkana, TX-Texarkana, AR... 0.7428
Miller County, AR.............
Bowie County, TX..............
45780........................ Toledo, OH.................... 0.9013
Fulton County, OH.............
Lucas County, OH..............
Ottawa County, OH.............
Wood County, OH...............
45820........................ Topeka, KS.................... 0.8974
Jackson County, KS............
Jefferson County, KS..........
Osage County, KS..............
Shawnee County, KS............
Wabaunsee County, KS..........
45940........................ Trenton-Ewing, NJ............. 1.0648
Mercer County, NJ.............
46060........................ Tucson, AZ.................... 0.8953
Pima County, AZ...............
46140........................ Tulsa, OK..................... 0.8145
Creek County, OK..............
Okmulgee County, OK...........
Osage County, OK..............
Pawnee County, OK.............
Rogers County, OK.............
Tulsa County, OK..............
Wagoner County, OK............
46220........................ Tuscaloosa, AL................ 0.8500
Greene County, AL.............
Hale County, AL...............
Tuscaloosa County, AL.........
46340........................ Tyler, TX..................... 0.8526
Smith County, TX..............
46540........................ Utica-Rome, NY................ 0.8769
Herkimer County, NY...........
Oneida County, NY.............
46660........................ Valdosta, GA.................. 0.7527
Brooks County, GA.............
Echols County, GA.............
Lanier County, GA.............
Lowndes County, GA............
46700........................ Vallejo-Fairfield, CA......... 1.6286
Solano County, CA.............
47020........................ Victoria, TX.................. 0.8949
Calhoun County, TX............
Goliad County, TX.............
Victoria County, TX...........
47220........................ Vineland-Millville-Bridgeton, 1.0759
NJ.
Cumberland County, NJ.........
47260........................ Virginia Beach-Norfolk-Newport 0.9121
News, VA-NC.
Currituck County, NC..........
Gloucester County, VA.........
Isle of Wight County, VA......
James City County, VA.........
Mathews County, VA............

[[Page 46007]]

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........................ Visalia-Porterville, CA....... 0.9947
Tulare County, CA.............
47380........................ Waco, TX...................... 0.8213
McLennan County, TX...........
47580........................ Warner Robins, GA............. 0.7732
Houston County, GA............
47644........................ Warren-Troy-Farmington Hills, 0.9432
MI.
Lapeer County, MI.............
Livingston County, MI.........
Macomb County, MI.............
Oakland County, MI............
St. Clair County, MI..........
47894........................ Washington-Arlington- 1.0533
Alexandria, DC-VA-MD-WV.
District of Columbia, DC......
Calvert County, MD............
Charles County, MD............
Prince George's County, MD....
Arlington County, VA..........
Clarke County, VA.............
Fairfax County, VA............
Fauquier County, VA...........
Loudoun County, VA............
Prince William County, VA.....
Spotsylvania County, VA.......
Stafford County, VA...........
Warren County, VA.............
Alexandria City, VA...........
Fairfax City, VA..............
Falls Church City, VA.........
Fredericksburg City, VA.......
Manassas City, VA.............
Manassas Park City, VA........
Jefferson County, WV..........
47940........................ Waterloo-Cedar Falls, IA...... 0.8331
Black Hawk County, IA.........
Bremer County, IA.............
Grundy County, IA.............
48140........................ Wausau, WI.................... 0.8802
Marathon County, WI...........
48300........................ Wenatchee-East Wenatchee, WA.. 1.0109
Chelan County, WA.............
Douglas County, WA............
48424........................ West Palm Beach-Boca Raton- 0.9597
Boynton Beach, FL.
Palm Beach County, FL.........
48540........................ Wheeling, WV-OH............... 0.6673
Belmont County, OH............
Marshall County, WV...........
Ohio County, WV...............
48620........................ Wichita, KS................... 0.8674
Butler County, KS.............
Harvey County, KS.............
Sedgwick County, KS...........
Sumner County, KS.............
48660........................ Wichita Falls, TX............. 0.9537
Archer County, TX.............
Clay County, TX...............
Wichita County, TX............
48700........................ Williamsport, PA.............. 0.8268
Lycoming County, PA...........
48864........................ Wilmington, DE-MD-NJ.......... 1.0593

[[Page 46008]]

New Castle County, DE.........
Cecil County, MD..............
Salem County, NJ..............
48900........................ Wilmington, NC................ 0.8862
Brunswick County, NC..........
New Hanover County, NC........
Pender County, NC.............
49020........................ Winchester, VA-WV............. 0.9034
Frederick County, VA..........
Winchester City, VA...........
Hampshire County, WV..........
49180........................ Winston-Salem, NC............. 0.8560
Davie County, NC..............
Forsyth County, NC............
Stokes County, NC.............
Yadkin County, NC.............
49340........................ Worcester, MA................. 1.1584
Worcester County, MA..........
49420........................ Yakima, WA.................... 1.0355
Yakima County, WA.............
49500........................ Yauco, PR..................... 0.3782
Gu[aacute]nica Municipio, PR..
Guayanilla Municipio, PR......
Pe[ntilde]uelas Municipio, PR.
Yauco Municipio, PR...........
49620........................ York-Hanover, PA.............. 0.9540
York County, PA...............
49660........................ Youngstown-Warren-Boardman, OH- 0.8262
PA.
Mahoning County, OH...........
Trumbull County, OH...........
Mercer County, PA.............
49700........................ Yuba City, CA................. 1.1759
Sutter County, CA.............
Yuba County, CA...............
49740........................ Yuma, AZ...................... 0.9674
Yuma County, AZ...............
------------------------------------------------------------------------
\1\ At this time, there are no hospitals located in this urban area on
which to base a wage index.

Table 2--FY 2015 Wage Index Based on CBSA Labor Market Areas for Rural
Areas
------------------------------------------------------------------------
Wage
State code Nonurban area index
------------------------------------------------------------------------
1............................. Alabama...................... 0.7147
2............................. Alaska....................... 1.3662
3............................. Arizona...................... 0.9166
4............................. Arkansas..................... 0.7343
5............................. California................... 1.2788
6............................. Colorado..................... 0.9802
7............................. Connecticut.................. 1.1311
8............................. Delaware..................... 1.0092
10............................ Florida...................... 0.7985
11............................ Georgia...................... 0.7459
12............................ Hawaii....................... 1.0739
13............................ Idaho........................ 0.7605
14............................ Illinois..................... 0.8434
15............................ Indiana...................... 0.8513
16............................ Iowa......................... 0.8434
17............................ Kansas....................... 0.7929
18............................ Kentucky..................... 0.7784
19............................ Louisiana.................... 0.7585
20............................ Maine........................ 0.8238
21............................ Maryland..................... 0.8696
22............................ Massachusetts................ 1.3614
23............................ Michigan..................... 0.8270
24............................ Minnesota.................... 0.9133
25............................ Mississippi.................. 0.7568
26............................ Missouri..................... 0.7775
27............................ Montana...................... 0.9098
28............................ Nebraska..................... 0.8855
29............................ Nevada....................... 0.9781
30............................ New Hampshire................ 1.0339
31............................ New Jersey \1\............... .........
32............................ New Mexico................... 0.8922
33............................ New York..................... 0.8220
34............................ North Carolina............... 0.8100
35............................ North Dakota................. 0.6785
36............................ Ohio......................... 0.8377
37............................ Oklahoma..................... 0.7704
38............................ Oregon....................... 0.9435
39............................ Pennsylvania................. 0.8430
40............................ Puerto Rico \1\.............. 0.4047
41............................ Rhode Island \1\............. .........
42............................ South Carolina............... 0.8329
43............................ South Dakota................. 0.8164
44............................ Tennessee.................... 0.7444
45............................ Texas........................ 0.7874
46............................ Utah......................... 0.8732
47............................ Vermont...................... 0.9740
48............................ Virgin Islands............... 0.7060
49............................ Virginia..................... 0.7758
50............................ Washington................... 1.0529
51............................ West Virginia................ 0.7407
52............................ Wisconsin.................... 0.8904
53............................ Wyoming...................... 0.9243
65............................ Guam......................... 0.9611
------------------------------------------------------------------------
\1\ All counties within the State are classified as urban, with the
exception of Puerto Rico. Puerto Rico has areas designated as rural;
however, no short-term, acute care hospitals are located in the
area(s) for FY 2015. The Puerto Rico wage index is the same as FY
2014.

Addendum C

[[Page 46009]]

IPF Code First Table
------------------------------------------------------------------------
Code first instructions ICD-10-CM (effective October
Code 1, 2014)
------------------------------------------------------------------------
F01.50............ Code first the underlying physiological condition or
sequelae of cerebrovascular disease.
F01.51............ Code first the underlying physiological condition or
sequelae of cerebrovascular disease.
F02.80............ Code first the underlying physiological condition,
such as: A52.17, A81.0-A81.9, E75.00-E75.09, E75.10-
E75.19, E75.4, E83.00-E83.09, G10, G30.0-G30.9,
G31.01, G31.09, G31.83, G35, G40.001-G40.319,
G40.401-G40.919, G40.A01-G40.B19, M30.8. This list
is a translation of the ICD-9 codes rather than a
list of the conditions in the ICD-10 codebook code
first note for category F02.
F02.81............ Code first the underlying physiological condition,
such as: A52.17, A81.0-A81.9, E75.00-E75.09, E75.10-
E75.19, E75.4, E83.00-E83.09, G10, G30.0-G30.9,
G31.01, G31.09, G31.83, G35, G40.001-G40.319,
G40.401-G40.919, G40.A01-G40.B19, M30.8.
F04............... Code first the underlying physiological condition.
F05............... Code first the underlying physiological condition,
such as: A52.17, A81.0-A81.9, E75.00-E75.09, E75.10-
E75.19, E75.4, E83.00-E83.09, G10, G30.0-G30.9,
G31.01, G31.09, G31.83, G35, G40.001-G40.319,
G40.401-G40.919, G40.A01-G40.B19, M30.8.
F06.0............. Code first the underlying physiological condition.
F06.1............. Code first the underlying physiological condition.
F06.2............. Code first the underlying physiological condition.
F06.30............ Code first the underlying physiological condition.
F06.31............ Code first the underlying physiological condition.
F06.32............ Code first the underlying physiological condition.
F06.33............ Code first the underlying physiological condition.
F06.34............ Code first the underlying physiological condition.
F06.4............. Code first the underlying physiological condition.
F06.8............. Code first the underlying physiological condition.
F45.42............ Code also associated acute or chronic pain.
------------------------------------------------------------------------

[FR Doc. 2014-18329 Filed 7-31-14; 4:15 pm]
BILLING CODE 4120-01-P