[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  

[[Page 45938]]


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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

[[Page 45939]]

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
------------------------------------------------------------------------
                             Total transfers
------------------------------------------------------------------------
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.
------------------------------------------------------------------------
                                  Costs
------------------------------------------------------------------------
 
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.
------------------------------------------------------------------------

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

[[Page 45942]]

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

    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

[[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