Part II

[Federal Register: May 4, 2005 (Volume 70, Number 85)]

[Proposed Rules]

[Page 23305-23673]

From the Federal Register Online via GPO Access [wais.access.gpo.gov]

[DOCID:fr04my05-18]

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Part II

Department of Health and Human Services

Centers for Medicare & Medicaid Services

42 CFR Parts 405, 412, et al.

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

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Parts 405, 412, 413, 415, 419, 422, and 485

[CMS-1500-P]

RIN 0938-AN57

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

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

ACTION: Proposed rule.

SUMMARY: We are proposing to revise the Medicare hospital inpatient prospective payment systems (IPPS) for operating and capital-related costs to implement changes arising from our continuing experience with these systems. In addition, in the Addendum to this proposed rule, we describe the proposed changes to the amounts and factors used to determine the rates for Medicare hospital inpatient services for operating costs and capital-related costs. We also are setting forth proposed rate-of-increase limits as well as proposed policy changes for hospitals and hospital units excluded from the IPPS that are paid in full or in part on a reasonable cost basis subject to these limits. These proposed changes would be applicable to discharges occurring on or after October 1, 2005, with one exception: The proposed changes relating to submittal of hospital wage data by a campus or campuses of a multicampus hospital system (that is, the proposed changes to Sec. 412.230(d)(2) of the regulations) would be effective upon publication of the final rule.

Among the policy changes that we are proposing to make are changes relating to: the classification of cases to the diagnosis-related groups (DRGs); the long-term care (LTC)-DRGs and relative weights; the wage data, including the occupational mix data, used to compute the wage index; rebasing and revision of the hospital market basket; applications for new technologies and medical services add-on payments; policies governing postacute care transfers, payments to hospitals for the direct and indirect costs of graduate medical education, submission of hospital quality data, payment adjustment for low-volume hospitals, changes in the requirements for provider-based facilities; and changes in the requirements for critical access hospitals (CAHs).

DATES: Comments will be considered if received at the appropriate address, as provided in the ADDRESSES section, no later than 5 p.m. on June 24, 2005.

ADDRESSES: In commenting, please refer to file code CMS-1500-P. Because of staff and resource limitations, we cannot accept comments by facsimile (FAX) transmission.

You may submit comments in one of three ways (no duplicates, please):

1. Electronically

You may submit electronic comments to http://www.cms.hhs.gov/regulations/ecomments (attachments should be in Microsoft Word,

WordPerfect, or Excel; however, we prefer Microsoft Word).

2. By Mail

You may mail written comments (one original and two copies) to the following address only: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1500-P, P.O. Box 8011, Baltimore, MD 21244-1850.

Please allow sufficient time for mailed comments to be received before the close of the comment period.

3. By Hand or Courier

If you prefer, you may deliver (by hand or courier) your written comments (one original and two copies) before the close of the comment period to one of the following addresses. If you intend to deliver your comments to the Baltimore address, please call telephone number (410) 786-7195 in advance to schedule your arrival with one of our staff members.

Room 445-G, Hubert H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC 20201, or 7500 Security Boulevard, Baltimore, MD 21244-1850.

(Because access to the interior of the Hubert H. Humphrey Building is not readily available to persons without Federal Government identification, commenters are encouraged to leave their comments in the CMS drop slots located in the main lobby of the building. A stamp- in clock is available for persons wishing to retain proof of filing by stamping in and retaining an extra copy of the comments being filed.)

Comments mailed to the addresses indicated as appropriate for hand or courier delivery may be delayed and received after the comment period.

Inspection of Public Comments: All comments received before the close of the comment period are available for viewing by the public, including any personally identifiable or confidential business information that is included in a comment. After the close of the comment period, CMS posts all electronic comments received before the close of the comment period on its public Web site. Written comments received timely will be available for public inspection as they are received, generally beginning approximately 4 weeks after publication of a document, at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security Boulevard, Baltimore, MD 21244, Monday through Friday of each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view public comments, phone 1-800-743-3951.

For comments that relate to information collection requirements, mail a copy of comments to the following addresses:

Centers for Medicare & Medicaid Services, Office of Strategic Operations and Regulatory Affairs, Security and Standards Group, Office of Regulations Development and Issuances, Room C4-24-02 7500 Security Boulevard, Baltimore, Maryland 21244-1850, Attn: James Wickliffe, CMS- 1500-P; and Office of Information and Regulatory Affairs, Office of Management and Budget, Room 3001, New Executive Office Building, Washington, DC 20503, Attn: Christopher Martin, CMS Desk Officer, CMS-1500-P, Christopher_Martin@omb.eop.gov. Fax (202) 395-6974.

FOR FURTHER INFORMATION CONTACT:

Marc Harstein, (410) 786-4539, Operating Prospective Payment, Diagnosis-Related Groups (DRGs), Wage Index, New Medical Services and Technology Add-On Payments, Hospital Geographic Reclassifications, Postacute Care Transfers, and Disproportionate Share Hospital Issues. Tzvi Hefter, (410) 786-4487, Capital Prospective Payment, Excluded Hospitals, Graduate Medical Education, Critical Access Hospitals, and Long-Term Care (LTC)-DRGs, and Provider-Based Facilities Issues. Steve Heffler, (410) 786-1211, Hospital Market Basket Revision and Rebasing. Siddhartha Mazumdar, (410) 786-6673, Rural Hospital Community Demonstration Project Issues. Mary Collins, (410) 786-3189, Critical Access Hospitals (CAHs) Issues. Dr. Mark Krushat, (410) 786-6809, Quality Data for Annual Payment Update Issues. Martha Kuespert, (410) 786-4605 Specialty Hospitals Definition Issues.

SUPPLEMENTARY INFORMATION:

Electronic Access

This Federal Register document is also available from the Federal Register

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online database through GPO Access, a service of the U.S. Government Printing Office. Free public access is available on a Wide Area Information Server (WAIS) through the Internet and via asynchronous dial-in. Internet users can access the database by using the World Wide Web; the Superintendent of Documents home page address is http://www.access. gpo.gov/nara--docs, by using local WAIS client software, or

by telnet to swais.access.gpo.gov, then login as guest (no password required). Dial-in users should use communications software and modem to call (202) 512-1661; type swais, then login as guest (no password required).

Acronyms

AAOS American Association of Orthopedic Surgeons ACGME Accreditation Council on Graduate Medical Education AHIMA American Health Information Management Association AHA American Hospital Association AICD Automatic cardioverter defibrillator AMI Acute myocardial infarction AOA American Osteopathic Association ASC Ambulatory Surgical Center ASP Average sales price AWP Average wholesale price BBA Balanced Budget Act of 1997, Pub. L. 105-33 BES Business Expenses Survey BIPA Medicare, Medicaid, and SCHIP [State Children's Health Insurance Program] Benefits Improvement and Protection Act of 2000, Pub. L. 106-554 BLS Bureau of Labor Statistics CAH Critical access hospital CBSAs Core-Based Statistical Areas CC Complication or comorbidity CIPI Capital Input Price Index CMS Centers for Medicare & Medicaid Services CMSA Consolidated Metropolitan Statistical Area COBRA Consolidated Omnibus Reconciliation Act of 1985, Pub. L. 99- 272 CoP Condition of Participation CPI Consumer Price Index CRNA Certified registered nurse anesthetist CRT Cardiac Resynchronization Therapy DRG Diagnosis-related group DSH Disproportionate share hospital ECI Employment Cost Index FDA Food and Drug Administration FIPS Federal Information Processing Standards FQHC Federally qualified health center FTE Full-time equivalent FY Federal fiscal year GAAP Generally accepted accounting principles GAF Geographic adjustment factor HIC Health Insurance Card HIS Health Information System GME Graduate medical education HCRIS Hospital Cost Report Information System HIPC Health Information Policy Council HIPAA Health Insurance Portability and Accountability Act of 1996, Pub. L. 104-191 HHA Home health agency HHS Department of Health and Human Services HPSA Health Professions Shortage Area HQA Hospital Quality Alliance ICD-9-CM International Classification of Diseases, Ninth Revision, Clinical Modification ICD-10-PCS International Classification of Diseases, Tenth Edition, Procedure Coding System ICF/MRs Intermediate care facilities for the mentally retarded ICU Intensive Care Unit IHS Indian Health Service IME Indirect medical education IPPS Acute care hospital inpatient prospective payment system IPF Inpatient psychiatric facility IRF Inpatient rehabilitation facility IRP Initial residency period JCAHO Joint Commission on Accreditation of Healthcare Organizations LAMCs Large area metropolitan counties LTC-DRG Long-term care diagnosis-related group LTCH Long-term care hospital MCE Medicare Code Editor MCO Managed care organization MDC Major diagnostic category MDH Medicare-dependent small rural hospital MedPAC Medicare Payment Advisory Commission MedPAR Medicare Provider Analysis and Review File MEI Medicare Economic Index MGCRB Medicare Geographic Classification Review Board MMA Medicare Prescription Drug, Improvement, and Modernization Act of 2003, Pub. L. 108-173 MRHFP Medicare Rural Hospital Flexibility Program MSA Metropolitan Statistical Area NAICS North American Industrial Classification System NCD National coverage determination NCHS National Center for Health Statistics NCVHS National Committee on Vital and Health Statistics NECMA New England County Metropolitan Areas NICU Neonatal intensive care unit NQF National Quality Forum NTIS National Technical Information Service NVHRI National Voluntary Hospital Reporting Initiative OES Occupational Employment Statistics OIG Office of the Inspector General OMB Executive Office of Management and Budget O.R. Operating room OSCAR Online Survey Certification and Reporting (System) OSHA Occupational Safety and Health Act PRM Provider Reimbursement Manual PPI Producer Price Index PMS Performance Measurement System PMSAs Primary Metropolitan Statistical Areas PPS Prospective payment system PRA Per resident amount ProPAC Prospective Payment Assessment Commission PRRB Provider Reimbursement Review Board PS&R Provider Statistical and Reimbursement System QIA Quality Improvement Organizations RHC Rural health clinic RHQDAPU Reporting Hospital Quality Data for Annual Payment Update RNHCI Religious nonmedical health care institution RRC Rural referral center RUCAs Rural-Urban Commuting Area Codes SCH Sole community hospital SDP Single Drug Pricer SIC Standard Industrial Codes SNF Skilled nursing facility SOCs Standard occupational classifications SOM State Operations Manual SSA Social Security Administration SSI Supplemental Security Income TEFRA Tax Equity and Fiscal Responsibility Act of 1982, Pub. L. 97- 248 UHDDS Uniform Hospital Discharge Data Set

Table of Contents

I. Background

A. Summary

1. Acute Care Hospital Inpatient Prospective Payment System (IPPS)

2. Hospitals and Hospital Units Excluded from the IPPS

a. IRFs

b. LTCH

c. IPFs

3. Critical Access Hospitals (CAHs)

4. Payments for Graduate Medical Education (GME)

B. Major Contents of this Proposed Rule

1. Proposed Changes to the DRG Reclassifications and Recalibrations of Relative Weights

2. Proposed Changes to the Hospital Wage Index

3. Proposed Revision and Rebasing of the Hospital Market Basket

4. Other Decisions and Proposed Changes to the PPS for Inpatient Operating and GME Costs

5. PPS for Capital-Related Costs

6. Proposed Changes for Hospitals and Hospital Units Excluded from the IPPS

7. Proposed Payment for Blood Clotting Factors for Inpatients with Hemophilia

8. Determining Proposed Prospective Payment Operating and Capital Rates and Rate-of-Increase Limits

9. Impact Analysis

10. Recommendation of Update Factor for Hospital Inpatient Operating Costs

11. Discussion of Medicare Payment Advisory Commission Recommendations II. Proposed Changes to DRG Classifications and Relative Weights

A. Background

B. DRG Reclassifications

1. General

2. Pre-MDC: Intestinal Transplantation

3. MDC 1 (Diseases and Disorders of the Nervous System)

a. Strokes

b. Unruptured Cerebral Aneurysms

4. MDC 5 (Diseases and Disorders of the Circulatory System)

a. Automatic Implantable Cardioverter/Defibrillator

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b. Coronary Artery Stents

c. Insertion of Left Atrial Appendage Device

d. External Heart Assist System Implant

e. Carotid Artery Stent

f. Extracorporeal Membrane Oxygenation (ECMO)

5. MDC 6 (Diseases and Disorders of the Digestive System): Artificial Anal Sphincter

6. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue)

a. Hip and Knee Replacements

b. Kyphoplasty

c. Multiple Level Spinal Fusion

7. MDC 18 (Infectious and Parasitic Diseases (Systemic or Unspecified Sites)): Severe Sepsis

8. MDC 20 (Alcohol/Drug Use and Alcohol/Drug Induced Organic Mental Disorders): Drug-Induced Dementia

9. Medicare Code Editor (MCE) Changes

a. Newborn Age Edit

b. Newborn Diagnoses Edit

c. Diagnoses Allowed for ``Males Only'' Edit

d. Tobacco Use Disorder Edit

e. Noncovered Procedure Edit

10. Surgical Hierarchies

11. Refinement of Complications and Comorbidities (CC) List

a. Background

b. Comprehensive Review of the CC List

c. CC Exclusion List for FY 2006

12. Review of Procedure Codes in DRGs 468, 476, and 477

a. Moving Procedure Codes from DRG 468 or DRG 477 to MDCs

b. Reassignment of Procedures among DRGs 468, 476, and 477

c. Adding Diagnosis or Procedure Codes to MDCs

13. Changes to the ICD-9-CM Coding System

14. Other Issues: Acute Intermittent Porphyria

C. Proposed Recalibration of DRG Weights

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

1. Background

2. Proposed Changes in the LTC-DRG Classifications

a. Background

b. Patient Classifications into DRGs

3. Development of the Proposed FY 2006 LTC-DRG Relative Weights

a. General Overview of Development of the LTC-DRG Relative Weights

b. Data

c. Hospital-Specific Relative Value Methodology

d. Proposed Low-Volume LTC-DRGs

4. Steps for Determining the Proposed FY 2006 LTC-DRG Relative Weights

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

1. Background

2. FY 2006 Status of Technology Approved for FY 2005 Add-On Payments

3. Reevaluation of FY 2005 Applications That Were Not Approved

4. FY 2006 Applicants for New Technology Add-On Payments III. Proposed Changes to the Hospital Wage Index

A. Background

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

C. Proposed Occupational Mix Adjustment to FY 2006 Index

1. Development of Data for the Proposed Occupational Mix Adjustment

2. Calculation of the Proposed Occupational Mix Adjustment Factor and the Proposed Occupational Mix Adjusted Wage Index

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

E. Verification of Worksheet S-3 Wage Data

F. Computation of the Proposed FY 2006 Unadjusted Wage Index

G. Computation of the Proposed FY 2006 Blended Wage Index

H. Proposed Revisions to the Wage Index Based on Hospital Redesignation

1. General

2. Effects of Reclassification

3. Proposed Application of Hold Harmless Protection for Certain Urban Hospitals Redesignated as Rural

4. FY 2006 MGCRB Reclassifications

5. Proposed FY 2006 Redesignations under Section 1886(d)(8)(B) of the Act

6. Reclassifications under Section 508 of Pub. L. 108-173

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

J. Process for Requests for Wage Index Data Corrections IV. Proposed Rebasing and Revision of the Hospital Market Baskets

A. Background

B. Rebasing and Revising the Hospital Market Basket

1. Development of Cost Categories and Weights

2. PPS--Selection of Price Proxies

3. Labor-Related Share

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

1. Hospitals Paid Based on Their Reasonable Costs

2. Excluded Hospitals Paid Under Blend Methodology

3. Development of Cost Categories and Weights for the Proposed 2002-Based Excluded Hospital Market Basket

D. Frequency of Updates of Weights in IPPS Hospital Market Basket

E. Capital Input Price Index Section V. Other Decisions and Proposed Changes to the IPPS for Operating Costs and GME Costs

A. Postacute Care Transfer Payment Policy

1. Background

2. Changes to DRGs Subject to the Postacute Care Transfer Policy

B. Reporting of Hospital Quality Data for Annual Hospital Payment Update

1. Background

2. Requirements for Hospital Reporting of Quality Data

C. Sole Community Hospitals and Medicare Dependent Hospitals

1. Background

2. Budget Neutrality Adjustment to Hospital Payments Based on Hospital-Specific Rate

3. Technical Change

D. Rural Referral Centers

1. Case-Mix Index

2. Discharges

3. Technical Change

E. Payment Adjustment for Low-Volume Hospitals

F. Indirect Medical Education (IME) Adjustment

1. Background

2. IME Adjustment for TEFRA Hospitals Converting to IPPS Hospitals

3. Section 1886(d)(3)(E) Teaching Hospitals That Withdraw Rural Reclassification

G. Payment to Disproportionate Share Hospitals (DSHs)

1. Background

2. Implementation of Section 951 of Pub. L. 108-173

H. Geographic Reclassifications

1. Background

2. Multicampus Hospitals

3. Urban Group Hospital Reclassifications

4. Clarification of Goldsmith Modification Criterion for Urban Hospitals Seeking Reclassification as Rural

I. Payment for Direct Graduate Medical Education

1. Background

2. Direct GME Initial Residency Period

a. Background

b. Direct GME Initial Residency Period Limitation: Simultaneous Match

3. New Teaching Hospitals' Participation in Medicare GME Affiliated Groups

4. GME FTE Cap Adjustments for Rural Hospitals

5. Technical Changes: Cross-References

J. Provider-Based Status of Facilities under Medicare

1. Background

2. Limits on Scope of Provider-Based Regulations--Facilities for Which Provider-Based Determinations Will Not Be Made

3. Location Requirement for Off-Campus Facilities: Application to Certain Neonatal Intensive Care Units

4. Technical and Clarifying Changes

K. Rural Community Hospital Demonstration Program

L. Definition of a Hospital in Connection with Specialty Hospitals VI. PPS for Capital-Related Costs VII. Proposed Changes for Hospitals and Hospital Units Excluded from the IPPS

A. Payments to Excluded Hospitals and Hospital Units

1. Payments to Existing Excluded Hospitals and Hospital Units

2. Updated Caps for New Excluded Hospitals and Units

3. Implementation of a PPS for IRFs

4. Implementation of a PPS for LTCHs

5. Implementation of a PPS for IPFs

B. Critical Access Hospitals (CAHs)

1. Background

2. Proposed Policy Change Relating to Continued Participation by CAHs in Lugar Counties

3. Proposed Policy Change Relating to Designation of CAHs as Necessary Providers

a. Determination of the Relocation Status of a CAH

b. Relocation of a CAH Using a Waiver to Meet the CoP for Distance

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VIII. Payment for Blood Clotting Factor Administered to Hemophilia Inpatients IX. MedPAC Recommendations

A. Medicare Payment Policy

B. Physician-Owned Specialty Hospitals

C. Other MedPAC Recommendations X. Other Required Information

A. Requests for Data from the Public

B. Collection of Information Requirements

C. Public Comments

Regulation Text

Addendum--Proposed Schedule of Standardized Amounts Effective with Discharges Occurring On or After October 1, 2004 and Update Factors and Rate-of-Increase Percentages Effective With Cost Reporting Periods Beginning On or After October 1, 2004 I. Summary and Background II. Proposed Changes to Prospective Payment Rates for Hospital Inpatient Operating Costs for FY 2006

A. Calculation of the Adjusted Standardized Amount

1. Standardization of Base-Year Costs or Target Amounts

2. Computing the Average Standardized Amount

3. Updating the Average Standardized Amount

4. Other Adjustments to the Average Standardized Amount

a. Recalibration of DRG Weights and Updated Wage Index--Budget Neutrality Adjustment

b. Reclassified Hospitals--Budget Neutrality Adjustment

c. Outliers

d. Rural Community Hospital Demonstration Program Adjustment (Section 410A of Pub. L. 108-173)

5. Proposed FY 2006 Standardized Amount

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

1. Adjustment for Area Wage Levels

2. Adjustment for Cost-of-Living in Alaska and Hawaii

C. DRG Relative Weights

D. Calculation of Proposed Prospective Payment Rates for FY 2006

1. Federal Rate

2. Hospital-Specific Rate (Applicable Only to SCHs and MDHs)

a. Calculation of Hospital-Specific Rate

b. Updating the FY 1982, FY 1987, and FY 1996 Hospital-Specific Rates for FY 2006

3. General Formula for Calculation of Proposed Prospective Payment Rates for Hospitals Located in Puerto Rico Beginning On or After October 1, 2005 and Before October 1, 2006

a. Puerto Rico Rate

b. National Rate III. Proposed Changes to Payment Rates for Acute Care Hospital Inpatient Capital-Related Costs for FY 2006

A. Determination of Proposed Federal Hospital Inpatient Capital- Related Prospective Payment Rate Update

1. Proposed Capital Standard Federal Rate Update

a. Description of the Update Framework

b. Comparison of CMS and MedPAC Update Recommendation

2. Proposed Outlier Payment Adjustment Factor

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

4. Proposed Exceptions Payment Adjustment Factor

5. Proposed Capital Standard Federal Rate for FY 2006

6. Proposed Special Capital Rate for Puerto Rico Hospitals

B. Calculation of Proposed Inpatient Capital-Related Prospective Payments for FY 2006

C. Capital Input Price Index

1. Background

2. Forecast of the CIPI for FY 2006 IV. Proposed Changes to Payment Rates for Excluded Hospitals and Hospital Units: Rate-of-Increase Percentages

A. Payments to Existing Excluded Hospitals and Units

B. Updated Caps for New Excluded Hospitals and Units V. Payment for Blood Clotting Factor Administered to Hemophilia Inpatients

Tables

Table 1A--National Adjusted Operating Standardized Amounts, Labor/ Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share If Wage Index Is Greater Than 1) Table 1B--National Adjusted Operating Standardized Amounts, Labor/ Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share If Wage Index Is Less Than or Equal to 1) Table 1C--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor Table 1D--Capital Standard Federal Payment Rate Table 2--Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2004; Hospital Average Hourly Wage for Federal Fiscal Years 2004 (2000 Wage Data), 2005 (2001 Wage Data), and 2006 (2002 Wage Data) Wage Indexes and 3-Year Average of Hospital Average Hourly Wages Table 3A--FY 2006 and 3-Year Average Hourly Wage for Urban Areas Table 3B--FY 2006 and 3-Year Average Hourly Wage for Rural Areas Table 4A--Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas Table 4B--Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas Table 4C--Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified Table 4F--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) Table 4J--Out-Migration Adjustment--FY 2006 Table 5--List of Diagnosis-Related Groups (DRGs), Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay (LOS) Table 6A--New Diagnosis Codes Table 6B--New Procedure Codes Table 6C--Invalid Diagnosis Codes Table 6D--Invalid Procedure Codes Table 6E--Revised Diagnosis Code Titles Table 6F--Revised Procedure Code Titles Table 6G--Additions to the CC Exclusions List Table 6H--Deletions from the CC Exclusions List Table 7A--Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2004 MedPAR Update December 2004 GROUPER V22.0 Table 7B--Medicare Prospective Payment System Selected Percentile Lengths of Stay: FY 2004 MedPAR Update December 2004 GROUPER V23.0 Table 8A--Statewide Average Operating Cost-to-Charge Ratios--March 2005 Table 8B--Statewide Average Capital Cost-to-Charge Ratios--March 2005 Table 9A--Hospital Reclassifications and Redesignations by Individual Hospital--FY 2006 Table 9B--Hospital Reclassifications and Redesignation by Individual Hospital Under Section 508 of Pub. L. 108-173--FY 2005 Table 9C--Hospitals Redesignated as Rural under Section 1886(d)(8)(E) of the Act--FY 2006 Table 10--Geometric Mean Plus the Lesser of .75 of the National Adjusted Operating Standardized Payment Amount (Increased to Reflect the Difference Between Costs and Charges) or .75 of One Standard Deviation of Mean Charges by Diagnosis-Related Groups (DRGs)--March 2005 Table 11--Proposed FY 2006 LTC-DRGs, Relative Weights, Geometric Average Length of Stay, and 5/6ths of the Geometric Average Length of Stay Appendix A--Regulatory Impact Analysis Appendix B--Recommendation of Update Factors for Operating Cost Rates of Payment for Inpatient Hospital Services

I. Background

A. Summary

1. Acute Care Hospital Inpatient Prospective Payment System (IPPS)

Section 1886(d) of the Social Security Act (the Act) sets forth a system of payment for the operating costs of acute care hospital inpatient stays under Medicare Part A (Hospital Insurance) based on prospectively set rates. Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of hospital inpatient stays under a prospective payment system (PPS). Under these PPSs, Medicare payment for hospital inpatient operating and capital-related costs is made at predetermined, specific rates for each hospital discharge. Discharges are classified according to a list of diagnosis- related groups (DRGs).

The base payment rate is comprised of a standardized amount that is divided into a labor-related share and a nonlabor-related share. The labor-related share is adjusted by the wage index applicable to the area where the

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hospital is located; and if the hospital is located in Alaska or Hawaii, the nonlabor-related share is adjusted by a cost-of-living adjustment factor. This base payment rate is multiplied by the DRG relative weight.

If the hospital treats a high percentage of low-income patients, it receives a percentage add-on payment applied to the DRG-adjusted base payment rate. This add-on payment, known as the disproportionate share hospital (DSH) adjustment, provides for a percentage increase in Medicare payments to hospitals that qualify under either of two statutory formulas designed to identify hospitals that serve a disproportionate share of low-income patients. For qualifying hospitals, the amount of this adjustment may vary based on the outcome of the statutory calculations.

If the hospital is an approved teaching hospital, it receives a percentage add-on payment for each case paid under the IPPS (known as the indirect medical education (IME) adjustment). This percentage varies, depending on the ratio of residents to beds.

Additional payments may be made for cases that involve new technologies or medical services that have been approved for special add-on payments. To qualify, a new technology or medical service must demonstrate that it is a substantial clinical improvement over technologies or services otherwise available, and that, absent an add- on payment, it would be inadequately paid under the regular DRG payment.

The costs incurred by the hospital for a case are evaluated to determine whether the hospital is eligible for an additional payment as an outlier case. This additional payment is designed to protect the hospital from large financial losses due to unusually expensive cases. Any outlier payment due is added to the DRG-adjusted base payment rate, plus any DSH, IME, and new technology or medical service add-on adjustments.

Although payments to most hospitals under the IPPS are made on the basis of the standardized amounts, some categories of hospitals are paid the higher of a hospital-specific rate based on their costs in a base year (the higher of FY 1982, FY 1987, or FY 1996) or the IPPS rate based on the standardized amount. For example, sole community hospitals (SCHs) are the sole source of care in their areas, and Medicare- dependent, small rural hospitals (MDHs) are a major source of care for Medicare beneficiaries in their areas. Both of these categories of hospitals are afforded this special payment protection in order to maintain access to services for beneficiaries. (An MDH receives only 50 percent of the difference between the IPPS rate and its hospital- specific rates if the hospital-specific rate is higher than the IPPS rate. In addition, an MDH does not have the option of using FY 1996 as the base year for its hospital-specific rate.)

Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of inpatient hospital services ``in accordance with a prospective payment system established by the Secretary.'' The basic methodology for determining capital prospective payments is set forth in our regulations at 42 CFR 412.308 and 412.312. Under the capital PPS, payments are adjusted by the same DRG for the case as they are under the operating IPPS. Similar adjustments are also made for IME and DSH as under the operating IPPS. In addition, hospitals may receive an outlier payment for those cases that have unusually high costs.

The existing regulations governing payments to hospitals under the IPPS are located in 42 CFR part 412, Subparts A through M. 2. Hospitals and Hospital Units Excluded From the IPPS

Under section 1886(d)(1)(B) of the Act, as amended, certain specialty hospitals and hospital units are excluded from the IPPS. These hospitals and units are: Psychiatric hospitals and units; rehabilitation hospitals and units; long-term care hospitals (LTCHs); children's hospitals; and cancer hospitals. Various sections of the Balanced Budget Act of 1997 (Pub. L. 105-33), the Medicare, Medicaid and SCHIP [State Children's Health Insurance Program] Balanced Budget Refinement Act of 1999 (Pub. L. 106-113), and the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (Pub. L. 106- 554) provide for the implementation of PPSs for rehabilitation hospitals and units (referred to as inpatient rehabilitation facilities (IRFs)), psychiatric hospitals and units (referred to as inpatient psychiatric facilities (IPFs)), and LTCHs, as discussed below. Children's hospitals and cancer hospitals continue to be paid under reasonable cost-based reimbursement.

The existing regulations governing payments to excluded hospitals and hospital units are located in 42 CFR Parts 412 and 413. a. IRFs

Under section 1886(j) of the Act, as amended, rehabilitation hospitals and units (IRFs) have been transitioned from payment based on a blend of reasonable cost reimbursement subject to a hospital-specific annual limit under section 1886(b) of the Act and the adjusted facility Federal prospective payment rate for cost reporting periods beginning January 1, 2002 through September 30, 2002, to payment at 100 percent of the Federal rate effective for cost reporting periods beginning on or after October 1, 2002 (66 FR 41316, August 7, 2001; 67 FR 49982, August 1, 2002; and 68 FR 45674, August 1, 2003). The existing regulations governing payments under the IRF PPS are located in 42 CFR Part 412, Subpart P. b. LTCHs

Under the authority of sections 123(a) and (c) of Pub. L. 106-113 and section 307(b)(1) of Pub. L. 106-554, LTCHs are being transitioned from being paid for inpatient hospital services based on a blend of reasonable cost-based reimbursement under section 1886(b) of the Act to 100 percent of the Federal rate during a 5-year period, beginning with cost reporting periods that start on or after October 1, 2002. For cost reporting periods beginning on or after October 1, 2006, LTCHs will be paid 100 percent of the Federal rate (May 7, 2004 LTCH PPS final rule (69 FR 25674)). LTCHs may elect to be paid based on 100 percent of the Federal rate instead of a blended payment in any year during the 5-year transition period. The existing regulations governing payment under the LTCH PPS are located in 42 CFR Part 412, Subpart O. c. IPFs

Under the authority of sections 124(a) and (c) of Pub. L. 106-113, inpatient psychiatric facilities (IPFs) (formerly psychiatric hospitals and psychiatric units of acute care hospitals) are paid under the new IPF PPS. Under the IPF PPS, some IPFs are transitioning from being paid for inpatient hospital services based on a blend of reasonable cost- based payment and a Federal per diem payment rate, effective for cost reporting periods beginning on or after January 1, 2005 (November 15, 2004 IPF PPS final rule (69 FR 66921)). For cost reporting periods beginning on or after July 1, 2008, IPFs will be paid 100 percent of the Federal per diem payment amount. The existing regulations governing payment under the IPF PPS are located in 42 CFR part 412, subpart N. 3. Critical Access Hospitals (CAHs)

Under sections 1814, 1820, and 1834(g) of the Act, payments are made to critical access hospitals (CAHs) (that is, rural hospitals or facilities that meet certain statutory requirements) for inpatient and outpatient services based

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on 101 percent of reasonable cost. Reasonable cost is determined under the provisions of section 1861(v)(1)(A) of the Act and existing regulations under 42 CFR Parts 413 and 415. 4. Payments for Graduate Medical Education (GME)

Under section 1886(a)(4) of the Act, costs of approved educational activities are excluded from the operating costs of inpatient hospital services. Hospitals with approved graduate medical education (GME) programs are paid for the direct costs of GME in accordance with section 1886(h) of the Act; the amount of payment for direct GME costs for a cost reporting period is based on the hospital's number of residents in that period and the hospital's costs per resident in a base year. The existing regulations governing payments to the various types of hospitals are located in 42 CFR Part 413.

On August 11, 2004, we published a final rule in the Federal Register (69 FR 48916) that implemented changes to the Medicare hospital inpatient prospective payment systems for both operating cost and capital-related costs, as well as changes addressing payments for excluded hospitals and payments for GME costs. Generally these changes were effective for discharges occurring on or after October 1, 2004. On October 7, 2004, we published a document in the Federal Register (69 FR 60242) that corrected technical errors made in the August 11, 2004 final rule. On December 30, 2004, we published another document in the Federal Register (69 FR 78525) that further corrected the August 11, 2004 final rule and the October 7, 2004 correction to that rule, effective January 1, 2005.

B. Major Contents of This Proposed Rule

In this proposed rule, we are setting forth proposed changes to the Medicare IPPS for operating costs and for capital-related costs in FY 2006. We also are setting forth proposed changes relating to payments for GME costs, payments to certain hospitals and units that continue to be excluded from the IPPS and paid on a reasonable cost basis, payments for DSHs, and requirements and payments for CAHs. The changes being proposed would be effective for discharges occurring on or after October 1, 2005, unless otherwise noted.

The following is a summary of the major changes that we are proposing to make: 1. Proposed Changes to the DRG Reclassifications and Recalibrations of Relative Weights

As required by section 1886(d)(4)(C) of the Act, in section II. of this proposed rule, we are proposing annual adjustments to the DRG classifications and relative weights. Based on analyses of Medicare claims data, we are proposing to establish a number of new DRGs and make changes to the designation of diagnosis and procedure codes under other existing DRGs.

The major DRG classification changes we are proposing include:

Reassigning procedure code 35.52 (Repair of atrial septal defect with prosthesis, closed technique) from DRG 108 to DRG 518 (Percutaneous Cardiovascular Procedure Without Coronary Artery Stent or AMI);

Reassigning procedure code 37.26 (Cardiac electrophysiologic stimulation and recording studies) from DRGs 535 and 536 to DRGs 515 (Cardiac Defibrillator Implant Without Cardiac Catheterization);

Splitting DRG 209 into two new DRGs based on the presence or absence of the procedure codes for major joint replacement or reattachment of lower extremity and revision of hip or knee replacement, DRG 545 (Revision of Hip or Knee Replacement) and DRG 544 (Major Joint Replacement or Reattachment of Lower Extremity);

Reassigning procedure code 26.12 (Open biopsy of salivary gland or duct) from DRG 468 to DRG 477 (Nonextensive O.R. Procedure Unrelated To Principal Diagnosis);

Reassigning the principal diagnosis codes for curvature of the spine or malignancy from DRGs 497 and 498 to proposed new DRG 546 (Spinal Fusion Except Cervical with PDX of Curvature of the Spine or Malignancy);

Splitting DRGs 516 and 526 into four new DRGs based on the presence or absence of a CC;

Reassigning procedure code 39.65 (Extracorporeal membrane oxygenation [ECMO]) from DRGs 104 and 105 to DRG 541 (ECMO or Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck Diagnoses With Major Operating Room Procedure).

We also are presenting our reevaluation of certain FY 2005 applicants for add-on payments for high-cost new medical services and technologies, and our analysis of FY 2006 applicants (including public input, as directed by Pub. L. 108-173, obtained in a town hall meeting).

We are proposing the annual update of the long-term care diagnosis- related group (LTC-DRG) classifications and relative weights for use under the LTCH PPS for FY 2006. 2. Proposed Changes to the Hospital Wage Index

In section III. of this preamble, we are proposing revisions to the wage index and the annual update of the wage data. Specific issues addressed include the following:

The FY 2006 wage index update, using wage data from cost reporting periods that began during FY 2002.

The proposed occupational mix adjustment to the wage index that we began to apply effective October 1, 2004.

The proposed revisions to the wage index based on hospital redesignations and reclassifications.

The proposed adjustment to the wage index for FY 2006 based on commuting patterns of hospital employees who reside in a county and work in a different area with a higher wage index.

The timetable for reviewing and verifying the wage data that will be in effect for the proposed FY 2006 wage index. 3. Proposed Revision and Rebasing of the Hospital Market Baskets

In section IV. of this proposed rule, we are proposing rebasing and revising the hospital operating and capital market baskets to be used in developing the FY 2006 update factor for the operating prospective payment rates and the excluded hospital market basket to be used in developing the FY 2006 update factor for the excluded hospital rate-of- increase limits. We are also setting forth the data sources used to determine the revised market basket relative weights and choice of price proxies. 4. Other Decisions and Proposed Changes to the PPS for Inpatient Operating and GME Costs

In section V. of this proposed rule, we discuss a number of provisions of the regulations in 42 CFR Parts 412 and 413 and set forth proposed changes concerning the following:

Solicitation of public comments on two options for possible expansion of the current postacute care transfer policy.

The reporting of hospital quality data as a condition for receiving the full annual payment update increase.

Proposed changes in the payment adjustment for low-volume hospitals.

Proposed IME adjustment for TEFRA hospitals that are converting to IPPS hospitals, and IME FTE resident caps for urban hospitals that are granted

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rural reclassification and then withdraw that rural classification.

Proposed changes to implement section 951 of Pub. L. 108- 173 relating to the provision of patient stay/SSI days data maintained by CMS to hospitals for the purpose of determining their DSH percentage.

Proposed changes relating to hospitals' geographic classifications, including multicampus hospitals and urban group hospital reclassifications.

Proposed changes and clarifications relating to GME, including GME initial residency period limitation, new teaching hospitals' participation in Medicare GME affiliated groups, and the GME FTE cap adjustment for rural hospitals;

Solicitation of public comments on possible changes in requirements for provider-based entities relating to entities the location requirements for certain neonatal intensive care units as off- campus facilities;

Discussion of the second year of implementation of the Rural Community Hospital Demonstration Program; and

Clarification of the definition of a hospital as it relates to ``specialty hospitals'' participating in the Medicare program. 5. PPS for Capital-Related Costs

In section VI. of this proposed rule, we are not proposing any policy changes to the capital-related prospective payment system. For the readers' benefit, we discuss the payment policy requirements for capital-related costs and capital payments to hospitals. 6. Proposed Changes for Hospitals and Hospital Units Excluded From the IPPS

In section VII. of this proposed rule, we discuss the proposed revisions and clarifications concerning excluded hospitals and hospital units, proposed policy changes relating to continued participation by CAHs located in counties redesignated under section 1886(d)(8)(B) of the Act (Lugar counties), and proposed policy changes relating to designation of CAHs as necessary providers. 7. Proposed Changes in Payment for Blood Clotting Factor

In section VIII of this proposed rule, we discuss the proposed change in payment for blood clotting factor administered to inpatients with hemophilia for FY 2006. 8. Determining Prospective Payment Operating and Capital Rates and Rate-of-Increase Limits

In the Addendum to this proposed rule, we set forth proposed changes to the amounts and factors for determining the FY 2006 prospective payment rates for operating costs and capital-related costs. We also establish the proposed threshold amounts for outlier cases. In addition, we address the proposed update factors for determining the rate-of-increase limits for cost reporting periods beginning in FY 2006 for hospitals and hospital units excluded from the PPS. 9. Impact Analysis

In Appendix A of this proposed rule, we set forth an analysis of the impact that the proposed changes would have on affected hospitals. 10. Recommendation of Update Factor for Hospital Inpatient Operating Costs

In Appendix B of this proposed rule, as required by sections 1886(e)(4) and (e)(5) of the Act, we provided our recommendations of the appropriate percentage changes for FY 2006 for the following:

A single average standardized amount for all areas for hospital inpatient services paid under the IPPS for operating costs (and hospital-specific rates applicable to SCHs and MDHs).

Target rate-of-increase limits to the allowable operating costs of hospital inpatient services furnished by hospitals and hospital units excluded from the IPPS. 11. Discussion of Medicare Payment Advisory Commission Recommendations

Under section 1805(b) of the Act, the Medicare Payment Advisory Commission (MedPAC) is required to submit a report to Congress, no later than March 1 of each year, in which MedPAC reviews and makes recommendations on Medicare payment policies. MedPAC's March 2005 recommendation concerning hospital inpatient payment policies addressed only the update factor for inpatient hospital operating costs and capital-related costs under the IPPS and for hospitals and distinct part hospital units excluded from the IPPS. This recommendation is addressed in Appendix B of this proposed rule. MedPAC issued a second Report to Congress: Physician-Owned Specialty Hospitals, March 2005, which addressed other issues relating to Medicare payments to hospitals for inpatient services. The recommendations on these issues from this second report are addressed in section IX. of this preamble. For further information relating specifically to the MedPAC March 2005 reports or to obtain a copy of the reports, contact MedPAC at (202) 220-3700 or visit MedPAC's Web site at: http://www.medpac.gov.

II. Proposed Changes to DRG Classifications and Relative Weights

A. Background

Section 1886(d) of the Act specifies that the Secretary shall establish a classification system (referred to as DRGs) for inpatient discharges and adjust payments under the IPPS based on appropriate weighting factors assigned to each DRG. Therefore, under the IPPS, we pay for inpatient hospital services on a rate per discharge basis that varies according to the DRG to which a beneficiary's stay is assigned. The formula used to calculate payment for a specific case multiplies an individual hospital's payment rate per case by the weight of the DRG to which the case is assigned. Each DRG weight represents the average resources required to care for cases in that particular DRG, relative to the average resources used to treat cases in all DRGs.

Congress recognized that it would be necessary to recalculate the DRG relative weights periodically to account for changes in resource consumption. Accordingly, section 1886(d)(4)(C) of the Act requires that the Secretary adjust the DRG classifications and relative weights at least annually. These adjustments are made to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources. The proposed changes to the DRG classification system and the recalibration of the DRG weights for discharges occurring on or after October 1, 2005, are discussed below.

B. DRG Reclassifications

(If you choose to comment on issues in this section, please include the caption ``DRG Reclassifications'' at the beginning of your comment.) 1. General

Cases are classified into DRGs for payment under the IPPS based on the principal diagnosis, up to eight additional diagnoses, and up to six procedures performed during the stay. In a small number of DRGs, classification is also based on the age, sex, and discharge status of the patient. The diagnosis and procedure information is reported by the hospital using codes from the International

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Classification of Diseases, Ninth Revision, Clinical Modification (ICD- 9-CM).

The process of forming the DRGs was begun by dividing all possible principal diagnoses into mutually exclusive principal diagnosis areas referred to as Major Diagnostic Categories (MDCs). The MDCs were formed by physician panels as the first step toward ensuring that the DRGs would be clinically coherent. The diagnoses in each MDC correspond to a single organ system or etiology and, in general, are associated with a particular medical specialty. Thus, in order to maintain the requirement of clinical coherence, no final DRG could contain patients in different MDCs. Most MDCs are based on a particular organ system of the body. For example, MDC 6 is Diseases and Disorders of the Digestive System. This approach is used because clinical care is generally organized in accordance with the organ system affected. However, some MDCs are not constructed on this basis because they involve multiple organ systems (for example, MDC 22 (Burns)). For FY 2005, cases are assigned to one of 519 DRGs in 25 MDCs. The table below lists the 25 MDCs.

[GRAPHIC] [TIFF OMITTED] TP04MY05.000

In general, cases are assigned to an MDC based on the patient's principal diagnosis before assignment to a DRG. However, for FY 2005, there are nine DRGs to which cases are directly assigned on the basis of ICD-9-CM procedure codes. These DRGs are for heart transplant or implant of heart assist systems, liver and/or intestinal transplants, bone marrow, lung, simultaneous pancreas/kidney, and pancreas transplants and for tracheostomies. Cases are assigned to these DRGs before they are classified to an MDC. The table below lists the current nine pre-MDCs.

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[GRAPHIC] [TIFF OMITTED] TP04MY05.001

Once the MDCs were defined, each MDC was evaluated to identify those additional patient characteristics that would have a consistent effect on the consumption of hospital resources. Since the presence of a surgical procedure that required the use of the operating room would have a significant effect on the type of hospital resources used by a patient, most MDCs were initially divided into surgical DRGs and medical DRGs. Surgical DRGs are based on a hierarchy that orders operating room (O.R.) procedures or groups of O.R. procedures by resource intensity. Medical DRGs generally are differentiated on the basis of diagnosis and age (less than or greater than 17 years of age). Some surgical and medical DRGs are further differentiated based on the presence or absence of a complication or a comorbidity (CC).

Generally, nonsurgical procedures and minor surgical procedures that are not usually performed in an operating room are not treated as O.R. procedures. However, there are a few non-O.R. procedures that do affect DRG assignment for certain principal diagnoses, for example, extracorporeal shock wave lithotripsy for patients with a principal diagnosis of urinary stones.

Once the medical and surgical classes for an MDC were formed, each class of patients was evaluated to determine if complications, comorbidities, or the patient's age would consistently affect the consumption of hospital resources. Physician panels classified each diagnosis code based on whether the diagnosis, when present as a secondary condition, would be considered a substantial complication or comorbidity.

A substantial complication or comorbidity was defined as a condition, which because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least one day in at least 75 percent of the patients. Each medical and surgical class within an MDC was tested to determine if the presence of any substantial comorbidities or complications would consistently affect the consumption of hospital resources.

The actual process of forming the DRGs was, and continues to be, highly iterative, involving a combination of statistical results from test data combined with clinical judgment. In deciding whether to create a separate DRG, we consider whether the resource consumption and clinical characteristics of the patients with a given set of conditions are significantly different than the remaining patients in the DRG. We evaluate patient care costs using average charges and length of stay as proxies for costs and rely on the judgment of our medical officers to decide whether patients are distinct or clinically similar to other patients in the DRG. In evaluating resource costs, we consider both the absolute and percentage differences in average charges between the cases we are selecting for review and the remainder of cases in the DRG. We also consider variation in charges within these groups; that is, whether observed average differences are consistent across patients or attributable to cases that are extreme in terms of charges or length of stay, or both. Further, we also consider the number of patients who will have a given set of characteristics and generally prefer not to create a new DRG unless it will include a substantial number of cases. As we explain in more detail in section IX. of this preamble, MedPAC has made a number of recommendations regarding the DRG system. As part of our review and analysis of MedPAC's recommendations, we will consider whether to establish guidelines for making DRG reclassification decisions.

A patient's diagnosis, procedure, discharge status, and demographic information is fed into the Medicare claims processing systems and subjected to a series of automated screens called the Medicare Code Editor (MCE). The MCE screens are designed to identify cases that require further review before classification into a DRG.

After patient information is screened through the MCE and any further development of the claim is conducted, the cases are classified into the appropriate DRG by the Medicare GROUPER software program. The GROUPER program was developed as a means of classifying each case into a DRG on the basis of the diagnosis and procedure codes and, for a limited number of DRGs, demographic information (that is, sex, age, and discharge status).

After cases are screened through the MCE and assigned to a DRG by the GROUPER, the PRICER software calculates a base DRG payment. The PRICER calculates the payments for each case covered by the IPPS based on the DRG relative weight and additional factors associated with each hospital, such as IME and DSH adjustments. These additional factors increase the payment amount to hospitals above the base DRG payment.

The records for all Medicare hospital inpatient discharges are maintained in the Medicare Provider Analysis and

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Review (MedPAR) file. The data in this file are used to evaluate possible DRG classification changes and to recalibrate the DRG weights. However, in the July 30, 1999 IPPS final rule (64 FR 41500), we discussed a process for considering non-MedPAR data in the recalibration process. In order for us to consider using particular non-MedPAR data, we must have sufficient time to evaluate and test the data. The time necessary to do so depends upon the nature and quality of the non-MedPAR data submitted. Generally, however, a significant sample of the non-MedPAR data should be submitted by mid-October for consideration in conjunction with the next year's proposed rule. This allows us time to test the data and make a preliminary assessment as to the feasibility of using the data. Subsequently, a complete database should be submitted by early December for consideration in conjunction with the next year's proposed rule.

Many of the changes to the DRG classifications are the result of specific issues brought to our attention by interested parties. We encourage individuals with concerns about DRG classifications to bring those concerns to our attention in a timely manner so they can be carefully considered for possible inclusion in the next proposed rule and if included, may be subjected to public review and comment. Therefore, similar to the timetable for interested parties to submit non-MedPAR data for consideration in the DRG recalibration process, concerns about DRG classification issues should be brought to our attention no later than early December in order to be considered and possibly included in the next annual proposed rule updating the IPPS.

The changes we are proposing to the DRG classification system for FY 2006 for the FY 2006 GROUPER, version 23.0 and to the methodology used to recalibrate the DRG weights are set forth below. Unless otherwise noted in this proposed rule, our DRG analysis is based on data from the December 2004 update of the FY 2004 MedPAR file, which contains hospital bills received through December 31, 2004 for discharges in FY 2004. 2. Pre-MDC: Intestinal Transplantation

In the FY 2005 IPPS final rule (69 FR 48976), we moved intestinal transplantation cases that were assigned to ICD-9-CM procedure code 46.97 (Transplant of intestine) out of DRG 148 (Major Small and Large Bowel Procedures with CC) and DRG 149 (Major Small and Large Bowel Procedures Without CC) and into DRG 480 (Liver Transplant). We also changed the title for DRG 480 to ``Liver Transplant and/or Intestinal Transplant.'' We moved these cases out of DRGs 148 and 149 because our analysis demonstrated that the average charges for intestinal transplants are significantly higher than the average charges for other cases in these DRGs. We stated at that time that we would continue to monitor these cases.

Based on our review of the FY 2004 MedPAR data, we found 959 cases assigned to DRG 480 with overall average charges of approximately $165,622. There were only three cases involving an intestinal transplant alone and one case in which both an intestinal transplant and a liver transplant were performed. The average charges for the intestinal transplant cases ($138,922) were comparable to the average charges for the liver transplant cases ($165,314), while the remaining combination of an intestinal transplant and a liver transplant case had much higher charges ($539,841), and would be paid as an outlier case. Therefore, we are not proposing any DRG modification for intestinal transplantation cases at this time.

We note that an institution that performs intestinal transplantation, in correspondence to us written following the publication of the FY 2005 IPPS final rule, agreed with our decision to move cases assigned to code 46.97 to DRG 480. 3. MDC 1 (Diseases and Disorders of the Nervous System) a. Strokes

In 1996, the Food and Drug Administration (FDA) approved the use of tissue plasminogen activator (tPA), one type of thrombolytic agent that dissolves blood clots. In 1998, the ICD-9-CM Coordination and Maintenance Committee created code 99.10 (Injection or infusion of thrombolytic agent) in order to be able to uniquely identify the administration of thrombolytic agents. Studies have shown that tPA can be effective in reducing the amount of damage the brain sustains during an ischemic stroke, which is caused by blood clots that block blood flow to the brain. The use of tPA is approved for patients who have blood clots in the brain, but not for patients who have a bleeding or hemorrhagic stroke. Thrombolytic therapy has been shown to be most effective when used within the first 3 hours after the onset of a stroke, and it is contraindicated in hemorrhagic stroke. The presence or absence of code 99.10 does not currently influence DRG assignment. Since code 99.10 became effective, we have been monitoring the DRGs and cases in which this code can be found, particularly with respect to cardiac and stroke DRGs.

Last year, we met with representatives from several hospital stroke centers who recommended modification of the existing stroke DRGs 14 (Intracranial Hemorrhage or Cerebral Infarction) and 15 (Nonspecific CVA and Precerebral Occlusion Without Infarction) by using the administration of tPA as a proxy to identify patients who have severe strokes. The representatives stated that using tPA as a proxy for the more severely ill stroke patient would recognize the higher charges these cases generate because of their higher hospital resource utilization.

The stroke representatives made two suggestions concerning DRGs 14 and 15. First, they proposed modifying DRG 14 by renaming it ``Ischemic Stroke Treatment with a Reperfusion Agent,'' and including only those cases containing code 99.10. The remainder of stroke cases where the patient was not treated with a reperfusion agent would be included in DRG 15, which would be renamed ``Hemorrhagic Stroke or Ischemic Stroke without a Reperfusion Agent.'' Hemorrhagic stroke cases now found in DRG 14 that are not treated with a reperfusion agent would migrate to DRG 15.

The second suggestion was to leave DRGs 14 and 15 as they currently exist, and create a new DRG, with a recommended title ``Ischemic Stroke Treatment with a Reperfusion Agent.'' This suggested DRG would only include strokes caused by clots, not by hemorrhages, and would include the administration of tPA, identified by procedure code 99.10.

We have examined the MedPAR data for the cases in DRGs 14 and 15, and have divided the cases based on the presence of a principal diagnosis of hemorrhage or occlusive ischemia, and the presence of procedure code 99.10. The following table displays the results:

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[GRAPHIC] [TIFF OMITTED] TP04MY05.002

The above table shows that the average standardized charges for cases treated with a reperfusion agent are more than $16,000 and $10,000 higher than all other cases in DRGs 14 and 15, respectively. While these data suggest that patients treated with a reperfusion agent are more expensive than all other stroke patients, this conclusion is based on a small number of cases. At this time, we are not proposing a change to the stroke DRGs because of this concern. However, we believe it is possible that more patients are being treated with a reperfusion agent than indicated by our data because the presence of code 99.10 does not affect DRG assignment and may be underreported.

We invite public comment on the changes to DRGs 14 and 15 suggested by the hospital representatives. In addition, we are interested in public comment on the number of patients currently being treated with a reperfusion agent as well as the potential costs of these patients relative to others with strokes that are also included in DRGs 14 and 15. b. Unruptured Cerebral Aneurysms

In the FY 2004 IPPS final rule (68 FR 45353), we created DRG 528 (Intracranial Vascular Procedures With a Principal Diagnosis of Hemorrhage) in MDC 1. We received a comment at that time that suggested we create another DRG for intracranial vascular procedures for unruptured cerebral aneurysms. For the FY 2004 IPPS final rule (68 FR 45353) and the FY 2005 IPPS final rule (69 FR 48957), we evaluated the data for cases in the MedPAR file involving unruptured cerebral aneurysms assigned to DRG 1 (Craniotomy Age >17 With CC) and DRG 2 (Craniotomy Age >17 Without CC) and concluded that the average charges were consistent with those for other cases found in DRGs 1 and 2. Therefore, we did not propose a change to the DRG assignment for unruptured cerebral aneurysms.

We have reviewed the latest data for unruptured cerebral aneurysms cases. In our analysis of the FY 2004 MedPAR data, we found 1,136 unruptured cerebral aneurysm cases assigned to DRG 1 and 964 unruptured cerebral aneurysm cases assigned to DRG 2. Although the average charges for the unruptured cerebral aneurysm cases in DRG 1 ($53,455) and DRG 2 ($34,028) were slightly higher than the average charges for all cases in DRG 1 ($51,466) and DRG 2 ($30,346), we do not believe these differences are significant enough to warrant a change in these two DRGs at this time. Therefore, we are not proposing a change in the structure of these DRGs relating to unruptured cerebral aneurysm cases for FY 2006. 4. MDC 5 (Diseases and Disorders of the Circulatory System) a. Automatic Implantable Cardioverter/Defibrillator

As part of our annual review of DRGs, for FY 2006, we performed a review of cases in the FY 2004 MedPAR file involving the implantation of a defibrillator in the following DRGs:

DRG 515 (Cardiac Defibrillator Implant Without Cardiac Catheterization).

DRG 535 (Cardiac Defibrillator Implant With Cardiac Catheterization With Acute Myocardial Infarction, Heart Failure, or Shock).

DRG 536 (Cardiac Defibrillator Implant With Cardiac Catheterization Without Acute Myocardial Infarction, Heart Failure, or Shock).

While conducting our review, we noted that there had been considerable comments from hospital coders on code 37.26 (Cardiac electrophysiologic stimulation and recording studies (EPS)), which is included in these DRGs. These comments from hospital coders were directed at both CMS and the American Hospital Association. The procedure codes for these three DRGs describe the procedures that are considered to be a cardiac catheterization. Code 37.26 is classified as a cardiac catheterization within these DRGs. Therefore, the submission of code

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37.26 affects the DRG assignment for defibrillator cases and leads to the assignment of DRGs 535 or 536. When a cardiac catheterization is performed, the case is assigned to DRGs 535 or 536, depending on whether or not the patient also had an acute myocardial infarction, heart failure, or shock. The following chart shows the number of cases in each DRG, along with their average length of stay and average charges, found in the data:

[GRAPHIC] [TIFF OMITTED] TP04MY05.003

We have received a number of questions from hospital coders regarding the correct use of code 37.26. There is considerable confusion about whether or not code 37.26 should be reported when the procedure is performed as part of the defibrillator implantation. Currently, the ICD-9-CM instructs the coder not to report code 37.26 when a defibrillator is inserted. There is an inclusion term under the defibrillator code 37.94 (Implantation or replacement of automatic cardioverter/defibrillator, total system [AICD]) which states that EPS is included in code 37.94. We discussed modifying this instruction at the October 7-8, 2004 meeting of the ICD-9-CM Coordination and Maintenance Committee. We received a number of comments opposing a modification to the use of code 37.26 to also allow it to be reported with an AICD insertion. A report of this meeting can be found on the Web site: http://www.cms.hhs.gov/paymentsystem/icd9.

We performed an analysis of cases within DRGs 535 and 536 with cardiac catheterization and with and without code 37.26 and with code 37.26 only reported without cardiac catheterization and found the following:

[GRAPHIC] [TIFF OMITTED] TP04MY05.004

The data show that when code 37.26 is the only procedure reported from the list of cardiac catheterizations, the average charges and the average length of stay are considerably lower. For example, the average standardized charges for a defibrillator implant with only an EPS are $85,390.88 in DRG 536, while the average standardized charges for DRG 536 with a cardiac catheterization, but not an EPS, are $110,493.86. The average standardized charges for all cases in DRG 536 are $94,453.62. The data show similar findings for DRG 535, with lower lengths of stay and average charges when the only code reported from the cardiac catheterization list is an EPS. When we also consider that there may be some coding problems in the use of code 37.26, we believe it is appropriate to propose a modification to these DRGs.

Data reflected in the chart above show that the average standardized charges for DRG 515 were $83,659.76. These average charges are closer to those in DRG 536 with code 37.26 and without any other cardiac catheterization code reported. While the cases in DRG 535 with code 37.26 and without a cardiac catheterization have higher average charges than the average charges for cases in DRG 515, these cases have much lower average charges than the average charges for overall cases in DRG 535. For these reasons, we are proposing to remove code 37.26 from the list of cardiac catheterizations for DRGs 535 and 536. If a defibrillator is implanted and an EPS is performed with no other type of cardiac catheterization, the case would be assigned to DRG 515.

CMS issued a National Coverage Determination for implantable cardioverter defibrillators, effective January 27, 2005, that expands coverage and requires, in certain cases, that patient data be reported when the defibrillator is implanted for the clinical indication of primary prevention of sudden cardiac death. The submission of data on patients receiving an implantable cardioverter defibrillator for primary prevention to a data collection system is needed for the determination that the implantable cardioverter

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defibrillator is reasonable and necessary and for quality improvement. These data will be made available in some form to providers and practitioners to inform their decisions, monitor performance quality, and benchmark and identify best practices. We made a temporary registry available for use when the policy became effective and used the Quality Net Exchange for data submission because Medicare-participating hospitals already use the Exchange to report data.

We intend to transition from the temporary registry using the Quality Net Exchange to a more sophisticated follow-on registry that will have the ability to collect longitudinal data. Some providers have suggested that CMS increase reimbursement for implantable cardioverter defibrillators to compensate the provider for reporting data. ICD data reporting includes elements of patient demographics, clinical characteristics and indications, medications, provider information, and complications. Since these data elements are commonly found in patient medical records, it is CMS' expectation that these data are readily available to the individuals abstracting and reporting data. Therefore, we believe that increased reimbursement is not needed at this time. b. Coronary Artery Stents

In the FY 2005 IPPS final rule (69 FR 48971 through 48974), we addressed two comments from industry representatives about the DRG assignments for coronary artery stents. These commenters had expressed concern about whether the reimbursement for stents is adequate, especially for insertion of multiple stents. They also expressed concern about whether the current DRG structure represents the most clinically coherent classification of stent cases.

The current DRG structure incorporates stent cases into the following two pairs of DRGs, depending on whether bare metal or drug- eluting stents are used and whether acute myocardial infarction (AMI) is present:

DRG 516 (Percutaneous Cardiovascular Procedures with AMI).

DRG 517 (Percutaneous Cardiovascular Procedures with Nondrug-Eluting Stent without AMI).

DRG 526 (Percutaneous Cardiovascular Procedures with Drug- Eluting Stent with AMI).

DRG 527 (Percutaneous Cardiovascular Procedures with Drug- Eluting Stent without AMI).

The commenters presented two recommendations for refinement and restructuring of the current coronary stent DRGs. One of the recommendations involved restructuring these DRGs to create two additional stent DRGs that are closely patterned after the existing pairs, and would reflect insertion of multiple stents with and without AMI. The commenters recommended incorporating either stenting code 36.06 (Insertion of nondrug-eluting coronary artery stent(s)) or code 36.07 (Insertion of drug-eluting coronary artery stent(s)) when they are reported along with code 36.05 (Multiple vessel percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy performed during the same operation, with or without mention of thrombolytic agent). The commenter's first concern was that hospitals may be steering patients toward coronary artery bypass graft surgery in place of stenting in order to avoid significant financial losses due to what it considered the inadequate reimbursement for inserting multiple stents.

In our response to comments in the FY 2005 IPPS final rule, we indicated that it was premature to act on this recommendation because the current coding structure for coronary artery stents cannot distinguish cases in which multiple stents are inserted from those in which only a single stent is inserted. Current codes are able to identify performance of PTCA in more than one vessel by use of code 36.05. However, while this code indicates that PTCA was performed in more than one vessel, its use does not reflect the exact number of procedures performed or the exact number of vessels treated. Similarly, when codes 36.06 and 36.07 are used, they document the insertion of at least one stent. However, these stenting codes do not identify how many stents were inserted in a procedure, nor distinguish insertion of a single stent from insertion of multiple stents. Even the use of one of the stenting codes in conjunction with multiple-PTCA code 36.05 does not distinguish insertion of a single stent from multiple stents. The use of code 36.05 in conjunction with code 36.06 or code 36.07 indicates only performance of PTCA in more than one vessel, along with insertion of at least one stent. The precise numbers of PTCA-treated vessels, the number of vessels into which stents were inserted, and the total number of stents inserted in all treated vessels cannot be determined. Therefore, the capabilities of the current coding structure do not permit the distinction between single and multiple vessel stenting that would be required under the recommended restructuring of the coronary stent DRGs.

We agree that the DRG classification of cases involving coronary stents must be clinically coherent and provide for adequate reimbursement, including those cases requiring multiple stents. For this reason, we created four new ICD-9-CM codes identifying multiple stent insertion (codes 00.45, 00.46, 00.47, and 00.48) and four new codes identifying multiple vessel treatment (codes 00.40, 00.41, 00.42, and 00.43) at the October 7, 2004 ICD-9-CM Coordination and Maintenance Committee Meeting. These eight new codes can be found in Table 6B of this proposed rule. We have worked closely with the coronary stent industry and the clinical community to identify the most logical code structure to identify new codes for both multiple vessel and multiple stent use. Effective October 1, 2005, code 36.05 will be deleted and the eight new codes will be used in its place. Coders are encouraged to use as many codes as necessary to describe each case, using one code to describe the angioplasty or atherectomy, and one code each for the number of vessels treated and the number of stents inserted. Coders are encouraged to record codes accurately, as these data will potentially be the basis for future DRG restructuring. While we agree that use of multiple vessel and stent codes will provide useful information in the future on hospital costs associated with percutaneous coronary procedures, we believe it remains premature to proceed with a restructuring of the current coronary stent DRGs on the basis of the number of vessels treated or the number of stents inserted, or both, in the absence of data reflecting use of this new coding structure.

The commenter's second recommendation was that we distinguish ``complex'' from ``noncomplex'' cases in the stent DRGs by expanding the higher weighted DRGs (516 and 526) to include conditions other than AMI. The commenter recommended recognizing certain comorbid and complicating conditions, including hypertensive renal failure, congestive heart failure, diabetes, arteriosclerotic cardiovascular disease, cerebrovascular disease, and certain procedures such as multiple vessel angioplasty or atherectomy (as evidenced by the presence of procedure code 36.05), as indicators of complex cases for this purpose. Specifically, the commenters recommended replacing the current structure with the following four DRGs:

Recommended restructured DRG 516 (Complex percutaneous

[[Page 23319]]

cardiovascular procedures with non-drug-eluting stents).

Recommended restructured DRG 517 (Noncomplex percutaneous cardiovascular procedures with non-drug-eluting stents).

Recommended restructured DRG 526 (Complex percutaneous cardiovascular procedures with drug-eluting stents).

Recommended restructured DRG 527 (Noncomplex percutaneous cardiovascular procedures with drug-eluting stents).

The commenter argued that this structure would provide an improvement in both clinical and resource coherence over the current structure that classifies cases according to the type of stent inserted and the presence or absence of AMI alone, without considering other complicating conditions. The commenter also presented an analysis, based on previous MedPAR data, that evaluated charges and lengths of stay for cases with expected high resource use and reclassified cases into its recommended new structure of paired ``complex'' and ``noncomplex'' DRGs. The commenter's analysis showed some evidence of clinical and resource coherence in the recommended DRG structure. However, we did not adopt the proposal in the FY 2005 IPPS final rule. First, the data presented by the commenter still represented preliminary experience under a relatively new DRG structure. Second, the analysis did not reveal significant gains in resource coherence compared to existing DRGs for stenting cases. Therefore, we were reluctant to adopt this approach because of comments and concern about whether the overall level of payment in the coronary stent DRGs was adequate. However, we indicated that this issue deserved further study and consideration, and that we would conduct an analysis of this recommendation and other approaches to restructuring these DRGs with updated data in the FY 2006 proposed rule.

This year, we have analyzed the MedPAR data to determine the impact of certain secondary diagnoses or complicating conditions on the four DRGs cited above. Specifically, we examined the data in DRGs 516, 517, 526, and 527, based on the presence of coronary stents (codes 36.06 and 36.07) and the following additional diagnoses:

Congestive heart failure (represented by codes 398.91 (Rheumatic heart failure (congestive)), 402.01 (Hypertensive heart disease, malignant, with heart failure), 402.11, (Hypertensive heart disease, benign, with heart failure), 402.91 (Hypertensive heart disease, unspecified, with heart failure), 404.01 (Hypertensive heart and renal disease, malignant, with heart failure), 404.03 (Hypertensive heart and renal disease, malignant, with heart failure and renal failure), 404.11 (Hypertensive heart and renal disease, benign, with heart failure), 404.13 (Hypertensive heart and renal disease, benign, with heart failure and renal failure), 404.91 (Hypertensive heart and renal disease, unspecified, with heart failure), 404.93 (Hypertensive heart and renal disease, unspecified, with heart failure and renal failure), 428.0 (Congestive heart failure, unspecified), and 428.1 (Left heart failure)).

Arteriosclerotic cardiovascular disease (represented by code 429.2 (Cardiovascular disease, unspecified)).

Cerebrovascular disease (represented by codes 430.0 (Subarachnoid hemorrhage), 431.0 (Intracerebral hemorrhage), 432.0 (Nontraumatic extradural hemorrhage), 432.1, Subdural hemorrhage, 432.9, (Unspecified intracranial hemorrhage), 433.01 (Occlusion and stenosis of basilar artery, with cerebral infarction), 433.11 (Occlusion and stenosis of carotid artery, with cerebral infarction), 433.21 (Occlusion and stenosis of vertebral artery, with cerebral infarction), 433.31 (Occlusion and stenosis of multiple and bilateral precerebral arteries, with cerebral infarction), 433.81 (Occlusion and stenosis of other specified precerebral artery, with cerebral infarction), 434.01 (Cerebral thrombosis with cerebral infarction), 434.11 (Cerebral embolism with cerebral infarction), 434.91 (Cerebral artery occlusion with cerebral infarction, unspecified), 436.0 (Acute, but ill-defined, cerebrovascular disease)).

Secondary diagnosis of acute myocardial infarction (represented by codes 410.01 (Acute myocardial infarction of anterolateral wall, initial episode of care), 410.11 (Acute myocardial infarction of other anterior wall, initial episode of care), 410.21 (Acute myocardial infarction of inferolateral wall, initial episode of care), 410.31 (Acute myocardial infarction of inferoposterior wall, initial episode of care), 410.41 (Acute myocardial infarction of other inferior wall, initial episode of care), 410.51 (Acute myocardial infarction of other lateral wall, initial episode of care), 410.61 (True posterior wall infarction, initial episode of care), 410.71 (Subendocardial infarction, initial episode of care), 410.81 (Acute myocardial infarction of other specified sites, initial episode of care), 410.91 (Acute myocardial infarction of unspecified site, initial episode of care)).

Renal failure (represented by codes 403.01 (Hypertensive renal disease, malignant, with renal failure), 403.11 (Hypertensive renal disease, benign, with renal failure), 403.91 (Hypertensive renal disease, unspecified, with renal failure), 585.0 (Chronic renal failure), V42.0 (Organ or tissue replaced by transplant, kidney), V45.1 (Renal dialysis status), V56.0 (Extracorporeal dialysis), V56.1 (Fitting and adjustment of extracorporeal dialysis catheter), V56.2 (Fitting and adjustment of peritoneal dialysis catheter)). Any renal failure with congestive heart failure will be captured in the 404.xx codes listed above.

We reviewed the cases in the four coronary stent DRGs and found that most of the additional or ``complicated'' cases did, in fact, have higher average charges in most instances. However, these results could potentially be duplicated for many DRGs, or sets of DRGs, within the PPS structure. That is, cases with selected complicating factors will tend to have higher average lengths of stay and average charges than cases without those complicating factors. Since cases with the selected complicating factors necessarily contain sicker patients, longer lengths of stay and higher average charges are to be expected. For example, cases in which patients with a cardiac condition also have renal failure are quite likely to consume higher resources than patients only with a cardiac condition. In addition, selectively recognizing the recommended secondary diagnoses or complicating conditions raises some issues related to the logic and structural integrity of the DRG system. Generally, we have taken into account the higher costs of cases with complications by maintaining a general list of comorbidities and complications (the CC) list), and, where appropriate, distinguishing pairs of DRGs by ``with and without CCs.'' (This system also specifies exclusions from each pair, to account for cases where a condition on the CC list is an expected and normal constituent of the diagnoses reflected in the paired DRGs.) In order to maintain the basic DRG body-system structure, we have not employed special lists of procedures and diagnoses from one MDC to make determinations about the structure of DRGs in another MDC. The recommended restructuring of the coronary stent DRGs is inconsistent with this principle and may create a new precedent of selecting specific comorbidities and complications to restructure DRGs. For example, the

[[Page 23320]]

presence of code 403.11 (Hypertensive renal disease, malignant, with renal failure) may distinguish cases with higher average charges, but the same argument could be raised for many other procedures across other MDCs.

Rather than establishing such a precedent, we are proposing to restructure the coronary stent DRGs on the basis of the standard CC list to differentiate cases that require greater resources. We believe this list to be more inclusive of true comorbid or complicating conditions than selection of specific secondary diagnosis codes. Therefore, restructuring these DRGs on this basis would result in a logical arrangement of cases with regard to both clinical coherence and resource consumption. We have compared the existing CC list with the list of the codes recommended by the commenter as secondary diagnoses. All of the recommended codes already appear on the CC list except for codes 429.2, 432.9, V56.1, and V56.2. Code 429.2 represents a very vague diagnosis (arteriosclerotic cardiovascular disease (ASCVD)). Code 432.9 represents a nonspecific principal diagnosis that is rejected by the MCE when reported as the principal diagnosis. Codes V56.1 and V56.2 describe conditions relating to dialysis for renal failure. Therefore, we believe that our proposal to utilize the existing CC list would encompass most of the cases on the recommended list, as well as other cases with additional CCs requiring additional resources. We have examined the MedPAR data for the cases in the coronary stent DRGs, distinguishing cases that include CCs and those that do not. The following table displays the results:

[GRAPHIC] [TIFF OMITTED] TP04MY05.005

The data show a clear differentiation in average charges between the cases in DRG 516 and 526 ``with CC'' and those ``without CC.'' Therefore, the data suggest that a ``with and without CC'' split in DRG 516 and 526 is warranted. At the same time, the data do not show such a clear differentiation, in either average charges or lengths of stay, among the cases in DRGs 517 and 527.

Therefore, we are proposing to delete DRGs 516 and 526, and to substitute four new DRGs in their place. These new DRGs would be patterned after existing DRGs 516 and 526, except that they would be split based on the presence or absence of a secondary diagnosis on the existing CC list. Specifically, we are proposing to create DRG 547 (Percutaneous Cardiovascular Procedure with AMI with CC), DRG 548 (Percutaneous Cardiovascular Procedure with AMI without CC), DRG 549 (Percutaneous Cardiovascular Procedure with Drug-Eluting Stent with AMI with CC), and DRG 550 (Percutaneous Cardiovascular Procedure with Drug- Eluting Stent with AMI without CC). As we noted above, the MedPAR data do not support restructuring DRGs 517 and 527 based on the presence or absence of a CC. Therefore, we are proposing to retain these two DRGs in their current forms. We believe this revised structure will result in a more inclusive and comprehensive array of cases within MDC 5 without selectively recognizing certain secondary diagnoses as ``complex.''

While we are proposing some restructuring of the coronary stent DRGs for FY 2006, it is important to note that we will continue to monitor and analyze clinical and resource trends in this area. For example, we have found indications in the current data that treatment may be moving toward use of drug-eluting stents, and away from use of bare metal stents. Specifically, cases in DRGs 516 and 517, which utilize bare metal stents, comprise only 44.4 percent, or less than half, of the cases in the four coronary stent DRGs in the MedPAR data we analyzed. As use of drug-eluting stents becomes the standard of treatment, we may consider over time whether to dispense with the distinction between these stents and the older bare metal stent technology in the structure of the coronary stent DRGs. In addition, we will continue to consider whether the structure of these DRGs ought to reflect differences in the number of vessels treated or the number of stents inserted, or both. As we discussed above, a new coding structure capable of identifying multiple vessel treatment and the insertion of multiple stents will go into effect on October 1, 2005. It remains premature to restructure the coronary stent DRGs on the basis of the number of vessels treated or the number of stents inserted, or both, until data reflecting the use of these new codes become available. However, we will analyze those data when they become available in order to determine whether a restructuring based on multiple vessel treatment or insertion of multiple stents, or both, is warranted. Our proposal to restructure two of the current coronary stent DRGs into paired ``with and without CC'' DRGs for FY 2006 does not preclude proposals in subsequent years to restructure the coronary stent DRGs in one or both of these ways.

[[Page 23321]]

c. Insertion of Left Atrial Appendage Device

Atrial fibrillation is a common heart rhythm disorder that can lead to a cardiovascular blood clot formation leading to increased risk of stroke. According to product literature, nearly all strokes are from embolic clots arising in the left atrial appendage of the heart: an appendage for which there is no useful function. Standard therapy uses anticoagulation drugs. However, these drugs may be contraindicated in certain patients and may cause complications such as bleeding. The underlying concept behind the left atrial appendage device is to block off the left atrial appendage, so that the blood clots formed therein cannot travel to other sites in the vascular system. The device is implanted using a percutaneous catheter procedure under fluoroscopy through the femoral vein. Implantation is performed in a hospital catheterization laboratory using standard transseptal technique, with the patient generally under local anesthesia. The procedure takes approximately 1 hour, and most patients stay overnight in the hospital.

In the FY 2005 IPPS final rule (69 FR 48978, August 11, 2004), we discussed the DRG assignment of new ICD-9-CM procedure code 37.90 (Insertion of left atrial appendage device) for clinical trials, effective for discharges occurring on or after October 1, 2004, to DRG 518 (Percutaneous Cardiovascular Procedure without Coronary Artery Stent or Acute Myocardial Infarction)). In that final rule, we addressed the DRG assignment of procedure code 37.90 in response to a comment from a manufacturer who suggested that placement of the code in DRG 108 (Other Cardiothoracic Procedures) was more representative of the complexity of the procedure than placement in DRG 518. The manufacturer indicated that the suggested placement of procedure code 37.90 in DRG 108 was justified because another percutaneous procedure, described by ICD-9-CM procedure code 35.52 (Repair of atrial septal defect with prosthesis, closed technique), was assigned to DRG 108. As we indicated in the FY 2005 final rule (69 FR 48978), this comment prompted us to examine data in the FY 2003 MedPAR file for cases of code 35.52 assigned to DRG 108 and DRG 518 in comparison to all cases assigned to DRG 108. We found the following:

[GRAPHIC] [TIFF OMITTED] TP04MY05.006

Therefore, we concluded that procedure code 35.52 showed a decided similarity to the cases found in DRG 518, not DRG 108. At that time, we determined that we would analyze the cases for both clinical coherence and charge data as part of the IPPS FY 2006 process of identifying the most appropriate DRG assignment for procedure code 35.52.

We have now examined data from the FY 2004 MedPAR file and found results for cases assigned to DRG 108 and DRG 518 that are similar to last year's findings as indicated in the chart below:

[GRAPHIC] [TIFF OMITTED] TP04MY05.007

From this comparison, we found that when an atrial septal defect is percutaneously repaired, and procedure code 35.52 is the only code reported in DRG 108, there is a significant discrepancy in both the average charges and the average length of stay between the cases with procedure code 35.52 reported in DRG 108 and the total cases in DRG 108. The total cases in DRG 108 have average charges of $51,744 greater than the 872 cases in DRG 108 reporting procedure code 35.52 as the only procedure. The total cases in DRG 108 also have an average length of stay of 7.39 days greater than the average length of stay for cases in DRG 108 with procedure code 35.52 reported. In comparison, the total cases in DRG 518 have average charges of only $1,988 lower than the cases in DRG 108 with only procedure code 35.52 reported. In addition, the length of stay in total cases in DRG 518 is more closely related to cases in DRG 108 with only procedure code 35.52 reported.

Based on our analysis of these data, we are proposing to move procedure code 35.52 out of DRG 108 and place it in DRG 518. We believe that this proposal would result in a more coherent group of cases in DRG 518 that reflect all percutaneous procedures. d. External Heart Assist System Implant

In the August 1, 2002, final rule (67 FR 49989), we attempted to clinically and financially align ventricular assist device (VAD) procedures by creating DRG 525 (Heart Assist System Implant). We also noted that cases in which a heart transplant also occurred during the same hospitalization episode would continue to be assigned to DRG 103 (Heart Transplant).

After further data review during the next 2 years, we decided to realign the

[[Page 23322]]

DRGs containing VAD codes for FY 2005. In the August 11, 2004 final rule (69 FR 48927), we announced changes to DRG 103, DRG 104 (Cardiac Valve and Other Major Cardiothoracic Procedure with Cardiac Catheterization), DRG 105 (Cardiac Valve and Other Major Cardiothoracic Procedures Without Cardiac Catheterization), and DRG 525.

In summary, these changes included--

Moving code 37.66 (Insertion of implantable heart assist system) out of DRG 525 and into DRG 103.

Renaming DRG 525 as ``Other Heart Assist System Implant.''

Moving code 37.62 (Insertion of non-implantable heart assist system) out of DRGs 104 and 105 and back into DRG 525.

DRG 525 currently consists of any principal diagnosis in MDC 5, plus the following surgical procedure codes:

37.52, Implantation of total replacement heart system *.

37.53, Replacement or repair of thoracic unit of total replacement heart system *.

37.54, Replacement or repair of other implantable component of total replacement heart system *.

37.62, Insertion of non-implantable heart assist system.

37.63, Repair of heart assist system.

37.65, Implant of external heart assist system.

* These codes represent noncovered services for Medicare beneficiaries. However, it is our longstanding practice to assign every code in the ICD-9-CM classification to a DRG. Therefore, they have been assigned to DRG 525.

Since that decision, we have been encouraged by a manufacturer to reevaluate DRG 525 for FY 2006. The manufacturer requested that we again review the data surrounding cases reporting code 37.65 and has suggested moving these cases into DRG 103. The manufacturer pointed out the following: Code 37.65 describes the implantation of an external heart assist system and is currently approved by the FDA as a bridge- to-recovery device. From the standpoint of clinical status, the patients in DRG 103 and receiving an external heart assist system are similar because their native hearts cannot support circulation, and absent a heart transplant, a mechanical pump is needed for patient survival. The surgical procedures for implantation of both an internal VAD and an external VAD are very similar. However, the external heart assist system (code 37.65) is a less expensive device than the implantable heart assist system (code 37.66). The manufacturer suggested that the payment differential between DRGs 103 and 525 is an incentive to choose the higher paying device, and asserted that only a subset of patients receiving an implantable heart assist system are best served by this device. The manufacturer also suggested that the initial use of the least expensive therapeutically appropriate device yields both the best clinical outcomes and the lowest total system costs.

We note that, under the DRG system, our intent is to create payments that are reflective of the average resources required to treat a particular case. Our goal is that physicians and hospitals should make treatment decisions based on the clinical needs of the patient and not financial incentives.

When we reviewed the FY 2004 MedPAR data, we were able to demonstrate the following comparisons:

[GRAPHIC] [TIFF OMITTED] TP04MY05.008

The above table shows that the 37.8 percent of cases in DRG 525 that reported code 37.65 have average charges that are nearly $33,000 higher than the average charges for all cases in the DRG. However, the average charges for the subset of cases with code 37.65 in DRG 525 ($206,497) are more than $107,086 lower than the average charges for all cases in DRG 103 ($313,583). Furthermore, the average length of stay for the subset of patients in DRG 525 receiving an external heart assist system was 9.26 days compared to 37.5 days for the 633 cases in DRG 103.

We note that the analysis above presents the difference in average charges, not costs. Because hospitals' charges are higher than costs, the difference in hospital costs will be less than the figures shown here. Moving cases containing code 37.65 from DRG 525 to DRG 103 would have two consequences. The cases in DRG 103 reporting code 37.65 would be appreciably overreimbursed, which would be inconsistent with our goal of coherent reimbursement structure within the DRGs. In addition, the relative weight of DRG 103 would decrease by moving the less resource-intensive external heart procedures into the same DRG with the more expensive heart transplant cases. The net effect would be an underpayment for heart transplant cases. Alternatively, we also reconsidered our position on moving the insertion of an implantable heart assist system (code 37.66) back into

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DRG 525. However, as shown in the FY 2005 IPPS final rule (69 FR 48929), the resource costs associated with caring for a patient receiving an implantable heart assist system are far more similar to those cases receiving a heart transplant in DRG 103 than they are to cases in DRG 525. For these reasons, we are not proposing to make any changes to the structure of either DRG 103 or DRG 525 in this proposed rule. e. Carotid Artery Stent

Stroke is the third leading cause of death in the United States and the leading cause of serious, long-term disability. Approximately 70 percent of all strokes occur in people age 65 and older. The carotid artery, located in the neck, is the principal artery supplying the head and neck with blood. Accumulation of plaque in the carotid artery can lead to stroke either by decreasing the blood flow to the brain or by having plaque break free and lodge in the brain or in other arteries to the head. The percutaneous transluminal angioplasty (PTA) procedure involves inflating a balloon-like device in the narrowed section of the carotid artery to reopen the vessel. A carotid stent is then deployed in the artery to prevent the vessel from closing or restenosing. A distal filter device (embolic protection device) may also be present, which is intended to prevent pieces of plaque from entering the bloodstream.

Effective July 1, 2001, Medicare covers PTA of the carotid artery concurrent with carotid stent placement when furnished in accordance with the FDA-approved protocols governing Category B Investigational Device Exemption (IDE) clinical trials. PTA of the carotid artery, when provided solely for the purpose of carotid artery dilation concurrent with carotid stent placement, is considered to be a reasonable and necessary service only when provided in the context of such clinical trials and, therefore, is considered a covered service for the purposes of these trials. Performance of PTA in the carotid artery when used to treat obstructive lesions outside of approved protocols governing Category B IDE clinical trials remains a noncovered service.

At the April 1, 2004 ICD-9-CM Coordination and Maintenance Committee meeting, we discussed creation of a new code or codes to identify carotid artery stenting, along with a concomitant percutaneous angioplasty or atherectomy (PTA) code for delivery of the stent(s). This subject was addressed in response to the need to identify carotid artery stenting for use in clinical trials in the upcoming fiscal year. Public comment confirmed the need for specific codes for this procedure. We established codes for carotid artery stenting procedures effective October 1, 2004, for patients who are enrolled in an FDA- approved clinical trial and are using on-label FDA approved stents and embolic protection devices.

New procedure codes 00.61 (Percutaneous angioplasty or atherectomy of precerebral (extracranial vessel(s)) and 00.63 (Percutaneous insertion of carotid artery stent(s)) were published in Table 6B, New Procedure Codes in the FY 2005 IPPS final rule (69 FR 49624).

Procedure code 00.61 was assigned to four MDCs and seven DRGs. The most likely scenario is that in which cases are assigned to MDC 1 (Diseases and Disorders of the Nervous System in DRGs 533 (Extracranial Procedures with CC) and 534 (Extracranial Procedures without CC). Cases may also be assigned to MDC 5 (Diseases and Disorders of the Circulatory System), MDC 21 (Injuries, Poisoning, and Toxic Effects of Drugs), and MDC 24 (Multiple Significant Trauma). Other less likely DRG assignments can be found in Table 6B in the Addendum to the FY 2005 IPPS final rule (69 FR 49624).

In the FY 2005 final rule, we indicated that we would continue to monitor DRGs 533 and 534 and procedure code 00.61 in combination with procedure code 00.63 in upcoming annual DRG reviews. For this proposed rule, we are using proxy codes to evaluate the costs and DRG assignments for carotid artery stenting because codes 00.61 and 00.63 were only approved for use beginning October 1, 2004, and because MedPAR data for this period are not yet available. We used procedure code 39.50 (Angioplasty or atherectomy of other noncoronary vessel(s)) in combination with procedure code 39.90 (Insertion of nondrug-eluting peripheral vessel stent(s)) in DRGs 533 and 534 as the proxy codes for coronary artery stenting. For this evaluation, we used principal diagnosis code 433.10 (Occlusion and stenosis of carotid artery, without mention of cerebral infarction) because this diagnosis most closely reflects the clinical trial criteria.

The following chart shows our findings:

[GRAPHIC] [TIFF OMITTED] TP04MY05.009

The patients receiving a carotid stent (codes 39.50 and 39.90) represented 3.5 percent of all cases in DRG 534. On average, patients receiving a carotid stent had slightly shorter average lengths of stay than other patients in DRGs 533 and 534. While the average charges for patients receiving a carotid artery stent were higher than for other patients in DRG 534, in our view, the small number of cases and the magnitude of the difference in average charges are not sufficient to justify a change in the DRGs.

Because we have a paucity of data for the carotid stent device and its insertion, and no data utilizing procedure codes 00.61 and 00.63 in a clinical trial setting, we believe it is premature to revise the DRG structure at this time. We expect to revisit this analysis once data become available on the new codes for carotid artery stents.

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f. Extracorporeal Membrane Oxygenation (ECMO)

Extracorporeal membrane oxygenation (ECMO) is a procedure to create a closed chest, heart-lung bypass system by insertion of vascular catheters. Patients receiving this procedure require mechanical ventilation. ECMO is performed for a small number of severely ill patients who are at high risk of dying without this procedure. Most often it is done for neonates with persistent pulmonary hypertension and respiratory failure for whom other treatments have failed, certain severely ill neonates receiving major cardiac procedures or diaphragmatic hernia repair, and certain older children and adults, most of whom are receiving major cardiac procedures.

We received several letters from institutions that perform ECMO. The commenters stated that, in the CMS GROUPER logic, this procedure has little or no impact on the DRG assignment in the newborn, pediatric, and adult population. According to these letters, patients receiving ECMO are highly resource intensive and should have a unique DRG that reflects the costs of these resources. The commenters recommended the creation of a new DRG for ECMO with a DRG weight equal to or greater than the DRG weight for tracheostomy.

ECMO is assigned to procedure code 39.65 (Extracorporeal membrane oxygenation). This code is classified as an O.R. procedure and is assigned to DRG 104 (Cardiac Valve and Other Major Cardiothoracic Procedure With Cardiac Catheterization) and DRG 105 (Cardiac Valve and Other Major Cardiothoracic Procedure Without Cardiac Catheterization). When ECMO is performed with other O.R. procedures, the case is assigned to the higher weighted DRG. For example, when ECMO and a tracheostomy are performed during the same admission, the case would be assigned to DRG 541 (Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth, and Neck Diagnoses With Major O.R.).

We note that the primary focus of updates to the Medicare DRG classification system is changes relating to the Medicare patient population, not the pediatric patient population. Because ECMO is primarily a pediatric procedure and rarely performed in an adult population, we have few cases in our data to use to evaluate resource costs. We are aware that other insurers sometimes use Medicare's rates to make payments. We advise private insurers to make appropriate modifications to our payment system when it is being used for children or other patients who are not generally found in the Medicare population.

To evaluate the appropriateness of payment under the current DRG assignment, we have reviewed the FY 2004 MedPAR data and found 78 ECMO cases in 13 DRGs. The following table illustrates the results of our findings:

[GRAPHIC] [TIFF OMITTED] TP04MY05.010

The average charges for all ECMO cases were approximately $258,821, and the average length of stay was approximately 20.7 days. The average charges for the ECMO cases are closer to the average charges for DRG 541 ($273,656) than to the average charges of DRG 104 ($147,766) and DRG 105 ($131,700). Of the 78 ECMO cases, 14 cases are already assigned to DRG 541. We believe that the data indicate that DRG 541 would be a more appropriate DRG assignment for cases where ECMO is performed. We further note that under the All Payer DRG System used in New York State, cases involving ECMO are assigned to the tracheostomy DRG. Thus, the assignment of ECMO cases to the tracheostomy DRG for Medicare would be similar to how these cases are grouped in another DRG system. For these reasons, we are proposing to reassign ECMO cases reporting code 39.65 to DRG 541. We are also proposing to change the title of DRG 541 to: ``ECMO or Tracheostomy With Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck Diagnoses With Major O.R.'' 5. MDC 6 (Diseases and Disorders of the Digestive System): Artificial Anal Sphincter

In the FY 2003 IPPS final rule (67 FR 50242), we created two new codes for procedures involving an artificial anal sphincter, effective for discharges occurring on or after October 1, 2002: code 49.75 (Implantation or revision of artificial anal sphincter) is used to identify cases involving implantation or revision of an artificial anal sphincter and code 49.76 (Removal of artificial anal sphincter) is used to identify cases involving the removal of the device. In Table 6B of that final rule, we assigned both codes to one of four MDCs, based on principal diagnosis, and one of six DRGs within those MDCs: MDC 6 (Diseases and Disorders of the Digestive System), DRGs 157 and 158 (Anal and Stomal Procedures With and Without CC, respectively); MDC 9 (Diseases and Disorders of the Skin, Subcutaneous Tissue and Breast), DRG 267 (Perianal and Pilonidal Procedures); MDC 21 (Injuries, Poisonings, and Toxic Effects of Drugs), DRGs 442 and 443 (Other O.R. Procedures for Injuries With and without CC, respectively); and MDC 24 (Multiple Significant Trauma), DRG 486 (Other O.R. Procedures for Multiple Significant Trauma).

In the FY 2004 IPPS final rule (68 FR 45372), we discussed the assignment of these codes in response to a request we had received to consider reassignment of these two codes to different MDCs and DRGs. The requester believed that the average charges ($44,000) for these codes warranted reassignment. In the FY 2004 IPPS final rule, we stated that we did not have sufficient MedPAR data available on the reporting of codes 49.75 and 49.76 to make a determination on

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DRG reassignment of these codes. We agreed that, if warranted, we would give further consideration to the DRG assignments of these codes because it is our customary practice to review DRG assignment(s) for newly created codes to determine clinical coherence and similar resource consumption after we have had the opportunity to collect MedPAR data on utilization, average lengths of stay, average charges, and distribution throughout the system. In the FY 2005 IPPS final rule, we reviewed the FY 2003 MedPAR data for the presence of codes 49.75 and 49.76 and determined that these procedures were not a clinical match with the other procedures in DRGs 157 and 158. Therefore, for FY 2005, we moved procedure codes 49.75 and 49.76 out of DRGs 157 and 158 and into DRGs 146 and 147 (Rectal Resection With and Without CC, respectively). This change had the effect of doubling the payment for the cases with procedure codes 49.75 and 49.76 assigned to DRGs 146 and 147 based on increases in the relative weights. One commenter had suggested that we create a new DRG for ``Complex Anal/Rectal Procedure with Implant.'' However, we noted that the DRG structure is a system of averages and is based on groups of patients with similar characteristics. At that time, we indicated that we would continue to monitor procedure codes 49.75 and 49.76 and the DRGs to which they are assigned.

For this FY 2006 proposed rule, we reviewed the FY 2004 MedPAR data for the presence of codes 49.75 and 49.76. We found that these two procedures are still of low incidence. Among the six possible DRG assignments, we found a total of 18 cases reported with codes 49.75 and 49.76 for the implant, revision, or removal of the artificial anal sphincter. We found 13 of these cases in DRGs 146 and 147 (compared to 12,558 total cases in these DRGs), and the remaining 5 cases in DRGs 442 and 443 (compared to 19,701 total cases in these DRGs).

We believe the number of cases with codes 49.75 and 49.76 in these DRGs is too low to provide meaningful data of statistical significance. Therefore, we are not proposing any further changes to the DRGs for these procedures at this time. Neither are we proposing to change the structure of DRGs 146 or 147 at this time. 6. MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue) a. Hip and Knee Replacements

Orthopedic surgeons representing the American Association of Orthopaedic Surgeons (AAOS) requested that we subdivide DRG 209 (Major Joint and Limb Reattachment Procedures of Lower Extremity) in MDC 8 by creating a new DRG for revision of lower joint procedures. The AAOS made a presentation at the October 7-8, 2004 meeting of the ICD-9-CM Coordination and Maintenance Committee meeting. A summary report of this meeting can be found at the CMS Web site: http://www.cms.hhs.gov/paymentsystems/icd9/. We also received written comments on this

request.

The AAOS surgeons stated that cases involving patients who require a revision of a prior replacement of a knee or hip require significantly more resources than cases in which patients receive an initial joint replacement. They pointed out that total joint replacement is one of the most commonly performed and successful operations in orthopedic surgery. The surgeons mentioned that, in 2002, over 300,000 hip replacement and 350,000 knee replacement procedures were performed in the United States. They also pointed out that these procedures are a frequent reason for Medicare hospitalization. The surgeons stated that total joint replacements have been shown to be highly cost-effective procedures, resulting in dramatic improvements in quality of life for patients suffering from disabling arthritic conditions involving the hip or knee. In addition, they reported that the medical literature indicates success rates of greater than 90 percent for implant survivorship, reduction in pain, and improvement in function at a 10-year to 15-year followup. However, despite these excellent results with primary total joint replacement, factors related to implant longevity and evolving patient demographics have led to an increase in the volume of revision total joint procedures performed in the United States over the past decade.

Total hip replacement is an operation that is intended to reduce pain and restore function in the hip joint by replacing the arthritic hip joint with a prosthetic ball and socket joint. The prosthetic hip joint consists of a metal alloy femoral component with a modular femoral head made of either metal or ceramic (the ``ball'') that articulates with a metal acetabular component with a modular liner made of either metal, ceramic, or high-density polyethylene (the ``socket'').

The AAOS surgeons stated that in a normal knee, four ligaments help hold the bones in place so that the joint works properly. When a knee becomes arthritic, these ligaments can become scarred or damaged. During knee replacement surgery, some of these ligaments, as well as the joint surfaces, are substituted or replaced by the new artificial prostheses. Two types of fixation are used to hold the prostheses in place. Cemented designs use polymethyl methacrylate to hold the prostheses in place. Cementless designs rely on bone growing into the surface of the implant for fixation.

The surgeons stated that all hip and knee replacements have an articular bearing surface that is subject to wear (the acetabular bearing surface in the hip and the tibial bearing surface in the knee). Traditionally, these bearing surfaces have been made of metal-on-metal or metal-on-polyethylene, although newer materials (both metals and ceramics) have been used more recently. Earlier hip and knee implant designs had nonmodular bearing surfaces, but later designs included modular articular bearing surfaces to reduce inventory and potentially simplify revision surgery. Wear of the articular bearing surface occurs over time and has been found to be related to many factors, including the age and activity level of the patient. In some cases, wear of the articular bearing surface can produce significant debris particles that can cause peri-prosthetic bone resorption (also known and osteolysis) and mechanical loosening of the prosthesis. Wear of the bearing surface can also lead to instability or prosthetic dislocation, or both, and is a common cause of revision hip or knee replacement surgery.

Depending on the cause of failure of the hip replacement, the type of implants used in the previous surgery, the amount and quality of the patient's remaining bone stock, and factors related to the patient's overall health and anatomy, revision hip replacement surgery can be relatively straightforward or extremely complex. Revision hip replacement can involve replacing any part or all of the implant, including the femoral or acetabular components, and the bearing surface (the femoral head and acetabular liner), and may involve major reconstruction of the bones and soft tissues around the hip. All of these procedures differ significantly in their clinical indications, outcomes, and resource intensity.

The AAOS surgeons provided the following summary of the types of

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revision knee replacement procedures: Among revision knee replacement procedures, patients who underwent complete revision of all components had longer operative times, higher complication rates, longer lengths of stay, and significantly higher resource utilization, according to studies conducted by the AAOS. Revision of the isolated modular tibial insert component was the next most resource-intensive procedure, and primary total knee replacement was the least resource-intensive of all the procedures studied.

Isolated Modular Tibial Insert Exchange. Isolated removal and exchange of the modular tibial bearing surface involves replacing the modular polyethylene bearing surface without removing the femoral, tibial, or patellar components of the prosthetic joint. Common indications for this procedure include wear of the polyethylene bearing surface or instability (for example, looseness) of the prosthetic knee joint. Patient recovery times are much shorter with this procedure than with removal and exchange of either the tibial, femoral, or patellar components.

Revision of the Tibial Component. Revision of the tibial component involves removal and exchange of the entire tibial component, including both the metal base plate and the modular polyethylene bearing surface. Common indications for tibial component revision are wear of the modular bearing surface, aseptic loosening (often associated with osteolysis), or infection. Depending on the amount of associated bone loss and the integrity of the ligaments around the knee, tibial component revision may require the use of specialized implants with stems that extend into the tibial canal and/or the use of metal augments or bone graft to fill bony defects.

Revision of the Femoral Component. Revision of the femoral component involves removal and exchange of the metal implant that covers the end of the thigh-bone (the distal femur). Common indications for femoral component revision are aseptic loosening with or without associated osteolysis/bone loss, or infection. Similar to tibial revision, femoral component revision that is associated with extensive bone loss often involves the use of specialized implants with stems that extend into the femoral canal and/or the use of metal augments or bone graft to fill bony defects.

Revision of the Patellar Component. Complications related to the patella-femoral joint are one of the most common indications for revision knee replacement surgery. Early patellar implant designs had a metal backing covered by high-density polyethylene; these implants were associated with a high rate of failure due to fracture of the relatively thin polyethylene bearing surface. Other common reasons for isolated patellar component revision include poor tracking of the patella in the femoral groove leading to wear and breakage of the implant, fracture of the patella with or without loosening of the patellar implant, rupture of the quadriceps or patellar tendon, and infection.

Revision of All Components (Tibial, Femoral, and Patellar). The most common type of revision knee replacement procedure is a complete total knee revision. A complete revision of all implants is more common in knee replacements than hip replacements because the components of an artificial knee are not compatible across vendors or types of prostheses. Therefore, even if only one of the implants is loose or broken, a complete revision of all components is often required in order to ensure that the implants are compatible. Complete total knee revision often involves extensive surgical approaches, including osteotomizing (for example, cutting) the tibia bone in order to adequately expose the knee joint and gain access to the implants. These procedures often involve extensive bone loss, requiring reconstruction with specialized implants with long stems and metal augments or bone graft to fill bony defects. Depending on the status of the ligaments in the knee, complete total knee revision at times requires implantation of a highly constrained or ``hinged'' knee replacement in order to ensure stability of the knee joint.

Reimplantation from previous resection or cement spacer. In cases of deep infection of a prosthetic knee, removal of the implants with implantation of an antibiotic-impregnated cement spacer, followed by 6 weeks of intravenous antibiotics is often required in order to clear the infection. Revision knee replacement from an antibiotic impregnated cement spacer often involves complex bony reconstruction due to extensive bone loss that occurs as a result of the infection and removal of the often well-fixed implants. As noted above, the clinical outcomes following revision from a spacer are often poor due to limited functional capacity while the spacer is in place, prolonged periods of protected weight bearing (following reconstruction of extensive bony defects), and the possibility of chronic infection.

The surgeons stated that the current ICD-9-CM codes did not adequately capture the complex nature of revisions of hip and knee replacements. Currently, code 81.53 (Revision of hip replacement) captures all ``partial'' and ``total'' revision hip replacement procedures. Code 81.55 (Revision of knee replacement) captures all revision knee replacement procedures. These two codes currently capture a wide variety of procedures that differ in their clinical indications, resource intensity, and clinical outcomes.

An AAOS representative made a presentation at the October 7-8, 2004 ICD-9-CM Coordination and Maintenance Committee. Based on the comments received at the October 7-8, 2004 meeting and subsequent written comments, new ICD-9-CM procedure codes were developed to better capture the variety of ways that revision of hip and knee replacements can be performed: codes 00.70 through 00.73 and code 81.53 for revisions of hip replacements and codes 00.80 through 00.84 and code 81.55 for revisions of knee replacements. These new and revised procedure codes, which will be effective on October 1, 2005, can be found in Table 6B and Table 6F of this proposed rule. The commenters stated that claims data using these new and specific codes should provide improved data on these procedures for future DRG modifications.

However, the commenters requested that CMS consider DRG modifications based on current data using the existing revision codes. The commenters reported on a recently completed study comparing detailed hospital resource utilization and clinical characteristics in over 10,000 primary and revision hip and knee replacement procedures at 3 high volume institutions: The Massachusetts General Hospital, the Mayo Clinic, and the University of California at San Francisco. The purpose of this study was to evaluate differences in clinical outcomes and resource utilization among patients who underwent different types of primary and revision hip or knee replacement procedures. The study found significant differences in operative time, complication rates, hospital length of stay, discharge disposition, and resource utilization among patients who underwent different types of revision hip or knee replacement procedures.

Among revision hip replacement procedures, patients who underwent both femoral and acetabular component revision had longer operative times, higher complication rates, longer lengths of stay, significantly higher resource utilization, and were more likely to be discharged to a subacute care facility. Isolated femoral

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component revision was the next most resource-intensive procedure, followed by isolated acetabular revision. Primary hip replacement was the least resource intensive of all the procedures studied. Similarly, among revision knee replacement procedures, patients who underwent complete revision of all components had longer operative times, higher complication rates, longer lengths of stay, and significantly higher resource utilization. Revision of one component was the next most resource-intensive procedure. Primary total knee replacement was the least resource intensive of all the procedures studied.

In addition, the commenters indicated that the data showed that extensive bone loss around the implants and the presence of a peri- prosthetic fracture were the most significant predictors of higher resource utilization among all revision hip and knee replacement procedures, even when controlling for other significant patient and procedural characteristics.

For this proposed rule, we examined data in the FY 2004 MedPAR file on the current hip replacement procedures (codes 81.51, 81.52, 81.53) as well as the replacements and revisions of knee replacement procedures (codes 81.54 and 81.55) in DRG 209. We found that revisions were significantly more resource intensive than the original hip and knee replacements. We found average charges for revisions of hip and knee replacements were approximately $7,000 higher than average charges for the original joint replacements, as shown in the following charts. The average charges for revisions of hip replacements were 21 percent higher than the average charges for initial hip replacements. The average charges for revisions of knee replacements were 25 percent higher than for initial knee replacements.

[GRAPHIC] [TIFF OMITTED] TP04MY05.011

We note that there were no cases in DRG 209 for reattachment of the foot, lower leg, or thigh (codes 84.29, 84.27, and 84.28).

To address the higher resource costs associated with hip and knee revisions relative to the initial joint replacement procedure, we are proposing to delete DRG 209, create a proposed new DRG 544 (Major Joint Replacement or Reattachment of Lower Extremity), and create a proposed new DRG 545 (Revision of Hip or Knee Replacement).

We are proposing to assign the following codes to the new proposed DRG 544:

81.51, Total hip replacement.

81.52, Partial hip replacement.

81.54, Total knee replacement.

81.56, Total ankle replacement.

84.26, Foot reattachment.

84.27, Lower leg/ankle reattach.

84.28, Thigh reattachment.

We are proposing to assign the following codes to the proposed new DRG 545:

00.70, Revision of hip replacement, both acetabular and femoral components.

00.71, Revision of hip replacement, acetabular component.

00.72, Revision of hip replacement, femoral component.

00.73, Revision of hip replacement, acetabular liner and/ or femoral head only.

00.80, Revision of knee replacement, total (all components).

00.81, Revision of knee replacement, tibial component.

00.82, Revision of knee replacement, femoral component.

00.83, Revision of knee replacement, patellar component.

00.84, Revision of knee replacement, tibial insert (liner).

81.53, Revision of hip replacement, not otherwise specified.

81.55, Revision of knee replacement, not otherwise specified.

We agree with the commenters and the AAOS that the creation of a new DRG for revisions of hip and knee replacements should resolve payment issues for hospitals that perform the more difficult revisions of joint replacements. In addition, as stated earlier, we have worked with the orthopedic community to develop new procedure codes that better capture data on the types of revisions of hip and knee replacements. These new codes will be implemented on October 1, 2005. Once we receive claims data using these new codes, we will review data to determine if additional DRG modifications are needed. This effort may include assigning some of the revision codes, such as 00.83 and 00.84 to a separate DRG. As stated earlier, the AAOS has found that some of the procedures may not be as resource intensive. Therefore, the AAOS has requested that CMS closely examine data from the use of the new codes and consider future revisions. b. Kyphoplasty

In the FY 2005 IPPS final rule (69 FR 48938), we discussed the creation of new codes for vertebroplasty (81.65) and kyphoplasty (81.66), which went into effect on October 1, 2004. Prior to October 1, 2004, both of these surgical procedures were assigned to code 78.49 (Other repair or plastic operation on bone). For FY 2005, we assigned these codes to DRGs 233 and 234 (Other Musculoskeletal System and Connective Tissue O.R. Procedure With and Without CC, respectively) in MDC 8 (Table 6B of the FY 2005 final rule). (In the FY 2005 IPPS final rule (69 FR 48938), we indicated that new codes 81.65 and 81.66 were assigned to DRGs 223 and 234. We made a typographical error when indicating that these codes were assigned to DRG 223. Codes 81.65 and 81.66 have been assigned to DRGs

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233 and 234.) Last year, we received comments opposing the assignment of code 81.66 to DRGs 233 and 234. The commenters supported the creation of the codes for kyphoplasty and vertebroplasty but recommended that code 81.66 be assigned to DRGs 497 and 498 (Spinal Fusion Except Cervical With and Without CC, respectively). The commenters stated that kyphoplasty requires special inflatable bone tamps and bone cement and is a significantly more resource intensive procedure than vertebroplasty. The commenters further stated that, while kyphoplasty involves internal fixation of the spinal fracture and restoration of vertebral heights, vertebroplasty involves only fixation. The commenters indicated that hospital costs for kyphoplasty procedures are more similar to resources used in a spinal fusion.

We stated in the FY 2005 IPPS final rule that we did not have data in the MedPAR file on kyphoplasty and vertebroplasty. Prior to October 1, 2004, both procedures were assigned in code 78.49, which was assigned to DRGs 233 and 234 in MDC 8. We stated that we would continue to review this area as part of our annual review of MedPAR data. While we do not have separate data for kyphoplasty because code 81.66 was not established until October 1, 2004, for this proposed rule, we did examine data on code 78.49, which includes both kyphoplasty and vertebroplasty procedures reported in DRGs 233 and 234. The following chart illustrates our findings:

[GRAPHIC] [TIFF OMITTED] TP04MY05.012

We do not believe these data findings support moving cases represented by code 78.49 out of DRGs 233 and 234. While we cannot distinguish cases that are kyphoplasty from cases that are vertebroplasty, cases represented by code 78.49 have lower charges than do other cases within DRGs 233 and 234. Therefore, we are not proposing to change the DRG assignment of code 81.66 to DRGs 233 and 234 at this time. However, once specific charge data are available, we will consider whether further changes are warranted. c. Multiple Level Spinal Fusion

On October 1, 2003, the following ICD-9-CM codes were created to identify the number of levels of vertebra fused during a spinal fusion procedure:

81.62, Fusion or refusion of 2-3 vertebrae.

81.63, Fusion or refusion of 4-8 vertebrae.

81.64, Fusion or refusion of 9 or more vertebrae.

Prior to the creation of these codes, we received a comment recommending the establishment of new DRGs that would be differentiated based on the number of vertebrae fused. In the FY 2005 IPPS final rule (69 FR 48936), we stated that we did not yet have any reported cases utilizing these multiple level spinal fusion codes. We stated that we would wait until sufficient data were available prior to making a final determination on whether to create separate DRGs based on the number of vertebrae fused. We also stated that spinal fusion surgery was an area undergoing rapid changes.

Effective October 1, 2004, we created a series of codes that describe a new type of spinal surgery, spinal disc replacement. Our medical advisors describe these procedures as a more conservative approach for back pain than the spinal fusion surgical procedure. These codes are as follows:

84.60, Insertion of spinal disc prosthesis, not otherwise specified.

84.61, Insertion of partial spinal disc prosthesis, cervical.

84.62, Insertion of total spinal disc prosthesis, cervical.

84.63, Insertion of spinal disc prosthesis, thoracic.

84.64, Insertion of partial spinal disc prosthesis, lumbosacral.

84.65, Insertion of total spinal disc prosthesis, lumbosacral.

84.66, Revision or replacement of artificial spinal disc prosthesis, cervical.

84.67, Revision or replacement of artificial spinal disc prosthesis, thoracic.

84.68, Revision or replacement of artificial spinal disc prosthesis, lumbosacral.

84.69, Revision or replacement of artificial spinal disc prosthesis, not otherwise specified.

We also created the following two codes effective October 1, 2004, for these new types of spinal surgery that are also a more conservative approach to back pain than is spinal fusion:

81.65 Vertebroplasty.

81.66 Kyphoplasty.

We do not yet have data in the MedPAR file on these new types of procedures. Therefore, we cannot yet determine what effect these new types of procedures will have on the frequency of spinal fusion procedures.

However, we do have data in the MedPAR file on multiple level spinal procedures for analysis for this year's proposed rule. We examined data in the FY 2004 MedPAR file on spinal fusion cases in the following DRGs:

DRG 496 (Combined Anterior/Posterior Spinal Fusion).

DRG 497 (Spinal Fusion Except Cervical With CC).

DRG 498 (Spinal Fusion Except Cervical Without CC).

DRG 519 (Cervical Spinal Fusion With CC).

DRG 520 (Cervical Spinal Fusion Without CC).

Multiple level spinal fusion is captured by code 81.63 (Fusion or refusion of 4-8 vertebrae) and code 81.64 (Fusion or refusion of 9 or more vertebrae). Code 81.62 includes the fusion of 2-3 vertebrae and is not considered a multiple level spinal fusion. Orthopedic surgeons stated at the October 7-8, 2004 ICD-9-CM Coordination and Maintenance Committee meeting that the most simple and common type of spinal fusion involves fusing either 2 or 3 vertebrae. These surgeons stated that there was not

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a significant difference in resource utilization for cases involving the fusion of 2 versus 3 vertebrae. For this reason, the orthopedic surgeons recommended that fusion of 2 and 3 vertebrae be grouped into one ICD-9-CM code.

We reviewed the Medicare charge data to determine whether the number of vertebrae fused or specific diagnoses have an effect on average length of stay and resource use for a patient. We found that, while fusing 4 or more levels of the spine results in a small increase in the average length of stay and a somewhat larger increase in average charges for spinal fusion patients, an even greater impact was made by the presence of a principal diagnosis of curvature of the spine or malignancy. The following list of diagnoses describes conditions that have a significant impact on resource use for spinal fusion patients:

170.2, Malignant neoplasm of vertebral column, excluding sacrum and coccyx.

198.5, Secondary malignant neoplasm of bone and bone marrow.

732.0, Juvenile osteochondrosis of spine.

733.13, Pathologic fracture of vertebrae.

737.0, Adolescent postural kyphosis.

737.10, Kyphosis (acquired) (postural).

737.11, Kyphosis due to radiation.

737.12, Kyphosis, postlaminectomy.

737.19, Kyphosis (acquired), other.

737.20, Lordosis (acquired) (postural).

737.21, Lordosis, postlaminectomy

737.22, Other postsurgical lordosis.

737.29, Lordosis (acquired), other.

737.30, Scoliosis [and kyphoscoliosis], idiopathic.

737.31, Resolving infantile idiopathic scoliosis.

737.32, Progressive infantile idiopathic scoliosis.

737.33, Scoliosis due to radiation.

737.34, Thoracogenic scoliosis.

737.39, Other kyphoscoliosis and scoliosis.

737.40, Curvature of spine, unspecified.

737.41, Curvature of spine associated with other conditions, kyphosis.

737.42, Curvature of spine associated with other conditions, lordosis.

737.43, Curvature of spine associated with other conditions, scoliosis.

737.8, Other curvatures of spine.

737.9, Unspecified curvature of spine.

754.2, Congenital scoliosis.

756.51, Osteogenesis imperfecta.

The majority of fusion patients with these diagnoses were in DRGs 497 and 498. The chart below reflects our findings. We also include in the chart statistics for cases in DRGs 497 and 498 with spinal fusion of 4 or more vertebrae and cases with a principal diagnosis of curvature of the spine or bone malignancy.

[GRAPHIC] [TIFF OMITTED] TP04MY05.013

Thus, these diagnoses result in a significant increase in resource use. While the fusing of 4 or more vertebrae resulted in average charges of $77,352, the impact of a principal diagnosis of curvature of the spine or bone malignancy was substantially greater with average charges of $95,315.

Based on this analysis, we are proposing to create a new DRG for noncervical spinal fusions with a principal diagnosis of curvature of the spine and malignancies. The proposed new DRG would be: proposed new DRG 546 (Spinal Fusions Except Cervical With Principal Diagnosis of Curvature of the Spine or Malignancy). Cases included in this proposed new DRG would include all noncervical spinal fusions previously assigned to DRGs 497 and 498 that have a principal diagnosis of curvature of the spine or malignancy and would include the following codes listed above: 170.2, 198.5, 732.0, 733.13, 737.0, 737.10, 737.11, 737.12, 737.19, 737.20, 737.21, 737.22, 737.29, 737.30, 737.31, 737.32, 737.33, 737.34, 737.39, 737.40, 737.41, 737.42, 737.43, 737.8, 737.9, 754.2, and 756.51. The proposed DRG 546 would not include cases currently assigned to DRGs 496, 519, or 520 that have a principal diagnosis of curvature of the spine or malignancy. The structure of DRGs 496, 519, and 520 would remain the same.

As part of our meeting with the AAOS on DRG 209 in February 2005 (discussed under section II.B.6.a. of this preamble), the AAOS offered to work with CMS to analyze clinical issues and make revisions to the spinal fusion DRGs (DRGs 496 through 498 and 519 and 520). At this time, we are limiting our proposed changes to the spinal fusion DRGs for FY 2006 to the creation of the proposed DRG 546 discussed above. However, we look forward to working with the AAOS to obtain its clinical recommendations concerning our proposed changes and potential additional modifications to the spinal fusion DRGs. We are also soliciting comments from the public on our proposed changes and how to incorporate new types of spinal procedures such as kyphoplasty and spinal disc prostheses into the spinal fusion DRGs. 7. MDC 18 (Infectious and Parasitic Diseases (Systemic or Unspecified Sites)): Severe Sepsis

As we did for FY 2005, we received a request to consider the creation of a separate DRG for the diagnosis of severe sepsis for FY 2006. Severe sepsis is described by ICD-9-CM code 995.92 (Systemic inflammatory response syndrome due to infection with organ dysfunction). Patients admitted with sepsis currently are assigned to DRG 416 (Septicemia Age > 17) and DRG 417

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(Septicemia Age 0-17) in MDC 18 (Infectious and Parasitic Diseases, Systemic or Unspecified Sites). The commenter requested that all cases in which severe sepsis is present on admission, as well as those cases in which it develops after admission (which are currently classified elsewhere), be included in this new DRG. We addressed this issue in the FY 2005 IPPS final rule (69 FR 48975). As indicated last year, we do not feel the current clinical definition of severe sepsis is specific enough to identify a meaningful cohort of patients in terms of clinical coherence and resource utilization to warrant a separate DRG. Sepsis is found across hundreds of medical and surgical DRGs, and the term ``organ dysfunction'' implicates numerous currently existing diagnosis codes. While we recognize that Medicare beneficiaries with severe sepsis are quite ill and require extensive hospital resources, we do not believe that they can be identified adequately to justify removing them from all of the other DRGs in which they appear. We are not proposing a new DRG for severe sepsis at this time. 8. MDC 20 (Alcohol/Drug Use and Alcohol/Drug Induced Organic Mental Disorders): Drug-Induced Dementia

In the FY 2005 IPPS final rule (69 FR 48939, August 11, 2004), we discussed a request that CMS modify DRGs 521 through 523 by removing the principal diagnosis code 292.82 (Drug-induced dementia) from these alcohol and drug abuse DRGs. These DRGs are as follows:

DRG 521 (Alcohol/Drug Abuse or Dependence With CC).

DRG 522 (Alcohol/Drug Abuse or Dependence With Rehabilitation Therapy Without CC).

DRG 523 (Alcohol/Drug Abuse or Dependence Without Rehabilitation Therapy Without CC).

The commenter indicated that a patient who has a drug-induced dementia should not be classified to an alcohol/drug DRG. However, the commenter did not propose a new DRG assignment for code 292.82. Our medical advisors evaluated the request and determined that the most appropriate DRG classification for a patient with drug-induced dementia was within MDC 20. The medical advisors indicated that because the dementia is drug induced, it is appropriately classified to DRGs 521 through 523 in MDC 20. Therefore, we did not propose a new DRG classification for the principal diagnosis code 292.82.

In the FY 2005 IPPS final rule, we addressed a comment from an organization representing hospital coders that disagreed with our decision to keep code 292.82 in DRGs 521 through 523. The commenter stated that DRGs 521 through 523 are described as alcohol/drug abuse and dependence DRGs, and that drug-induced dementia can be caused by an adverse effect of a prescribed medication or a poisoning. The commenter did not believe that assignment to DRGs 521 through 523 was appropriate if the drug-induced dementia is due to one of these events and the patient is not alcohol or drug dependent. The commenter recommended that admissions for drug-induced dementia be classified to DRGs 521 through 523 only if there is a secondary diagnosis indicating alcohol/ drug abuse or dependence.

The commenter recommended that drug-induced dementia that is due to the adverse effect of a drug or poisoning be classified to the same DRGs as other types of dementia, such as DRG 429 (Organic Disturbances and Mental Retardation). The commenter believed that when drug-induced dementia is caused by a poisoning, either accidental or intentional, the appropriate poisoning code would be sequenced as the principal diagnosis and, therefore, these cases would likely already be assigned to DRGs 449 and 450 (Poisoning and Toxic Effects of Drugs, Age Greater than 17, With and Without CC, respectively) and DRG 451 (Poisoning and Toxic Effects of Drugs, Age 0-17). The commenter stated that these would be the appropriate DRG assignments for drug-induced dementia due to a poisoning. We received a similar comment from a hospital organization.

In the FY 2005 IPPS final rule, we acknowledged that the commenters raised additional issues surrounding the DRG assignment for code 292.82 that should be considered. The commenters provided alternatives for DRG assignment based on sequencing of the principal diagnosis and reporting of additional secondary diagnoses. We recognized that patients may develop drug-induced dementia from drugs that are prescribed, as well as from drugs that are not prescribed. However, because dementia develops as a result of use of a drug, we believed the current DRG assignment to DRGs 521 through 523 remained appropriate. Some commenters have agreed with the current DRG assignment of code 292.82 since the dementia was caused by use of a drug. We agree that if either accidental or intentional poisoning caused the drug-induced dementia, the appropriate poisoning code should be sequenced as the principal diagnosis. As one commenter stated, these cases would be assigned to DRGs 449 through 451. We encouraged hospitals to examine the coding for these types of cases to determine if there were any coding or sequencing errors. As suggested by the commenter, if code 292.82 were reported as a secondary diagnosis and not a principal diagnosis in cases of poisoning or adverse drug reactions, the number of cases on DRGs 521 through 523 would decline.

In the FY 2005 IPPS final rule, we agreed to analyze this area for FY 2006 and to look at the alternative DRG assignments suggested by the commenters. For this proposed rule, we examined data from the FY 2004 MedPAR file on cases in DRGs 521 through 523 with a principal diagnosis of code 292.82. We found that there were only 134 cases reported with the principal diagnosis code 292.82 in DRGs 521 through 523 without a diagnosis of drug and alcohol abuse. The average standardized charges for cases with a principal diagnosis of code 292.82 that did not have a secondary diagnosis of drug/alcohol abuse or dependence were $12,244.35, compared to the average standardized charges for all cases in DRG 521, which were $10,543.69. There were no cases in DRG 522 with a principal diagnosis of code 292.82. We found only 24 cases in DRG 523 with a principal diagnosis of code 292.82. Given the small number of cases in DRG 522 and 523, and the similarity in average standardized charges between those cases in DRG 521 with a principal diagnosis of code 292.82 and without a secondary diagnosis of drug/alcohol abuse or dependence to the overall average for all cases in the DRG, we do not believe the data suggest that a modification to DRGs 521 through 523 is warranted. Therefore, we are not proposing changes to the current structure of DRGs 521 through 523 for FY 2006. 9. Medicare Code Editor (MCE) Changes

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

As explained under section II.B.1. of this preamble, the Medicare Code Editor (MCE) is a software program that detects and reports errors in the coding of Medicare claims data. Patient diagnoses, procedure(s), discharge status, and demographic information go into the Medicare claims processing systems and are subjected to a series of automated screens. The MCE screens are designed to identify cases that require further review before classification into a DRG.

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a. Newborn Age Edit

In the past, we have discussed and received comments concerning revision of the pediatric portions of the Medicare IPPS DRG classification system, that is, MDC 15 (Newborns and Other Neonates With Conditions Originating in the Perinatal Period). Most recently, we addressed these comments in both the FY 2005 proposed rule (69 FR 28210) and the FY 2005 IPPS final rule (69 FR 48938). In those rules, we indicated that we would be responsive to specific requests for updating MDC 15 on a limited, case-by-case basis.

We have recently received a request through the Open Door Forum to revise the MCE ``newborn age edit'' by removing over 100 codes located in Chapter 15 of ICD-9-CM that are identified as ``newborn'' codes. This request was made because these codes usually cause an edit or denial to be triggered when they are used on children greater than 1 year of age. However, the underlying issue with these particular edits is that other payers have adopted the CMS Medicare Code Editor in a wholesale manner, instead of adapting it for use in their own patient populations.

We acknowledge that Medicare DRGs are sometimes used to classify other patient groups. However, CMS' primary focus of updates to the Medicare DRG classification system is on changes relating to the Medicare patient population, not the pediatric or neonatal patient populations.

There are practical considerations regarding the assumption of a larger role for the Medicare DRG in the pediatric or neonatal areas, given the difference between the Medicare population and that of newborns and children. There are also challenges surrounding the development of DRG classification systems and applications appropriate to children. We do not have the clinical expertise to make decisions about these patients, and must rely on outside clinicians for advice. In addition, because newborns and other children are generally not eligible for Medicare, we must rely on outside data to make decisions. We recognize that there are evolving alternative classification systems for children and encourage payers to use the CMS MCE as a template while making modifications appropriate for pediatric patients.

Therefore, we would encourage those non-Medicare systems needing a more comprehensive pediatric system of edits to update their systems by choosing from other existing systems or programs that are currently in use. Because of our reluctance to assume expertise in the pediatric arena, we are not proposing to make the commenter's suggested changes to the MCE ``newborn age edit'' for FY 2006. b. Newborn Diagnoses Edit

Last year, in our changes to the MCE, we inadvertently added code 796.6 (Abnormal findings on neonatal screening) to both the MCE edit for ``Maternity Diagnoses--age 12 through 55'', and the MCE edit for ``Diagnoses Allowed for Females Only''. We are proposing to remove code 796.6 from these two edits and add it to the ``Newborn Diagnoses'' edit. c. Diagnoses Allowed for ``Males Only'' Edit

We have received a request to remove two codes from the ``Diagnoses Allowed for Males Only'' edit, related to androgen insensitivity syndrome (AIS). AIS is a new term for testicular feminization. Code 257.8 (Other testicular dysfunction) is used to describe individuals who, despite having XY chromosomes, develop as females with normal female genitalia and mammary glands. Testicles are present in the same general area as the ovaries, but are undescended and are at risk for development of testicular cancer, so are generally surgically removed. These individuals have been raised as females, and would continue to be considered female, despite their XY chromosome makeup. Therefore, as AIS is coded to 257.8, and has posed a problem associated with the gender edit, we are proposing to remove this code from the ``Males Only'' edit in the MCE.

A similar clinical scenario can occur with certain disorders that cause a defective biosynthesis of testicular androgen. This disorder is included in code 257.2 (Other testicular hypofunction). Therefore, we also are proposing to remove code 257.2 from the ``Male Only'' gender edit in the MCE. d. Tobacco Use Disorder Edit

We have become aware of the possible need to add code 305.1 (Tobacco use disorder) to the MCE in order to make admissions for tobacco use disorder a noncovered Medicare service when code 305.1 is reported as the principal diagnosis. On March 22, 2005, CMS published a final decision memorandum and related national coverage determination (NCD) on smoking cessation counseling services on its Web site: (http://www.cms.hhs.gov/ coverage/). Among other things, this NCD provides

that: ``Inpatient hospital stays with the principal diagnosis of 305.1, Tobacco Use Disorder, are not reasonable and necessary for the effective delivery of tobacco cessation counseling services. Therefore, we will not cover tobacco cessation services if tobacco cessation is the primary reason for the patient's hospital stay.'' Therefore, in order to maintain internal consistency with CMS programs and decisions, we are proposing to add code 305.1 to the MCE edit ``Questionable Admission-Principal Diagnosis Only'' in order to make tobacco use disorder a noncovered admission. e. Noncovered Procedure Edit

Effective October 1, 2004, CMS adopted the use of code 00.61 (Percutaneous angioplasty or atherectomey of precerebral (extracranial) vessel(s) (PTA)) and code 00.63 (Percutaneous insertion of carotid artery stent(s). Both codes are to be recorded to indicate the insertion of a carotid artery stent or stents. At the time of the creation of the codes, the coverage indication for carotid artery stenting was only for patients in a clinical trial setting, and diagnostic code V70.7 (Examination of participation in a clinical trial) was required for payment of these cases. However, effective October 12, 2004, Medicare covers PTA of the carotid artery concurrent with the placement of an FDA-approved carotid stent for an FDA-approved indication when furnished in accordance with FDA-approved protocols governing post-approval studies. Therefore, as the coverage indication has changed, we are proposing to remove codes 00.61, 00.63, and V70.7 from the MCE noncovered procedure edit. 10. Surgical Hierarchies

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

Some inpatient stays entail multiple surgical procedures, each one of which, occurring by itself, could result in assignment of the case to a different DRG within the MDC to which the principal diagnosis is assigned. Therefore, it is necessary to have a decision rule within the GROUPER by which these cases are assigned to a single DRG. The surgical hierarchy, an ordering of surgical classes from most resource-intensive to least resource-intensive, performs that function. Application of this hierarchy ensures that cases involving multiple surgical procedures are assigned to the DRG associated with the most resource- intensive surgical class.

Because the relative resource intensity of surgical classes can shift as a function of DRG reclassification and recalibrations, we reviewed the surgical

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hierarchy of each MDC, as we have for previous reclassifications and recalibrations, to determine if the ordering of classes coincides with the intensity of resource utilization.

A surgical class can be composed of one or more DRGs. For example, in MDC 11, the surgical class ``kidney transplant'' consists of a single DRG (DRG 302) and the class ``kidney, ureter and major bladder procedures'' consists of three DRGs (DRGs 303, 304, and 305). Consequently, in many cases, the surgical hierarchy has an impact on more than one DRG. The methodology for determining the most resource- intensive surgical class involves weighting the average resources for each DRG by frequency to determine the weighted average resources for each surgical class. For example, assume surgical class A includes DRGs 1 and 2 and surgical class B includes DRGs 3, 4, and 5. Assume also that the average charge of DRG 1 is higher than that of DRG 3, but the average charges of DRGs 4 and 5 are higher than the average charge of DRG 2. To determine whether surgical class A should be higher or lower than surgical class B in the surgical hierarchy, we would weight the average charge of each DRG in the class by frequency (that is, by the number of cases in the DRG) to determine average resource consumption for the surgical class. The surgical classes would then be ordered from the class with the highest average resource utilization to that with the lowest, with the exception of ``other O.R. procedures'' as discussed below.

This methodology may occasionally result in assignment of a case involving multiple procedures to the lower-weighted DRG (in the highest, most resource-intensive surgical class) of the available alternatives. However, given that the logic underlying the surgical hierarchy provides that the GROUPER search for the procedure in the most resource-intensive surgical class, in cases involving multiple procedures, this result is sometimes unavoidable.

We note that, notwithstanding the foregoing discussion, there are a few instances when a surgical class with a lower average charge is ordered above a surgical class with a higher average charge. For example, the ``other O.R. procedures'' surgical class is uniformly ordered last in the surgical hierarchy of each MDC in which it occurs, regardless of the fact that the average charge for the DRG or DRGs in that surgical class may be higher than that for other surgical classes in the MDC. The ``other O.R. procedures'' class is a group of procedures that are only infrequently related to the diagnoses in the MDC, but are still occasionally performed on patients in the MDC with these diagnoses. Therefore, assignment to these surgical classes should only occur if no other surgical class more closely related to the diagnoses in the MDC is appropriate.

A second example occurs when the difference between the average charges for two surgical classes is very small. We have found that small differences generally do not warrant reordering of the hierarchy because, as a result of reassigning cases on the basis of the hierarchy change, the average charges are likely to shift such that the higher- ordered surgical class has a lower average charge than the class ordered below it.

Based on the preliminary recalibration of the DRGs, we are proposing to revise the surgical hierarchy for MDC 5 (Diseases and Disorders of the Circulatory System) and MDC 8 (Diseases and Disorders of the Musculoskeletal System and Connective Tissue) as follows:

In MDC 5, we are proposing to reorder--

DRG 116 (Other Permanent Cardiac Pacemaker Implant) above DRG 549 (Percutaneous Cardiovascular Procedure With Drug-Eluting Stent With AMI With CC).

DRG 549 above DRG 550 (Percutaneous Cardiovascular Procedure With Drug-Eluting Stent With AMI Without CC).

DRG 550 above DRG 547 (Percutaneous Cardiovascular Procedure With AMI With CC).

DRG 547 above DRG 548 (Percutaneous Cardiovascular Procedure With AMI Without CC).

DRG 548 above DRG 527 (Percutaneous Cardiovascular Procedure With Drug-Eluting Stent Without AMI).

DRG 527 above DRG 517 (Percutaneous Cardiovascular Procedure With Non-Drug Eluting Stent Without AMI).

DRG 517 above DRG 518 (Percutaneous Cardiovascular Procedure Without Coronary Artery Stent or AMI).

DRG 518 above DRGs 478 and 479 (Other Vascular Procedures With and Without CC, respectively).

In MDC 8, we are proposing to reorder--

DRG 496 (Combined Anterior/Posterior Spinal Fusion) above DRG 546 (Spinal Fusion Except Cervical With Principal Diagnosis of Curvature of the Spine or Malignancy).

DRG 546 above DRGs 497 and 498 (Spinal Fusion Except Cervical With and Without CC, respectively).

DRG 217 (Wound Debridement and Skin Graft Except Hand, For Musculoskeletal and Connective Tissue Disease) above DRG 545 (Revision of Hip or Knee Replacement).

DRG 545 above DRG 544 (Major Joint Replacement or Reattachment).

DRG 544 above DRGs 519 and 520 (Cervical Spinal Fusion With and Without CC, respectively). 11. Refinement of Complications and Comorbidities (CC) List

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

As indicated earlier in this preamble, under the IPPS DRG classification system, we have developed a standard list of diagnoses that are considered complications or comorbidities (CCs). Historically, we developed this list using physician panels that classified each diagnosis code based on whether the diagnosis, when present as a secondary condition, would be considered a substantial complication or comorbidity. A substantial complication or comorbidity was defined as a condition that, because of its presence with a specific principal diagnosis, would cause an increase in the length of stay by at least 1 day in at least 75 percent of the patients. b. Comprehensive Review of the CC List

In previous years, we have made changes to the standard list of CCs, either by adding new CCs or deleting CCs already on the list, but we have never conducted a comprehensive review of the list. There are currently 3,285 diagnosis codes on the CC list. There are 121-paired DRGs that are split on the presence or absence of a CC.

We have reviewed these paired DRGs and found that the majority of cases that are assigned to DRGs that have a CC split fall into the DRG with CC. While this fact is not new, we have found that a much higher proportion of cases are being grouped to the DRG with a CC than had occurred in the past. In our review of the DRGs included in Table 7b of the September 1, 1987 Federal Register rule (52 FR 33125), we found the following percentages of cases assigned a CC in those DRGs that had a CC split (DRG Definitions Manual, GROUPER Version 5.0 (1986 data)):

Cases with CC: 61.9 percent.

Cases without CC: 38.1 percent.

When we compared the above DRG 1986 data to the DRG 2004 data that were included in the DRGs Definitions Manual, GROUPER Version 22.0, we found the following:

Cases with CC: 79.9 percent.

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Cases without CC: 20.1 percent.

(We used DRGs Definitions Manual, GROUPER Version 5.0, for this analysis because prior versions of the DRGs Definitions Manual used age as a surrogate for a CC and the split was ``CC and/or age greater than 69''.)

The vast majority of patients being treated in inpatient settings have a CC as currently defined, and we believe that it is possible that the CC distinction has lost much of its ability to differentiate the resource needs of patients. The original definition used to develop the CC list (the presence of a CC would be expected to extend the length of stay of at least 75 percent of the patients who had the CC by at least one day) was used beginning in 1981 and has been part of the IPPS since its inception in 1983. There has been no substantive review of the CC list since its original development. In reviewing this issue, our clinical experts found several diseases that appear to be obvious candidates to be on the CC list, but currently are not:

[GRAPHIC] [TIFF OMITTED] TP04MY05.014

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

[GRAPHIC] [TIFF OMITTED] TP04MY05.015

We note that the above conditions are examples only of why we believe the CC list needs a comprehensive review. In addition to this review, we note that these conditions may be treated differently under several DRG systems currently in use. For instance, ICD-9-CM code 414.12 (Dissection of coronary artery) is listed as a ``Major CC'' under the All Patient (AP) DRGs, GROUPER Version 21.0 and an ``Extreme'' CC under the All Patient Refined (APR) DRGs, GROUPER Version 20.0, but is not listed as a CC at all in GROUPER Version 22.0 of the DRGs Definitions Manual used by Medicare. Similarly, ICD-9-CM code 424.0 (Mitral valve disorder) is a CC under GROUPER Version 22.0 of the DRGs Definitions Manual for Medicare's DRG system, a minor CC under the GROUPER Version 20.0 of the APR-DRGs, and not a CC at all under GROUPER Version 21.0 of the AP-DRGs.

Given the long period of time that has elapsed since the original CC list was developed, the incremental nature of changes to it, and changes in the way inpatient care is delivered, we are planning a comprehensive and systematic review of the CC list for the IPPS rule for FY 2007. As part of this process, we plan to consider revising the standard for determining when a condition is a CC. For instance, we may use an alternative to classifying a condition as a CC based on how it affects the length of stay of a case. Similar to other aspects of the DRG system, we may consider the effect of a specific secondary diagnosis on the charges or costs of a case to evaluate whether to include the condition on the CC list. Using a statistical algorithm, we may classify each diagnosis based on its effect on hospital charges (or costs) relative to other cases when present as a secondary diagnosis to obtain better information on when a particular condition is likely to increase hospital costs. For example, Code 293.84 (Anxiety disorder in conditions classified elsewhere), which is currently listed as a CC, might be removed from the CC list if analysis of the data do not support the fact that it represents a significant increase in resource utilization, and a code such as 359.4 (Toxic myopathy), which is currently not listed as a CC, could be added to the CC list if the data support it. In addition to using hospital charge data as a basis for a review, we would expect to supplement the process with review by our medical experts. Further, we may also consider doing a comparison of the Medicare DRG CC list with other DRG systems such as the AP-DRGs and the APR-DRGs to determine how the same secondary diagnoses are treated under these systems.

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By performing a comprehensive review of the CC list, we expect to revise the DRG classification system to better reflect resource utilization and remove conditions from the CC list that only have a marginal impact on a hospital's costs. We believe that a comprehensive review of the CC list would be consistent with MedPAC's recommendation that we improve the DRG system to better recognize severity. We will provide more detail about how we expect to undertake this analysis in the future, and any changes to the CC list will only be adopted after a notice and comment rulemaking that fully explains the methodology we plan to use in conducting this review. We encourage comment at this time regarding possible ways that more meaningful indicators of clinical severity and their implications for resource use can be incorporated into our comprehensive review and possible restructuring of the CC list. c. CC Exclusions List for FY 2006

In the September 1, 1987 final notice (52 FR 33143) concerning changes to the DRG classification system, we modified the GROUPER logic so that certain diagnoses included on the standard list of CCs would not be considered valid CCs in combination with a particular principal diagnosis. We created the CC Exclusions List for the following reasons: (1) to preclude coding of CCs for closely related conditions; (2) to preclude duplicative or inconsistent coding from being treated as CCs; and (3) to ensure that cases are appropriately classified between the complicated and uncomplicated DRGs in a pair. As we indicated above, we developed this list of diagnoses, using physician panels, to include those diagnoses that, when present as a secondary condition, would be considered a substantial complication or comorbidity. In previous years, we have made changes to the list of CCs, either by adding new CCs or deleting CCs already on the list. At this time, we are not proposing to delete any of the diagnosis codes on the CC list for FY 2006.

In the May 19, 1987 proposed notice (52 FR 18877) and the September 1, 1987 final notice (52 FR 33154), we explained that the excluded secondary diagnoses were established using the following five principles:

Chronic and acute manifestations of the same condition should not be considered CCs for one another.

Specific and nonspecific (that is, not otherwise specified (NOS)) diagnosis codes for the same condition should not be considered CCs for one another.

Codes for the same condition that cannot coexist, such as partial/total, unilateral/bilateral, obstructed/unobstructed, and benign/malignant, should not be considered CCs for one another.

Codes for the same condition in anatomically proximal sites should not be considered CCs for one another.

Closely related conditions should not be considered CCs for one another.

The creation of the CC Exclusions List was a major project involving hundreds of codes. We have continued to review the remaining CCs to identify additional exclusions and to remove diagnoses from the master list that have been shown not to meet the definition of a CC.\1\

\1\ See the FY 1989 final rule (53 FR 38485) [September 30, 1988] for the revision made for the discharges occurring in FY 1989; the FY 1990 final rule (54 FR 36552) [September 1, 1989] for the FY 1990 revision; the FY 1991 final rule (55 FR 36126) [September 4, 1990] for the FY 1991 revision; the FY 1992 final rule (56 FR 43209)

[August 30, 1991] for the FY 1992 revision; the FY 1993 final rule (57 FR 39753) [September 1, 1992] for the FY 1993 revision; the FY 1994 final rule (58 FR 46278) [September 1, 1993] for the FY 1994 revisions; the FY 1995 final rule (59 FR 45334) [September 1, 1994] for the FY 1995 revisions; the FY 1996 final rule (60 FR 45782)

[September 1, 1995] for the FY 1996 revisions; the FY 1997 final rule (61 FR 46171) [August 30, 1996] for the FY 1997 revisions; the FY 1998 final rule (62 FR 45966) [August 29, 1997] for the FY 1998 revisions; the FY 1999 final rule (63 FR 40954) [July 31, 1998] for the FY 1999 revisions; the FY 2001 final rule (65 FR 47064) [August 1, 2000] for the FY 2001 revisions; the FY 2002 final rule (66 FR 39851) [August 1, 2001] for the FY 2002 revisions; the FY 2003 final rule (67 FR 49998) [August 1, 2002] for the FY 2003 revisions; the FY 2004 final rule (68 FR 45364) [August 1, 2003] for the FY 2004 revisions; and the FY 2005 final rule (69 FR 49848) [August 11, 2004] for the FY 2005 revisions. In the FY 2000 final rule (64 FR 41490) [July 30, 1999], we did not modify the CC Exclusions List because we did not make any changes to the ICD-9-CM codes for FY 2000.

We are proposing a limited revision of the CC Exclusions List to take into account the proposed changes that will be made in the ICD-9- CM diagnosis coding system effective October 1, 2004. (See section II.B.13. of this preamble for a discussion of ICD-9-CM changes.) We are proposing these changes in accordance with the principles established when we created the CC Exclusions List in 1987.

Tables 6G and 6H in the Addendum to this proposed rule contain the revisions to the CC Exclusions List that would be effective for discharges occurring on or after October 1, 2005. Each table shows the principal diagnoses with changes to the excluded CCs. Each of these principal diagnoses is shown with an asterisk, and the additions or deletions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis.

CCs that are added to the list are in Table 6G--Additions to the CC Exclusions List. Beginning with discharges on or after October 1, 2005, the indented diagnoses would not be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis.

CCs that are deleted from the list are in Table 6H--Deletions from the CC Exclusions List. Beginning with discharges on or after October 1, 2005, the indented diagnoses would be recognized by the GROUPER as valid CCs for the asterisked principal diagnosis.

Copies of the original CC Exclusions List applicable to FY 1988 can be obtained from the National Technical Information Service (NTIS) of the Department of Commerce. It is available in hard copy for $152.50 plus shipping and handling. A request for the FY 1988 CC Exclusions List (which should include the identification accession number (PB) 88- 133970) should be made to the following address: National Technical Information Service, United States Department of Commerce, 5285 Port Royal Road, Springfield, VA 22161; or by calling (800) 553-6847.

Users should be aware of the fact that all revisions to the CC Exclusions List (FYs 1989, 1990, 1991, 1992, 1993, 1994, 1995, 1996, 1997, 1998, 1999, 2001, 2002, 2003, 2004, and 2005) and those in Tables 6G and 6H of this proposed rule for FY 2006 must be incorporated into the list purchased from NTIS in order to obtain the CC Exclusions List applicable for discharges occurring on or after October 1, 2005. (Note: There was no CC Exclusions List in FY 2000 because we did not make changes to the ICD-9-CM codes for FY 2000.)

Alternatively, the complete documentation of the GROUPER logic, including the current CC Exclusions List, is available from 3M/Health Information Systems (HIS), which, under contract with CMS, is responsible for updating and maintaining the GROUPER program. The current DRG Definitions Manual, Version 22.0, is available for $225.00, which includes $15.00 for shipping and handling. Version 23.0 of this manual, which will include the final FY 2006 DRG changes, will be available for $225.00. These manuals may be obtained by writing 3M/HIS at the following address: 100 Barnes Road, Wallingford, CT 06492; or by calling (203) 949-0303. Please specify the revision or revisions requested.

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12. Review of Procedure Codes in DRGs 468, 476, and 477

(If you choose to comment on issues in this section, please include the caption ``DRGs 468, 476, and 477'' at the beginning of your comment.)

Each year, we review cases assigned to DRG 468 (Extensive O.R. Procedure Unrelated to Principal Diagnosis), DRG 476 (Prostatic O.R. Procedure Unrelated to Principal Diagnosis), and DRG 477 (Nonextensive O.R. Procedure Unrelated to Principal Diagnosis) to determine whether it would be appropriate to change the procedures assigned among these DRGs.

DRGs 468, 476, and 477 are reserved for those cases in which none of the O.R. procedures performed are related to the principal diagnosis. These DRGs are intended to capture atypical cases, that is, those cases not occurring with sufficient frequency to represent a distinct, recognizable clinical group. DRG 476 is assigned to those discharges in which one or more of the following prostatic procedures are performed and are unrelated to the principal diagnosis:

60.0, Incision of prostate.

60.12, Open biopsy of prostate.

60.15, Biopsy of periprostatic tissue.

60.18, Other diagnostic procedures on prostate and periprostatic tissue.

60.21, Transurethral prostatectomy.

60.29, Other transurethral prostatectomy.

60.61, Local excision of lesion of prostate.

60.69, Prostatectomy, not elsewhere classified.

60.81, Incision of periprostatic tissue.

60.82, Excision of periprostatic tissue.

60.93, Repair of prostate.

60.94, Control of (postoperative) hemorrhage of prostate.

60.95, Transurethral balloon dilation of the prostatic urethra.

60.96, Transurethral destruction of prostate tissue by microwave thermotherapy.

60.97, Other transurethral destruction of prostate tissue by other thermotherapy.

60.99, Other operations on prostate.

All remaining O.R. procedures are assigned to DRGs 468 and 477, with DRG 477 assigned to those discharges in which the only procedures performed are nonextensive procedures that are unrelated to the principal diagnosis.\2\

\2\ The original list of the ICD-9-CM procedure codes for the procedures we consider nonextensive procedures, if performed with an unrelated principal diagnosis, was published in Table 6C in section IV. of the Addendum to the FY 1989 final rule (53 FR 38591). As part of the FY 1991 final rule (55 FR 36135), the FY 1992 final rule (56 FR 43212), the FY 1993 final rule (57 FR 23625), the FY 1994 final rule (58 FR 46279), the FY 1995 final rule (59 FR 45336), the FY 1996 final rule (60 FR 45783), the FY 1997 final rule (61 FR 46173), and the FY 1998 final rule (62 FR 45981), we moved several other procedures from DRG 468 to DRG 477, and some procedures from DRG 477 to DRG 468. No procedures were moved in FY 1999, as noted in the final rule (63 FR 40962); in FY 2000 (64 FR 41496); in FY 2001 (65 FR 47064); or in FY 2002 (66 FR 39852). In the FY 2003 final rule (67 FR 49999) we did not move any procedures from DRG 477. However, we did move procedure codes from DRG 468 and placed them in more clinically coherent DRGs. In the FY 2004 final rule (68 FR 45365), we moved several procedures from DRG 468 to DRGs 476 and 477 because the procedures are nonextensive. In the FY 2005 final rule (69 FR 48950), we moved one procedure from DRG 468 to 477. In addition, we added several existing procedures to DRGs 476 and 477.

a. Moving Procedure Codes From DRG 468 or DRG 477 to MDCs

We annually conduct a review of procedures producing assignment to DRG 468 or DRG 477 on the basis of volume, by procedure, to see if it would be appropriate to move procedure codes out of these DRGs into one of the surgical DRGs for the MDC into which the principal diagnosis falls. The data are arrayed two ways for comparison purposes. We look at a frequency count of each major operative procedure code. We also compare procedures across MDCs by volume of procedure codes within each MDC.

We identify those procedures occurring in conjunction with certain principal diagnoses with sufficient frequency to justify adding them to one of the surgical DRGs for the MDC in which the diagnosis falls. Based on this year's review, we did not identify any procedures in DRGs 468 or 477 that should be removed to one of the surgical DRGs. Therefore, in this proposed rule, we are not proposing any changes for FY 2006. b. Reassignment of Procedures Among DRGs 468, 476, and 477

We also annually review the list of ICD-9-CM procedures that, when in combination with their principal diagnosis code, result in assignment to DRGs 468, 476, and 477, to ascertain if any of those procedures should be reassigned from one of these three DRGs to another of the three DRGs based on average charges and the length of stay. We look at the data for trends such as shifts in treatment practice or reporting practice that would make the resulting DRG assignment illogical. If we find these shifts, we would propose to move cases to keep the DRGs clinically similar or to provide payment for the cases in a similar manner. Generally, we move only those procedures for which we have an adequate number of discharges to analyze the data.

It has come to our attention that procedure code 26.12 (Open biopsy of salivary gland or duct) is assigned to DRG 468 (Extensive O.R. Procedure Unrelated to Principal Diagnosis). We believe this to be an error, as code 26.31 (Partial sialoadenectomy), which is a more extensive procedure than code 26.12, is assigned to DRG 477. Therefore, we are proposing to correct this error by moving code 26.12 out of DRG 468 and reassigning it to DRG 477.

We are not proposing to move any procedure codes from DRG 476 to DRGs 468 or 477, or from DRG 477 to DRGs 468 or 476. c. Adding Diagnosis or Procedure Codes to MDCs

Based on our review this year, we are not proposing to add any diagnosis codes to MDCs. 13. Changes to the ICD-9-CM Coding System

As described in section II.B.1. of this preamble, the ICD-9-CM is a coding system used for the reporting of diagnoses and procedures performed on a patient. In September 1985, the ICD-9-CM Coordination and Maintenance Committee was formed. This is a Federal interdepartmental committee, co-chaired by the National Center for Health Statistics (NCHS) and CMS, charged with maintaining and updating the ICD-9-CM system. The Committee is jointly responsible for approving coding changes, and developing errata, addenda, and other modifications to the ICD-9-CM to reflect newly developed procedures and technologies and newly identified diseases. The Committee is also responsible for promoting the use of Federal and non-Federal educational programs and other communication techniques with a view toward standardizing coding applications and upgrading the quality of the classification system.

The Official Version of the ICD-9-CM contains the list of valid diagnosis and procedure codes. (The Official Version of the ICD-9-CM is available from the Government Printing Office on CD-ROM for $25.00 by calling (202) 512-1800.) The Official Version of the ICD-9-CM is no longer available in printed manual form from the Federal Government; it is only available on CD-ROM. Users who need a paper version are referred to one of the many products available from publishing houses.

The NCHS has lead responsibility for the ICD-9-CM diagnosis codes included in the Tabular List and Alphabetic Index for Diseases, while CMS has lead

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responsibility for the ICD-9-CM procedure codes included in the Tabular List and Alphabetic Index for Procedures.

The Committee encourages participation in the above process by health-related organizations. In this regard, the Committee holds public meetings for discussion of educational issues and proposed coding changes. These meetings provide an opportunity for representatives of recognized organizations in the coding field, such as the American Health Information Management Association (AHIMA), the American Hospital Association (AHA), and various physician specialty groups, as well as individual physicians, medical record administrators, health information management professionals, and other members of the public, to contribute ideas on coding matters. After considering the opinions expressed at the public meetings and in writing, the Committee formulates recommendations, which then must be approved by the agencies.

The Committee presented proposals for coding changes for implementation in FY 2006 at a public meeting held on October 7-8, 2004, and finalized the coding changes after consideration of comments received at the meetings and in writing by January 12, 2005. Those coding changes are announced in Tables 6A through 6F of the Addendum to this proposed rule. The Committee held its 2005 meeting on March 31- April l, 2005. Proposed new codes for which there was a consensus of public support and for which complete tabular and indexing charges can be made by May 2005 will be included in the October 1, 2005 update to ICD-9-CM. These additional codes will be included in Tables 6A through 6F of the final rule.

Copies of the minutes of the procedure codes discussions at the Committee's October 7-8, 2004 meeting can be obtained from the CMS Web site: http://www.cms.hhs.gov/paymentsystems/icd9/. The minutes of the

diagnoses codes discussions at the October 7-8, 2004 meeting are found at: http://www.cdc.gov/nchs/icd9.htm. Paper copies of these minutes are

no longer available and the mailing list has been discontinued. These Web sites also provide detailed information about the Committee, including information on requesting a new code, attending a Committee meeting, and timeline requirements and meeting dates.

We encourage commenters to address suggestions on coding issues involving diagnosis codes to: Donna Pickett, Co-Chairperson, ICD-9-CM Coordination and Maintenance Committee, NCHS, Room 2402, 3311 Toledo Road, Hyattsville, MD 20782. Comments may be sent by e-mail to: dfp4@cdc.gov.

Questions and comments concerning the procedure codes should be addressed to: Patricia E. Brooks, Co-Chairperson, ICD-9-CM Coordination and Maintenance Committee, CMS, Center for Medicare Management, Hospital and Ambulatory Policy Group, Division of Acute Care, C4-08-06, 7500 Security Boulevard, Baltimore, MD 21244-1850. Comments may be sent by e-mail to: Patricia.Brooks1@cms.hhs.gov.

The ICD-9-CM code changes that have been approved will become effective October 1, 2005. The new ICD-9-CM codes are listed, along with their DRG classifications, in Tables 6A and 6B (New Diagnosis Codes and New Procedure Codes, respectively) in the Addendum to this proposed rule. As we stated above, the code numbers and their titles were presented for public comment at the ICD-9-CM Coordination and Maintenance Committee meetings. Both oral and written comments were considered before the codes were approved. In this proposed rule, we are only soliciting comments on the proposed classification of these new codes.

For codes that have been replaced by new or expanded codes, the corresponding new or expanded diagnosis codes are included in Table 6A. New procedure codes are shown in Table 6B. Diagnosis codes that have been replaced by expanded codes or other codes or have been deleted are in Table 6C (Invalid Diagnosis Codes). These invalid diagnosis codes will not be recognized by the GROUPER beginning with discharges occurring on or after October 1, 2005. Table 6D contains invalid procedure codes. These invalid procedure codes will not be recognized by the GROUPER beginning with discharges occurring on or after October 1, 2005. Revisions to diagnosis code titles are in Table 6E (Revised Diagnosis Code Titles), which also includes the DRG assignments for these revised codes. Table 6F includes revised procedure code titles for FY 2006.

In the September 7, 2001 final rule implementing the IPPS new technology add-on payments (66 FR 46906), we indicated we would attempt to include proposals for procedure codes that would describe new technology discussed and approved at the April meeting as part of the code revisions effective the following October. As stated previously, ICD-9-CM codes discussed at the March 31-April 1, 2005 Committee meeting that receive consensus and that can be finalized by May 2005 will be included in Tables 6A through 6F of the final rule.

Section 503(a) of Pub. L. 108-173 included a requirement for updating ICD-9-CM codes twice a year instead of a single update on October 1 of each year. This requirement was included as part of the amendments to the Act relating to recognition of new technology under the IPPS. Section 503(a) amended section 1886(d)(5)(K) of the Act by adding a clause (vii) which states that the ``Secretary shall provide for the addition of new diagnosis and procedure codes in April 1 of each year, but the addition of such codes shall not require the Secretary to adjust the payment (or diagnosis-related group classification) * * * until the fiscal year that begins after such date.'' This requirement improves the recognition of new technologies under the IPPS system by providing information on these new technologies at an earlier date. Data will be available 6 months earlier than would be possible with updates occurring only once a year on October 1.

While section 503(a) states that the addition of new diagnosis and procedure codes on April 1 of each year shall not require the Secretary to adjust the payment, or DRG classification under section 1886(d) of the Act until the fiscal year that begins after such date, we have to update the DRG software and other systems in order to recognize and accept the new codes. We also publicize the code changes and the need for a mid-year systems update by providers to capture the new codes. Hospitals also have to obtain the new code books and encoder updates, and make other system changes in order to capture and report the new codes.

The ICD-9-CM Coordination and Maintenance Committee holds its meetings in the Spring and Fall, usually in April and September, in order to update the codes and the applicable payment and reporting systems by October 1 of each year. Items are placed on the agenda for the ICD-9-CM Coordination and Maintenance Committee meeting if the request is received at least 2 months prior to the meeting. This requirement allows time for staff to review and research the coding issues and prepare material for discussion at the meeting. It also allows time for the topic to be publicized in meeting announcements in the Federal Register as well as on the CMS Web site. The public decides whether or not to attend the meeting based on the topics listed on the agenda. Final decisions on code title revisions are currently made by March 1 so that these titles can be included in the IPPS proposed rule. A

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complete addendum describing details of all changes to ICD-9-CM, both tabular and index, are publicized on CMS and NCHS Web pages in May of each year. Publishers of coding books and software use this information to modify their products that are used by health care providers. This 5-month time period has proved to be necessary for hospitals and other providers to update their systems.

A discussion of this timeline and the need for changes are included in the December 4-5, 2003 ICD-9-CM Coordination and Maintenance Committee minutes. The public agreed that there was a need to hold the fall meetings earlier, in September or October, in order to meet the new implementation dates. The public provided comment that additional time would be needed to update hospital systems and obtain new code books and coding software. There was considerable concern expressed about the impact this new April update would have on providers.

In the FY 2005 IPPS final rule, we implemented section 503(a) by developing a mechanism for approving, in time for the April update, diagnoses and procedure code revisions needed to describe new technologies and medical services for purposes of the new technology add-on payment process. We also established the following process for making these determinations. Topics considered during the Fall ICD-9-CM Coordination and Maintenance Committee meeting are considered for an April 1 update if a strong and convincing case is made by the requester at the Committee's public meeting. The request must identify the reason why a new code is needed in April for purposes of the new technology process. The participants at the meeting and those reviewing the Committee meeting summary report are provided the opportunity to comment on this expedited request. All other topics are considered for the October 1 update. Participants at the Committee meeting are encouraged to comment on all such requests. There were no requests for an expedited April l, 2005 implementation of an ICD-9-CM code at the October 7-8, 2004 Committee meeting. Therefore, there were no new ICD- 9-CM codes implemented on April 1, 2005.

We believe that this process captures the intent of section 503(a). This requirement was included in the provision revising the standards and process for recognizing new technology under the IPPS. In addition, the need for approval of new codes outside the existing cycle (October 1) arises most frequently and most acutely where the new codes will capture new technologies that are (or will be) under consideration for new technology add-on payments. Thus, we believe this provision was intended to expedite data collection through the assignment of new ICD- 9-CM codes for new technologies seeking higher payments.

Current addendum and code title information is published on the CMS Web page at: http://www.cms.hhs.gov/paymentsystems/icd9. Summary tables

showing new, revised, and deleted code titles are also posted on the following CMS Web page: http://www.cms.hhs.gov/medlearn/icd9code.asp.

Information on ICD-9-CM diagnosis codes, along with the Official ICD-9- CM Coding Guidelines, can be found on the Wep page at: http://www.cdc.gov/nchs/icd9.htm. Information on new, revised, and deleted

ICD-9-CM codes is also provided to the AHA for publication in the Coding Clinic for ICD-9-CM. AHA also distributes information to publishers and software vendors.

CMS also sends copies of all ICD-9-CM coding changes to its contractors for use in updating their systems and providing education to providers.

These same means of disseminating information on new, revised, and deleted ICD-9-CM codes will be used to notify providers, publishers, software vendors, contractors, and others of any changes to the ICD-9- CM codes that are implemented in April. Currently, code titles are also published in the IPPS proposed and final rules. The code titles are adopted as part of the ICD-9-CM Coordination and Maintenance Committee process. The code titles are not subject to comment in the proposed or final rules. We will continue to publish the October code updates in this manner within the IPPS proposed and final rules. For codes that are implemented in April, we will assign the new procedure code to the same DRG in which its predecessor code was assigned so there will be no DRG impact as far as DRG assignment. This mapping was specified by Pub. L. 108-173. Any midyear coding updates will be available through the websites indicated above and through the Coding Clinic for ICD-9-CM. Publishers and software vendors currently obtain code changes through these sources in order to update their code books and software systems. We will strive to have the April 1 updates available through these websites 5 months prior to implementation (that is, early November of the previous year), as is the case for the October 1 updates. Codebook publishers are evaluating how they will provide any code updates to their subscribers. Some publishers may decide to publish mid-year book updates. Others may decide to sell an addendum that lists the changes to the October 1 code book. Coding personnel should contact publishers to determine how they will update their books. CMS and its contractors will also consider developing provider education articles concerning this change to the effective date of certain ICD-9-CM codes. 14. Other Issues: Acute Intermittent Porphyria

Acute intermittent porphyria is a rare metabolic disorder. The condition is described by code 277.1 (Disorders of porphyrin metabolism). Code 277.1 is assigned to DRG 299 (Inborn Errors of Metabolism) under MDC 10 (Endocrine, Nutritional, and Metabolic Diseases and Disorders).

In the FY 2005 final rule (69 FR 48981), we discussed the DRG assignment of acute intermittent porphyria. This discussion was a result of correspondence that we received during the comment period for the FY 2005 proposed rule in which the commenter suggested that Medicare hospitalization payments do not accurately reflect the cost of treatment. At that time, we indicated that we would take this comment into consideration when we analyzed the MedPAR data for this proposed rule for FY 2006.

Our review of the most recent MedPAR data shows a total of 1,370 cases overall in DRG 299, of which 471 had a principal diagnosis coded as 277.1. The average length of stay for all cases in DRG 299 was 5.17 days, while the average length of stay for porphyria cases with code 277.1 was 6.0 days. The average charges for all cases in DRG 299 were $15,891, while the average changes for porphyria cases with code 277.1 were $21,920. Based on our analysis of these data, we do not believe that there is a sufficient difference between the average charges and average length of stay for these cases to justify a change to the DRG assignment for treating this condition.

C. Proposed Recalibration of DRG Weights

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

We are proposing to use the same basic methodology for the FY 2006 recalibration as we did for FY 2005 (FY 2005 IPPS final rule (69 FR 48981)). That is, we have recalibrated the DRG weights based on charge data for

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Medicare discharges using the most current charge information available (the FY 2004 MedPAR file).

The MedPAR file is based on fully coded diagnostic and procedure data for all Medicare inpatient hospital bills. The FY 2004 MedPAR data used in this final rule include discharges occurring between October 1, 2003 and September 30, 2004, based on bills received by CMS through December 31, 2004, from all hospitals subject to the IPPS and short- term acute care hospitals in Maryland (which are under a waiver from the IPPS under section 1814(b)(3) of the Act). The FY 2004 MedPAR file includes data for approximately 11,910,025 Medicare discharges. Discharges for Medicare beneficiaries enrolled in a Medicare+Choice managed care plan are excluded from this analysis. The data excludes CAHs, including hospitals that subsequently became CAHs after the period from which the data were taken.

The proposed methodology used to calculate the DRG relative weights from the FY 2004 MedPAR file is as follows:

To the extent possible, all the claims were regrouped using the DRG classification revisions discussed in section II.B. of this preamble.

The transplant cases that were used to establish the relative weight for heart and heart-lung, liver, and lung transplants (DRGs 103, 480, and 495) were limited to those Medicare-approved transplant centers that have cases in the FY 2004 MedPAR file. (Medicare coverage for heart, heart-lung, liver, and lung transplants is limited to those facilities that have received approval from CMS as transplant centers.)

Organ acquisition costs for kidney, heart, heart-lung, liver, lung, pancreas, and intestinal (or multivisceral organs) transplants continue to be paid on a reasonable cost basis. Because these acquisition costs are paid separately from the prospective payment rate, it is necessary to subtract the acquisition charges from the total charges on each transplant bill that showed acquisition charges before computing the average charge for the DRG and before eliminating statistical outliers.

Charges were standardized to remove the effects of differences in area wage levels, indirect medical education and disproportionate share payments, and, for hospitals in Alaska and Hawaii, the applicable cost-of-living adjustment.

The average standardized charge per DRG was calculated by summing the standardized charges for all cases in the DRG and dividing that amount by the number of cases classified in the DRG. A transfer case is counted as a fraction of a case based on the ratio of its transfer payment under the per diem payment methodology to the full DRG payment for nontransfer cases. That is, a transfer case receiving payment under the transfer methodology equal to half of what the case would receive as a nontransfer would be counted as 0.5 of a total case.

Statistical outliers were eliminated by removing all cases that are beyond 3.0 standard deviations from the mean of the log distribution of both the charges per case and the charges per day for each DRG.

The average charge for each DRG was then recomputed (excluding the statistical outliers) and divided by the national average standardized charge per case to determine the relative weight.

The proposed new weights are normalized by an adjustment factor of 1.47263 so that the average case weight after recalibration is equal to the average case weight before recalibration. This proposed adjustment is intended to ensure that recalibration by itself neither increases nor decreases total payments under the IPPS.

When we recalibrated the DRG weights for previous years, we set a threshold of 10 cases as the minimum number of cases required to compute a reasonable weight. We used that same case threshold in recalibrating the proposed DRG weights for FY 2006. Using the FY 2004 MedPAR data set, there are 41 DRGs that contain fewer than 10 cases. We are proposing to compute the weights for these low-volume DRGs by adjusting the FY 2005 weights of these DRGs by the percentage change in the average weight of the cases in the other DRGs.

Section 1886(d)(4)(C)(iii) of the Act requires that, beginning with FY 1991, reclassification and recalibration changes be made in a manner that assures that the aggregate payments are neither greater than nor less than the aggregate payments that would have been made without the changes. Although normalization is intended to achieve this effect, equating the average case weight after recalibration to the average case weight before recalibration does not necessarily achieve budget neutrality with respect to aggregate payments to hospitals because payments to hospitals are affected by factors other than average case weight. Therefore, as we have done in past years and as discussed in section II.A.4.a. of the Addendum to this proposed rule, we are making a budget neutrality adjustment to ensure that the requirement of section 1886(d)(4)(C)(iii) of the Act is met.

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

(If you choose to comment on issues in this section, please include the caption ``LTC-DRGs'' at the beginning of your comment.) 1. Background

In the June 6, 2003 LTCH PPS final rule (68 FR 34122), we changed the LTCH PPS annual payment rate update cycle to be effective July 1 through June 30 instead of October 1 through September 30. In addition, because the patient classification system utilized under the LTCH PPS is based directly on the DRGs used under the IPPS for acute care hospitals, in that same final rule, we explained that the annual update of the long-term care diagnosis-related group (LTC-DRG) classifications and relative weights will continue to remain linked to the annual reclassification and recalibration of the CMS-DRGs used under the IPPS. In that same final rule, we specified that we will continue to update the LTC-DRG classifications and relative weights to be effective for discharges occurring on or after October 1 through September 30 each year. Furthermore, we stated that we will publish the annual update of the LTC-DRGs in the proposed and final rules for the IPPS.

In the past, the annual update to the IPPS DRGs has been based on the annual revisions to the ICD-9-CM codes and was effective each October 1. As discussed in the FY 2005 IPPS final rule (69 FR 48954 through 48957) and in the February 3, 2005 LTCH PPS proposed rule (70 FR 5729 through 5733), with the implementation of section 503 (a) of Pub. L. 108-173, there is the possibility that one feature of the GROUPER software program may be updated twice during a Federal fiscal year (October 1 and April 1) as required by the statute for the IPPS. Specifically, ICD-9-CM diagnosis and procedure codes for new medical technology may be created and added to existing DRGs in the middle of the Federal fiscal year on April 1. This policy change will have no effect, however, on the LTC-DRG relative weights which will continue to be updated only once a year (October 1), nor will there be any impact on Medicare payments under the LTCH PPS. The use of the ICD-9-CM code set is also compliant with the current requirements of the Transactions and Code Sets Standards regulations at 45 CFR Parts 160 and 162, promulgated in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), Pub. L. 104-191.

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In the health care industry, historically annual changes to the ICD-9-CM codes were effective for discharges occurring on or after October 1 each year. Thus, the manual and electronic versions of the GROUPER software, which are based on the ICD-9-CM codes, were also revised annually and effective for discharges occurring on or after October 1 each year. As noted above, the patient classification system used under the LTCH PPS (LTC-DRGs) is based on the patient classification system used under the IPPS (CMS-DRGs), which historically had been updated annually and effective for discharges occurring on or after October 1 through September 30 each year. As mentioned above, the ICD-9-CM coding update process has been revised, as discussed in greater detail in the FY 2005 IPPS final rule (69 FR 48954 through 48957). Specifically, section 503(a) of Pub. L. 108-173 includes a requirement for updating ICD-9-CM codes as often as twice a year instead of the current process of annual updates on October 1 of each year. This requirement is included as part of the amendments to the Act relating to recognition of new medical technology under the IPPS. Section 503(a) of Pub L. 108-173 amended section 1886(d)(5)(K) of the Act by adding a new clause (vii) which states that ``the Secretary shall provide for the addition of new diagnosis and procedure codes in

[sic] April 1 of each year, but the addition of such codes shall not require the Secretary to adjust the payment (or diagnosis-related group classification) * * * until the fiscal year that begins after such date.'' This requirement will improve the recognition of new technologies under the IPPS by accounting for those ICD-9-CM codes in the MedPAR claims data at an earlier date. Despite the fact that aspects of the GROUPER software may be updated to recognize any new technology ICD-9-CM codes, as discussed in the February 3, 2005 LTCH PPS proposed rule (70 FR 5730 through 5733), there will be no impact on either LTC-DRG assignments or payments under the LTCH PPS at that time. That is, changes to the LTC-DRGs (such as the creation or deletion of LTC-DRGs) and the relative weights will continue to be updated in the manner and timing (October 1) as they are now.

As noted above and as described in the February 3, 2005 LTCH PPS proposed rule (70 FR 5730), updates to the GROUPER for both the IPPS and the LTCH PPS (with respect to relative weights and the creation or deletion of DRGs) are made in the annual IPPS proposed and final rules and are effective each October 1. We explained in the FY 2005 IPPS final rule (69 FR 48955 and 48956), that since we do not publish a midyear IPPS rule, April 1 code updates discussed above will not be published in a midyear IPPS rule. Rather, we will assign any new diagnostic or procedure codes to the same DRG in which its predecessor code was assigned, so that there will be no impact on the DRG assignments. Any proposed coding updates will be available through the websites indicated in the same rule and provided above in section II.B. of this preamble and through the Coding Clinic for ICD-9-CM. Publishers and software vendors currently obtain code changes through these sources in order to update their code books and software system. If new codes are implemented on April 1, revised code books and software systems, including the GROUPER software program, will be necessary because we must use current ICD-9-CM codes. Therefore, for purposes of the LTCH PPS, since each ICD-9-CM code must be included in the GROUPER algorithm to classify each case into a LTC-DRG, the GROUPER software program used under the LTCH PPS would need to be revised to accommodate any new codes.

As we discussed in the FY 2005 IPPS final rule (69 FR 48956), in implementing section 503(a) of Pub. L. 108-173, there will only be an April 1 update if new technology codes are requested and approved. It should be noted that any new codes created for April 1 implementation will be limited to those diagnosis and procedure code revisions primarily needed to describe new technologies and medical services. However, we reiterate that the process of discussing updates to the ICD-9-CM has been an open process through the ICD-9-CM C&M Committee since 1995. Requestors will be given the opportunity to present the merits of their proposed new code and make a clear and convincing case for the need to update ICD-9-CM codes for purposes of the IPPS new technology add-on payment process through an April 1 update.

In addition, in the FY 2005 IPPS final rule (69 FR 48956), we stated that at the October 2004 ICD-9-CM Coordination and Maintenance Committee meeting, no new codes were proposed for an April 1, 2005 implementation, and the next update to the ICD-9-CM coding system would not occur until October 1, 2005 (FY 2006). Presently, as there were no coding changes suggested for an April 1, 2005 update, the ICD-9-CM coding set implemented on October 1, 2004 will continue through September 30, 2005 (FY 2005). The proposed update to the ICD-9-CM coding system for FY 2006 is discussed above in section II.B. of this preamble.

In this proposed rule, we are proposing revisions to the LTC-DRG classifications and relative weights and, to the extent that they are finalized, we will publish them in the corresponding IPPS final rule, to be effective October 1, 2005 through September 30, 2006 (FY 2006), using the latest available data. The proposed LTC-DRGs and relative weights for FY 2006 in this proposed rule are based on the proposed IPPS DRGs (GROUPER Version 23.0) discussed in section II. of this proposed rule. 2. Proposed Changes in the LTC-DRG Classifications a. Background

Section 123 of Pub. L. 106-113 specifically requires that the PPS for LTCHs be a per discharge system with a DRG-based patient classification system reflecting the differences in patient resources and costs in LTCHs while maintaining budget neutrality. Section 307(b)(1) of Pub. L. 106-554 modified the requirements of section 123 of Pub. L. 106-113 by specifically requiring that the Secretary examine ``the feasibility and the impact of basing payment under such a system

[the LTCH PPS] on the use of existing (or refined) hospital diagnosis- related groups (DRGs) that have been modified to account for different resource use of long-term care hospital patients as well as the use of the most recently available hospital discharge data.''

In accordance with section 307(b)(1) of Pub. L. 106-554 and Sec. 412.515 of our existing regulations, the LTCH PPS uses information from LTCH patient records to classify patient cases into distinct LTC-DRGs based on clinical characteristics and expected resource needs. The LTC- DRGs used as the patient classification component of the LTCH PPS correspond to the DRGs under the IPPS for acute care hospitals. Thus, in this proposed rule, we are proposing to use the IPPS GROUPER Version 23.0 for FY 2006 to process LTCH PPS claims for LTCH occurring from October 1, 2005 through September 30, 2006. The proposed changes to the CMS DRG classification system used under the IPPS for FY 2006 (GROUPER Version 23.0) are discussed in section II.B. of the preamble to this proposed rule.

Under the LTCH PPS, we determine relative weights for each of the CMS DRGs to account for the difference in resource use by patients exhibiting the

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case complexity and multiple medical problems characteristic of LTCH patients. In a departure from the IPPS, as we discussed in the August 30, 2002 LTCH PPS final rule (67 FR 55985), which implemented the LTCH PPS, and the FY 2004 IPPS final rule (68 FR 45374), we use low-volume quintiles in determining the LTC-DRG weights for LTC-DRGs with less than 25 LTCH cases, because LTCHs do not typically treat the full range of diagnoses as do acute care hospitals. Specifically, we group those low-volume LTC-DRGs (LTC-DRGs with fewer than 25 cases) into 5 quintiles based on average charge per discharge. (A listing of the composition of low-volume quintiles for the FY 2005 LTC-DRGs (based on FY 2003 MedPAR data) appears in section II.D.3. of the FY 2005 IPPS final rule (69 FR 48985 through 48989).) We also adjust for cases in which the stay at the LTCH is less than or equal to five-sixths of the geometric average length of stay; that is, short-stay outlier cases (Sec. 412.529), as discussed below in section II.D.4. of this preamble. b. Patient Classifications into DRGs

Generally, under the LTCH PPS, Medicare payment is made at a predetermined specific rate for each discharge; that is, payment varies by the LTC-DRG to which a beneficiary's stay is assigned. Similar to case classification for acute care hospitals under the IPPS (see section II.B. of this preamble), cases are classified into LTC-DRGs for payment under the LTCH PPS based on the principal diagnosis, up to eight additional diagnoses, and up to six procedures performed during the stay, as well as age, sex, and discharge status of the patient. The diagnosis and procedure information is reported by the hospital using codes from the ICD-9-CM.

As discussed in section II.B. of this preamble, the CMS DRGs are organized into 25 major diagnostic categories (MDCs), most of which are based on a particular organ system of the body; the remainder involve multiple organ systems (such as MDC 22, Burns). Accordingly, the principal diagnosis determines MDC assignment. Within most MDCs, cases are then divided into surgical DRGs and medical DRGs. Some surgical and medical DRGs are further differentiated based on the presence or absence of CCs. (See section II.B. of this preamble for further discussion of surgical DRGs and medical DRGs.)

Because the assignment of a case to a particular LTC-DRG will help determine the amount that is paid for the case, it is important that the coding is accurate. As used under the IPPS, classifications and terminology used under the LTCH PPS are consistent with the ICD-9-CM and the Uniform Hospital Discharge Data Set (UHDDS), as recommended to the Secretary by the National Committee on Vital and Health Statistics (``Uniform Hospital Discharge Data: Minimum Data Set, National Center for Health Statistics, April 1980'') and as revised in 1984 by the Health Information Policy Council (HIPC) of the U.S. Department of Health and Human Services. We point out again that the ICD-9-CM coding terminology and the definitions of principal and other diagnoses of the UHDDS are consistent with the requirements of the Transactions and Code Sets Standards under HIPAA (45 CFR Parts 160 and 162).

The emphasis on the need for proper coding cannot be overstated. Inappropriate coding of cases can adversely affect the uniformity of cases in each LTC-DRG and produce inappropriate weighting factors at recalibration and result in inappropriate payments under the LTCH PPS. LTCHs are to follow the same coding guidelines used by the acute care hospitals to ensure accuracy and consistency in coding practices. There will be only one LTC-DRG assigned per long-term care hospitalization; it will be assigned at the discharge. Therefore, it is mandatory that the coders continue to report the same principal diagnosis on all claims and include all diagnostic codes that coexist at the time of admission, that are subsequently developed, or that affect the treatment received. Similarly, all procedures performed during that stay are to be reported on each claim.

Upon the discharge of the patient from a LTCH, the LTCH must assign appropriate diagnosis and procedure codes from the ICD-9-CM. Completed claim forms are to be submitted electronically to the LTCH's Medicare fiscal intermediary. Medicare fiscal intermediaries enter the clinical and demographic information into their claims processing systems and subject this information to a series of automated screening processes called the Medicare Code Editor (MCE). These screens are designed to identify cases that require further review before assignment into an LTC-DRG can be made.

After screening through the MCE, each LTCH claim will be classified into the appropriate LTC-DRG by the Medicare LTCH GROUPER. The LTCH GROUPER is specialized computer software based on the same GROUPER used under the IPPS. After the LTC-DRG is assigned, the Medicare fiscal intermediary determines the prospective payment by using the Medicare LTCH PPS PRICER program, which accounts for LTCH hospital-specific adjustments. As provided for under the IPPS, we provide an opportunity for the LTCH to review the LTC-DRG assignments made by the fiscal intermediary and to submit additional information within a specified timeframe (Sec. 412.513(c)).

The GROUPER is used both to classify past cases in order to measure relative hospital resource consumption to establish the LTC-DRG weights and to classify current cases for purposes of determining payment. The records for all Medicare hospital inpatient discharges are maintained in the MedPAR file. The data in this file are used to evaluate possible DRG classification changes and to recalibrate the DRG weights during our annual update (as discussed in section II. of this preamble). The LTC-DRG relative weights are based on data for the population of LTCH discharges, reflecting the fact that LTCH patients represent a different patient mix than patients in short-term acute care hospitals. 3. Development of the Proposed FY 2006 LTC-DRG Relative Weights a. General Overview of Development of the LTC-DRG Relative Weights

As we stated in the August 30, 2002 LTCH PPS final rule (67 FR 55981), one of the primary goals for the implementation of the LTCH PPS is to pay each LTCH an appropriate amount for the efficient delivery of care to Medicare patients. The system must be able to account adequately for each LTCH's case-mix in order to ensure both fair distribution of Medicare payments and access to adequate care for those Medicare patients whose care is more costly. To accomplish these goals, we adjust the LTCH PPS standard Federal prospective payment system rate by the applicable LTC-DRG relative weight in determining payment to LTCHs for each case. Under the LTCH PPS, relative weights for each LTC- DRG are a primary element used to account for the variations in cost per discharge and resource utilization among the payment groups (Sec. 412.515). To ensure that Medicare patients classified to each LTC-DRG have access to an appropriate level of services and to encourage efficiency, we calculate a relative weight for each LTC-DRG that represents the resources needed by an average inpatient LTCH case in that LTC-DRG. For example, cases in an LTC-DRG with a relative weight of 2 will, on average, cost twice as much as cases in an LTC-DRG with a weight of 1.

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b. Data

To calculate the proposed LTC-DRG relative weights for FY 2006 in this proposed rule, we obtained total Medicare allowable charges from FY 2004 Medicare hospital bill data from the December 2004 update of the MedPAR file, and we used the proposed Version 23.0 of the CMS GROUPER for IPPS (as discussed in section II.B. of this preamble) to classify cases. Consistent with the methodology under the IPPS, we are proposing to recalculate the FY 2006 LTC-DRG relative weights based on the best available data for this proposed rule.

As we discussed in the FY 2005 IPPS final rule (69 FR 48984), we have excluded the data from LTCHs that are all-inclusive rate providers and LTCHs that are reimbursed in accordance with demonstration projects authorized under section 402(a) of Pub. L. 90-248 (42 U.S.C. 1395b-1) or section 222(a) of Pub. L. 92-603 (42 U.S.C. 1395b-1). Therefore, in the development of the proposed FY 2006 LTC-DRG relative weights, we have excluded the data of the 19 all-inclusive rate providers and the 3 LTCHs that are paid in accordance with demonstration projects that had claims in the FY 2003 MedPAR file.

In the FY 2005 IPPS final rule (6 FR 48984), we discussed coding inaccuracies that were found in the claims data for a large chain of LTCHs in the FY 2002 MedPAR file, which were used to determine the LTC- DRG relative weights for FY 2004. As we discussed in the same final rule, after notifying the large chain of LTCHs whose claims contained the coding inaccuracies to request that they resubmit those claims with the correct diagnosis, from an analysis of LTCH claims data from the December 2003 update of the FY 2003 MedPAR file, it appeared that such claims data no longer contain coding errors. Therefore, it was not necessary to correct the FY 2003 MedPAR data for the development of the FY 2005 LTC-DRGs and relative weights established in the same final rule.

As stated above, in this proposed rule, we are proposing to use the December 2004 update of the FY 2004 MedPAR file for the determination of the proposed FY 2006 LTC-DRG relative weights as these are the best available data. Based on an analysis of LTCH claims data from the December 2004 update of the FY 2004 MedPAR file, it appears that such claims data do not contain coding inaccuracies found previously in LTCH claims data. Therefore, it was not necessary to correct the FY 2004 MedPAR data for the development of the proposed FY 2006 LTC-DRGs and relative weights presented in this proposed rule. c. Hospital-Specific Relative Value Methodology

By nature, LTCHs often specialize in certain areas, such as ventilator-dependent patients and rehabilitation and wound care. Some case types (DRGs) may be treated, to a large extent, in hospitals that have, from a perspective of charges, relatively high (or low) charges. This nonarbitrary distribution of cases with relatively high (or low) charges in specific LTC-DRGs has the potential to inappropriately distort the measure of average charges. To account for the fact that cases may not be randomly distributed across LTCHs, we use a hospital- specific relative value method to calculate the LTC-DRG relative weights instead of the methodology used to determine the DRG relative weights under the IPPS described above in section II.C. of this preamble. We believe this method will remove this hospital-specific source of bias in measuring LTCH average charges. Specifically, we reduce the impact of the variation in charges across providers on any particular LTC-DRG relative weight by converting each LTCH's charge for a case to a relative value based on that LTCH's average charge.

Under the hospital-specific relative value method, we standardize charges for each LTCH by converting its charges for each case to hospital-specific relative charge values and then adjusting those values for the LTCH's case-mix. The adjustment for case-mix is needed to rescale the hospital-specific relative charge values (which, by definition, averages 1.0 for each LTCH). The average relative weight for a LTCH is its case-mix, so it is reasonable to scale each LTCH's average relative charge value by its case-mix. In this way, each LTCH's relative charge value is adjusted by its case-mix to an average that reflects the complexity of the cases it treats relative to the complexity of the cases treated by all other LTCHs (the average case- mix of all LTCHs).

In accordance with the methodology established under Sec. 412.523, we standardize charges for each case by first dividing the adjusted charge for the case (adjusted for short-stay outliers under Sec. 412.529 as described in section II.D.4. (step 3) of this preamble) by the average adjusted charge for all cases at the LTCH in which the case was treated. Short-stay outliers under Sec. 412.529 are cases with a length of stay that is less than or equal to five-sixths the average length of stay of the LTC-DRG. The average adjusted charge reflects the average intensity of the health care services delivered by a particular LTCH and the average cost level of that LTCH. The resulting ratio is multiplied by that LTCH's case-mix index to determine the standardized charge for the case.

Multiplying by the LTCH's case-mix index accounts for the fact that the same relative charges are given greater weight in a LTCH with higher average costs than they would at a LTCH with low average costs which is needed to adjust each LTCH's relative charge value to reflect its case-mix relative to the average case-mix for all LTCHs. Because we standardize charges in this manner, we count charges for a Medicare patient at a LTCH with high average charges as less resource intensive than they would be at a LTCH with low average charges. For example, a $10,000 charge for a case in a LTCH with an average adjusted charge of $17,500 reflects a higher level of relative resource use than a $10,000 charge for a case in a LTCH with the same case-mix, but an average adjusted charge of $35,000. We believe that the adjusted charge of an individual case more accurately reflects actual resource use for an individual LTCH because the variation in charges due to systematic differences in the markup of charges among LTCHs is taken into account. d. Proposed Low-Volume LTC-DRGs

In order to account for LTC-DRGs with low-volume (that is, with fewer than 25 LTCH cases), in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55984), we group those low-volume LTC-DRGs into one of five categories (quintiles) based on average charges, for the purposes of determining relative weights. For this proposed rule, using LTCH cases from the December 2004 update of the FY 2004 MedPAR file, we identified 172 LTC- DRGs that contained between 1 and 24 cases. This list of proposed LTC- DRGs was then divided into one of the 5 low-volume quintiles, each containing a minimum of 34 LTC-DRGs (172/5 = 34 with 2 LTC-DRGs as the remainder). For FY 2006, we are proposing to make an assignment to a specific low-volume quintile by sorting the low-volume proposed LTC- DRGs in ascending order by average charge. For this proposed rule, this results in an assignment to a specific low volume quintile of the sorted 172 low-volume proposed LTC-DRGs by ascending order by average charge. Because the number of LTC-DRGs with less than 25 LTCH cases is not evenly divisible by five, the average charge of the low-volume proposed LTC-DRG was used to determine which low-

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volume quintile received the additional proposed LTC-DRG. After sorting the 172 low-volume LTC-DRGs in ascending order, we are proposing that the first fifth of low-volume LTC-DRGs with the lowest average charge would be grouped into Quintile 1. The highest average charge cases would be grouped into Quintile 5. Since the average charge of the proposed 35th LTC-DRG in the sorted list is closer to the proposed 34th LTC-DRG's average charge (assigned to Quintile 1) than to the average charge of the proposed 36th LTC-DRG in the sorted list (to be assigned to Quintile 2), we are proposing to place it into Quintile 1. This process was repeated through the remaining low-volume proposed LTC-DRGs so that 2 proposed low-volume quintiles contain 35 proposed LTC-DRGs and 3 proposed low-volume quintiles contain 34 proposed LTC-DRGs.

In order to determine the proposed relative weights for the proposed LTC-DRGs with low volume for FY 2006, in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55984), we are proposing to use the proposed five low-volume quintiles described above. The composition of each of the proposed five low-volume quintiles shown in the chart below would be used in determining the proposed LTC-DRG relative weights for FY 2006. We would determine a proposed relative weight and (geometric) average length of stay for each of the proposed five low-volume quintiles using the formula that we apply to the regular proposed LTC-DRGs (25 or more cases), as described below in section II.D.4. of this preamble. We are proposing to assign the same relative weight and average length of stay to each of the proposed LTC-DRGs that make up that proposed low-volume quintile. We note that, as this system is dynamic, it is possible that the number and specific type of LTC-DRGs with a low volume of LTCH cases will vary in the future. We use the best available claims data in the MedPAR file to identify low-volume LTC-DRGs and to calculate the relative weights based on our methodology.

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4. Steps for Determining the Proposed FY 2006 LTC-DRG Relative Weights

As we noted previously, the proposed FY 2006 LTC-DRG relative weights are determined in accordance with the methodology established in the August 1, 2003 IPPS final rule (68 FR 45367). In summary, LTCH cases must be grouped in the appropriate LTC-DRG, while taking into account the low-volume proposed LTC-DRGs as described above, before the proposed FY 2006 LTC-DRG relative weights can be determined. After grouping the cases in the appropriate proposed LTC-DRG, we are proposing to calculate the proposed relative weights for FY 2006 in this proposed rule by first removing statistical outliers and cases with a length of stay of 7 days or less, as discussed in greater detail below. Next, we are proposing to adjust the number of cases in each proposed LTC-DRG for the effect of short-stay outlier cases under Sec. 412.529, as also discussed in greater detail below. The short-stay adjusted discharges and corresponding charges are used to calculate ``relative adjusted weights'' in each proposed LTC-DRG using the hospital-specific relative value method described above.

Below we discuss in detail the steps for calculating the proposed FY 2006 LTC-DRG relative weights.

Step 1--Remove statistical outliers.

The first step in the calculation of the proposed FY 2006 LTC-DRG relative weights is to remove statistical outlier cases. We define statistical outliers as cases that are outside of 3.0 standard deviations from the mean of the log distribution of both charges per case and the charges per day for each LTC-DRG. These statistical outliers are removed prior to calculating the proposed relative weights. We believe that they may represent aberrations in the data that distort the measure of average resource use. Including those LTCH cases in the calculation of the proposed relative weights could result in an inaccurate proposed relative weight that does not truly reflect relative resource use among the proposed LTC-DRGs.

Step 2--Remove cases with a length of stay of 7 days or less.

The proposed FY 2006 LTC-DRG relative weights reflect the average of resources used on representative cases of a specific type. Generally, cases with a length of stay 7 days or less do not belong in a LTCH because these stays do not fully receive or benefit from treatment that is typical in a LTCH stay, and full resources are often not used in the earlier stages of admission to a LTCH. If we were to include stays of 7 days or less in the computation of the proposed FY 2006 LTC-DRG relative weights, the value of many proposed relative weights would decrease and, therefore, payments would decrease to a level that may no longer be appropriate.

We do not believe that it would be appropriate to compromise the integrity of the payment determination for those LTCH cases that actually benefit from and receive a full course of treatment at a LTCH, in order to include data from these very short-stays. Thus, in determining the proposed FY 2006 LTC-DRG relative weights, we remove LTCH cases with a length of stay of 7 days or less.

Step 3--Adjust charges for the effects of short-stay outliers.

After removing cases with a length of stay of 7 days or less, we are left with cases that have a length of stay of greater than or equal to 8 days. The next step in the calculation of the proposed FY 2006 LTC-DRG relative weights is to adjust each LTCH's charges per discharge for those remaining cases for the effects of short-stay outliers as defined in Sec. 412.529(a). (However, we note that even if a case was removed in Step 2 (that is, cases with a length of stay of 7 days or less), it was paid as a short-stay outlier if its length of stay was less than or equal to five-sixths of the average length of stay of the LTC-DRG, in accordance with Sec. 412.529.)

We make this adjustment by counting a short-stay outlier as a fraction of a discharge based on the ratio of the length of stay of the case to the average length of stay for the proposed LTC-DRG for nonshort-stay outlier cases. This has the effect of proportionately reducing the impact of the lower charges for the short-stay outlier cases in calculating the average charge for the proposed LTC-DRG. This process produces the same result as if the actual charges per discharge of a short-stay outlier case were adjusted to what they would have been had the patient's length of stay been equal to the average length of stay of the proposed LTC-DRG.

As we explained in the FY 2005 IPPS final rule (69 FR 48991), counting short-

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stay outlier cases as full discharges with no adjustment in determining the proposed LTC-DRG relative weights would lower the proposed LTC-DRG relative weight for affected proposed LTC-DRGs because the relatively lower charges of the short-stay outlier cases would bring down the average charge for all cases within a proposed LTC-DRG. This would result in an ``underpayment'' to nonshort-stay outlier cases and an ``overpayment'' to short-stay outlier cases. Therefore, in this proposed rule, we adjust for short-stay outlier cases under Sec. 412.529 in this manner because it results in more appropriate payments for all LTCH cases.

Step 4--Calculate the Proposed FY 2006 LTC-DRG relative weights on an iterative basis.

The process of calculating the proposed LTC-DRG relative weights using the hospital specific relative value methodology is iterative. First, for each LTCH case, we calculate a hospital-specific relative charge value by dividing the short-stay outlier adjusted charge per discharge (see step 3) of the LTCH case (after removing the statistical outliers (see step 1)) and LTCH cases with a length of stay of 7 days or less (see step 2) by the average charge per discharge for the LTCH in which the case occurred. The resulting ratio is then multiplied by the LTCH's case-mix index to produce an adjusted hospital-specific relative charge value for the case. An initial case-mix index value of 1.0 is used for each LTCH.

For each proposed LTC-DRG, the proposed FY 2006 LTC-DRG relative weight is calculated by dividing the average of the adjusted hospital- specific relative charge values (from above) for the proposed LTC-DRG by the overall average hospital-specific relative charge value across all cases for all LTCHs. Using these recalculated proposed LTC-DRG relative weights, each proposed LTCH's average relative weight for all of its cases (case-mix) is calculated by dividing the sum of all the proposed LTCH's LTC-DRG relative weights by its total number of cases. The LTCHs' hospital-specific relative charge values above are multiplied by these hospital specific case-mix indexes. These hospital- specific case-mix adjusted relative charge values are then used to calculate a new set of proposed LTC-DRG relative weights across all LTCHs. In this proposed rule, this iterative process is continued until there is convergence between the weights produced at adjacent steps, for example, when the maximum difference is less than 0.0001.

Step 5-Adjust the proposed FY 2006 LTC-DRG relative weights to account for nonmonotonically increasing relative weights.

As explained in section II.B. of this preamble, the proposed FY 2006 CMS DRGs, which the proposed FY 2006 LTC-DRGs are based, contain ``pairs'' that are differentiated based on the presence or absence of CCs. The proposed LTC-DRGs with CCs are defined by certain secondary diagnoses not related to or inherently a part of the disease process identified by the principal diagnosis, but the presence of additional diagnoses does not automatically generate a CC. As we discussed in the FY 2005 IPPS final rule (69 FR 48991), the value of monotonically increasing relative weights rises as the resource use increases (for example, from uncomplicated to more complicated). The presence of CCs in a proposed LTC-DRG means that cases classified into a ``without CC'' proposed LTC-DRG are expected to have lower resource use (and lower costs). In other words, resource use (and costs) are expected to decrease across ``with CC''/``without CC'' pairs of proposed LTC-DRGs.

For a case to be assigned to a proposed LTC-DRG with CCs, more coded information is called for (that is, at least one relevant secondary diagnosis), than for a case to be assigned to a proposed LTC- DRG ``without CCs'' (which is based on only one principal diagnosis and no relevant secondary diagnoses). Currently, the LTCH claims data include both accurately coded cases without complications and cases that have complications (and cost more), but were not coded completely. Both types of cases are grouped to a proposed LTC-DRG ``without CCs'' because only one principal diagnosis was coded. Since the LTCH PPS was only implemented for cost reporting periods beginning on or after October 1, 2002 (FY 2003) and LTCHs were previously paid under cost- based reimbursement, which is not based on patient diagnoses, coding by LTCHs for these cases may not have been as detailed as possible.

Thus, in developing the FY 2003 LTC-DRG relative weights for the LTCH PPS based on FY 2001 claims data, as we discussed in the August 30, 2002 LTCH PPS final rule (67 FR 55990), we found on occasion that the data suggested that cases classified to the LTC-DRG ``with CCs'' of a ``with CC''/``without CC'' pair had a lower average charge than the corresponding LTC-DRG ``without CCs.'' Similarly, as discussed in the FY 2005 IPPS final rule (69 FR 48991 through 48992), based on FY 2003 claims data, we also found on occasion that the data suggested that cases classified to the LTC-DRG ``with CCs'' of a ``with CC''/``without CC'' pair have a lower average charge than the corresponding LTC-DRG ``without CCs'' for the FY 2005 LTC-DRG relative weights.

We believe this anomaly may be due to coding that may not have fully reflected all comorbidities that were present. Specifically, LTCHs may have failed to code relevant secondary diagnoses, which resulted in cases that actually had CCs being classified into a ``without CC'' LTC-DRG. It would not be appropriate to pay a lower amount for the ``with CC'' LTC-DRG because, in general, cases classified into a ``with CC'' LTC-DRG are expected to have higher resource use (and higher cost) as discussed above. Therefore, previously when we determined the LTC-DRG relative weights in accordance with the methodology established in the August 30, 2002 LTCH PPS final rule (67 FR 55990), we grouped both the cases ``with CCs'' and ``without CCs'' together for the purpose of calculating the LTC-DRG relative weights for FYs 2003 through 2005. As we stated in that same final rule, we will continue to employ this methodology to account for nonmonotonically increasing relative weights until we have adequate data to calculate appropriate separate weights for these anomalous LTC- DRG pairs. We expect that, as was the case when we first implemented the IPPS, this problem will be self-correcting, as LTCHs submit more completely coded data in the future.

There are three types of ``with CC'' and ``without CC'' pairs that could be nonmonotonic; that is, where the ``without CC'' proposed LTC- DRG would have a higher average charge than the ``with CC'' proposed LTC-DRG. For this proposed rule, using the LTCH cases in the December 2004 update of the FY 2004 MedPAR file (the best available data at this time), we identified one of the three types of nonmonotonic LTC-DRG pairs.

The first category of nonmonotonically increasing proposed relative weights for FY 2006 proposed LTC-DRG pairs ``with and without CCs'' contains zero pairs of proposed LTC-DRGs in which both the proposed LTC-DRG ``with CCs'' and the proposed LTC-DRG ``without CCs'' had 25 or more LTCH cases and, therefore, did not fall into one of the 5 low- volume quintiles. For those nonmonotonic proposed LTC-DRG pairs, we would combine the LTCH cases and compute a new proposed relative weight based on the case-weighted average of the combined LTCH cases of the proposed LTC-DRGs.

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The case-weighted average charge is determined by dividing the total charges for all LTCH cases by the total number of LTCH cases for the combined proposed LTC-DRG. This new proposed relative weight would then be assigned to both of the proposed LTC-DRGs in the pair. In this proposed rule, for FY 2006, there are no proposed LTC-DRGs that fall into this category.

The second category of nonmonotonically increasing relative weights for proposed LTC-DRG pairs ``with and without CCs'' consists of one pair of proposed LTC-DRGs that has fewer than 25 cases, and each proposed LTC-DRG would be grouped to different proposed low-volume quintiles in which the ``without CC'' proposed LTC-DRG is in a higher- weighted proposed low-volume quintile than the ``with CC'' proposed LTC-DRG. For those pairs, we would combine the LTCH cases and determine the case-weighted average charge for all LTCH cases. The case-weighted average charge is determined by dividing the total charges for all LTCH cases by the total number of LTCH cases for the combined proposed LTC- DRG. Based on the case-weighted average LTCH charge, we determine within which low-volume quintile the ``combined LTC-DRG'' is grouped. Both proposed LTC-DRGs in the pair are then grouped into the same proposed low-volume quintile, and thus have the same proposed relative weight. In this proposed rule, for FY 2006, proposed LTC-DRGs 531 and 532 fall into this category.

The third category of nonmonotonically increasing relative weights for proposed LTC-DRG pairs ``with and without CCs'' consists of zero pairs of proposed LTC-DRGs where one of the proposed LTC-DRGs has fewer than 25 LTCH cases and is grouped to a proposed low-volume quintile and the other proposed LTC-DRG has 25 or more LTCH cases and has its own proposed LTC-DRG relative weight, and the proposed LTC-DRG ``without CCs'' has the higher proposed relative weight. We remove the proposed low-volume LTC-DRG from the proposed low-volume quintile and combine it with the other proposed LTC-DRG for the computation of a new proposed relative weight for each of these proposed LTC-DRGs. This new proposed relative weight is assigned to both proposed LTC-DRGs, so they each have the same proposed relative weight. In this proposed rule, for FY 2006, there are no proposed LTC-DRGs that fall into this category.

Step 6-Determine a proposed FY 2006 LTC-DRG relative weight for proposed LTC-DRGs with no LTCH cases.

As we stated above, we determine the proposed relative weight for each proposed LTC-DRG using charges reported in the December 2004 update of the FY 2004 MedPAR file. Of the 526 proposed LTC-DRGs for FY 2006, we identified 194 proposed LTC-DRGs for which there were no LTCH cases in the database. That is, based on data from the FY 2004 MedPAR file used in this proposed rule, no patients who would have been classified to those LTC-DRGs were treated in LTCHs during FY 2004 and, therefore, no charge data were reported for those proposed LTC-DRGs. Thus, in the process of determining the proposed LTC-DRG relative weights, we are unable to determine weights for these 194 proposed LTC- DRGs using the methodology described in steps 1 through 5 above. However, because patients with a number of the diagnoses under these proposed LTC-DRGs may be treated at LTCHs beginning in FY 2006, we assign proposed relative weights to each of the 194 ``no volume'' proposed LTC-DRGs based on clinical similarity and relative costliness to one of the remaining 332 (156--194 = 332) proposed LTC-DRGs for which we are able to determine proposed relative weights, based on FY 2004 claims data.

As there are currently no LTCH cases in these ``no volume'' proposed LTC-DRGs, we determine proposed relative weights for the 194 proposed LTC-DRGs with no LTCH cases in the FY 2004 MedPAR file used in this proposed rule by grouping them to the appropriate proposed low- volume quintile. This methodology is consistent with our methodology used in determining proposed relative weights to account for the proposed low-volume LTC-DRGs described above.

Our methodology for determining proposed relative weights for the proposed ``no volume'' LTC-DRGs is as follows: We crosswalk the proposed no volume LTC-DRGs by matching them to other similar proposed LTC-DRGs for which there were LTCH cases in the FY 2004 MedPAR file based on clinical similarity and intensity of use of resources as determined by care provided during the period of time surrounding surgery, surgical approach (if applicable), length of time of surgical procedure, post-operative care, and length of stay. We assign the proposed relative weight for the applicable proposed low-volume quintile to the proposed no volume LTC-DRG if the proposed LTC-DRG to which it is crosswalked is grouped to one of the proposed low-volume quintiles. If the proposed LTC-DRG to which the proposed no volume LTC- DRG is crosswalked is not one of the proposed LTC-DRGs to be grouped to one of the proposed low-volume quintiles, we compare the proposed relative weight of the proposed LTC-DRG to which the proposed no volume LTC-DRG is crosswalked to the proposed relative weights of each of the five quintiles and we assign the proposed no volume LTC-DRG the proposed relative weight of the proposed low-volume quintile with the closest weight. For this proposed rule, a list of the proposed no volume FY 2006 LTC-DRGs and the proposed FY 2006 LTC-DRG to which it is crosswalked in order to determine the appropriate proposed low-volume quintile for the assignment of a relative weight for FY 2006 is shown in the chart below.

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To illustrate this methodology for determining the proposed relative weights for the 194 proposed LTC-DRGs with no LTCH cases, we are providing the following examples, which refer to the proposed no volume LTC-DRGs crosswalk information for FY 2006 provided in the chart above.

Example 1:

There were no cases in the FY 2004 MedPAR file used for this proposed rule for proposed LTC-DRG 163 (Hernia Procedures Age 0-17). Since the procedure is similar in resource use and the length and complexity of the procedures and the length of stay are similar, we determined that proposed LTC-DRG 178 (Uncomplicated Peptic Ulcer Without CC), which is assigned to proposed low-volume Quintile 3 for the purpose of determining the proposed FY 2006 relative weights, would display similar clinical and resource use. Therefore, we assign the same proposed relative weight of proposed LTC-DRG 178 of 0.7586 (proposed Quintile 3) for FY 2006 (Table 11 in the Addendum to this proposed rule) to proposed LTC-DRG 163.

Example 2:

There were no LTCH cases in the FY 2004 MedPAR file used in this proposed rule for proposed LTC-DRG 91 (Simple Pneumonia and Pleurisy Age 0-17). Since the severity of illness in patients with bronchitis and asthma is similar in patients regardless of age, we determined that proposed LTC-DRG 90 (Simple Pneumonia and Pleurisy Age >17 Without CC) would display similar clinical and resource use characteristics and have a similar length of stay to proposed LTC-DRG 91. There were over 25 cases in proposed LTC-DRG 90. Therefore, it would not be assigned to a low-volume quintile for the purpose of determining the proposed LTC- DRG relative weights. However, under our established methodology, proposed LTC-DRG 91, with no LTCH cases, would need to be grouped to a proposed low-volume quintile. We determined that the proposed low- volume quintile with the closest weight to proposed LTC-DRG 90 (0.5004) (refer to Table 11 in the Addendum to this proposed rule) would be proposed low-volume Quintile 1 (0. 4502) (refer to Table 11 in the Addendum to this proposed rule). Therefore, we assign proposed LTC-DRG 91 a proposed relative weight of 0.4502 for FY 2006.

Furthermore, we are proposing LTC-DRG relative weights of 0.0000 for heart, kidney, liver, lung, pancreas, and simultaneous pancreas/ kidney transplants (LTC-DRGs 103, 302, 480, 495, 512, and 513, respectively) for FY 2006 because Medicare will only cover these procedures if they are performed at a hospital that has been certified for the specific procedures by Medicare and presently no LTCH has been so certified.

Based on our research, we found that most LTCHs only perform minor surgeries, such as minor small and large bowel procedures, to the extent any surgeries are performed at all. Given the extensive criteria that must be met to become certified as a transplant center for Medicare, we believe it is unlikely that any LTCHs would become certified as a transplant center. In fact, in the nearly 20 years since the implementation of the IPPS, there has never been a LTCH that even expressed an interest in becoming a transplant center.

However, if in the future a LTCH applies for certification as a Medicare-approved transplant center, we believe that the application and approval procedure would allow sufficient time for us to determine appropriate weights for the LTC-DRGs affected. At the present time, we would only include these six transplant LTC-DRGs in the GROUPER program for administrative purposes. Because we use the same GROUPER program for LTCHs as is used under the IPPS, removing these LTC-DRGs would be administratively burdensome.

Again, we note that as this system is dynamic, it is entirely possible that the number of proposed LTC-DRGs with a zero volume of LTCH cases based on the system will vary in the future. We used the best most recent available claims data in the MedPAR file to identify zero volume LTC-DRGs and to determine the proposed relative weights in this proposed rule.

Table 11 in the Addendum to this proposed rule lists the proposed LTC-DRGs and their respective proposed relative weights, geometric mean length of stay, and five-sixths of the geometric mean length of stay (to assist in the determination of short-stay outlier payments under Sec. 412.529) for FY 2006. E. Proposed Add-On Payments for New Services and Technologies

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

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1. Background

Sections 1886(d)(5)(K) and (L) of the Act establish a process of identifying and ensuring adequate payment for new medical services and technologies under the IPPS. Section 1886(d)(5)(K)(vi) of the Act specifies that a medical service or technology will be considered new if it meets criteria established by the Secretary after notice and opportunity for public comment. Section 1886(d)(5)(K)(ii)(I) of the Act specifies that the process must apply to a new medical service or technology if, ``based on the estimated costs incurred with respect to discharges involving such service or technology, the DRG prospective payment rate otherwise applicable to such discharges under this subsection is inadequate.''

The regulations implementing this provision establish three criteria for new medical services and techniques to receive an additional payment. First, Sec. 412.87(b)(2) defines when a specific medical service or technology will be considered new for purposes of new medical service or technology add-on payments. The statutory provision contemplated the special payment treatment for new medical services or technologies until such time as data are available to reflect the cost of the technology in the DRG weights through recalibration. There is a lag of 2 to 3 years from the point a new medical service or technology is first introduced on the market and when data reflecting the use of the medical service or technology are used to calculate the DRG weights. For example, data from discharges occurring during FY 2004 are used to calculate the proposed FY 2006 DRG weights in this proposed rule. Section 412.87(b)(2) provides that a ``medical service or technology may be considered new within 2 or 3 years after the point at which data begin to become available reflecting the ICD-9-CM code assigned to the new medical service or technology (depending on when a new code is assigned and data on the new medical service or technology become available for DRG recalibration). After CMS has recalibrated the DRGs, based on available data, to reflect the costs of an otherwise new medical service or technology, the medical service or technology will no longer be considered `new' under the criterion for this section.''

The 2-year to 3-year period during which a technology or medical service can be considered new would ordinarily begin with FDA approval, unless there was some documented delay in bringing the product onto the market after that approval (for instance, component production or drug production had been postponed until FDA approval due to shelf life concerns or manufacturing issues). After the DRGs have been recalibrated to reflect the costs of an otherwise new medical service or technology, the special add-on payment for new medical services or technology ceases (Sec. 412.87(b)(2)). For example, an approved new technology that received FDA approval in October 2004 and entered the market at that time may be eligible to receive add-on payments as a new technology until FY 2007 (discharges occurring before October 1, 2006), when data reflecting the costs of the technology would be used to recalibrate the DRG weights. Because the FY 2007 DRG weights will be calculated using FY 2005 MedPAR data, the costs of such a new technology would likely be reflected in the FY 2007 DRG weights.

Section 412.87(b)(3) further provides that, to receive special payment treatment, new medical services or technologies must be inadequately paid otherwise under the DRG system. To assess whether technologies would be inadequately paid under the DRGs, we establish thresholds to evaluate applicants for new technology add-on payments. In the FY 2004 IPPS final rule (68 FR 45385), we established the threshold at the geometric mean standardized charge for all cases in the DRG plus 75 percent of 1 standard deviation above the geometric mean standardized charge (based on the logarithmic values of the charges and transformed back to charges) for all cases in the DRG to which the new medical service or technology is assigned (or the case- weighted average of all relevant DRGs, if the new medical service or technology occurs in many different DRGs). Table 10 in the Addendum to the FY 2004 IPPS final rule (68 FR 45648) listed the qualifying threshold by DRG, based on the discharge data that we used to calculate the FY 2004 DRG weights.

However, section 503(b)(1) of Pub. L. 108-173 amended section 1886(d)(5)(K)(ii)(I) of the Act to provide for ``applying a threshold* * *that is the lesser of 75 percent of the standardized amount (increased to reflect the difference between cost and charges) or 75 percent of 1 standard deviation for the diagnosis-related group involved.'' The provisions of section 503(b)(1) apply to classification for fiscal years beginning with FY 2005. We updated Table 10 from the October 6, 2003 Federal Register correction document, which contains the thresholds that we used to evaluate applications for new service or technology add-on payments for FY 2005, using the section 503(b)(1) measures stated above, and posted these new thresholds on our Web site at: http://www.cms.hhs.gov/providers/hipps/newtech.asp. In the FY 2005

IPPS final rule (in Table 10 of the Addendum), we included the final thresholds that are being used to evaluate applicants for new technology add-on payments for FY 2006. (Refer to section IV.D. of the preamble to the FY 2005 IPPS final rule (69 FR 49084) for a discussion of a revision of the regulations to incorporate the change made by section 503(b)(1) of Pub. L. 108-173.)

Section 412.87(b)(1) of our existing regulations provides that a new technology is an appropriate candidate for an additional payment when it represents an advance in medical technology that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries. For example, a new technology represents a substantial clinical improvement when it reduces mortality, decreases the number of hospitalizations or physician visits or reduces recovery time compared to the technologies previously available. (See the September 7, 2001 final rule (66 FR 46902) for a complete discussion of this criterion.)

The new medical service or technology add-on payment policy provides additional payments for cases with high costs involving eligible new medical services or technologies while preserving some of the incentives under the average-based payment system. The payment mechanism is based on the cost to hospitals for the new medical service or technology. Under Sec. 412.88, Medicare pays a marginal cost factor of 50 percent for the costs of a new medical service or technology in excess of the full DRG payment. If the actual costs of a new medical service or technology case exceed the DRG payment by more than the 50- percent marginal cost factor of the new medical service or technology, Medicare payment is limited to the DRG payment plus 50 percent of the estimated costs of the new technology.

The report language accompanying section 533 of Pub. L. 106-554 indicated Congressional intent that the Secretary implement the new mechanism on a budget neutral basis (H.R. Conf. Rep. No. 106-1033, 106th Cong., 2nd Sess. at 897 (2000)). Section 1886(d)(4)(C)(iii) of the Act requires that the adjustments to annual DRG classifications and relative weights must be made in a manner that ensures that aggregate payments to hospitals are not affected. Therefore, in

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From the Federal Register Online via GPO Access [wais.access.gpo.gov] ]

[[pp. 23355-23404]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2006 Rates

[[Continued from page 23354]]

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the past, we accounted for projected payments under the new medical service and technology provision during the upcoming fiscal year at the same time we estimated the payment effect of changes to the DRG classifications and recalibration. The impact of additional payments under this provision was then included in the budget neutrality factor, which was applied to the standardized amounts and the hospital-specific amounts.

Section 503(d)(2) of Pub. L. 108-173 amended section 1886(d)(5)(K)(ii)(III) of the Act to provide that there shall be no reduction or adjustment in aggregate payments under the IPPS due to add-on payments for new medical services and technologies. Therefore, add-on payments for new medical services or technologies for FY 2005 and later years will not be budget neutral.

Applicants for add-on payments for new medical services or technologies for FY 2007 must submit a formal request, including a full description of the clinical applications of the medical service or technology and the results of any clinical evaluations demonstrating that the new medical service or technology represents a substantial clinical improvement, along with a significant sample of data to demonstrate the medical service or technology meets the high-cost threshold, no later than October 15, 2005. Applicants must submit a complete database no later than December 30, 2005. Complete application information, along with final deadlines for submitting a full application, will be available after publication of the FY 2006 final rule at our Web site: http://www.cms.hhs.gov/providers/hipps/default.asp. To allow interested parties to identify the new medical

services or technologies under review before the publication of the proposed rule for FY 2007, the website will also list the tracking forms completed by each applicant. 2. Public Input Before Publication of This Notice of Proposed Rulemaking on Add-On Payments

Section 503(b)(2) of Pub. L. 108-173 amended section 1886(d)(5)(K) of the Act by adding a clause (viii) to provide for a mechanism for public input before publication of a notice of proposed rulemaking regarding whether a medical service or technology represents a substantial improvement or advancement. The revised process for evaluating new medical service and technology applications requires the Secretary to--

Provide, before publication of a proposed rule, for public input regarding whether a new service or technology represents an advance in medical technology that substantially improves the diagnosis or treatment of Medicare beneficiaries.

Make public and periodically update a list of the services and technologies for which an application for add-on payments is pending.

Accept comments, recommendations, and data from the public regarding whether a service or technology represents a substantial improvement.

Provide, before publication of a proposed rule, for a meeting at which organizations representing hospitals, physicians, manufacturers, and any other interested party may present comments, recommendations, and data regarding whether a new service or technology represents a substantial clinical improvement to the clinical staff of CMS.

In order to provide an opportunity for public input regarding add- on payments for new medical services and technologies for FY 2006 before publication of this proposed rule, we published a notice in the Federal Register on December 30, 2004 (69 FR 78466) and held a town hall meeting at the CMS Headquarters Office in Baltimore, MD, on February 23, 2005. In the announcement notice for the meeting, we stated that the opinions and alternatives provided during the meeting would assist us in our evaluations of applications by allowing public discussions of the substantial clinical improvement criteria for each of the FY 2006 new medical service and technology add-on payment applications before the publication of this FY 2006 IPPS proposed rule.

Approximately 45 participants registered and attended in person, while additional participants listened over an open telephone line. The participants focused on presenting data on the substantial clinical improvement aspect of their products, as well as the need for additional payments to ensure access to Medicare beneficiaries. In addition, we received written comments regarding the substantial clinical improvement criterion for the applicants. We have considered these comments in our evaluation of each new application for FY 2006 in this proposed rule. We have summarized these comments or, if applicable, indicated that no comments were received, at the end of the discussion of the individual applications.

Section 503(c) of Pub. L. 108-173 amended section 1886(d)(5)(K) of the Act by adding a new clause (ix) requiring that, before establishing any add-on payment for a new medical service or technology, the Secretary shall seek to identify one or more DRGs associated with the new technology, based on similar clinical or anatomical characteristics and the costs of the technology and assign the new technology into a DRG where the average costs of care most closely approximate the costs of care using the new technology. No add-on payment shall be made with respect to such a new technology.

At the time an application for new technology add-on payments is submitted, the DRGs associated with the new technology are identified. We only determine that a new technology add-on payment is appropriate when the reimbursement under these DRGs is not adequate for this new technology. The criterion for this determination is the cost threshold, which we discuss below. We discuss the assignments of several new technologies within the DRG payment system in section II.B. of this proposed rule.

In this proposed rule, we evaluate whether new technology add-on payments will continue in FY 2006 for the three technologies that currently receive such payments. In addition, we present our evaluations of eight applications for add-on payments in FY 2006. The eight applications for FY 2006 include two applications for products that were denied new technology add-on payments for FY 2005. 3. FY 2006 Status of Technology Approved for FY 2005 Add-On Payments a. INFUSE TM(Bone Morphogenetic Proteins (BMPs) for Spinal Fusions)

INFUSE TMwas approved by FDA for use on July 2, 2002, and became available on the market immediately thereafter. In the FY 2004 IPPS final rule (68 FR 45388), we approved INFUSE TM for add-on payments under Sec. 412.88, effective for FY 2004. This approval was on the basis of using INFUSE TMfor single- level, lumbar spinal fusion, consistent with the FDA's approval and the data presented to us by the applicant. Therefore, we limited the add-on payment to cases using this technology for anterior lumbar fusions in DRGs 497 (Spinal Fusion Except Cervical With CC) and 498 (Spinal Fusion Except Cervical Without CC). Cases involving INFUSE TMthat are eligible for the new technology add-on payment are identified by assignment to DRGs 497 and 498 as a lumbar spinal fusion, with the combination of ICD-9-CM procedure codes 84.51 (Insertion of

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interbody spinal fusion device) and 84.52 (Insertion of recombinant bone morphogenetic protein).

The FDA approved INFUSE TMfor use on July 2, 2002. For FY 2005, INFUSE TMwas still within the 2-year to 3-year period during which a technology can be considered new under the regulations. Therefore, in the FY 2005 IPPS final rule (69 FR 49007 through 49009), we continued add-on payments for FY 2005 for cases receiving INFUSE TMfor spinal fusions in DRGs 497 (Spinal Fusion Except Cervical With CC) and 498 (Spinal Fusion Except Cervical Without CC).

As we discussed in the September 7, 2001 final rule (66 FR 46915), an approval of a new technology for special payment should extend to all technologies that are substantially similar. Otherwise, our payment policy would bestow an advantage to the first applicant to receive approval for a particular new technology. In last year's final rule (69 FR 49008), we discussed another product, called OP-1 Putty, manufactured by Stryker Biotech, that promotes natural bone growth by using a closely related bone morphogenetic protein called rhBMP-7. (INFUSE TMis rhBMP-2.) We also stated in last year's final rule that we had determined that the costs associated with the OP-1 Putty are similar to those associated with INFUSE TM. Because the OP-1 Putty became available on the market in May 2004 (when it received FDA approval for spinal fusions) for similar spinal fusion procedures and because this product also eliminates the need for the autograft bone surgery, we extended new technology add-on payments to this technology as well for FY 2005.

As noted above, the period for which technologies are eligible to receive new technology add-on payments is 2 to 3 years after the product becomes available on the market and data reflecting the cost of the technology are reflected in the DRG weights. The FDA approved INFUSE TMbone graft on July 2, 2002. Therefore, data reflecting the cost of the technology are now reflected in the DRG weights. In addition, by the end of FY 2005, the add-on payment will have been made for 2 years. Therefore, we are proposing to discontinue new technology add-on payment for INFUSE TMfor FY 2006. Because we apply the same policies in making new technology payment for OP-1 Putty as we do for INFUSE TM, we are proposing to discontinue new technology add-on payment for OP-1 Putty as well for FY 2006. b. InSync[supreg] Defibrillator System (Cardiac Resynchronization Therapy With Defibrillation (CRT-D))

Cardiac Resynchronization Therapy (CRT), also known as bi- ventricular pacing, is a therapy for chronic heart failure. A CRT implantable system provides electrical stimulation to the right atrium, right ventricle, and left ventricle to coordinate or resynchronize ventricular contractions and improve cardiac output.

In the FY 2005 IPPS final rule (69 FR 49016), we determined that cardiac resynchronization therapy with defibrillator (CRT-D) was eligible for add-on payments in FY 2005. Cases involving CRT-D that are eligible for new technology add-on payments are identified by either one of the following two ICD-9-CM procedure codes: 00.51 (Implantation of Cardiac Resynchronization Defibrillator, Total System (CRT-D)) or 00.54 (Implantation or Replacement of Pulse Generator Device Only (CRT- D)). InSync[supreg] Defibrillation System received FDA approval on June 26, 2002. However, another manufacturer, Guidant, received FDA approval for its CRT-D device on May 2, 2002. As we discussed in the September 7, 2001 final rule (66 FR 46915), an approval of a new technology for special payment should extend to all technologies that are substantially similar. Otherwise, our payment policy would bestow an advantage to the first applicant to receive approval for a particular new technology. We also noted that we would extend new technology add- on payments for the entire FY 2005 even though the 2-3 year period of newness ended in May 2005 for CRT-D since predictability is an important aspect of the prospective payment methodology and, therefore, we believe it is appropriate to apply a consistent payment methodology for new technologies throughout the fiscal year (69 FR 49016).

As noted in the FY 2005 IPPS final rule (69 FR 49014), because CRT- Ds were available upon the initial FDA approval in May 2002, we considered the technology to be new from this date. As a result, for FY 2006, the CRT-D will be beyond the 2-3 year period during which a technology can be considered new. Therefore, we are proposing to discontinue add-on payments for the CRT-D for FY 2006. c. Kinetra[supreg] Implantable Neurostimulator for Deep Brain Stimulation

Medtronic, Inc. submitted an application for approval of the Kinetra[supreg] implantable neurostimulator device for new technology add-on payments for FY 2005. The Kinetra[supreg] device was approved by the FDA on December 16, 2003. The Kinetra[supreg] implantable neurostimulator is designed to deliver electrical stimulation to the subthalamic nucleus (STN) or internal globus pallidus (GPi) in order to ameliorate symptoms caused by abnormal neurotransmitter levels that lead to abnormal cell-to-cell electrical impulses in Parkinson's Disease and essential tremor. Before the development of Kinetra[supreg], treating bilateral symptoms of patients with these disorders required the implantation of two neurostimulators (in the form of a product called SoletraTM, also manufactured by Medtronic): one for the right side of the brain (to control symptoms on the left side of the body), the other for the left side of the brain (to control symptoms on the right side of the body). Additional procedures were required to create pockets in the chest cavity to place the two generators required to run the individual leads. The Kinetra[supreg] neurostimulator generator, implanted in the pectoral area, is designed to eliminate the need for two devices by accommodating two leads that are placed in both the left and right sides of the brain to deliver the necessary impulses. The manufacturer argued that the development of a single neurostimulator that treats bilateral symptoms provides a less invasive treatment option for patients, and simpler implantation, follow up, and programming procedures for physicians.

In December 2003, the FDA approved the device. Therefore, for FY 2006, Kinetra[supreg] qualifies under the newness criterion because FDA approval was within the statutory timeframe of 2 to 3 years and its costs are not yet reflected in the DRG weights. Because there were no data available to evaluate costs associated with Kinetra[supreg], in the FY 2005 IPPS final rule, we conducted the cost analysis using SoletraTM, the predecessor technology used to treat this condition, as a proxy for Kinetra[supreg]. The preexisting technology provided the closest means to track cases that have actually used similar technology and served to identify the need and use of the new device. The manufacturer informed us that the cost of the Kinetra[supreg] device is twice the price of a single SoletraTMdevice. Because most patients would receive two SoletraTMdevices if the Kinetra[supreg] device is not implanted, we believed data regarding the cost of SoletraTM would give a good measure of the actual costs that would be incurred. Medtronic submitted data for 104 cases that involved the SoletraTMdevice (26 cases in DRG 1 (Craniotomy Age > 17

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With CC), and 78 cases in DRG 2 (Craniotomy Age > 17 Without CC)). These cases were identified from the FY 2002 MedPAR file using procedure codes 02.93 (Implantation, intracranial neurostimulator) and 86.09 (Other incision of skin and subcutaneous tissue). In the analysis presented by the applicant, the mean standardized charges for cases involving SoletraTMin DRGs 1 and 2 were $69,018 and $44,779, respectively. The mean standardized charge for these SoletraTMcases according to Medtronic's data was $50,839.

Last year, we used the same procedure codes to identify 187 cases involving the SoletraTMdevice in DRGs 1 and 2 in the FY 2003 MedPAR file. Similar to the Medtronic data, 53 of the cases were found in DRG 1, and 134 cases were found in DRG 2. The average standardized charges for these cases in DRGs 1 and 2 were $51,163 and $44,874, respectively. Therefore, the case-weighted average standardized charge for cases that included implantation of the SoletraTMdevice was $46,656. The new cost thresholds established under the revised criteria in Pub. L. 108-173 for DRGs 1 and 2 are $43,245 and $30,129, respectively. Accordingly, the case- weighted threshold to qualify for new technology add-on payment using the data we identified was determined to be $33,846. Under this analysis, Kinetra[supreg] met the cost threshold.

We note that an ICD-9-CM code was approved for dual array pulse generator devices, effective October 1, 2004, for IPPS tracking purposes. The new ICD-9-CM code that will be assigned to this device is 86.95 (Insertion or replacement of dual array neurostimulator pulse generator), which includes dual array and dual channel generators for intracranial, spinal, and peripheral neurostimulators. The code will not separately identify cases with the Kinetra[supreg] device and will only be used to distinguish single versus dual channel-pulse generator devices. Because the code only became effective on October 1, 2004, we do not have any specific data regarding the costs of cases involving dual array pulse generator devices.

The manufacturer claimed that Kinetra[supreg] provides a range of substantial improvements beyond previously available technology. These include a reduced rate of device-related complications and hospitalizations or physician visits and less surgical trauma because only one generator implantation procedure is required. Kinetra[supreg] has a reed switch disabling function that physicians can use to prevent inadvertent shutoff of the device, as occurs when accidentally tripped by electromagnetic inference (caused by common products such as metal detectors and garage door openers). Kinetra[supreg] also provides significant patient control, allowing patients to monitor whether the device is on or off, to monitor battery life, and to fine-tune the stimulation therapy within clinician-programmed parameters. While Kinetra[supreg] provides the ability for patients to better control their symptoms and reduce the complications associated with the existing technology, it does not eliminate the necessity for two surgeries. Because the patients who receive the device are often frail, the implantation generally occurs in two phases: the brain leads are implanted in one surgery, and the generator is implanted in another surgery, typically on another day. However, implanting Kinetra[supreg] does reduce the number of potential surgeries compared to its predecessor (which requires two surgeries to implant the two single- lead arrays to the brain and an additional surgery for implantation of the second generator). Therefore, the Kinetra[supreg] device reduces the number of surgeries from 3 to 2.

Last year, we solicited comments on (1) the issue of whether the device is sufficiently different from the previously used technology to qualify as a substantially improved treatment for the same patient symptoms; (2) the cost of the device; and (3) the approval of the device for add-on payment, given the uncertainty over the frequency with which the patients receiving the device have the generator implanted in a second hospital stay, and the frequency with which this implantation occurs in an outpatient setting. In the response, we received sufficient evidence to demonstrate that Kinetra[supreg] does represent a substantial clinical improvement over the previous Soletra TMdevice. Specifically, the increased patient control, reduced surgery, fewer complications, and elimination of environmental interference significantly improve patient outcomes. Therefore, we approved Kinetra[supreg] for new technology add-on payments for FY 2005.

Cases receiving Kinetra[supreg] for Parkinson's disease or essential tremor on or after October 1, 2004, are eligible to receive an add-on payment of up to $8,285, or half the cost of the device, which is approximately $16,570. These cases are identified by the presence of procedure codes 02.93 (Implantation or replacement of intracranial neurostimulator leads) and 86.95 (Insertion or replacement of dual array neurostimulator pulse generator). If a claim has only the procedure code identifying the implantation of the intracranial leads, or if the claim identifies only insertion of the generator, no add-on payment will be made.

This technology received FDA approval on December 16, 2003, and remains within the 2 to 3 year period during which it can be considered new. Therefore, we are proposing to continue add-on payments for Kinetra[supreg] Inplantable Neurostimulator for deep brain stimulation for FY 2006. 4. FY 2006 Applications for New Technology Add-On a. INFUSE TMBone Graft (Bone Morphogenetic Proteins (BMPs) for Tibia Fractures)

Bone Morphogenetic Proteins (BMPs) have been shown to have the capacity to induce new bone formation and, therefore, to enhance the healing of fractures. Using recombinant techniques, some BMPs (also referred to as rhBMPs) can be produced in large quantities. This innovation has cleared the way for the potential use of BMPs in a variety of clinical applications such as in delayed union and nonunion of fractured bones and spinal fusions. One such product, rhBMP-2, is developed as an alternative to bone graft with spinal fusions.

Medtronic Sofamor Danek (Medtronic) resubmitted an application (previously submitted for consideration for FY 2005) for a new technology add-on payment in FY 2006 for the use of INFUSE TMBone Graft in open tibia fractures. In cases of open tibia fractures, INFUSE TMis applied using an absorbable collagen sponge, which is then applied to the fractured bone to promote new bone formation and improved healing. The manufacturer contends that patient access to this technology is restricted due to the increased costs of treating these cases with INFUSE TM. The FDA approved use of INFUSE TMfor open tibia fractures on April 30, 2004.

Medtronic's first application for a new technology add-on payment for INFUSE TMBone Graft in open tibia fractures was denied. As we discussed in the FY 2005 IPPS final rule (69 FR 49010), the FY 2005 application for INFUSE TMfor open tibia fractures was denied because a similar product, OP-1, was approved in 2001 for the treatment of nonunion of tibia fractures.

Comment: In comments presented at the February 2005 new technology town hall meeting, Medtronic contended that there was no opportunity for public

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comment on our decision regarding OP-1 Putty: ``the public had no opportunity to comment on whether the follow-on products were `substantially similar' to the primary technologies under consideration. The absence of such provisions led to unpredictability and confusion about the new-technology add-on program.''

Response: In the FY 2005 IPPS final rule, we noted that a commenter brought the existence of the Stryker Biotech OP-1 product to our attention during the comment period on the IPPS proposed rule for FY 2005. The commenter noted OP-1's clinical similarity to INFUSE TMand contended that the products should be treated the same with respect to new technology payments when the product is used for tibia fractures. At that time, we determined that, despite the differences in indications under the respective FDA approvals, the two products were in use for many of the same kinds of cases. Specifically, clinical studies on the safety of OP-1 included patients with complicated fractures of the tibia, and those cases were similar to the cases described in the clinical trials for INFUSE TMfor open tibia fractures. In addition, cases involving the use of OP-1 for long bone union and open tibia fractures are assigned to the same DRGs (DRGs 218 and 219 (Lower Extremity Procedures With and Without CC, respectively)) as cases involving INFUSE TM. Therefore, we denied new technology add-on payments for INFUSE TMfor open tibia fractures for FY 2005 on the grounds that the technology involving the use of bone morphogenetic proteins to treat severe long bone fractures (including open tibia fractures) and recalcitrant long bone fractures had been in use for more than 3 years.

We note that Medtronic had ample opportunity, prior to the issuance of the FY 2005 IPPS final rule, to bring to our attention the fact that there was a similar product on the market that was being used in long bone fractures. We based our decision for FY 2005 on the record that was placed at our disposal by the applicant and by commenters during the comment period. Nevertheless, we have considered the issues raised by these two products again in the course of evaluating Medtronic's new application for approval of INFUSE TMfor new technology add-on payments in FY 2006.

As part of its FY 2006 application, Medtronic advanced several arguments designed to demonstrate that OP-1 and INFUSE TM are substantially different. The application cites data from several studies as evidence of the clinical superiority of INFUSE TM over OP-1. Medtronic presented studies at the February 2005 new technology town hall meeting to provide evidence that INFUSE TMis superior to OP-1 in the time it takes for critical- sized defects to heal and in radiographic assessment, mechanical testing of the repaired bone, and histology of the union for trial subjects receiving INFUSE TMcompared with OP-1. (Study subjects were canines whose ulnas had 2.5 cm each of bone removed and then equal amounts of OP-1 and INFUSE TMwere put into the front legs in a head to head trial.) Medtronic has also argued that these studies demonstrate that OP-1 has been shown to be less effective than using the patient's own bone or the current standard of care (nail fixation with soft tissue medical management). Medtronic argued that the INFUSE TMproduct is not only superior to OP-1 for patients with open tibia fractures, but also that it is superior to any other treatment for these serious injuries.

Medtronic also pointed out that the FDA approved OP-1 for Humanitarian Device Exemption (HDE) status, whereas INFUSE TMreceived a Pre-Market Approval (PMA). To receive HDE approval, a product only needs to meet a safety standard, while standards of both safety and efficacy have to be met for a PMA approval. Medtronic argued that, because the only point the manufacturer of OP-1 was able to prove was that it did not harm those individuals that received it, the efficacy of OP-1 not only has not been demonstrated for the general population, but also more specifically, it has not been proven in the Medicare population. Medtronic presented arguments that INFUSE TMis a superior product to OP-1 because the INFUSE TMproduct has demonstrated safety and efficacy, while the OP-1 product has merely demonstrated that it is safe to use in humans. Medtronic pointed to the labeled indications and package inserts provided with the two products, stating that only INFUSE TMprovides a substantial clinical improvement to patients receiving a BMP product.

We do not believe that the different types of FDA approvals for the two products are relevant to distinguish between the two products in determining whether either product should be considered for new technology add-on payments under the IPPS. Manufacturers seek different types of FDA approval for many different reasons, including timing, the availability of adequate studies, the availability of resources to pursue research studies, and the size of the patient population that may be affected. The FDA has stated that the HDE approval process was established to address cases involving devices used in the treatment or diagnosis of diseases affecting fewer than 4,000 individuals in the United States per year: ``A device manufacturer's research and development costs could exceed its market returns for diseases or conditions affecting small patient populations. FDA, therefore, developed and published [the regulation establishing the HDE process] to provide an incentive for the development of devices for use in the treatment or diagnosis of diseases affecting these populations.'' (http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfHDE/HDEInformation.cfm ). The fact that two products received different

types of approval does not demonstrate either that they are substantially different for purposes of new technology add-on payments, or that one is new and the other is not. Nor do the different types of FDA approval imply that one product could meet our substantial clinical improvement criterion and the other could not. Neither type of FDA approval requires that products establish substantial clinical improvement, as is required for approval of new technology add-on payments. Theoretically, a product that receives an FDA HDE approval could subsequently meet our substantial clinical improvement criterion, while a product that receives an FDA PMA approval could fail to do so. We base our substantial clinical improvement determinations on the evidence presented in the course of the application process, and not on the type of FDA approval.

For purposes of determining whether the use of rhBMPs for open tibia fracture represents a new technology, the crucial consideration is whether the costs of this technology are represented in the weights of the relevant DRGs. Cases that involve treatment of non-healed and acute tibia fractures fall into the same DRGs. We have identified 10,047 cases involving the use of rhBMPs in the FY 2004 MedPAR data file. This use includes the approved indications for INFUSE TMin spinal fusions (6,712 cases) and tibia DRGs (77 cases). However, we note that an additional 3,258 cases involving the off-label use of rhBMPs were found in 47 DRGs in the FY 2004 MedPAR data. We also note that, in our analysis of the FY 2003 MedPAR data, an additional 890 cases of off-label use (identified by the presence of ICD-9-CM code 84.52) were found in 36 DRGs. Therefore, we note

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that the use of rhBMPs, made by Medtronic or otherwise, has penetrated the cost data that were used to set the FY 2005 and FY 2006 DRG weights. Whether or not it is possible to differentiate between patient populations that would be eligible to receive the OP-1 Implant for nonunions or the INFUSE TMbone graft for open tibia fractures, the patient populations both fall into the same DRGs. In addition, we have determined that the costs associated with the two products are comparable (69 FR 49009). Therefore, because BMP products have been used in treating both types of fractures included in the same DRGs since 2001, we continue to believe that the hospital charge data used in developing the relative weights reflect the costs of these products.

Comment: In our Federal Register announcement of the February 23, 2005 new technology town hall meeting, held on February 23, 2005, we solicited comments on the issue of when products should be considered substantially similar. As a result, Medtronic recommended several criteria for determining whether two or more products are substantially similar and requested that we apply these criteria in determining whether OP-1 and INFUSE TMare similar for new technology add-on payment purposes. The three criteria recommended by Medtronic are:

The technologies or services in question use the same, or a similar, mechanism of action to achieve the therapeutic outcome.

The technologies or services are indicated for use in the same population for the same condition.

The technologies or services achieve the same level of substantial improvement.

Medtronic has also argued that, according to its proposed criteria, OP-1 would fail on two of the three proposed tests for substantial similarity:

According to Medtronic, the OP-1 implant ``arguably'' uses the same or a similar mechanism of action to achieve the therapeutic outcome.

OP-1 and INFUSE TMare indicated for use in different population and different conditions. According to Medtronic, INFUSE TMBone Graft has an indication for acute, open tibia fractures only, used within 14 days, and is to be used with an intramedullary (IM) nail as part of the primary procedure. There is no limitation on the number of patients that can receive the technology. OP-1 Implant is indicated only for recalcitrant long-bone non-unions that have failed to heal. The HDE approval also specifies that use of OP-1 is limited to secondary procedures (as would be expected with nonunions). The number of patients able to receive the device is limited to 4,000 patients per year and with oversight from an Institutional Review Board.

Medtronic argues the products do not achieve the same level of substantial improvement (as discussed above).

Response: We agree with Medtronic that the first proposed criterion has some relevance in determining whether products are substantially similar. In evaluating the application for new technology add-on payments last year, we made the determination that, while these products are not identical chemically, the products do use the same mechanism of action to achieve the therapeutic outcome. However, we do not agree that the other two criteria recommended by Medtronic are relevant considerations for this purpose. As we have discussed above, we believe that whether cases involving different products are assigned to the same DRGs is a more relevant consideration than whether the products have the same specific indications. In addition, as we have already stated, we continue to believe that the hospital charge data used in developing the relative weights of the relevant DRGs reflect the costs of these products. Furthermore, we do not necessarily agree that considerations about the degrees of clinical improvements offered by different products should enter into decisions about whether products are new. We have always based our decisions about new technology add-on payments on a logical sequence of determinations, moving from the newness criterion to the cost criterion and finally to the substantial clinical improvement criterion. Specifically, we do not make determinations about substantial improvement unless a product has already been determined to be new and to meet the cost criterion. Therefore, we are reluctant to import substantial clinical improvement considerations into the logical prior decision about whether technologies are new. Furthermore, while we may sometimes need to make separate determinations about whether similar products meet the substantial clinical improvement criterion, we do not believe that it would be appropriate to make determinations about whether one product or another is clinically superior. However, we welcome comments while we continue to consider these issues.

Comment: Medtronic suggested revisions to the application process that are designed to assist in identifying substantially similar products and provide the public with opportunity for comment on specific instances in which substantial similarity is an issue. The suggested proposed revisions are:

After receipt of all new applications for a fiscal year, CMS should publish a Federal Register notice specifically asking manufacturers to identify if they wish to receive consideration for products that may be substantially similar to applications received. Such notice would probably occur in January. Responses would be required by a date certain in advance of the new technology town hall meeting, and would include justification of how the products meet the ``substantial similarity'' criteria.

The new technology town hall meeting should include a discussion of products identified by manufacturers as ``substantially similar'' to other approved products or pending applications.

CMS should publish initial findings about ``substantial similarity'' in the proposed hospital inpatient rule, with opportunity for public comment.

CMS should publish ultimate findings in the inpatient final rule.

Alternatively, Medtronic suggested that, if a manufacturer identifies a product that may be substantially similar to a technology with an approved add-on payment, the manufacturer may choose to submit an application under the normal deadlines for the add-on payment program.

Response: We appreciate Medtronic's suggestions for evaluating similar technologies for new technology add-on payment. We have stated on several occasions that we wish to avoid creating situations in which similar products receive different treatment because only one manufacturer has submitted an application for new technology add-on payments. As we discussed in the September 7, 2001 Federal Register (66 FR 46915), an approval of a new technology for special payment should extend to all technologies that are substantially similar. Otherwise, our payment policy would bestow an advantage to the first applicant to receive approval for a particular new technology.

In addition, we note that commenters on the FY 2005 proposed rule placed a great deal of emphasis on the fact that many manufacturers developing new technologies are not aware of the existence of the add- on payment provision or lack the resources to apply for add-on payment. Therefore, commenters on that proposed rule argued that the regulations we have established are already too stringent and cumbersome, especially for small manufacturers to access the new

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technology add-on payment process. The proposal by Medtronic would place further burden on these small manufacturers, both to know that an application has been made for a similar product and to make representations on a product that may or may not be on the market. Therefore, we are reluctant to adopt a process that places the formal burden on a competitor to seek equal treatment. However, we welcome comments while we continue to consider these issues.

We note that Medtronic submitted data on 236 cases using INFUSE TMfor open tibia fractures in the FY 2003 MedPAR data file, as identified by procedure code 79.36 (Reduction, fracture, open, internal fixation, tibia and fibula) and diagnosis codes of either 823.30 (Fracture of tibia alone, shaft, open) or 823.32 (Fracture of fibula and tibia, shaft, open). Medtronic also noted that the patients in clinical trials with malunion fractures (diagnosis code 733.81) or nonunion fractures (diagnosis code 733.82) would also be likely candidates to receive INFUSE TM. Based on the data submitted by the applicant, INFUSE TMwould be used primarily in two different DRGs: 218 and 219 (Lower Extremity and Humerus Procedures Except Hip, Foot, Femur Age > 17, With and Without CC, respectively). The analysis performed by the applicant resulted in a case-weighted cost threshold of $24,461 for these DRGs. The average case-weighted standardized charge for cases using INFUSE TMin these DRGs would be $39,537. Therefore, the applicant maintains that INFUSE TMfor open tibia fractures meets the cost criterion.

However, because the costs of INFUSE TMand OP-1 are already reflected in the relevant DRGs, these products cannot be considered new. Therefore, we are proposing to deny new technology add- on payments for INFUSE TMbone graft for open tibia fractures for FY 2006. b. AquadexTMSystem 100 Fluid Removal System (System 100)

CHF Solutions, Inc. resubmitted an application (previously submitted for consideration for FY 2005) for the approval of the System 100 for new technology add-on payments for FY 2006. The System 100 is designed to remove excess fluid (primarily excess water) from patients suffering from severe fluid overload through the process of ultrafiltration. Fluid retention, sometimes to an extreme degree, is a common problem for patients with chronic congestive heart failure. This technology removes excess fluid without causing hemodynamic instability. It also avoids the inherent nephrotoxicity and tachyphylaxis associated with aggressive diuretic therapy, the mainstay of current therapy for fluid overload in congestive heart failure.

The System 100 consists of: (1) An S-100 console; (2) a UF 500 blood circuit; (3) an extended length catheter (ELC); and (4) a catheter extension tubing. The System 100 is designed to monitor the extracorporeal blood circuit and to alert the user to abnormal conditions. Vascular access is established via the peripheral venous system, and up to 4 liters of excess fluid can be removed in an 8-hour period.

On June 3, 2002, FDA approved the System 100 for use with peripheral venous access. On November 20, 2003, FDA approved the System 100 for expanded use with central venous access and catheter extension use for infusion or withdrawal circuit line with other commercially applicable venous catheters. According to the applicant, although the FDA first approved System 100 in June 2002, it was not used by hospitals until August 2002 because of the substantial amount of time necessary to market and sell the device to hospitals. The applicant presented data and evidence demonstrating that the System 100 was not marketed until August 2002.

We note the applicant submitted an application for FY 2005 and was denied new technology add-on payments. Our review indicated that the applicant did not present sufficient objective clinical evidence to determine that the System 100 meets the substantial clinical improvement criterion (such as a large prospective, randomized clinical trial) even though it is indicated for use in patients with congestive heart failure, a common condition in the Medicare population. However, for FY 2006, we are proposing to deny System 100 new technology add-on payments on the basis of our determination that it is no longer new. Technology is no longer considered new 2 to 3 years after data reflecting its costs begin to become available. Because data on the costs of the System 100 first became available in 2002, the costs are currently reflected in the DRG weights and the device is no longer new.

The applicant also submitted information for the cost and substantial clinical improvement criteria. As stated last year, it is important to note at the outset of the cost analysis that the console is reusable and is, therefore, a capital cost. Only the circuits and catheters are components that represent operating expenses. Section 1886(d)(5)(K)(i) of the Act requires that the Secretary establish a mechanism to recognize the costs of new medical services or technologies under the payment system established under subsection (d) of section 1886, which establishes the system for paying for the operating costs of inpatient hospital services. The system of payment for capital costs is established under section 1886(g) of the Act, which makes no mention of any add-on payments for a new medical service or technology. Therefore, it is not appropriate to include capital costs in the add-on payments for a new medical service or technology and these costs should also not be considered in evaluating whether a technology meets the cost criterion. The applicant has applied for add- on payments for only the circuits and catheter, which represent the operating expenses of the device. However, as stated in the FY 2005 IPPS final rule, we believe that the catheters cannot be considered new technology for this device. As a result, we considered only the UF 500 disposable blood circuit as relevant to the evaluation of the cost criterion.

The applicant submitted data from the FY 2003 MedPAR file in support of its application for new technology add-on payments for FY 2006. The applicant used a combination of diagnosis codes to determine which cases could potentially use the System 100. The applicant found 28,155 cases with the following combination of ICD-9-CM diagnosis codes: 428.0 through 428.9 (Heart Failure), 402.91 (Unspecified with Heart Failure), or 402.11 (Hypertensive Heart Disease with Heart Failure), in combination with 276.6 (Fluid Overload) and 782.3 (Edema). The 28,155 cases were found among 148 DRGs with 50.1 percent of cases mapped across DRGs 88, 89, 127, 277 and 316. The applicant eliminated those DRGs with less than 150 cases, which resulted in a total of 22,620 cases that could potentially use the System 100. The case- weighted average standardized charge across all DRGs was $13,619.32. The case-weighted threshold across all DRGs was $16,125.42. Although the case-weighted threshold is greater than the case-weighted standardized charge, it is necessary to include the standardized charge for the circuits used in each case. In order to establish the charge per circuit, the applicant submitted data regarding 76 actual cases that used the System 100. Based on these 76 cases, the standardized charge per circuit was $2,591. The applicant also stated that an average of two circuits are used per case. Therefore, adding $5,182 for the charge of the two

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circuits to the case-weighted average standardized charge of $13,619.32 results in a total case-weighted standardized charge of $18,801.32. This amount is greater than the case-weighted threshold of $16,125.42.

The applicant contended that the System 100 represents a substantial clinical improvement for the following reasons: It removes excess fluid without the use of diuretics; it does not lead to electrolyte imbalance, hemodynamic instability or worsening renal function; it can restore diuretic responsiveness; it does not adversely affect the renin-angiotensin system; it reduces length of hospital stay for the treatment of congestive heart failure, and it requires only peripheral venous access. The applicant also noted that there are some clinical trials that have demonstrated the clinical safety and effectiveness as well as cost effectiveness of the System 100 in treating patients with fluid overload.

However, as stated above, we are proposing to deny new technology add-on payments for the System 100 because it does not meet the newness criterion.

We received no public comments regarding this application for add- on payments. c. CHARITETMArtificial Disc (CHARITETM)

DePuy SpineTMsubmitted an application for new technology add-on payments for the CHARITETMArtificial Disc for FY 2006. This device is a prosthetic intervertebral disc. DePuy SpineTMstated that the CHARITETMArtificial Disc is the first artificial disc approved for use in the United States. It is a 3-piece articulating medical device consisting of a sliding core that is placed between two metal endplates. The sliding core is made from a medical grade plastic and the endplates are made from medical grade cobalt chromium alloy. The endplates support the core and have small teeth that are secured to the vertebrae above and below the disc space. The sliding core fits in between the endplates.

On October 26, 2004, the FDA approved the CHARITETM Artificial Disc for single level spinal arthroplasty in skeletally mature patients with degenerative disc disease (DDD) between L4 and S1. The FDA further stated that DDD is defined as discogenic back pain with degeneration of the disc confirmed by patient history and radiographic studies. These DDD patients should have no more than 3 mm of spondylolisthesis at an involved level. Patients receiving the CHARITETMArtificial Disc should have failed at least 6 months of conservative treatment prior to implantation of the CHARITETMArtificial Disc. Because the device is within the statutory timeframe of 2 to 3 years and data is not yet reflected within the DRGs, we consider the CHARITETMArtificial Disc to meet the newness criterion.

We note that an ICD-9-CM code was effective October 1, 2004, for IPPS tracking purposes. The code assigned to the CHARITETM was 84.65 (Insertion of total spinal disc prosthesis, lumbosacral).

For analysis of the cost criterion, the applicant submitted two sets of data: one that used actual cases and one that used FY 2003 MedPAR cases. The applicant expects that cases using the CHARITETMwill map to DRGs 499 and 500. The applicant submitted 68 actual cases from 35 hospitals that used the CHARITETM. Of these 68 cases, only 3 were Medicare patients; the remaining cases were privately insured patients or patients for whom the payer was unknown. Using data from the 68 actual cases, the average standardized charge was $40,722. The applicant maintained that this figure is well in excess of the thresholds for DRGs 499 and 500 (regardless of a case weighted threshold) of $24,828 and $17,299 respectively. Based on this analysis, the applicant maintained that the CHARIT[Eacute]TMmeets the cost criterion because the average standardized charge exceeds the charge thresholds for DRGs 499 and 500.

In addition, as stated above, the applicant submitted cases from the FY 2003 MedPAR file. The applicant searched the MedPAR file for ICD-9-CM procedure codes 81.06, 81.07, and 81.08 in combination with diagnosis codes 722.10, 722.2, 722.5, 722.52, 722.6, 722.7, 722.73 and 756.12, to identify a patient population that could be eligible for the CHARITETMArtificial Disc and found a total of 12,680 cases. However, these cases are from the FY 2003 MedPAR file and precede the effective date of ICD-9-CM code 84.65 that is currently used to track the device. Of these 12,680 cases, 55.5 percent were reported in DRG 497, and 44.5 percent were reported in DRG 498. The applicant stated that cases using the CHARITETMdevice group to the DRGs for back and neck procedures that exclude spinal fusions (DRGs 499 and 500). However, the applicant argues that the CHARITETMcould be a substitute for spinal fusion procedures found in DRGs 497 and 498 and, therefore, used cases from these DRGs to evaluate whether the CHARITETMmeets the cost criterion and to argue that procedures using the technology should be grouped to the spinal fusion DRGs. The average standardized charge per case was $50,098 for DRG 497 and $41,290 for DRG 498. Using revenue codes 272 and 278 from the MedPAR file, the applicant then subtracted the charges for surgical and medical supplies used in connection with spinal fusion procedures, which resulted in a standardized charge of all other charges of $24,333 for DRG 497 and $22,183 for DRG 498. Based on the actual cases above, the applicant then estimated the average standardized charge for surgical and medical supplies per case for the CHARITETMwas $20,033. The applicant estimated that charges have grown by 15 percent from FY 2003 to FY 2005 and, therefore, deflated the average standardized charge for surgical and medical supplies of the CHARITETMby 15 percent to $17,420. The applicant then added the average standardized charge for surgical and medical supplies of the CHARITETMto the standardized charge of all other charges for DRG 497 and 498 and also inflated the charges by 15 percent in order to update the data to FY 2005 charge levels. This amounted to a case-weighted average standardized charge of $46,256. Although the analysis was completed with DRGs 497 and 498, it is necessary to compare the average standardized charge to the thresholds of DRGs 499 and 500 because the GROUPER maps these cases to DRGs 499 and 500. As a result, the case-weighted threshold was $21,480. Similar to the analysis above, the applicant stated that the case-weighted average standardized charge is greater than the case-weighted threshold and, as a result, the applicant maintained that the CHARITETMmeets the cost criterion.

The applicant also contended that the CHARITETM represents a substantial clinical improvement over existing technology. Use of the CHARITETMmay eliminate the need for spinal fusion and the use of autogenous bone, and the applicant stated that, based on the Investigational Device Exemption (IDE) study, ``A Prospective Randomized Multicenter Comparison of Artificial Disc vs. Fusion for Single Level Lumbar Degenerative Disc Disease'' (Blumenthal, S, et al, National American Spine Society 2004 Abstract) that patients who received the CHARITETMArtificial Disc were discharged from the hospital after an average of 3.7 days compared to 4.2 days in the fusion group. Furthermore, the applicant stated that patients who received the CHARITETMArtificial Disc had a statistically greater improvement in Oswetry Disability Index scores and Visual Analog Scale Pain scores compared to the fusion group at 6 weeks

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and 3, 6 and 12 months. The study also showed greater improvement from baseline compared to the fusion group on the Physical Component Score at 3, 6, and 23 months. In addition, the applicant states that patients receiving the CHARITETMArtificial Disc returned to normal activities in half the time, compared to patients who underwent fusion, and at the 2 year follow up, 15 percent of patients who underwent a fusion were dissatisfied with the postoperative improvements compared to 2 percent who received the CHARITETMArtificial Disc. Also, patients who received the CHARITETMArtificial Disc returned to work on average of 12.3 weeks after surgery compared to 16.3 weeks after circumferential fusion and 14.4 weeks with Bagby and Kuslich cages. The applicant finally stated that the motion preserving technology of the CHARITETMArtificial Disc may reduce the risk of increase of degenerative disc disease (DDD). The applicant explained that degeneration of adjacent discs due to increased stress has been strongly associated with spinal fusion utilizing instrumentation. In a followup of 100 patients (minimum 10 years) who received the CHARITETMArtificial Disc, the incidence of adjacent level DDD was 2 percent.

We are continuing to review the information on whether the CHARITE TMArtificial Disc would appear to represent a substantial clinical improvement over existing technology for certain patient populations. Based on the studies submitted to the FDA and CMS, we remain concerned that the information presented may not definitively substantiate whether the CHARITE TMArtificial Disc is a substantial clinical improvement over spinal fusion. In addition, we are concerned that the cited IDE study enrolled no patients over 60 years of age, which excludes much of the Medicare population, and we are concerned that the device is contraindicated in patients with ``significant osteoporosis,'' which is quite common in the Medicare population. We invite comment on both of these points and on the more general question of whether the device satisfies the substantial clinical improvement criterion.

Despite the issues mentioned above, we are still considering whether it is appropriate to approve new technology add-on payment status for the CHARITE TMArtificial Disc for FY 2006. If approved for add-on payments, the device would be reimbursed up to half of the costs for the device. Because the manufacturer has stated that the cost for the CHARITE TMArtificial Disc would be $11,500, the maximum add-on payment for the device would be $5,750. In the final rule, we will make a final determination on whether the CHARITE TMArtificial Disc should receive new technology add-on payments for FY 2006 based on public comments and our continuing analyses.

We finally note that the applicant requested a DRG reassignment for cases of the CHARITE TMArtificial Disc from DRGs 499 (Back and Neck Procedures Except Spinal Fusion With CC) and 500 (Back and Neck Procedures Except Spinal Fusion Without CC) to DRGs 497 (Spinal Fusion Except Cervical With CC) and 498 (Spinal Fusion Except Cervical Without CC). The applicant argued that the costs associated with an artificial disc surgery are similar to spinal fusion and inclusion in DRGs 497 and 498 would obviate the need to make a new technology add-on payment. On October 1, 2004, we created new codes for the insertion of spinal disc prostheses (codes 84.60 through 84.69). In the FY 2005 IPPS proposed rule and the final rule, we described the new DRG assignments for these new codes in Table 6B of the Addendum to the rules. We received a number of comments recommending that we change the DRG assignments from DRGs 499 and 500 in MDC 8 to the DRGs for spinal fusion (DRGs 497 and 498). In the FY 2005 IPPS final rule (69 FR 48938), we indicated that DRGs 497 and 498 are limited to spinal fusion procedures. Because the surgery involving the CHARITE TMis not a spinal fusion, we decided not to include this procedure in these DRGs. However, we will continue to analyze this issue and are interested in public comments on both the new technology application for the CHARITE TMand the DRG assignment for spinal disc prostheses.

We received no public comments regarding this application for new technology add-on payments. d. Endovascular Graft Repair of the Thoracic Aorta

Endovascular stent-grafting of the descending thoracic aorta (TA) provides a less invasive alternative to the traditional open surgical approach required for the management of descending thoracic aortic aneurysms. W.L. Gore & Associates, Inc. submitted an application for consideration of its Endovascular Graft Repair of the Thoracic Aorta (GORE TAG) for new technology add-on payments for FY 2006. The GORE TAG device is a tubular stent-graft mounted on a catheter-based delivery system, and it replaces the synthetic graft normally sutured in place during open surgery. The device is identified using ICD-9-CM procedure code 39.79 (Other endovascular repair (of aneurysm) of other vessels). The applicant has requested a unique ICD-9-CM procedure code.

At this point the time of the initial application, the FDA hads not yet approved this technology for general use. Subsequently, however, we were notified that FDA approval was granted on March 23, 2005. Although we discuss some of the data submitted with the application for new technology add-on payments below, we are unable to include a detailed analysis of cost data and substantial clinical improvement data in this proposed rule because FDA approval occurred too late for us to conduct a complete analysis.

The applicant submitted cost threshold information for the GORE TAG device. According to the manufacturer, cases using the GORE TAG device would fall into DRGs 110 and 111 (Major Cardiovascular Procedures With and Without CC, respectively). The applicant identified 185 cases in the FY 2003 MedPAR using procedure code 39.79 (Other endovascular repair (of aneurysm) of other vessels) and primary diagnosis codes 441.2 (Thoracic aneurysm, without mention of rupture), 441.1 (Thoracic aneurysm, ruptured), or 441.01 (Dissection of aorta, thoracic). The case-weighted standardized charge for 177 of these cases was $60,905. According to the manufacturer, the case-weighted cost threshold for these DRGs is $49,817. Based on this analysis, the manufacturer maintained that the technology meets our cost threshold.

The manufacturer argued that the GORE TAG represents a substantial clinical improvement over existing technology, primarily by avoiding the traditional open aneurysm repair procedure with its associated high morbidity and mortality. The applicant argued that a descending thoracic aorta aneurysm is a potentially life threatening condition that currently requires a major operative procedure for its treatment. The mortality and complication rates associated with this surgery are very high, and the surgery is frequently performed under urgent or emergent conditions. The applicant noted that such complications can increase the length of the hospital stay and can include neurological damage, paralysis, renal failure, pulmonary emboli, hemorrhage, and sepsis. The average time for patients undergoing surgical repair to return to normal activity is 3 to 4 months, but can be significantly longer.

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In comparison, the applicant argued that endovascular stent- grafting done with the GORE TAG thoracic endoprosthesis is minimally invasive. The manufacturer noted that patients treated with the endovascular technique experience far less aneurysm-related mortality and morbidity, compared to those patients that receive the open procedure resulting in reduced overall length-of-stay, less intensive care unit days and less operative complications.

We received the following public comments, in accordance with section 503(b)(2) of Pub. L. 108-173, regarding this application for add-on payments.

Comment: Several commenters expressed support for approval of new technology add-on payments for the GORE TAG device. These commenters noted that the data presented to the FDA advisory panel for consideration for FDA approval of the device clearly demonstrate the safety and efficacy of the GORE TAG device. They also noted that nearly 200 patients have been treated with the endografts, with a highly significant difference in both postoperative mortality and a reduction in the incidence of spinal cord ischemic complications, with some commenters noting the trial results, which showed a reduction in the rate of paraplegia from 14 percent to 3 percent, compared to open surgery. The commenters also stressed the rigorous nature of the open surgery, which requires a left lateral thoracotomy, resulting in significant morbidity. The commenters further argued that, since many of the patients with degenerative aneurysm of the thoracic aorta are elderly or present with significant comorbidities, or both, it is ``a common circumstance in clinical practice to deny repair to such patients because of the magnitude of the conventional open surgery.'' Other commenters stated that the 5-year mortality in all patients diagnosed with thoracic aortic aneurysm is as high as 80 percent in some groups of patients. Therefore, the commenters argued, the GORE TAG device for thoracic aortic aneurysm satisfies the criteria for substantial clinical improvement.

Response: We appreciate the commenters' input on this criterion. We will consider these comments regarding the substantial clinical improvement criterion in the final rule if we determine that the technology meets the other two criteria.

Comment: A representative of another device manufacturer stated at the town hall meeting that the manufacturer has a similar product awaiting FDA approval.

Response: As we discussed in the September 7, 2001 Federal Register (66 FR 46915), an approval of a new technology for special payment should extend to all technologies that are substantially similar. Otherwise, our payment policy would bestow an advantage to the first applicant to receive approval for a particular new technology. In this case, we will determine whether the GORE TAG device qualifies for new technology add-on payments in the FY 2006 final rule. In the event that this technology satisfies all the criteria, we would extend new technology payments to any substantially similar technology that also receives FDA approval prior to publication of the FY 2006 final rule. We welcome comments regarding this technology in light of its recent FDA approval, particularly with regard to the cost threshold and the substantial clinical improvement criteria. e. Restore[supreg] Rechargeable Implantable Neurostimulator

Medtronic Neurological submitted an application for new technology add-on payments for its Restore[supreg] Rechargeable Implantable Neurostimulator. The Restore[supreg] Rechargeable Implantable Neurostimulator is designed to deliver electrical stimulation to the spinal cord for treatment of chronic, intractable pain.

Neurostimulation is designed to deliver electrical stimulation to the spinal cord to block the sensation of pain. The current technology standard for neurostimulators utilizes internal sealed batteries as the power source to generate the electrical current. These internal batteries have finite lives, and require replacement when their power has been completely discharged. According to the manufacturer, the Restore[supreg] Rechargeable Implantable Neurostimulator ``represents the next generation of neurostimulator technology, allowing the physician to set the voltage parameters in such a way that fully meets the patient's requirements to achieve adequate pain relief without fear of premature depletion of the battery.'' The applicant stated that the expected life of the Restore[supreg] rechargeable battery is 9 years, compared to an average life of 3 years for conventional neurostimulator batteries. The applicant stated that this represents a significant clinical improvement because patients can use any power settings that are necessary to achieve pain relief with less concern for battery depletion and subsequent battery replacement.

This device has not yet received approval for use by the FDA; however, another manufacturer has received approval for a similar device. (Advanced Bionics' Precision[supreg] Rechargeable Neurostimulator was approved by the FDA on April 27, 2004.)

Medtronic Neurological also provided data to determine whether the Restore[supreg] Rechargeable Implantable Neurostimulator meets the cost criterion. Medtronic Neurological stated that the cases involving use of the device would primarily fall into DRGs 499, 500, 531 and 532, which have a case-weighted threshold of $24,090. The manufacturer stated that the anticipated average standardized charge per case involving the Restore[supreg] technology is $59,265. This manufacturer derived this estimate by identifying cases in the FY 2003 MedPAR that reported procedure code 03.93 (Insertion or replacement of spinal neurostimulators). The manufacturer then added the total cost of the Restore[supreg] Rechargeable Implantable Neurostimulator to the average standardized charges for those cases. Of the applicable charges for the Restore[supreg] Rechargeable Implantable Neurostimulator, only the components that the applicant identified as new would be eligible for new technology add-on payments. Medtronic Neurological submitted information that distinguished the old and new components of the device and submitted data indicating that the neurostimulator itself is $17,995 and the patient recharger, antenna, and belt are $3,140. Thus, the total cost for new components would be $21,135, with a maximum add- on amount of $10,568 if the product were to be approved for new technology payments.

We note that we reviewed a technology for add-on payments for FY 2003 called Renew\TM\ Radio Frequency Spinal Cord Stimulation (SCS) Therapy, made by Advanced Neuromodulation Systems (ANS). In the FY 2003 final rule, we discussed and subsequently denied an application for new technology add-on payment for Renew\TM\ SCS because ``Renew\TM\ SCS was introduced in July 1999 as a device for the treatment of chronic intractable pain of the trunk and limbs.'' (67 FR 50019) We also noted, ``[t]his system only requires one surgical placement and does not require additional surgeries to replace batteries as do other internal SCS systems.''

The applicant also stated in its application for Restore[supreg] that cases where it is used will be identified by ICD-9-CM procedure code 03.93 (Insertion or replacement of spinal neurostimulators). As we discussed in the FY 2003 final rule (67 FR 50019), the Renew\TM\ SCS is identified by the same ICD-9-CM procedure code. The

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applicant has also applied for a new ICD-9-CM code for rechargeable neurostimulator pulse generator (We refer readers to Tables 6A through 6H in the Addendum to this proposed rule for information regarding ICD- 9-CM codes.) Because both technologies are similar, we asked Medtronic to provide information that would demonstrate how the products were substantially different. The applicant noted that the Renew\TM\ SCS, while programmable and rechargeable, is not a good option for those patients who have high energy requirements because of chronic intractable pain that will result in more battery wear and subsequent surgery to replace the device. Both systems rely on rechargeable batteries, and in the case of Renew\TM\ SCS the energy is transmitted through the skin from a radiofrequency source for the purpose of recharging. The manufacturer of the Restore[supreg] device contends that it is superior to the Renew\TM\ device because Renew\TM\ requires an external component that uses a skin adhesive that is uncomfortable and inconvenient (causes skin irritation, is affected by moisture that will come from bathing, sweating, swimming, etc.), leading to patient noncompliance.

Because FDA approval has not yet been received for this device, we are making no decision concerning the Restore[supreg] application at this time. We will make a formal determination if FDA approval occurs in sufficient time for full consideration in the final FY 2006 rule. However, we have reservations about whether this technology is new for purposes of the new technology add-on payments because of its similarity to other products that are also used to treat the same conditions. Although we recognize the benefits of a more easily rechargeable neurostimulator system, we believe that the Restore[supreg] device may not be sufficiently different from predecessor devices to meet the newness criterion for the new technology add-on payment. As we discussed above, similar products have been on the market since 1999. Therefore, these technologies are already represented in the DRG weights and are not considered new for the purposes of the new technology add-on payment provision. We welcome comments on this issue, specifically regarding how the Restore[supreg] device may or may not be significantly different from previous devices. We also seek comments on whether the product meets the cost and significant improvement criteria.

We received no public comments regarding this application for add- on payments.

f. Safe-Cross[supreg] Radio Frequency Total Occlusion Crossing System (Safe-Cross[supreg])

Intraluminal Therapeutics submitted an application for the Safe Cross[supreg] Radio Frequency (RF) Total Occlusion Crossing System. This device performs the function of a guidewire during percutaneous transluminal angioplasty of chronic total occlusions of peripheral and coronary arteries. Using fiberoptic guidance and radiofrequency ablation, it is able to cross lesions where a standard guidewire is unsuccessful. On November 21, 2003, the FDA approved the Safe Cross[supreg] for use in iliac and superficial femoral arteries. The device was approved by the FDA for all native peripheral arteries except carotids in August 2004. In January 2004, the FDA approved the Safe Cross[supreg] for coronary arteries as well. Because the device is within the statutory timeframe of 2 to 3 years for all approved uses and data regarding the cost of this device are not yet reflected within the DRG weights, we consider the Safe Cross[supreg] to meet the newness criterion.

We note that the applicant submitted an application for a distinctive ICD-9-CM code. The applicant noted in its application that the device is currently coded with ICD-9-CM procedure codes 36.09 (Other removal of coronary artery obstruction) and 39.50 (Angioplasty or atherectomy of other noncoronary vessels).

As we stated in last year's final rule, section 1886(d)(5)(K)(i) of the Act requires that the Secretary establish a mechanism to recognize the costs of new medical services or technologies under the payment system established under subsection (d) of section 1886, which establishes the system for paying for the operating costs of inpatient hospital services. The system of payment for capital costs is established under section 1886(g) of the Act, which makes no mention of any add-on payments for a new medical service or technology. Therefore, it is not appropriate to include capital costs in the add-on payments for a new medical service or technology, and these costs should not be considered in evaluating whether a technology meets the cost criterion. As a result, we consider only the Safe Cross[supreg] crossing wire, ground pad, and accessories to be operating equipment that is relevant to the evaluation of the cost criterion.

The applicant submitted the following two analyses on the cost criterion. The first analysis contained 27 actual cases from two hospitals. Of these 27 cases, 25.1 percent of the cases were reported in DRGs 24 (Seizure and Headache Age >17 With CC), 107 (Coronary Bypass With Cardiac Catheterization), 125 (Circulatory Disorders Except AMI, With Cardiac Catheterization and Without Complex Diagnosis), 518 (Percutaneous Cardiovascular Procedure Without Coronary Artery Stent or AMI), and 526 (Percutaneous Cardiovascular Procedure With Drug-Eluting Stent With AMI); and 74.9 percent were reported in DRG 527 (Percutaneous Cardiovascular Procedure With Drug-Eluting Stent Without AMI). This resulted in a case-weighted threshold of $35,956 and a case- weighted average standardized charge of $40,319. Because the case- weighted average standardized charge is greater than the case-weighted threshold, the applicant maintained that the Safe Cross[supreg] meets the cost criterion.

The applicant also submitted cases from the FY 2003 MedPAR. The applicant found a total of 1,274,535 cases that could be eligible for the Safe Cross[supreg] using diagnosis codes 411 through 411.89 (Other acute and subacute forms of ischemic heart disease) or 414 through 414.19 (Other forms of chronic ischemic heart disease) in combination with any of the following procedure codes: 36.01 (Single vessel percutaneous transluminal coronary angioplasty (PTCA) or coronary atherectomy without mention of thrombolytic agent), 36.02 (Single vessel PTCA or coronary atherectomy with mention of thrombolytic agent), 36.05 (Multiple vessel PTCA or coronary atherectomy performed during the same operation with or without mention of thrombolytic agent), 36.06 (Insertion of nondrug-eluting coronary artery stent(s)), 36.07 (Insertion of drug-eluting coronary artery stent(s)) and 36.09 (Other removal of coronary artery obstruction). A total of 59.40 percent of these cases fell into DRG 517 (Percutaneous Cardiovascular Procedure With Nondrug-Eluting Stent Without AMI), 16.4 percent of cases into DRG 516 (Percutaneous Cardiovascular Procedure With AMI), and 16.2 percent of cases into DRG 527, while the rest of the cases fell into the remaining DRGs 124, 518 and 526. The average case- weighted standardized charge per case was $40,318. This amount included an extra $6,000 for the charges related to the Safe Cross[supreg]. The case-weighed threshold across the DRGs mentioned above was $35,955. Similar to the analysis above, because the case-weighted average standardized charge is greater than the case-weighted

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threshold, the applicant maintained that the Safe Cross[supreg] meets the cost criterion.

The applicant maintained that the device meets the substantial clinical improvement criterion. The applicant explained that many traditional guidewires fail to cross a total arterial occlusion due to difficulty in navigating the vessel and to the fibrotic nature of the obstructing plaque. By using fiberoptic guidance and radiofrequency ablation, the Safe Cross[supreg] succeeds where standard guidewires fail. The applicant further maintained that in clinical trials where traditional guidewires failed, the Safe Cross[supreg] succeeded in 54 percent of cases of coronary artery chronic total occlusions (CTOs), and in 76 percent of cases of peripheral artery CTOs.

However, we note that we use similar standards to evaluate substantial clinical improvement in the IPPS and OPPS. The IPPS regulations provide that technology may be approved for add-on payments when it ``represents an advance in medical technology that substantially improves, relative to technologies previously available, the diagnosis or treatment of Medicare beneficiaries'' (66 FR 46912). Under the OPPS, the standard for approval of new devices is ``a substantial improvement in medical benefits for Medicare beneficiaries compared to the benefits obtained by devices in previously established (that is, existing or previously existing) categories or other available treatments'' (67 FR 66782). Furthermore, the OPPS and IPPS employ identical language (for IPPS, see 66 FR 46914, and for OPPS, see 67 FR 66782) to explain and elaborate on the kinds of considerations that are taken into account in determining whether a new technology represents substantial improvement. In both systems, we employ the following kinds of considerations in evaluating particular requests for special payment for new technology:

The device offers a treatment option for a patient population unresponsive to, or ineligible for, currently available treatments.

The device offers the ability to diagnose a medical condition in a patient population where that medical condition is currently undetectable or offers the ability to diagnose a medical condition earlier in a patient population than allowed by currently available methods. There must also be evidence that use of the device to make a diagnosis affects the management of the patient.

Use of the device significantly improves clinical outcomes for a patient population as compared to currently available treatments. Some examples of outcomes that are frequently evaluated in studies of medical devices are the following:

--Reduced mortality rate with use of the device. --Reduced rate of device-related complications. --Decreased rate of subsequent diagnostic or therapeutic interventions (for example, due to reduced rate of recurrence of the disease process). --Decreased number of future hospitalizations or physician visits. --More rapid beneficial resolution of the disease process treatment because of the use of the device. --Decreased pain, bleeding, or other quantifiable symptom. --Reduced recovery time.

In a letter to the applicant dated October 25, 2004, we denied approval of the Safe Cross[supreg] for pass-through payments for the OPPS on the basis that the technology did not meet the substantial clinical improvement criterion. In particular, we found that studies failed to show long-term or intermediate-term results, and the device had a relatively low rate of successfully opening occlusions. Since that initial determination, the applicant has requested reconsideration for pass-through payments under the IPPS. However, on the basis of the original findings under the OPPS, we do not now believe that the technology can qualify for new technology add-on payments under the IPPS. Therefore, we are proposing to deny new technology add-on payment for FY 2006 for Safe Cross[supreg] on the grounds that it does not appear to be a substantial clinical improvement over existing technologies. We welcome further information on whether this device meets the substantial clinical improvement criterion, and we will consider any further information prior to making our final determination in the final rule.

We received no public comments regarding this application for add- on payments. g. Trident[supreg] Ceramic Acetabular System

Stryker Orthopaedics submitted an application for new technology add-on payments for the Trident[supreg] Ceramic Acetabular System. This system is used to replace the ``ball and socket'' joint of a hip when a total hip replacement is performed for patients suffering from arthritis or related conditions. The applicant stated that, unlike conventional hip replacement systems, the Trident[supreg] system utilizes alumina ceramic-on-ceramic bearing surfaces rather than metal- on-plastic or metal-on-metal. Alumina ceramic is the hardest material next to diamond. The Trident[supreg] System is a patented design that captures the ceramic insert in a titanium sleeve. This design increases the strength of the ceramic insert by 50 percent over other designs. The manufacturer stated that the alumina ceramic bearing of the device is a substantial clinical improvement because it is extremely hard and scratch resistant, has a low coefficient of friction and excellent wear resistance, has improved lubrication over metal or polyethylene, has no potential for metal ion release, and has less alumina particle debris. The manufacturer also stated that fewer hip revisions are needed when this product is used (2.7 percent of ceramic versus 7.5 percent for polyethylene). Stryker stated that the ceramic implant also causes less osteolysis (or bone loss from particulate debris). Due to these improvements over traditional hip implants, the manufacturer stated the Trident[supreg] Ceramic Acetabular System has demonstrated significantly lower wear versus the conventional plastic/metal system in the laboratory; therefore, it is anticipated that these improved wear characteristics will extend the life of the implant.

The Trident[supreg] Ceramic Acetabular System received FDA approval in February 3, 2003. However, this product was not available on the market until April 2003. The period that technologies are eligible to receive new technology add-on payment is no less than 2 years but not more than 3 years from the point the product comes on the market. At this point, we begin to collect charges reflecting the cost of the device in the MedPAR data. Because the device became available on the market in April 2003, charges reflecting the cost of the device may have been included in the data used to calculate the DRG weights in FY 2005 and the proposed DRG weights for FY 2006. Therefore, the technology may no longer be considered new for the purposes of new technology add-on payments. For this reason, we are proposing to deny add-on payments for the Trident[supreg] Ceramic Acetabular System for FY 2006.

Although we are proposing not to approve this application because the Trident[supreg] Ceramic Acetabular System does not meet the newness criterion, we note that the applicant submitted information on the cost and substantial clinical improvement criteria.

The applicant submitted cost threshold information for the Trident[supreg] Ceramic Acetabular System, stating that cases using the system would be

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included in DRG 209 (Major Joint and Limb Reattachment Procedures of Lower Extremity). The manufacturer indicated that there is not an ICD- 9-CM code specific to ceramic hip arthroplasty, but it is currently reported using code 81.51 (Total hip replacement). Of the applicable charges for the Trident[supreg] Ceramic Acetabular System, only the components that the applicant identified as new would be eligible for new technology add-on payments. The estimated cost of the new portions of the device, according to the information provided in the application, is $6,009. The charge threshold for DRG 209 is $34,195. The data submitted by Stryker Orthopaedics showed an average standardized charge, assuming a 28 percent implant markup, of $34,230.

Regarding the issue of substantial clinical improvement, we recognize that the Trident[supreg] Ceramic Acetabular System represents an incremental advance in prosthetic hip technology. However, we also recognize that there are a number of other new prostheses available that utilize a variety of bearing surface materials that also offer increased longevity and decreased wear. For this reason, we do not believe that the Trident[supreg] system has demonstrated itself to be a clearly superior new technology.

We received the following public comments, in accordance with section 503(b)(2) of Pub. L. 108-173, regarding this application for add-on payments.

Comment: One commenter noted that clinical outcomes for the Trident[supreg] Ceramic Acetabular System are not a significant clinical improvement over similar devices on the market. A member of the orthopedic community noted at the new technology town hall meeting that this system is not the only new product that promises significantly improved results because of enhancements to materials and design. This commenter suggested that it may be inappropriate to recognize only one of these new hip replacement products for new technology add-on payments.

Response: We appreciate the commenter's input on this criterion. We will consider these comments regarding the substantial clinical improvement criterion. However, based on the observations provided at the town hall meeting, we are considering alternative methods of recognizing technological improvements in this area other than approving only one of these new technologies for add-on payments. For example, as discussed in section II.B.6.a. of the preamble to this proposed rule, we are proposing to split DRG 209 to create a new DRG for revisions of hip and knee replacements. We would leave all other replacements and attachment procedures in a separate, new DRG. We also stated that we will be reviewing these DRGs based on new procedure codes that will provide more detailed data on the specific nature of the revision procedures performed. In addition, we are creating new procedure codes that will identify the type of bearing surface of a hip replacement. As we obtain data from these new codes, we will consider additional DRG revisions to better capture the various types of joint procedures. We may consider a future restructuring of the joint replacement and revision DRGs that would better capture the higher costs of products that offer greater durability, extended life, and improved outcomes. In doing so, of course, we may need to create additional, more precise ICD-9-CM codes. We welcome comments on this issue, and generally on whether the Trident[supreg] Ceramic Acetabular System meets the criteria to qualify for new technology add-on payments. h. Wingspan TMStent System with Gateway TMPTA Balloon Catheter

Boston Scientific submitted an application for the Wingspan TMStent System with Gateway TMPTA Balloon Catheter for new technology add-on payments. The device is designed for the treatment of patients with intracranial atherosclerotic disease who suffer from recurrent stroke despite medical management. The device consists of the following: a self-expanding nitinol stent, a multilumen over the wire delivery catheter, and a Gateway PTA Balloon Catheter. The device is used to treat stenoses that occur in the intracranial vessels. Prior to stent placement, the Gateway PTA Balloon is inflated to dilate the target lesion, and then the stent is deployed across the lesion to restore and maintain luminal patency. Effective October 1, 2004, two new ICD-9-CM procedure codes were created to code intracranial angioplasty and intracranial stenting procedures: procedure codes 00.62 (Percutaneous angioplasty or atherectomy of intracranial vessels) and 00.65 (Percutaneous insertion of intracranial vascular stents).

On January 9, 2004, the FDA designated the Wingspan TM as a Humanitarian Use Designation (HUD). The manufacturer has also applied for Humanitarian Device Exemption (HDE) status and expects approval from the FDA in July 2005. It is important to note that currently CMS has a noncoverage policy for percutaneous transluminal angioplasty to treat lesions of intracranial vessels. The applicant is working closely with CMS to review this decision upon FDA approval. Because the device is neither FDA-approved nor Medicare-covered, we do not believe it is appropriate to present our full analysis on whether the technology meets the individual criteria for the new technology add-on payment. However, we note that the applicant did submit the following information below on the cost criterion and substantial clinical improvement criterion.

The manufacturer submitted data from MedPAR and non-MedPAR databases. The non-MedPAR data was from the 2003 patient discharge data from California's Office of Statewide Health Planning and Development database for hospitals in California and from the 2003 patient data from Florida's Agency for Health Care Administration for hospitals in Florida. The applicant identified cases that had a diagnosis code of 437.0 (Cerebral atherosclerosis), 437.1 (Other generalized ischemic cerebrovascular disease) or 437.9 (Unspecified) or any diagnosis code that begins with the prefix of 434 (Occlusion of cerebral arteries) in combination with procedure code 39.50 (Angioplasty or atherectomy of noncoronary vessel) or procedure code 39.90 (Insertion of nondrug- eluting, noncoronary artery stents). The applicant used procedure codes 39.50 and 39.90 because procedure codes 00.62 and 00.65 were not available until FY 2005. The applicant found cases in DRG 5 (Extracranial Vascular Procedures) (which previously existed under the Medicare IPPS DRG system prior to a DRG split) and in DRGs 533 (Extracranial Procedure with CC) and 534 (Extracranial Procedure Without CC). Even though DRG 5 was split into DRGs 533 and 534 in FY 2003, some hospitals continued to use DRG 5 for non-Medicare cases. The applicant found 22 cases that had an intracranial PTA with a stent. The average (nonstandardized) charge per case was $78,363.

The applicant also submitted data from the FY 2002 and FY 2003 MedPAR files. Using the latest data from the FY 2003 MedPAR and the same combination of diagnosis and procedure codes mentioned above to identify cases of intracranial PTA with stenting, the applicant found 116 cases in DRG 533 and 20 cases in DRG 534. The case-weighted average standardized charge per case was $51,173. The average case-weighted threshold was $25,394. Based on this analysis, the applicant maintained that the technology meets the cost criteria since the average case- weighted standardized charge per case

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is greater than the average case-weighted threshold.

The applicant also maintained that the technology meets the substantial clinical improvement criterion. Currently, there is no available surgical or medical treatment for recurrent stroke that occurs despite optimal medical management. The Wingspan TM is the first commercially available PTA/stent system designed specifically for the intracranial vasculature. However, because the Wingspan TMdoes not have FDA approval or Medicare coverage, as stated above, we are proposing to deny add-on payment for this new technology.

We received no public comments regarding this application for add- on payments.

III. Proposed Changes to the Hospital Wage Index

A. Background

Section 1886(d)(3)(E) of the Act requires that, as part of the methodology for determining prospective payments to hospitals, the Secretary must adjust the standardized amounts ``for area differences in hospital wage levels by a factor (established by the Secretary) reflecting the relative hospital wage level in the geographic area of the hospital compared to the national average hospital wage level.'' In accordance with the broad discretion conferred under the Act, we currently define hospital labor market areas based on the definitions of statistical areas established by the Office of Management and Budget (OMB). A discussion of the proposed FY 2006 hospital wage index based on the statistical areas, including OMB's revised definitions of Metropolitan Areas, appears under section III.B. of this preamble.

Beginning October 1, 1993, section 1886(d)(3)(E) of the Act requires that we update the wage index annually. Furthermore, this section provides that the Secretary base the update on a survey of wages and wage-related costs of short-term, acute care hospitals. The survey should measure the earnings and paid hours of employment by occupational category, and must exclude the wages and wage-related costs incurred in furnishing skilled nursing services. This provision also requires us to make any updates or adjustments to the wage index in a manner that ensures that aggregate payments to hospitals are not affected by the change in the wage index. The proposed adjustment for FY 2006 is discussed in section II.B. of the Addendum to this proposed rule.

As discussed below in section III.G. of this preamble, we also take into account the geographic reclassification of hospitals in accordance with sections 1886(d)(8)(B) and 1886(d)(10) of the Act when calculating the wage index. Under section 1886(d)(8)(D) of the Act, the Secretary is required to adjust the standardized amounts so as to ensure that aggregate payments under the IPPS after implementation of the provisions of sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the Act are equal to the aggregate prospective payments that would have been made absent these provisions. The proposed budget neutrality adjustment for FY 2006 is discussed in section II.B. of the Addendum to this proposed rule.

Section 1886(d)(3)(E) of the Act also provides for the collection of data every 3 years on the occupational mix of employees for short- term, acute care hospitals participating in the Medicare program, in order to construct an occupational mix adjustment to the wage index. A discussion of the proposed occupational mix adjustment that we are proposing to apply beginning October 1, 2005 (the proposed FY 2006 wage index) appears under section III.C. of this preamble.

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

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

The wage index is calculated and assigned to hospitals on the basis of the labor market area in which the hospital is located. In accordance with the broad discretion under section 1886(d)(3)(E) of the Act, beginning with FY 2005, we define hospital labor market areas based on the Core-Based Statistical Areas (CBSAs) established by OMB and announced in December 2003 (69 FR 49027). OMB defines a CBSA, beginning in 2003, as ``a geographic entity associated with at least one core of 10,000 or more population, plus adjacent territory that has a high degree of social and economic integration with the core as measured by commuting ties.'' The standards designate and define two categories of CBSAs: Metropolitan Statistical Areas (MSAs) and Micropolitan Statistical Areas (65 FR 82235).

According to OMB, MSAs are based on urbanized areas of 50,000 or more population, and Micropolitan Statistical Areas (referred to in this discussion as Micropolitan Areas) are based on urban clusters with a population of at least 10,000 but less than 50,000. Counties that do not fall within CBSAs are deemed ``Outside CBSAs.'' In the past, OMB defined MSAs around areas with a minimum core population of 50,000, and smaller areas were ``Outside MSAs.''

The general concept of the CBSAs is that of an area containing a recognized population nucleus and adjacent communities that have a high degree of integration with that nucleus. The purpose of the standards is to provide nationally consistent definitions for collecting, tabulating, and publishing Federal statistics for a set of geographic areas. CBSAs include adjacent counties that have a minimum of 25 percent commuting to the central counties of the area. (This is an increase over the minimum commuting threshold of 15 percent for outlying counties applied in the previous MSA definition.)

The new CBSAs established by OMB comprised MSAs and the new Micropolitan Areas based on Census 2000 data. (A copy of the announcement may be obtained at the following Internet address: http://www.whitehouse.gov/omb/bulletins/fy04/b04-03.html. ) The definitions

recognize 49 new MSAs and 565 new Micropolitan Areas, and extensively revised the composition of many of the existing MSAs.

The new area designations resulted in a higher wage index for some areas and lower wage index for others. Further, some hospitals that were previously classified as urban are now in rural areas. Given the significant payment impacts upon some hospitals because of these changes, we provided a transition period to the new labor market areas in the FY 2005 IPPS final rule (69 FR 49027 through 49034). As part of that transition, we allowed urban hospitals that became rural under the new definitions to maintain their assignment to the Metropolitan Statistical Area (MSA) where they were previously located for the 3- year period of FY 2005, FY 2006, and FY 2007. Specifically, these hospitals were assigned the wage index of the urban area to which they previously belonged. (For purposes of wage index computation, the wage data of these hospitals remained assigned to the statewide rural area in which they are located.) The hospitals receiving this transition will not be considered urban hospitals; rather they will maintain their status as rural hospitals. Thus, the hospital would not be eligible, for example, for a large urban add-on payment under the capital PPS. In other words, it is the wage index, but not the urban or rural status, of these hospitals that is being affected by this transition. The higher wage indices that these hospitals are receiving are also being taken into consideration in determining

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whether they qualify for the out-commuting adjustment discussed in section III.I. of this preamble and the amount of any adjustment.

FY 2006 will be the second year of this transition period. We will continue to assign the wage index for the urban area in which the hospital was previously located through FY 2007. In order to ensure this provision remains budget neutral, we will continue to adjust the standardized amount by a transition budget neutrality factor to account for these hospitals. Doing so is consistent with the requirement of section 1886(d)(3)(E) of the Act that any ``adjustments or updates [to the adjustment for different area wage levels] * * * shall be made in a manner that assures that aggregate payments * * * are not greater or less than those that would have been made in the year without such adjustment.''

Beginning in FY 2008, these hospitals will receive their statewide rural wage index, although they will be eligible to apply for reclassification by the MGCRB, both during this transition period as well as in subsequent years.

In addition, in the FY 2005 IPPS final rule (69 FR 49032 through 49033), we provided a 1-year transition blend for hospitals that, due solely to the changes in the labor market definitions, experienced a decrease in their FY 2005 wage index compared to the wage index they would have received using the labor market areas included in calculating their FY 2004 wage index. Hospitals that experienced a decrease in their wage index as a result of adoption of the new labor market area changes received a wage index based on 50 percent of the CBSA labor market area definitions and 50 percent of the wage index that the provider would have received under the FY 2004 MSA boundaries (in both cases using the FY 2001 wage data). This blend applied to any provider experiencing a decrease due to the new definitions, including providers who were reclassifying under MGCRB requirements, section 1886(d)(8)(B) of the Act, or section 508 of Pub. L. 108-173. In the FY 2005 IPPS final rule (69 FR 49027 through 49033), we described the determination of this blend in detail. We noted that this blend would not prevent a decrease in wage index due to any reason other than adoption of CBSAs, nor did it apply to hospitals that benefited from a higher wage index due to the new labor market definitions.

Consistent with the FY 2005 IPPS final rule, we are proposing that hospitals receive 100 percent of their wage index based upon the new CBSA configurations beginning in FY 2006. Specifically, we will determine for each hospital a new wage index employing wage index data from FY 2002 hospital cost reports and using the CBSA labor market definitions.

C. Proposed Occupational Mix Adjustment to FY 2006 Index

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

As stated earlier, section 1886(d)(3)(E) of the Act provides for the collection of data every 3 years on the occupational mix of employees for each short-term, acute care hospital participating in the Medicare program, in order to construct an occupational mix adjustment to the wage index, for application beginning October 1, 2004 (the FY 2005 wage index). The purpose of the occupational mix adjustment is to control for the effect of hospitals' employment choices on the wage index. For example, hospitals may choose to employ different combinations of registered nurses, licensed practical nurses, nursing aides, and medical assistants for the purpose of providing nursing care to their patients. The varying labor costs associated with these choices reflect hospital management decisions rather than geographic differences in the costs of labor. 1. Development of Data for the Proposed Occupational Mix Adjustment

In the FY 2005 IPPS final rule (69 FR 49034), we discussed in detail the data we used to calculate the occupational mix adjustment to the FY 2005 wage index. For the FY 2006 wage index, we are proposing to use the same CMS Wage Index Occupational Mix Survey and Bureau of Labor Statistics (BLS) data that we used for the FY 2005 wage index, with two exceptions. The CMS survey requires hospitals to report the number of total paid hours for directly hired and contract employees in occupations that provide the following services: nursing, physical therapy, occupational therapy, respiratory therapy, medical and clinical laboratory, dietary, and pharmacy. These services each include several standard occupational classifications (SOCs), as defined by the BLS' Occupational Employment Statistics (OES) survey. For the proposed FY 2006 wage index, we used revised survey data for 20 hospitals that took advantage of the opportunity we afforded hospitals to submit changes to their occupational mix data during the FY 2006 wage index data collection process (see discussion of wage data corrections process under section III.J. of this preamble). We also excluded survey data for hospitals that became designated as CAHs since the original survey data were collected and hospitals for which there are no corresponding cost report data for the proposed FY 2006 wage index. The proposed FY 2006 wage index includes occupational mix data from 3,563 out of 3,765 hospitals (94.6 percent response rate). The results of the occupational mix survey are included in the chart below:

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[GRAPHIC] [TIFF OMITTED] TP04MY05.026

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2. Calculation of the Proposed FY 2006 Occupational Mix Adjustment Factor and the Proposed FY 2006 Occupational Mix Adjusted Wage Index

For the proposed FY 2006 wage index, we are proposing to use the same methodology that we used to calculate the occupational mix adjustment to the FY 2005 wage index (69 FR 49042). We are proposing to use the following steps for calculating the proposed FY 2006 occupational mix adjustment factor and the occupational mix adjusted wage index:

Step 1--For each hospital, the percentage of the general service category attributable to an SOC is determined by dividing the SOC hours by the general service category's total hours. Repeat this calculation for each of the 19 SOCs.

Step 2--For each hospital, the weighted average hourly rate for an SOC is determined by multiplying the percentage of the general service category (from Step 1) by the national average hourly rate for that SOC from the 2001 BLS OES survey, which was used in calculating the occupational mix adjustment for the FY 2005 wage index. The 2001 OES survey is BLS' latest available hospital-specific survey. (See Chart 4 in the FY 2005 IPPS final rule, 69 FR 49038.) Repeat this calculation for each of the 19 SOCs.

Step 3--For each hospital, the hospital's adjusted average hourly rate for a general service category is computed by summing the weighted hourly rate for each SOC within the general category. Repeat this calculation for each of the 7 general service categories.

Step 4--For each hospital, the occupational mix adjustment factor for a general service category is calculated by dividing the national adjusted average hourly rate for the category by the hospital's adjusted average hourly rate for the category. (The national adjusted average hourly rate is computed in the same manner as Steps 1 through 3, using instead, the total SOC and general service category hours for all hospitals in the occupational mix survey database.) Repeat this calculation for each of the 7 general service categories. If the hospital's adjusted rate is less than the national adjusted rate (indicating the hospital employs a less costly mix of employees within the category), the occupational mix adjustment factor will be greater than 1.0000. If the hospital's adjusted rate is greater than the national adjusted rate, the occupational mix adjustment factor will be less than 1.0000.

Step 5--For each hospital, the occupational mix adjusted salaries and wage-related costs for a general service category is calculated by multiplying the hospital's total salaries and wage-related costs (from Step 5 of the unadjusted wage index calculation in section F) by the percentage of the hospital's total workers attributable to the general service category and by the general service category's occupational mix adjustment factor (from Step 4 above). Repeat this calculation for each of the 7 general service categories. The remaining portion of the hospital's total salaries and wage-related costs that is attributable to all other employees of the hospital is not adjusted for occupational mix.

Step 6--For each hospital, the total occupational mix adjusted salaries and wage-related costs for a hospital are calculated by summing the occupational mix adjusted salaries and wage-related costs for the 7 general service categories (from Step 5) and the unadjusted portion of the hospital's salaries and wage-related costs for all other employees. To compute a hospital's occupational mix adjusted average hourly wage, divide the hospital's total occupational mix adjusted salaries and wage-related costs by the hospital's total hours (from Step 4 of the unadjusted wage index calculation in Section F).

Step 7--To compute the occupational mix adjusted average hourly wage for an urban or rural area, sum the total occupational mix adjusted salaries and wage-related costs for all hospitals in the area, then sum the total hours for all hospitals in the area. Next, divide the area's occupational mix adjusted salaries and wage-related costs by the area's hours.

Step 8--To compute the national occupational mix adjusted average hourly wage, sum the total occupational mix adjusted salaries and wage- related costs for all hospitals in the nation, then sum the total hours for all hospitals in the nation. Next, divide the national occupational mix adjusted salaries and wage-related costs by the national hours. The proposed national occupational mix adjusted average hourly wage for FY 2006 is $27.9988.

Step 9--To compute the occupational mix adjusted wage index, divide each area's occupational mix adjusted average hourly wage (Step 7) by the national occupational mix adjusted average hourly wage (Step 8).

Step 10--To compute the Puerto Rico specific occupational mix adjusted wage index, follow the Steps 1 through 9 above. The proposed Puerto Rico occupational mix adjusted average hourly wage for FY 2006 is $12.9875.

An example of the occupational mix adjustment was included in the FY 2005 IPPS final rule (69 FR 49043).

For the FY 2005 final wage index, we used the unadjusted wage data for hospitals that did not submit occupational mix survey data. For calculation purposes, this equates to applying the national SOC mix to the wage data for these hospitals, because hospitals having the same mix as the Nation would have an occupational mix adjustment factor equaling 1.0000. In the FY 2005 IPPS final rule (69 FF 49035), we noted that we would revisit this matter with subsequent collections of the occupational mix data. Because we are using essentially the same survey data for the proposed FY 2006 occupational mix adjustment that we used for FY 2005, with the only exceptions as stated in section III.C.1. of this preamble, we are proposing to treat the wage data for hospitals that did not respond to the survey in this same manner for the proposed FY 2006 wage index.

In implementing an occupational mix adjusted wage index based on the above calculation, the proposed wage index values for 14 rural areas (29.8 percent) and 206 urban areas (53.5 percent) would decrease as a result of the adjustment. Six (6) rural areas (12.8 percent) and 111 urban areas (28.8 percent) would experience a decrease of 1 percent or greater in their wage index values. The largest negative impact for a rural area would be 1.9 percent and for an urban area, 4.3 percent. Meanwhile, 33 rural areas (70.2 percent) and 179 urban areas (46.5 percent) would experience an increase in their wage index values. Although these results show that rural hospitals would gain the most from an occupational mix adjustment to the wage index, their gains may not be as great as might have been expected. Further, it might not have been anticipated that almost one-third of rural hospitals would actually fare worse under the adjustment. Overall, a fully implemented occupational mix adjusted wage index would have a redistributive effect on Medicare payments to hospitals.

In the FY 2005 IPPS, we indicated that, for future data collections, we would revise the occupational mix survey to allow hospitals to provide both salaries and hours data for each of the employment categories that are included on the survey. We also indicated that we would assess whether future occupational mix surveys should be based on the calendar year or if the data should be collected on a fiscal year basis as part of the Medicare cost report. (One logistical problem is that cost

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report data are collected yearly, but occupational mix survey data are collected only every 3 years.) We are currently reviewing options for revising the occupational mix survey and improving the data collection process. We will publish any changes we make to the occupational mix survey in a Federal Register notice.

In our continuing efforts to meet the information needs of the public, we are providing three additional public use files for the proposed occupational mix adjusted wage index: (1) A file including each hospital's unadjusted and adjusted average hourly wage (FY 2006 Proposed Rule Occupational Mix Adjusted and Unadjusted Average Hourly Wage by Provider); (2) a file including each CBSA's adjusted and unadjusted average hourly wage (FY 2006 Proposed Rule Occupational Mix Adjusted and Unadjusted Average Hourly Wage and Pre-Reclassified Wage Index by CBSA); and (3) a file including each hospital's occupational mix adjustment factors by occupational category (Provider Occupational Mix Adjustment Factors for Each Occupational Category). These additional files are being released concurrently with the publication of this proposed rule and are posted on the Internet, at http://www.cms.hhs.gov/providers/hipps/ippswage.asp. We will also post these

files with future applications of the occupational mix adjustment.

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

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

The proposed FY 2006 wage index values (effective for hospital discharges occurring on or after October 1, 2005 and before October 1, 2006) in section VI. of the Addendum to this proposed rule are based on the data collected from the Medicare cost reports submitted by hospitals for cost reporting periods beginning in FY 2002 (the FY 2005 wage index was based on FY 2001 wage data).

The proposed FY 2006 wage index includes the following categories of data associated with costs paid under the IPPS (as well as outpatient costs):

Salaries and hours from short-term, acute care hospitals (including paid lunch hours and hours associated with military leave and jury duty).

Home office costs and hours.

Certain contract labor costs and hours (which includes direct patient care, certain top management, pharmacy, laboratory, and nonteaching physician Part A services).

Wage-related costs, including pensions and other deferred compensation costs.

The September 1, 1994 Federal Register (59 FR 45356) included a list of core wage-related costs that are included in the wage index, and discussed criteria for including other wage-related costs. In that discussion, we instructed hospitals to use generally accepted accounting principles (GAAPs) in developing wage-related costs for the wage index for cost reporting periods beginning on or after October 1, 1994. We discussed our rationale that ``the application of GAAPs for purposes of compiling data on wage-related costs used to construct the wage index will more accurately reflect relative labor costs, because certain wage-related costs (such as pension costs), as recorded under GAAPs, tend to be more static from year to year.''

Since publication of the September 1, 1994 rule, we have periodically received inquiries for more specific guidance on developing wage-related costs for the wage index. In response, we have provided clarifications in the IPPS rules (for example, health insurance costs (66 FR 39859)) and in the cost report instructions (Provider Reimbursement Manual (PRM), Part II, Section 3605.2). Due to recent questions and concerns we received regarding inconsistent reporting and overreporting of pension and other deferred compensation plan costs, as a result of an ongoing Office of Inspector General review, we are clarifying in this proposed rule that hospitals must comply with the PRM, Part I, sections 2140. 2141, and 2142 and related Medicare program instructions for developing pension and other deferred compensation plan costs as wage-related costs for the wage index. The Medicare instructions for pension costs and other deferred compensation costs combine GAAPs, Medicare payment principles, and other Federal labor requirements. We believe that the Medicare instructions allow for consistent reporting among hospitals and for the development of reasonable deferred compensation plan costs for purposes of the wage index.

Beginning with the FY 2007 wage index, hospitals and fiscal intermediaries must ensure that pension, post-retirement health benefits, and other deferred compensation plan costs for the wage index are developed according to the above terms.

Consistent with the wage index methodology for FY 2005, the proposed wage index for FY 2006 also excludes the direct and overhead salaries and hours for services not subject to IPPS payment, such as SNF services, home health services, costs related to GME (teaching physicians and residents) and certified registered nurse anesthetists (CRNAs), and other subprovider components that are not paid under the IPPS. The proposed FY 2006 wage index also excludes the salaries, hours, and wage-related costs of hospital-based rural health clinics (RHCs), and Federally qualified health centers (FQHCs) because Medicare pays for these costs outside of the IPPS (68 FR 45395). In addition, salaries, hours and wage-related costs of CAHs are excluded from the wage index, for the reasons explained in the FY 2004 IPPS final rule (68 FR 45397).

Data collected for the IPPS wage index are also currently used to calculate wage indices applicable to other providers, such as SNFs, home health agencies, and hospices. In addition, they are used for prospective payments to rehabilitation, psychiatric, and long-term care hospitals, and for hospital outpatient services.

In the August 11, 2004 final rule, we stated that a commenter had asked CMS to designate provider-based clinics as IPPS-excluded areas in order to remove the costs from the wage index (69 FR 49049). The commenter noted that provider-based clinics are like physician private offices, which are excluded from the wage index calculation, and that services provided in the provider-based clinics are paid for not through the IPPS, but rather under the hospital outpatient PPS. In response to the comment, we stated that we were not prepared to grant the commenter's request without first studying the issue, and that we would explore the matter of salaries related to provider-based clinics in a future rule.

Regulations at 42 CFR 413.65 describe the criteria and procedures for determining whether a facility or organization is provider-based. Historically, under the Medicare program, some providers, referred to as ``main providers,'' have functioned as single entities while owning and operating multiple provider-based departments, locations, and facilities that are treated as part of the main provider for Medicare purposes. Section 413.65(a)(2) defines various types of provider-based facilities, including ``department of a provider.'' A ``department of a provider'' means a facility or organization that is either created by, or acquired by, a main provider for the purposes of furnishing health care services of the same type as those furnished by the main provider under the name, ownership, and financial and administrative control of the main provider * * * a department

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of a provider may not itself be qualified to participate in Medicare as a provider under Sec. 489.2 * * * the term `department of a provider' does not include an RHC or * * * an FQHC.'' Thus, if a facility offers services that are similar to those provided in a freestanding physician's office, and the facility meets the criteria to become provider-based under Sec. 413.65, the facility would be considered a ``department of a provider.'' More specifically, the facility would be part of the main provider's outpatient department, since the facility offers health care services of the same type as those furnished by the main provider, and because a physician's office would not be subject to a provider agreement or receive a Medicare provider number under Sec. 489.2. (We note that a provider-based RHC or FQHC may, by itself, be qualified to participate in Medicare as a provider under Sec. 489.2 and, thus, would be classified not as a ``department of a provider'' but as a ``provider-based entity,'' as defined at Sec. 413.65(a)(2)). This provider-based facility, or provider-based clinic, as the commenter referred to it, would be reported on the main provider's Medicare cost report as an outpatient service cost center, on Worksheet A, line 60. With the exception of RHC and FQHC salaries that have been excluded from the wage index beginning with FY 2004 (68 FR 45395, August 1, 2003), the salaries attributable to employees working in these outpatient service cost centers, including emergency departments, are included in the main provider's total salaries on Worksheet S-3, Part II, line 1, and accordingly, are included in the wage index calculation. We have historically included the salaries and wages of hospital employees working in the outpatient departments in the calculation of the hospital wage index since these employees often work in both the IPPS and in the outpatient areas of the hospital. Consistent with this longstanding treatment of outpatient salary costs in the wage index calculation, we believe it is appropriate to continue to include the salaries and wages of employees working in outpatient departments, including provider-based clinics, in the wage index calculation.

E. Verification of Worksheet S-3 Wage Data

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

The wage data for the proposed FY 2006 wage index were obtained from Worksheet S-3, Parts II and III of the FY 2002 Medicare cost reports. Instructions for completing the Worksheet S-3, Parts II and III are in the Provider Reimbursement Manual, Part I, sections 3605.2 and 3605.3. The data file used to construct the proposed wage index includes FY 2002 data submitted to us as of February 23, 2005. As in past years, we performed an intensive review of the wage data, mostly through the use of edits designed to identify aberrant data.

We asked our fiscal intermediaries to revise or verify data elements that resulted in specific edit failures. Some unresolved data elements are included in the calculation of the proposed FY 2006 wage index, pending their resolution before calculation of the final FY 2006 index. We instructed the fiscal intermediaries to complete their data verification of questionable data elements and to transmit any changes to the wage data no later than April 15, 2005. We believe all unresolved data elements will be resolved by the date the final rule is issued. The revised data will be reflected in the final rule.

Also, as part of our editing process, we removed the data for 438 hospitals from our database: 402 hospitals became CAHs by the time we published the February public use file, and 28 hospitals were low Medicare utilization hospitals or failed edits that could not be corrected because the hospitals terminated the program or changed ownership. In addition, we removed the wage data for 8 hospitals with incomplete or inaccurate data resulting in zero or negative, or otherwise aberrant, average hourly wages. We have notified the fiscal intermediaries of these hospitals and will continue to work with the fiscal intermediaries to correct these data until we finalize our database to compute the final wage index. The data for these hospitals will be included in the final wage index if we receive corrected data that passes our edits. As a result, the proposed FY 2006 wage index is calculated based on FY 2002 wage data from 3,765 hospitals.

In constructing the proposed FY 2006 wage index, we include the wage data for facilities that were IPPS hospitals in FY 2002, even for those facilities that have since terminated their participation in the program as hospitals, as long as those data do not fail any of our edits for reasonableness. We believe that including the wage data for these hospitals is, in general, appropriate to reflect the economic conditions in the various labor market areas during the relevant past period. However, we exclude the wage data for CAHs (as discussed in 68 FR 45397). The proposed wage index in this proposed rule excludes hospitals that are designated as CAHs by February 1, 2005, the date of the latest available Medicare CAH listing at the time we released the proposed wage index public use file on February 25, 2005.

F. Computation of the Proposed FY 2006 Unadjusted Wage Index

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

The method used to compute the proposed FY 2006 wage index without an occupational mix adjustment follows:

Step 1--As noted above, we based the proposed FY 2006 wage index on wage data reported on the FY 2002 Medicare cost reports. We gathered data from each of the non-Federal, short-term, acute care hospitals for which data were reported on the Worksheet S-3, Parts II and III of the Medicare cost report for the hospital's cost reporting period beginning on or after October 1, 2001 and before October 1, 2002. In addition, we included data from some hospitals that had cost reporting periods beginning before October 2001 and reported a cost reporting period covering all of FY 2002. These data were included because no other data from these hospitals would be available for the cost reporting period described above, and because particular labor market areas might be affected due to the omission of these hospitals. However, we generally describe these wage data as FY 2002 data. We note that, if a hospital had more than one cost reporting period beginning during FY 2002 (for example, a hospital had two short cost reporting periods beginning on or after October 1, 2001 and before October 1, 2002), we included wage data from only one of the cost reporting periods, the longer, in the wage index calculation. If there was more than one cost reporting period and the periods were equal in length, we included the wage data from the later period in the wage index calculation.

Step 2--Salaries--The method used to compute a hospital's average hourly wage excludes certain costs that are not paid under the IPPS. In calculating a hospital's average salaries plus wage-related costs, we subtracted from Line 1 (total salaries) the GME and CRNA costs reported on Lines 2, 4.01, 6, and 6.01, the Part B salaries reported on Lines 3, 5 and 5.01, home office salaries reported on Line 7, and excluded salaries reported on Lines 8 and 8.01 (that is, direct salaries attributable to SNF services, home health services, and other subprovider components not

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subject to the IPPS). We also subtracted from Line 1 the salaries for which no hours were reported. To determine total salaries plus wage- related costs, we added to the net hospital salaries the costs of contract labor for direct patient care, certain top management, pharmacy, laboratory, and nonteaching physician Part A services (Lines 9 and 10), home office salaries and wage-related costs reported by the hospital on Lines 11 and 12, and nonexcluded area wage-related costs (Lines 13, 14, and 18).

We note that contract labor and home office salaries for which no corresponding hours are reported were not included. In addition, wage- related costs for nonteaching physician Part A employees (Line 18) are excluded if no corresponding salaries are reported for those employees on Line 4.

Step 3--Hours--With the exception of wage-related costs, for which there are no associated hours, we computed total hours using the same methods as described for salaries in Step 2.

Step 4--For each hospital reporting both total overhead salaries and total overhead hours greater than zero, we then allocated overhead costs to areas of the hospital excluded from the wage index calculation. First, we determined the ratio of excluded area hours (sum of Lines 8 and 8.01 of Worksheet S-3, Part II) to revised total hours (Line 1 minus the sum of Part II, Lines 2, 3, 4.01, 5, 5.01, 6, 6.01, 7, and Part III, Line 13 of Worksheet S-3). We then computed the amounts of overhead salaries and hours to be allocated to excluded areas by multiplying the above ratio by the total overhead salaries and hours reported on Line 13 of Worksheet S-3, Part III. Next, we computed the amounts of overhead wage-related costs to be allocated to excluded areas using three steps: (1) We determined the ratio of overhead hours (Part III, Line 13) to revised hours (Line 1 minus the sum of Lines 2, 3, 4.01, 5, 5.01, 6, 6.01, 7, 8, and 8.01); (2) we computed overhead wage-related costs by multiplying the overhead hours ratio by wage- related costs reported on Part II, Lines 13, 14, and 18; and (3) we multiplied the computed overhead wage-related costs by the above excluded area hours ratio. Finally, we subtracted the computed overhead salaries, wage-related costs, and hours associated with excluded areas from the total salaries (plus wage-related costs) and hours derived in Steps 2 and 3.

Step 5--For each hospital, we adjusted the total salaries plus wage-related costs to a common period to determine total adjusted salaries plus wage-related costs. To make the wage adjustment, we estimated the percentage change in the employment cost index (ECI) for compensation for each 30-day increment from October 14, 2001 through April 15, 2003 for private industry hospital workers from the Bureau of Labor Statistics' Compensation and Working Conditions. We use the ECI because it reflects the price increase associated with total compensation (salaries plus fringes) rather than just the increase in salaries. In addition, the ECI includes managers as well as other hospital workers. This methodology to compute the monthly update factors uses actual quarterly ECI data and assures that the update factors match the actual quarterly and annual percent changes. The factors used to adjust the hospital's data were based on the midpoint of the cost reporting period, as indicated below.

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[GRAPHIC] [TIFF OMITTED] TP04MY05.027

For example, the midpoint of a cost reporting period beginning January 1, 2002 and ending December 31, 2002 is June 30, 2002. An adjustment factor of 1.03083 would be applied to the wages of a hospital with such a cost reporting period. In addition, for the data for any cost reporting period that began in FY 2002 and covered a period of less than 360 days or more than 370 days, we annualized the data to reflect a 1-year cost report. Dividing the data by the number of days in the cost report and then multiplying the results by 365 accomplishes annualization.

Step 6--Each hospital was assigned to its appropriate urban or rural labor market area before any reclassifications under section 1886(d)(8)(B), section 1886(d)(8)(E), or section 1886(d)(10) of the Act. Within each urban or rural labor market area, we added the total adjusted salaries plus wage-related costs obtained in Step 5 for all hospitals in that area to determine the total adjusted salaries plus wage-related costs for the labor market area.

Step 7--We divided the total adjusted salaries plus wage-related costs obtained under both methods in Step 6 by the sum of the corresponding total hours (from Step 4) for all hospitals in each labor market area to determine an average hourly wage for the area.

Step 8--We added the total adjusted salaries plus wage-related costs obtained in Step 5 for all hospitals in the nation and then divided the sum by the national sum of total hours from Step 4 to arrive at a national average hourly wage. Using the data as described above, the proposed national average hourly wage is $27.9730.

Step 9--For each urban or rural labor market area, we calculated the hospital wage index value by dividing the area average hourly wage obtained in Step 7 by the national average hourly wage computed in Step 8.

Step 10--Following the process set forth above, we developed a separate Puerto Rico-specific wage index for purposes of adjusting the Puerto Rico standardized amounts. (The national Puerto Rico standardized amount is adjusted by a wage index calculated for all Puerto Rico labor market areas based on the national average hourly wage as described above.) We added the total adjusted salaries plus wage-related costs (as calculated in Step 5) for all hospitals in Puerto Rico and divided the sum by the total hours for Puerto Rico (as calculated in Step 4) to arrive at an overall proposed average hourly wage of $12.9957 for Puerto Rico. For each labor market area in Puerto Rico, we calculated the Puerto Rico-specific wage index value by dividing the area average hourly wage (as calculated in Step 7) by the overall Puerto Rico average hourly wage.

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Step 11--Section 4410 of Pub. L. 105-33 provides that, for discharges on or after October 1, 1997, the area wage index applicable to any hospital that is located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas in that State. Furthermore, this wage index floor is to be implemented in such a manner as to ensure that aggregate IPPS payments are not greater or less than those that would have been made in the year if this section did not apply. For FY 2006, this change affects 147 hospitals in 52 urban areas. The areas affected by this provision are identified by a footnote in Table 4A in the Addendum of this proposed rule.

G. Computation of the Proposed FY 2006 Blended Wage Index

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

For the final FY 2005 wage index, we used a blend of the occupational mix adjusted wage index and the unadjusted wage index. Specifically, we adjusted 10 percent of the FY 2005 wage index adjustment factor by a factor reflecting occupational mix. Given that 2003-2004 was the first time for the administration of the occupational mix survey, hospitals had a short timeframe for collecting their occupational mix survey data and documentation, the wage data were not in all cases from a 1-year period, and there was no baseline data for purposes of developing a desk review program, we found it prudent not to adjust the entire wage index factor by the occupational mix. However, we did find the data sufficiently reliable for applying an adjustment to 10 percent of the wage index. We found the data reliable because hospitals were given an opportunity to review their survey data and submit changes in the Spring of 2004, hospitals were already familiar with the BLS OES survey categories, hospitals were required to be able to provide documentation that could be used by fiscal intermediaries to verify survey data, and the results of our survey were consistent with the findings of the 2001 BLS OES survey, especially for nursing and physical therapy categories. In addition, we noted that we were moving cautiously with implementing the occupational mix adjustment in recognition of changing trends in hiring nurses, the largest group in the survey. We noted that some States had recently established floors on the minimum level of registered nurse staffing in hospitals in order to maintain licensure. In addition, in some rural areas, we believed that hospitals might be accounting for shortages of physicians by hiring more registered nurses. (A complete discussion of the FY 2005 wage index adjustment factor can be found in section III.G. of the FY 2005 IPPS final rule (69 FR 49052)).

In the FY 2005 final rule, we noted that while the statute required us to collect occupational mix data every 3 years, the statute does not specify how the occupational mix adjustment is to be constructed or applied. We are clarifying in this proposed rule that the October 1, 2004 deadline for implementing an occupational mix adjustment is not codified in section 1886(d)(3)(E) of the Act, which requires only a collection and measurement of occupational mix data, but rather stems from the effective date provisions in section 304(c) of the Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000, Pub. L. 106-554 (BIPA). Although we believe that applying the occupational mix to 10 percent of the wage index factor fully implements the occupational mix adjustment, we also interpret BIPA as requiring only that we begin applying an adjustment by October 1, 2004. BIPA required the Secretary to complete, ``by not later than September 30, 2003, for application beginning October 1, 2004,'' both the collection of occupational mix data and the measurement of such data. (BIPA, section 304(c)(3).) Thus, even if adjusting 10 percent of the wage index for occupational mix were not (as we believe it to be) considered to be full implementation of the BIPA effective date, we certainly began our application of the adjustment as of October 1, 2004.

In addition, section 1886(d)(3)(E) of the Act provides broad authority for us to establish the factor we use to adjust hospital costs to take into account area differences in wage levels. The statute is clear that the wage index factor is to be ``established by the Secretary.'' The occupational mix is only one part of this wage index factor, which, for the most part, is calculated on the basis of average hourly wage data submitted by all hospitals in the United States. In exercising the Secretary's broad discretion to establish the factor that adjusts for geographic wage differences, in FY 2005 we adjusted 10 percent of such factor to account for occupational mix.

Indeed, we have often used percentage figures or blended amounts in exercising the Secretary's authority to establish the factor that adjusts for wage differences. For example, in the FY 2005 final rule, we implemented new mapping boundaries for assigning hospitals to the geographic labor market areas used for calculating the wage index. For hospitals that were harmed by the new geographic boundaries, we used a blended rate based on 50 percent of the wage index that would apply using the new geographic boundaries effective for FY 2005 and 50 percent of the wage index that would apply using the old geographic boundaries that were effective during FY 2004 (69 FR 49033). Similarly, beginning with FY 2000, we began phasing out costs related to GME and CRNAs from the wage index (64 FR 41505). Thus, for example, the FY 2001 wage index was based on a blend of 60 percent of an average hourly wage including these costs, and 40 percent of an average hourly wage excluding these costs (65 FR 47071).

For FY 2006, we are again proposing to adjust 10 percent of the wage index factor for occupational mix. In computing the occupational mix adjustment for the proposed FY 2006 wage index, we used the occupational mix survey data that we collected for the FY 2005 wage index, replacing the survey data for 20 hospitals that submitted revised data, and excluding the survey data for hospitals with no corresponding Worksheet S-3 wage data for FY 2006 wage index. While we considered adjusting 100 percent of the wage index by the occupational mix, we did not believe it was appropriate to use first-year survey data to make such a large adjustment. As hospitals gain additional experience with the occupational mix survey, and as we develop more information upon which to audit the data we receive, we expect to increase the portion of the wage index that is adjusted.

We also acknowledge the District Court opinion in Bellevue Hospital Center v. Leavitt, No. 04-8639 (S.D.N.Y, March 2005) finding that the statute requires full implementation of the occupational mix adjustment beginning October 1, 2004, and granting summary judgment to plaintiffs on the matter. At the time this proposed rule was written, an appeal had not yet been heard in the Circuit Court. Thus, because it was not yet clear whether the decision would be appealed, we determined that, for FY 2006, we would continue to propose the policy we believe to be most prudent in light of the survey data being used to adjust the wage index.

With 10 percent of the proposed FY 2006 wage index adjusted for occupational mix, the wage index values for 13 rural areas (27.7 percent) and 204 urban areas (53.0 percent) would decrease as a result of the adjustment. These decreases would be minimal; the largest negative impact for

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a rural area would be 0.19 percent and for an urban area, 0.42 percent. Conversely, 34 rural areas (72.3 percent) and 181 urban areas (47.0 percent) would benefit from this adjustment, with 1 urban area increasing 2.1 percent and 1 rural area increasing 0.39 percent. As there are no significant differences between the FY 2005 and the FY 2006 occupational mix survey data and results, we believe it is appropriate to again apply the occupational mix to 10 percent of the proposed FY 2006 wage index. (See Appendix A to this proposed rule for further analysis of the impact of the occupational mix adjustment on the proposed FY 2006 wage index.)

The wage index values in Tables 4A, 4B, 4C, and 4F and the average hourly wages in Tables 2, 3A, and 3B in the Addendum to this proposed rule include the occupational mix adjustment.

H. Proposed Revisions to the Wage Index Based on Hospital Redesignation

(If you choose to comment on issues in this section, please include the caption ``Hospital Redesignations and Reclassifications'' at the beginning of your comment.) 1. General

Under section 1886(d)(10) of the Act, the Medicare Geographic Classification Review Board (MGCRB) considers applications by hospitals for geographic reclassification for purposes of payment under the IPPS. Hospitals must apply to the MGCRB to reclassify by September 1 of the year preceding the year during which reclassification is sought. Generally, hospitals must be proximate to the labor market area to which they are seeking reclassification and must demonstrate characteristics similar to hospitals located in that area. The MGCRB issues its decisions by the end of February for reclassifications that become effective for the following fiscal year (beginning October 1). The regulations applicable to reclassifications by the MGCRB are located in Sec. Sec. 412.230 through 412.280.

Section 1886(d)(10)(D)(v) of the Act provides that, beginning with FY 2001, a MGCRB decision on a hospital reclassification for purposes of the wage index is effective for 3 fiscal years, unless the hospital elects to terminate the reclassification. Section 1886(d)(10)(D)(vi) of the Act provides that the MGCRB must use the 3 most recent years' average hourly wage data in evaluating a hospital's reclassification application for FY 2003 and any succeeding fiscal year.

Section 304(b) of Pub. L. 106-554 provides that the Secretary must establish a mechanism under which a statewide entity may apply to have all of the geographic areas in the State treated as a single geographic area for purposes of computing and applying a single wage index, for reclassifications beginning in FY 2003. The implementing regulations for this provision are located at Sec. 412.235.

Section 1886(d)(8)(B) of the Act requires the Secretary to treat a hospital located in a rural county adjacent to one or more urban areas as being located in the MSA to which the greatest number of workers in the county commute if: the rural county would otherwise be considered part of an urban area under the standards for designating MSAs if the commuting rates used in determining outlying counties were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or counties of all contiguous MSAs. In light of the new CBSA definitions and the Census 2000 data that we implemented for FY 2005 (69 FR 49027), we undertook to identify those counties meeting these criteria. The eligible counties are identified below under section III.H.5. of this preamble. 2. Effects of Reclassification

Section 1886(d)(8)(C) of the Act provides that the application of the wage index to redesignated hospitals is dependent on the hypothetical impact that the wage data from these hospitals would have on the wage index value for the area to which they have been redesignated. These requirements for determining the wage index values for redesignated hospitals is applicable both to the hospitals located in rural counties deemed urban under section 1886(d)(8)(B) of the Act and hospitals that were reclassified as a result of the MGCRB decisions under section 1886(d)(10) of the Act. Therefore, as provided in section 1886(d)(8)(C) of the Act,\3\ the wage index values were determined by considering the following:

\3\ Although section 1886(d)(8)(C)(iv)(I) of the Act also provides that the wage index for an urban area may not decrease as a result of redesignated hospitals if the urban area wage index is already below the wage index for rural areas in the State in which the urban area is located, the provision was effectively made moot by section 4410 of Pub. L. 105-33, which provides that the area wage index applicable to any hospital that is located in an urban area of a State may not be less than the area wage index applicable to hospitals located in rural areas in that State. Also, section 1886(d)(8)(C)(iv)(II) of the Act provides that an urban area's wage index may not decrease as a result of redesignated hospitals if the urban area is located in a State that is composed of a single urban area.

If including the wage data for the redesignated hospitals would reduce the wage index value for the area to which the hospitals are redesignated by 1 percentage point or less, the area wage index value determined exclusive of the wage data for the redesignated hospitals applies to the redesignated hospitals.

If including the wage data for the redesignated hospitals reduces the wage index value for the area to which the hospitals are redesignated by more than 1 percentage point, the area wage index determined inclusive of the wage data for the redesignated hospitals (the combined wage index value) applies to the redesignated hospitals.

If including the wage data for the redesignated hospitals increases the wage index value for the urban area to which the hospitals are redesignated, both the area and the redesignated hospitals receive the combined wage index value. Otherwise, the hospitals located in the urban area receive a wage index excluding the wage data of hospitals redesignated into the area.

The wage data for a reclassified urban hospital is included in both the wage index calculation of the area to which the hospital is reclassified (subject to the rules described above) and the wage index calculation of the urban area where the hospital is physically located.

Rural areas whose wage index values would be reduced by excluding the wage data for hospitals that have been redesignated to another area continue to have their wage index values calculated as if no redesignation had occurred (otherwise, redesignated rural hospitals are excluded from the calculation of the rural wage index).

The wage index value for a redesignated rural hospital cannot be reduced below the wage index value for the rural areas of the State in which the hospital is located. 3. Proposed Application of Hold Harmless Protection for Certain Urban Hospitals Redesignated as Rural

Section 401(a) of Pub. L. 106-113 (the Balanced Budget Refinement Act of 1999) amended section 1886(d)(8) of the Act by adding paragraph (E). Section 401(a) created a mechanism that permits an urban hospital to apply to the Secretary to be treated, for purposes of subsection (d), as being located in the rural area of the State in which the hospital is located. A hospital that is granted redesignation under section 1886(d)(8)(E) of the Act, as added by section 401 of Pub. L. 106-113 is, therefore, treated as a rural hospital for

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all purposes of payment under the Medicare IPPS, including the standardized amount, wage index, and disproportionate share calculations as of the effective date of the redesignation. Under current policy, as a result of an approved redesignation of an urban hospital as a rural hospital, the wage index data are excluded from the wage index calculation for the area where the urban hospital is geographically located and included in the rural hospital wage index calculation.

Last year, we became aware of an instance where the approved redesignation of an urban hospital as rural under section 1886(d)(8)(E) of the Act resulted in the hospital's data having an adverse impact on the rural wage index. We received a public comment noting that specific ``hold harmless'' provisions apply to reclassifications that occur under section 1886(d)(8)(B) and section 1886(d)(10) of the Act. That is, if a hospital is granted geographic reclassification under section 1886(d)(8)(B) or section 1886(d)(10) of the Act, there are certain rules that apply when the inclusion of the hospital's data results in a reduction of the reclassification area's wage index, and these rules are slightly different for urban areas versus rural areas. These rules are more fully described in the FY 2005 IPPS final rule (69 FR 49053). Generally stated, these rules prevent a rural area from being adversely affected as a result of reclassification. That is, if excluding the reclassifying hospitals' wage data would decrease the wage index of the rural area, the reclassifying hospitals are included in the rural area's wage index. Otherwise, the reclassifying hospitals are excluded. For hospitals reclassifying out of urban areas, the rules provide that the wage data for the reclassified urban hospital is included in the wage index calculation of the urban area where the hospital is physically located.

The commenter recommended that we revise our regulations and apply similar hold harmless provisions and treat hospitals redesignated under 1886(d)(8)(E) of the Act in the same manner as reclassifications under section 1886(d)(8)(B) and section 1886(d)(10) of the Act. In our continued effort to promote consistency, equity and to simplify our rules with respect to how we construct the wage indexes of rural and urban areas, we are persuaded that there is a need to modify our policy when hospital redesignations occur under section 1886(d)(8)(E) of the Act. Therefore, for the FY 2006 wage index, we are proposing to apply the hold harmless rule that currently applies when rural hospitals are reclassifying out of the rural area (from rural to urban) to situations where hospitals are reclassifying into the rural area (from urban to rural under section 1886(d)(8)(E) of the Act). Thus, the rule would be that the wage data of the urban hospital reclassifying into the rural area is included in the rural area's wage index, if including the urban hospital's data increases the wage index of the rural area. Otherwise, the wage data is excluded. Similarly, we are proposing to apply to these cases the rule that currently applies when urban hospitals reclassify under the MGCRB process. Thus, the wage data for an urban hospital reclassifying under section 1886(d)(8)(E) of the Act is always included in the wage index of the urban area where the hospital is located, and can also be included in the wage index of the rural area to which it is reclassifying (if doing so increases the rural area's wage index). We believe this proposal provides uniformity in the way geographic areas are treated under all types of reclassifications. In addition, our proposal promotes predictability by alleviating fluctuations in the wage indexes due to a section 401 redesignation.

We are including in the Addendum to this proposed rule Table 9C, which shows hospitals redesignated under section 1886(d)(8)(E) of the Act. 4. FY 2006 MGCRB Reclassifications

At the time this proposed rule was constructed, the MGCRB had completed its review of FY 2006 reclassification requests. There were 295 hospitals approved for wage index reclassifications by the MGCRB for FY 2006. Because MGCRB wage index reclassifications are effective for 3 years, hospitals reclassified during FY 2004 or FY 2005 are eligible to continue to be reclassified based on prior reclassifications to current MSAs during FY 2006. There were 395 hospitals reclassified for wage index for FY 2005, and 94 hospitals reclassified for wage index in FY 2004. Some of the hospitals that reclassified in FY 2004 and FY 2005 have elected not to continue their reclassifications in FY 2006 because, under the new labor market area definitions, they are now physically located in the areas to which they previously reclassified. Of all of the hospitals approved for reclassification for FY 2004, FY 2005, and FY 2006, 672 hospitals will be in a reclassification status for FY 2006.

Prior to FY 2004, hospitals had been able to apply to be reclassified for purposes of either the wage index or the standardized amount. Section 401 of Pub. L. 108-173 established that all hospitals will be paid on the basis of the large urban standardized amount, beginning with FY 2004. Consequently, all hospitals are paid on the basis of the same standardized amount, which made such reclassifications moot. Although there could still be some benefit in terms of payments for some hospitals under the DSH payment adjustment for operating IPPS, section 402 of Pub. L. 108-173 equalized DSH payment adjustments for rural and urban hospitals, with the exception that the rural DSH adjustment is capped at 12 percent (except that RRCs have no cap). (A detailed discussion of this application appears in section IV.I. of the preamble of the FY 2005 IPPS final rule (69 FR 49085.) 5. Proposed FY 2006 Redesignations Under Section 1886(d)(8)(B) of the Act

Beginning October 1, 1988, section 1886(d)(8)(B) of the Act required us to treat a hospital located in a rural county adjacent to one or more urban areas as being located in the MSA if certain criteria were met. Prior to FY 2005, the rule was that a rural county adjacent to one or more urban areas would be treated as being located in the MSA to which the greatest number of workers in the county commute, if the rural county would otherwise be considered part of an urban area under the standards published in the Federal Register on January 3, 1980 (45 FR 956) for designating MSAs (and NECMAs), and if the commuting rates used in determining outlying counties (or, for New England, similar recognized areas) were determined on the basis of the aggregate number of resident workers who commute to (and, if applicable under the standards, from) the central county or counties of all contiguous MSAs (or NECMAs). Hospitals that met the criteria using the January 3, 1980 version of these OMB standards were deemed urban for purposes of the standardized amounts and for purposes of assigning the wage data index.

On June 6, 2003, OMB announced the new CBSAs based on Census 2000 data. For FY 2005, we used OMB's 2000 CBSA standards and the Census 2000 data to identify counties qualifying for redesignation under section 1886(d)(8)(B) for the purpose of assigning the wage index to the urban area. We presented this listing, effective for discharges occurring on or after October 1, 2004 (FY 2005), in Chart 6 of the FY 2005 final rule (69 FR 49057). However, Chart 6 in the FY 2005 final rule contained a printing error in which we misidentified rural counties that qualified for redesignation under

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section 1886(d)(8)(B) of the Act. The list of rural counties qualifying to be urban in that Chart 6 incorrectly included Monroe, PA and Walworth, WI. This error was made only in the chart and not in the application of the rules; that is, we correctly applied the rules to the correct rural counties qualifying to be urban for FY 2005.

In addition, we discovered that, in the FY 2005 IPPS final rule, we had erroneously printed the names of the entire Metropolitan Statistical Areas rather than the Metropolitan Division names. Because we recognized Metropolitan Divisions as MSAs in the FY 2005 IPPS final rule (69 FR 49029), we should have printed the division names for the following counties: Henry, FL; Starke, IN; Henderson, TX; Fannin, TX; and Island, WA.

The chart below contains the corrected listing of the rural counties designated as urban under section 1886(d)(8)(B) of the Act that we are proposing to use for FY 2006. We are proposing that, for discharges occurring on or after October 1, 2005, hospitals located in the first column of this chart will be redesignated for purposes of using the wage index of the urban area listed in the second column. BILLING CODE 4120-01-P

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As in the past, hospitals redesignated under section 1886(d)(8)(B) of the Act are also eligible to be reclassified to a different area by the MGCRB. Affected hospitals are permitted to compare the reclassified wage index for the labor market area in Table 4C in the Addendum of this proposed rule into which they have been reclassified by the MGCRB to the wage index for the area to which they are redesignated under section 1886(d)(8)(B) of the Act. Hospitals may withdraw from an MGCRB reclassification within 45 days of the publication of this proposed rule. 6. Reclassifications Under Section 508 of Pub. L. 108-173

Under section 508 of Pub. L. 108-173, a qualifying hospital could appeal the wage index classification otherwise applicable to the hospital and apply for reclassification to another area of the State in which the hospital is located (or, at the discretion of the Secretary, to an area within a contiguous State). We implemented this process through notices published in the Federal Register on January 6, 2004 (69 FR 661) and February 13, 2004 (69 FR 7340). Such reclassifications are applicable to discharges occurring during the 3-year period beginning April 1, 2004 and ending March 31, 2007. Under section 508(b), reclassifications under this process do not affect the wage index computation for any area or for any other hospital and cannot be effected in a budget neutral manner.

We show the reclassifications effective under the one-time appeal process in Table 9B in the Addendum to this proposed rule.

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

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

In accordance with the broad discretion under section 1886(d)(13) of the Act, as added by section 505 of Pub. L. 108-173, beginning with FY 2005, we established a process to make adjustments to the hospital wage index based on commuting patterns of hospital employees. The process, outlined in the FY 2005 IPPS final rule (69 FR 49061), provides for an increase in the wage index for hospitals located in certain counties that have a relatively high percentage of hospital employees who reside in the county but work in a different county (or counties) with a higher wage index. Such adjustments to the wage index are effective for 3 years, unless a hospital requests to waive the application of the adjustment. A county will not lose its status as a qualifying county due to wage index changes during the 3-year period, and counties will receive the same wage index increase for those 3 years. However, a county that qualifies in any given year may no longer qualify after the 3-year period, or it may qualify but receive a different adjustment to the wage index level. Hospitals that receive this adjustment to their wage index are not eligible for reclassification under section 1886(d)(8) or section 1886(d)(10) of the Act. Adjustments under this provision are not subject to the IPPS budget neutrality requirements at section 1886(d)(3)(E) or section 1886(d)(8)(D) of the Act.

Hospitals located in counties that qualify for the wage index adjustment are to receive an increase in the wage index that is equal to the average of the differences between the wage indexes of the labor market area(s) with higher wage indexes and the wage index of the resident county, weighted by the overall percentage of hospital workers residing in the qualifying county who are employed in any labor market area with a higher wage index. We have employed the prereclassified wage indexes in making these calculations.

We are proposing that hospitals located in the qualifying counties identified in Table 4J in the Addendum to this proposed rule that have not already reclassified through section 1886(d)(10) of the Act, redesignated through section 1886(d)(8) of the Act, received a section 508 reclassification, or requested to waive the application of the out- migration adjustment would receive the wage index adjustment listed in the table for FY 2006. We used the same formula described in the FY 2005 final rule (69 FR 49064) to calculate the out-migration adjustment. This proposed adjustment was calculated as follows:

Step 1. Subtract the wage index for the qualifying county from the wage index for the higher wage area(s).

Step 2. Divide the number of hospital employees residing in the qualifying county who are employed in such higher wage index area by the total number of hospital employees residing in the qualifying county who are employed in any higher wage index area. Multiply this result by the result obtaining in Step 1.

Step 3. Sum the products resulting from Step 2 (if the qualifying county has workers commuting to more than one higher wage area).

Step 4. Multiply the result from Step 3 by the percentage of hospital employees who are residing in the qualifying county and who are

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employed in any higher wage index area.

The proposed adjustments calculated for qualifying hospitals are listed in Table 4J in the Addendum to this proposed rule. These proposed adjustments would be effective for each county for a period of 3 fiscal years. Hospitals that received the adjustment in FY 2005 will be eligible to retain that same adjustment for FY 2006 and FY 2007. For hospitals in newly qualified counties, adjustments to the wage index would be effective for 3 years, beginning with discharges occurring on or after October 1, 2005.

As previously noted, hospitals receiving the wage index adjustment under section 1886(d)(13)(F) of the Act are not eligible for reclassification under section 1886(d)(10) of the Act or reclassifications under section 508 of Pub. L. 108-173. Hospitals that wish to waive the application of this wage index adjustment must notify CMS within 45 days of the publication of this proposed rule. Waiver notification should be sent to the following address: Centers for Medicare and Medicaid Services, Center for Medicare Management, Attention: Wage Index Adjustment Waivers, Division of Acute Care, Room C4-08-06, 7500 Security Boulevard, Baltimore, MD 21244-1850. We will assume that hospitals that have been redesignated under section 1886(d)(8) of the Act or reclassified under section 886(d)(10) of the Act or under section 508 of Pub. L. 108-173 would prefer to keep their redesignation/reclassification unless they explicitly notify CMS that they would like to receive the out-migration adjustment instead. In addition, hospitals that wish to retain their redesignation/ reclassification (instead of receiving the out-migration adjustment) for FY 2006 do not need to submit a formal request to CMS, and will automatically retain their redesignation/reclassification status for FY 2006. However, consistent with Sec. 412.273, hospitals that have been reclassified by the MGCRB are permitted to withdraw their applications within 45 days of the publication of this proposed rule. Hospitals that have been reclassified by the MGCRB (including reclassifications under section 508 of Pub. L. 108-173) may terminate an existing 3-year reclassification within 45 days of the publication of this proposed rule in order to receive the wage index adjustment under this provision. Hospitals that are eligible to receive the wage index adjustment and that withdraw their application for reclassification will then automatically receive the wage index adjustment listed in Table 4J in the Addendum to this proposed rule. The request for withdrawal of an application for reclassification or termination of an existing 3-year reclassification that would be effective in FY 2006 must be received by the MGCRB within 45 days of the publication of this proposed rule. Hospitals should carefully review the wage index adjustment that they would receive under this provision (as listed in Table 2 in the Addendum to this proposed rule) in comparison to the wage index adjustment that they would receive under the MGCRB reclassification (Table 9 in the Addendum to this proposed rule).

J. Process for Requests for Wage Index Data Corrections

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

In the FY 2005 IPPS final rule (68 FR 27194), we revised the process and timetable for application for development of the wage index, beginning with the FY 2005 wage index. The preliminary and unaudited Worksheet S-3 wage data and occupational mix survey files were made available on October 8, 2004 through the Internet on the CMS Web site at: http://cms.hhs.gov/providers/hipps/ippswage.asp. In a

memorandum dated October 6, 2004, we instructed all Medicare fiscal intermediaries to inform the IPPS hospitals they service of the availability of the wage index data files and the process and timeframe for requesting revisions (including the specific deadlines listed below). We also instructed the fiscal intermediaries to advise hospitals that these data are also made available directly through their representative hospital organizations.

If a hospital wished to request a change to its data as shown in the October 8, 2004 wage and occupational mix data files, the hospital was to submit corrections along with complete, detailed supporting documentation to its fiscal intermediary by November 29, 2004. Hospitals were notified of this deadline and of all other possible deadlines and requirements, including the requirement to review and verify their data as posted on the preliminary wage index data file on the Internet, through the October 6, 2004 memorandum referenced above.

In the October 6, 2004 memorandum, we also specified that a hospital could only request revisions to the occupational mix data for the reporting period that the hospital used in its original FY 2005 wage index occupational mix survey. That is, a hospital that submitted occupational mix data for the 12-month reporting period could not switch to submitting data for the 4-week reporting period and vice versa. Further, a hospital could not submit an occupational mix survey for the periods beginning before January 1, 2003, or after January 11, 2004. In addition, a hospital that did not submit an occupational mix survey for the FY 2005 wage index was not permitted to submit a survey for the FY 2006 wage index.

The fiscal intermediaries notified the hospitals by mid-February 2005 of any changes to the wage index data as a result of the desk reviews and the resolution of the hospitals' late November 2004 change requests. The fiscal intermediaries also submitted the revised data to CMS by mid-February 2005. CMS published the proposed wage index public use files that included hospitals' revised wage data on February 25, 2005. In a memorandum also dated February 25, 2005, we instructed fiscal intermediaries to notify all hospitals regarding the availability of the proposed wage index public use files and the criteria and process for requesting corrections and revisions to the wage index data. Hospitals had until March 14, 2005 to submit requests to the fiscal intermediaries for reconsideration of adjustments made by the fiscal intermediaries as a result of the desk review, and to correct errors due to CMS's or the fiscal intermediary's mishandling of the wage index data. Hospitals were also required to submit sufficient documentation to support their requests.

After reviewing requested changes submitted by hospitals, fiscal intermediaries are to submit any additional revisions resulting from the hospitals' reconsideration requests by April 15, 2005. The deadline for a hospital to request CMS intervention in cases where the hospital disagrees with the fiscal intermediary's policy interpretations is April 22, 2005.

Hospitals should also examine Table 2 in the Addendum to this proposed rule. Table 2 contains each hospital's adjusted average hourly wage used to construct the wage index values for the past 3 years, including the FY 2002 data used to construct the FY 2006 wage index. We note that the hospital average hourly wages shown in Table 2 only reflect changes made to a hospital's data and transmitted to CMS by February 23, 2005.

We will release a final wage index data public use file in early May 2005 to hospital associations and the public on the Internet at http://www.cms.hhs.gov/providers/hipps/

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ippswage.asp. The May 2005 public use file will be made available solely for the limited purpose of identifying any potential errors made by CMS or the fiscal intermediary in the entry of the final wage data that result from the correction process described above (revisions submitted to CMS by the fiscal intermediaries by April 15, 2005). If, after reviewing the May 2005 final file, a hospital believes that its wage data were incorrect due to a fiscal intermediary or CMS error in the entry or tabulation of the final wage data, it should send a letter to both its fiscal intermediary and CMS that outlines why the hospital believes an error exists and provide all supporting information, including relevant dates (for example, when it first became aware of the error). CMS and the fiscal intermediaries must receive these requests no later than June 10, 2005. Requests mailed to CMS should be sent to:

Centers for Medicare & Medicaid Services, Center for Medicare Management, Attention: Wage Index Team, Division of Acute Care, C4-08- 06, 7500 Security Boulevard, Baltimore, MD 21244-1850.

Each request also must be sent to the fiscal intermediary. The fiscal intermediary will review requests upon receipt and contact CMS immediately to discuss its findings.

At this point in the process, that is, after the release of the May 2005 wage index data file, changes to the hospital wage data will only be made in those very limited situations involving an error by the fiscal intermediary or CMS that the hospital could not have known about before its review of the final wage index data file. Specifically, neither the intermediary nor CMS will approve the following types of requests:

Requests for wage data corrections that were submitted too late to be included in the data transmitted to CMS by fiscal intermediaries on or before April 15, 2005.

Requests for correction of errors that were not, but could have been, identified during the hospital's review of the February 25, 2005 wage index data file.

Requests to revisit factual determinations or policy interpretations made by the fiscal intermediary or CMS during the wage index data correction process.

Verified corrections to the wage index received timely by CMS and the fiscal intermediaries (that is, by June 10, 2005) will be incorporated into the final wage index to be published by August 1, 2005, and to be effective October 1, 2005.

We created the processes described above to resolve all substantive wage index data correction disputes before we finalize the wage and occupational mix data for the FY 2006 payment rates. Accordingly, hospitals that do not meet the procedural deadlines set forth above will not be afforded a later opportunity to submit wage index data corrections or to dispute the fiscal intermediary's decision with respect to requested changes. Specifically, our policy is that hospitals that do not meet the procedural deadlines set forth above will not be permitted to challenge later, before the Provider Reimbursement Review Board, the failure of CMS to make a requested data revision (See W. A. Foote Memorial Hospital v. Shalala, No. 99-CV- 75202-DT (E.D. Mich. 2001), also Palisades General Hospital v. Thompson, No. 99-1230 (D.D.C. 2003)).

Again, we believe the wage index data correction process described above provides hospitals with sufficient opportunity to bring errors in their wage index data to the fiscal intermediaries' attention. Moreover, because hospitals will have access to the final wage index data by early May 2005, they have the opportunity to detect any data entry or tabulation errors made by the fiscal intermediary or CMS before the development and publication of the final FY 2006 wage index by August 1, 2005, and the implementation of the FY 2006 wage index on October 1, 2005. If hospitals avail themselves of the opportunities afforded to provide and make corrections to the wage data, the wage index implemented on October 1 should be accurate. Nevertheless, in the event that errors are identified by hospitals and brought to our attention after June 10, 2005, we retain the right to make midyear changes to the wage index under very limited circumstances.

Specifically, in accordance with Sec. 412.64(k)(1) of our existing regulations, we make midyear corrections to the wage index for an area only if a hospital can show that: (1) The fiscal intermediary or CMS made an error in tabulating its data; and (2) the requesting hospital could not have known about the error or did not have an opportunity to correct the error, before the beginning of the fiscal year. For purposes of this provision, ``before the beginning of the fiscal year'' means by the June deadline for making corrections to the wage data for the following fiscal year's wage index. This provision is not available to a hospital seeking to revise another hospital's data that may be affecting the requesting hospital's wage index for the labor market area. As indicated earlier, since CMS makes the wage data available to a hospital on the CMS website prior to publishing both the proposed and final IPPS rules, and the fiscal intermediaries notify hospitals directly of any wage data changes after completing their desk reviews, we do not expect that midyear corrections would be necessary. However, under our current policy, if the correction of a data error changes the wage index value for an area, the revised wage index value will be effective prospectively from the date the correction is made.

We are proposing to revise Sec. 412.64(k)(2) to specify that a change to the wage index can be made retroactive to the beginning of the Federal fiscal year only when: (1) The fiscal intermediary or CMS made an error in tabulating data used for the wage index calculation; (2) the hospital knew about the error and requested that the fiscal intermediary and CMS correct the error using the established process and within the established schedule for requesting corrections to the wage data, before the beginning of the fiscal year for the applicable IPPS update (that is, by the June 10, 2005 deadline for the FY 2006 wage index); and (3) CMS agreed that the fiscal intermediary or CMS made an error in tabulating the hospital's wage data and the wage index should be corrected. We are proposing this change because there may be instances in which a hospital identifies an error in its wage data and submits a correction request using all appropriate procedures and by the June deadline, CMS agrees that the fiscal intermediary or CMS caused the error in the hospital's wage data and that the wage index must be corrected, but CMS fails to publish or implement the corrected wage index value by the beginning of the Federal fiscal year. We believe that the above proposed revision to Sec. 412.64(k)(2) is appropriate and fair. We also believe that unlike a generalized retroactive policy, the situations where this will occur will be minimal, thus minimizing the administrative burden associated with such retroactive corrections. In those circumstances where a hospital requests a correction to its wage data before CMS calculates the final wage index (that is, by the June deadline), and CMS acknowledges that the error in the hospital's wage data caused by CMS's or the fiscal intermediary's mishandling of the data, we believe that the hospital should not be penalized by our delay in publishing or implementing the correction. As with our current policy, this provision would not be available to a hospital seeking to revise another

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hospital's data. In addition, the provision could not be used to correct prior years' wage data; it could only be used for the current Federal fiscal year. In other situations, we continue to believe that it is appropriate to make prospective corrections to the wage index in those circumstances where a hospital could not have known about or did not have the opportunity to correct the fiscal intermediary's or CMS's error before the beginning of the fiscal year (that is, by the June deadline).

We are proposing to make this change to Sec. 412.64(k)(2) effective on October 1, 2005, that is, beginning with the FY 2006 wage index. We note that, as with prospective changes to the wage index, the proposed retroactive correction would be made irrespective of whether the change increases or decreases a hospital's payment rate. In addition, we note that the policy of retroactive adjustment would still apply in those instances where a judicial decision reverses a CMS denial of a hospital's wage data revision request.

In addition, we are proposing to correct the FY 2005 wage index retroactively (that is, from October 1, 2004) on a one-time only basis for a limited circumstance using the authority provided under section 903(a)(1) of Pub. L. 108-173. This provision authorizes the Secretary to make retroactive changes to items and services if failure to apply such changes would be contrary to the public interest. However, as indicated, our current regulations at Sec. 412.64(k)(1) allow only for a prospective correction to the hospitals' area wage index values. We are proposing to correct the FY 2005 wage index retroactively in the limited circumstance where a hospital meets all of the following criteria: (1) The fiscal intermediary or CMS made an error in tabulating a hospital's FY 2005 wage index data; (2) the hospital informed the fiscal intermediary or CMS, or both, about the error, following the established schedule and process for requesting corrections to its FY 2005 wage index data; and (3) CMS agreed before October 1 that the fiscal intermediary or CMS made an error in tabulating the hospital's wage data and the wage index should be corrected by the beginning of the Federal fiscal year (that is, by October 1, 2004), but CMS was unable to publish the correction by the beginning of the fiscal year.

On December 30, 2004, we published in the Federal Register a correction notice to the FY 2005 IPPS final rule that included the corrected wage data for four hospitals that meet all of the three above stated criteria (69 FR 78526). These corrections were effective January 1, 2005. As noted, our current regulations allow only for a prospective correction to the hospitals' area wage index values. However, we believe that, in the limited circumstance mentioned above, a retroactive correction to the FY 2005 wage index is appropriate and meets the condition of section 903(a)(1) of Pub. L. 108-173 that ``failure to apply the change retroactively would be contrary to the public interest.''

IV. Proposed Rebasing and Revision of the Hospital Market Baskets

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

A. Background

Effective for cost reporting periods beginning on or after July 1, 1979, we developed and adopted a hospital input price index (that is, the hospital market basket for operating costs). Although ``market basket'' technically describes the mix of goods and services used to produce hospital care, this term is also commonly used to denote the input price index (that is, cost category weights and price proxies combined) derived from that market basket. Accordingly, the term ``market basket'' as used in this document refers to the hospital input price index.

The terms ``rebasing'' and ``revising,'' while often used interchangeably, actually denote different activities. ``Rebasing'' means moving the base year for the structure of costs of an input price index (for example, in this proposed rule, we are proposing to shift the base year cost structure for the IPPS hospital index from FY 1997 to FY 2002). ``Revising'' means changing data sources, or price proxies, used in the input price index.

The percentage change in the market basket reflects the average change in the price of goods and services hospitals purchase in order to furnish inpatient care. We first used the market basket to adjust hospital cost limits by an amount that reflected the average increase in the prices of the goods and services used to provide hospital inpatient care. This approach linked the increase in the cost limits to the efficient utilization of resources.

Since the inception of the IPPS, the projected change in the hospital market basket has been the integral component of the update factor by which the prospective payment rates are updated every year. An explanation of the hospital market basket used to develop the prospective payment rates was published in the Federal Register on September 1, 1983 (48 FR 39764). We also refer the reader to the August 1, 2002 Federal Register (67 FR 50032) in which we discussed the previous rebasing of the hospital input price index.

The hospital market basket is a fixed weight, Laspeyres-type price index that is constructed in three steps. First, a base period is selected (in this proposed rule, FY 2002) and total base period expenditures are estimated for a set of mutually exclusive and exhaustive spending categories based upon type of expenditure. Then the proportion of total operating costs that each category represents is determined. These proportions are called cost or expenditure weights. Second, each expenditure category is matched to an appropriate price or wage variable, referred to as a price proxy. In nearly every instance, these price proxies are price levels derived from publicly available statistical series that are published on a consistent schedule, preferably at least on a quarterly basis.

Finally, the expenditure weight for each cost category is multiplied by the level of its respective price proxy. The sum of these products (that is, the expenditure weights multiplied by their price levels) for all cost categories yields the composite index level of the market basket in a given period. Repeating this step for other periods produces a series of market basket levels over time. Dividing an index level for a given period by an index level for an earlier period produces a rate of growth in the input price index over that time period.

The market basket is described as a fixed-weight index because it describes the change in price over time of the same mix of goods and services purchased to provide hospital services in a base period. The effects on total expenditures resulting from changes in the quantity or mix of goods and services (intensity) purchased subsequent to the base period are not measured. For example, shifting a traditionally inpatient type of care to an outpatient setting might affect the volume of inpatient goods and services purchased by the hospital, but would not be factored into the price change measured by a fixed weight hospital market basket. In this manner, the market basket measures only the pure price change. Only when the index is rebased using a more recent base period would the quantity and intensity effects be captured in the cost weights. Therefore, we rebase the market basket periodically so the cost weights reflect changes in the mix of goods and services that hospitals purchase (hospital inputs) to furnish inpatient care between base periods. We last

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rebased the hospital market basket cost weights effective for FY 2003 (67 FR 50032, August 1, 2002), with FY 1997 data used as the base period for the construction of the market basket cost weights.

B. Rebasing and Revising the Hospital Market Basket

1. Development of Cost Categories and Weights a. Medicare Cost Reports

The major source of expenditure data for developing the proposed rebased and revised hospital market basket cost weights is the FY 2002 Medicare cost reports. These cost reports are from IPPS hospitals only. They do not reflect data from hospitals excluded from the IPPS or CAHs. The IPPS cost reports yield seven major expenditure or cost categories: wages and salaries, employee benefits, contract labor, pharmaceuticals, professional liability insurance (malpractice), blood and blood products, and a residual ``all other.''

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b. Other Data Sources

In addition to the Medicare cost reports, other sources of data used in developing the market basket weights are the Benchmark Input- Output Tables (I-Os) created by the Bureau of Economic Analysis, U.S. Department of Commerce, and the Business Expenses Survey developed by the Bureau of the Census, U.S. Department of Commerce, from its Economic Census.

New data for these Census sources are scheduled for publication every 5 years, but often take up to 7 years after the reference year. Only an Annual I-O is produced each year, but the Annual I-O contains less industry detail than does the Benchmark I-O. When we rebased the market basket using FY 1997 data in the FY 2003 IPPS final rule, the 1997 Benchmark I-O was not yet available. Therefore, we did not incorporate data from that source into the FY 1997-based market basket (67 FR 50033). However, we did use a secondary source, the 1997 Annual Input-Output tables. The third source of data, the 1997 Business Expenditure Survey (now known as the Business Expenses Survey) was used to develop weights for the utilities and telephone services categories.

The 1997 Benchmark I-O data are a much more comprehensive and complete set of data than the 1997 Annual I-O estimates. The 1997 Annual I-O is an update of the 1992 I-O tables, while the 1997 Benchmark I-O is an entirely new set of numbers derived from the 1997 Economic Census. The 2002 Benchmark Input-Output tables are not yet available. Therefore, we are proposing to use the 1997 Benchmark I-O data in the proposed FY 2002-based market basket, to be effective for FY 2006. Instead of using the less detailed, less accurate Annual I-O data, we aged the 1997 Benchmark I-O data forward to FY 2002. The methodology we used to age the data involves applying the annual price changes from the price proxies to the appropriate cost categories. We repeat this practice for each year.

The ``all other'' cost category is further divided into other hospital expenditure category shares using the 1997 Benchmark Input- Output tables. Therefore, the ``all other'' cost category expenditure shares are proportional to their relationship to ``all other'' totals in the I-O tables. For instance, if the cost for telephone services were to represent 10 percent of the sum of the ``all other'' I-O (see below) hospital expenditures, then telephone services would represent 10 percent of the market basket's ``all other'' cost category. 2. PPS--Selection of Price Proxies

After computing the FY 2002 cost weights for the proposed rebased hospital market basket, it is necessary to select appropriate wage and price proxies to reflect the rate-of-price change for each expenditure category. With the exception of the Professional Liability proxy, all the indicators are based on Bureau of Labor Statistics (BLS) data and are grouped into one of the following BLS categories:

Producer Price Indexes--Producer Price Indexes (PPIs) measure price changes for goods sold in other than retail markets. PPIs are preferable price proxies for goods that hospitals purchase as inputs in producing their outputs because the PPIs would better reflect the prices faced by hospitals. For example, we use a special PPI for prescription drugs, rather than the Consumer Price Index (CPI) for prescription drugs because hospitals generally purchase drugs directly from the wholesaler. The PPIs that we use measure price change at the final stage of production.

Consumer Price Indexes--Consumer Price Indexes (CPIs) measure change in the prices of final goods and services bought by the typical consumer. Because they may not represent the price faced by a producer, we used CPIs only if an appropriate PPI

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was not available, or if the expenditures were more similar to those of retail consumers in general rather than purchases at the wholesale level. For example, the CPI for food purchased away from home is used as a proxy for contracted food services.

Employment Cost Indexes--Employment Cost Indexes (ECIs) measure the rate of change in employee wage rates and employer costs for employee benefits per hour worked. These indexes are fixed-weight indexes and strictly measure the change in wage rates and employee benefits per hour. Appropriately, they are not affected by shifts in employment mix.

We evaluated the price proxies using the criteria of reliability, timeliness, availability, and relevance. Reliability indicates that the index is based on valid statistical methods and has low sampling variability. Timeliness implies that the proxy is published regularly, at least once a quarter. Availability means that the proxy is publicly available. Finally, relevance means that the proxy is applicable and representative of the cost category weight to which it is applied. The CPIs, PPIs, and ECIs selected meet these criteria.

Chart 2 sets forth the complete proposed market basket including cost categories, weights, and price proxies. For comparison purposes, the corresponding FY 1997-based market basket is listed as well. A summary outlining the choice of the various proxies follows the chart. BILLING CODE 4120-01-P

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BILLING CODE 4120-01-C

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BILLING CODE 4120-01-C a. Wages and Salaries

For measuring the price growth of wages in the proposed FY 2002- based market basket, we are proposing to use the ECI for wages and salaries for civilian hospital workers as the proxy for wages in the hospital market basket. This same proxy was used for the 1997-based market basket. b. Employee Benefits

The proposed FY 2002-based hospital market basket uses the ECI for employee benefits for civilian hospital workers. This is the same proxy that was used in the FY 1997-based market basket. c. Nonmedical Professional Fees

The ECI for compensation for professional and technical workers in private industry is applied to this category because it includes occupations such as management and consulting, legal, accounting and engineering services. The same proxy was used in the FY 1997-based market basket. d. Fuel, Oil, and Gasoline

The percentage change in the price of gas fuels as measured by the PPI (Commodity Code 0552) is applied to this component. The same proxy was used in the FY 1997-based market basket. e. Electricity

The percentage change in the price of commercial electric power as measured by the PPI (Commodity Code 0542) is applied to this component. The same proxy was used in the FY 1997-based market basket. f. Water and Sewerage

The percentage change in the price of water and sewerage maintenance as measured by the CPI for all urban consumers (CPI Code CUUR0000SEHG01) is applied to this component. The same proxy was used in the FY 1997-based market basket. g. Professional Liability Insurance

The proposed FY 2002-based index uses the percentage change in the hospital professional liability insurance (PLI) premiums as estimated by the CMS Hospital Professional Liability Index, which we use as a proxy in the Medicare Economic Index (68 FR 63244), for the proxy of this category. Similar to the Physicians Professional Liability Index, we attempt to collect commercial insurance premiums for a fixed level of coverage, holding nonprice factors constant (such as a change in the level of coverage). In the FY 1997-based market basket, the same price proxy was used.

We continue to research options for improving our proxy for professional liability insurance. This research includes exploring various options for expanding our current survey, including the identification of another entity that would be willing to work with us to collect more complete and comprehensive data. We are also exploring other options such as third party or industry data that might assist us in creating a more precise measure of PLI premiums. At this time, we have not yet identified a preferred option. Therefore, we are not proposing to make any changes to the proxy in this proposed rule. h. Pharmaceuticals

The percentage change in the price of prescription drugs as measured by the PPI (PPI Code PPI283DRX) is used as a proxy for this category. This is a special index produced by BLS and is the same proxy used in the 1997-based index. i. Food: Direct Purchases

The percentage change in the price of processed foods and feeds as measured by the PPI (Commodity Code 02) is applied to this component. The same proxy was used in the FY 1997-based market basket. j. Food: Contract Services

The percentage change in the price of food purchased away from home as measured by the CPI for all urban consumers (CPI Code CUUR0000SEFV) is applied to this component. The same proxy was used in the FY 1997-based market basket. k. Chemicals

The percentage change in the price of industrial chemical products as measured by the PPI (Commodity Code 061) is applied to this component. While the chemicals hospitals purchase include industrial as well as other types of chemicals, the industrial chemicals component constitutes the largest proportion by far. Thus, we believe that Commodity Code 061 is the appropriate proxy. The same proxy was used in the FY 1997-based market basket. l. Medical Instruments

The percentage change in the price of medical and surgical instruments as

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measured by the PPI (Commodity Code 1562) is applied to this component. The same proxy was used in the FY 1997-based market basket. m. Photographic Supplies

The percentage change in the price of photographic supplies as measured by the PPI (Commodity Code 1542) is applied to this component. The same proxy was used in the FY 1997-based market basket. n. Rubber and Plastics

The percentage change in the price of rubber and plastic products as measured by the PPI (Commodity Code 07) is applied to this component. The same proxy was used in the FY 1997-based market basket. o. Paper Products

The percentage change in the price of converted paper and paperboard products as measured by the PPI (Commodity Code 0915) is used. The same proxy was used in the FY 1997-based market basket. p. Apparel

The percentage change in the price of apparel as measured by the PPI (Commodity Code 381) is applied to this component. The same proxy was used in the FY 1997-based market basket. q. Machinery and Equipment

The percentage change in the price of machinery and equipment as measured by the PPI (Commodity Code 11) is applied to this component. The same proxy was used in the FY 1997-based market basket. r. Miscellaneous Products

The percentage change in the price of all finished goods less food and energy as measured by the PPI (Commodity Code SOP3500) is applied to this component. Using this index removes the double-counting of food and energy prices, which are already captured elsewhere in the market basket. The same proxy was used in the FY 1997-based index. The weight for this cost category is higher than in the FY 1997-based index because the weight for blood and blood products (1.082) is added to it. In the FY 1997-based market basket, we included a separate cost category for blood and blood products, using the BLS PPI (Commodity Code 063711) for blood and derivatives as a price proxy. A review of recent trends in the PPI for blood and derivatives suggests that its movements may not be consistent with the trends in blood costs faced by hospitals. While this proxy did not match exactly with the product hospitals are buying, its trend over time appears to be reflective of the historical price changes of blood purchased by hospitals. However, an apparent divergence over recent periods led us to reevaluate whether the PPI for blood and derivatives was an appropriate measure of the changing price of blood. We ran test market baskets classifying blood in three separate cost categories: blood and blood products, contained within chemicals as was done for the FY 1992- based index, and within miscellaneous products. These categories use as proxies the following PPIs: The PPI for blood and blood products, the PPI for chemicals, and the PPI for finished goods less food and energy, respectively. Of these three proxies, the PPI for finished goods less food and energy moved most like the recent blood cost and price trends. In addition, the impact on the overall market basket by using different proxies for blood was negligible, mostly due to the relatively small weight for blood in the market basket. Therefore, we chose the PPI for finished goods less food and energy for the blood proxy because we believe it will best be able to proxy price changes (not quantities or required tests) associated with blood purchased by hospitals. We will continue to evaluate this proxy for its appropriateness and will explore the development of alternative price indexes to proxy the price changes associated with this cost. s. Telephone

The percentage change in the price of telephone services as measured by the CPI for all urban consumers (CPI Code CUUR0000SEED) is applied to this component. The same proxy was used in the FY 1997-based market basket. t. Postage

The percentage change in the price of postage as measured by the CPI for all urban consumers (CPI Code CUUR0000SEEC01) is applied to this component. The same proxy was used in the FY 1997-based market basket. u. All Other Services: Labor Intensive

The percentage change in the ECI for compensation paid to service workers employed in private industry is applied to this component. The same proxy was used in the FY 1997-based market basket. v. All Other Services: Nonlabor Intensive

The percentage change in the all-items component of the CPI for all urban consumers (CPI Code CUUR0000SA0) is applied to this component. The same proxy was used in the FY 1997-based market basket.

For further discussion of the rationales for choosing many of the specific price proxies, we refer the reader to the August 1, 2002 final rule (67 FR 50037).

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3. Labor-Related Share

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

Under section 1886(d)(3)(E) of the Act, the Secretary estimates from time to time the proportion of payments that are labor-related. ``The Secretary shall adjust the proportion (as estimated by the Secretary from time to time) of hospitals' costs which are attributable to wages and wage-related costs of the DRG prospective payment rates. * * *'' We refer to the proportion of hospitals' costs that are attributable to wages and wage-related costs as the ``labor-related share.''

The labor-related share is used to determine the proportion of the national PPS base payment rate to which the area wage index is applied. We are proposing to continue to use our current methodology of defining the labor-related share as the national average proportion of operating costs that are related to, influenced by, or vary with the local labor markets. We believe that the operating cost categories that are related to, influenced by, or vary with the local labor markets are wages and salaries, fringe benefits, professional fees, contract labor, and labor intensive services. Therefore, we are proposing to calculate the labor- related share by adding the relative weights for these operating cost categories. After we reviewed all cost categories in the proposed IPPS market basket using this definition of labor-related, we removed postage costs from the proposed FY 2002-based labor-related share because we no longer believe these costs are likely to vary with the local labor market. Using the cost category weights that we determined in section IV.B. of this preamble, we calculated a labor-related share of 69.731 percent, using the FY 2002-based PPS market basket. Accordingly, we are proposing to implement a labor-related share of 69.7 percent for discharges occurring on or after October 1, 2005. We note that section 403 of Pub. L. 108-173 amended sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act to provide that the Secretary must employ 62 percent as the labor-related share unless this employment ``would result in lower payments than would otherwise be made.''

We also are proposing an update to the labor-related share for Puerto Rico. Consistent with our methodology for determining the national labor-related share, we are proposing to add the Puerto Rico- specific relative weights for wages and salaries, fringe benefits, and contract labor. Because there are no Puerto Rico-specific relative weights for professional fees and labor intensive services, we are proposing to use the national weights. Alternatively, we could apply the national labor-related share to the Puerto Rico-specific rate. We note that we are still reviewing our data and have not yet calculated the updated Puerto Rico-specific labor-related share percentage. Therefore, the labor-related and nonlabor-related portions of the Puerto Rico-specific standardized amount listed in Table 1C of the Addendum to this proposed rule reflect the current (FY 2005) labor- related share for Puerto Rico of 71.3 percent. Once we have calculated the updated labor-related share for Puerto Rico, we will post it on the CMS website at http://www.cms.hhs.gov/providers/hipps. In addition, if

we adopt this proposal, we would publish the updated Puerto Rico labor- related share in the IPPS final rule. We welcome comments on our proposal to update the labor-related share for Puerto Rico.

Unlike the 1997 Annual I-O which was based on Standard Industrial Codes (SIC), the 1997 Benchmark I-O is categorized using the North American Industrial Classification System (NAICS). This change required us to classify all cost categories under NAICS, including a reevaluation of labor-related costs on the NAICS definitions. Chart 4 compares the FY 1992-based labor-related share, the current measure, with the FY 2002-based labor-related share. When we rebased the market basket to

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reflect FY 1997 data, we did not change the labor-related share (67 FR 50041). Therefore, the FY 1992-based labor-related share is the current measure.

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Although we are proposing to continue to calculate the labor- related share by adding the relative weights of the labor-related operating cost categories, we continue to evaluate alternative methodologies. In the May 9, 2002 Federal Register (67 FR 31447), we discussed our research on the methodology for the labor-related share. This research involved analyzing the compensation share (the sum of wages and salaries and benefits) separately for urban and rural hospitals, using regression analysis to determine the proportion of costs influenced by the area wage index, and exploring alternative methodologies to determine whether all or only a portion of professional fees and nonlabor intensive services should be considered labor-related.

Our original analysis, which appeared in the May 9, 2002 Federal Register (67 FR 31447) and which focused mainly on edited FY 1997 hospital data, found that the compensation share of costs for hospitals in rural areas was higher on average than the compensation share for hospitals in urban areas. We also researched whether only a proportion of the costs in professional fees and labor-intensive services should be considered labor-related, not the entire cost categories. However, there was not enough information available to make this determination.

Our finding that the average compensation share of costs for rural hospitals was higher than the average compensation for urban hospitals was validated consistently through our regression analysis. Regression analysis is a statistical technique that determines the relationship between a dependent variable and one or more independent variables. We tried several regression specifications in an effort to determine the proportion of costs that are influenced by the area wage index. Furthermore, MedPAC raised the possibility that regression may be an alternative to the current market basket methodology. Our initial regression specification (in log form) was Medicare operating cost per Medicare discharge as the dependent variable and the independent variables being the area wage index, the case-mix index, the ratio of residents per bed (as proxy for IME status), and a dummy variable that equals one if the hospital is located in a metropolitan area with a population of 1 million or more. (A dummy variable represents the presence or absence of a particular characteristic.) This regression produced a coefficient for all hospitals for the area wage index of 0.638 (which is equivalent to the labor share and can be interpreted as an elasticity because of the log specification) with an adjusted R- squared of 64.3. (Adjusted R-squared is a measure of how well the regression model fits the data.) While, on the surface, this appeared to be a reasonable result, this same specification for urban hospitals had a coefficient of 0.532 (adjusted R-squared = 53.2) and a coefficient of 0.709 (adjusted R-squared = 36.4) for rural hospitals. This highlighted some apparent problems with the specification because the overall regression results appear to be masking underlying problems. It did not seem reasonable that urban hospitals would have a labor share below their actual compensation share or that the discrepancy between urban and rural hospitals would be this large. When we standardized the Medicare operating cost per Medicare discharge for case mix, the fit, as measured by adjusted R-squared, fell dramatically and the urban/rural discrepancy became even larger.

Based on this initial result, we tried two modifications to the FY 1997 regressions to correct for the underlying problems. First, we edited the data differently to determine if a few reports were causing the inconsistent results. We found when we tightened the edits, the wage index coefficient was lower and the fit was worse. When we loosened the edits, we found higher wage index coefficients and still a worse fit. Second, we added additional variables to the regression equation to attempt to explain some of the variation that was not being captured. We found the best fit occurred when the following variables were added: The occupancy rate, the number of hospital beds, a dummy variable that equals one if the hospital is privately owned and zero otherwise, a dummy variable that equals one if the hospital is government-controlled and zero otherwise, the Medicare length-of-stay, the number of FTEs per bed, and the age of fixed

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assets. The result of this specification was a wage index coefficient of 0.620 (adjusted R-squared = 68.7), with the regression on rural hospitals having a coefficient of 0.772 (adjusted R-squared = 45.0) and the regression on urban hospitals having a coefficient of 0.474 (adjusted R-squared = 60.9). Neither of these alternatives seemed to help the underlying difficulties with the regression analysis.

Subsequent to the work described above, we have undertaken the research necessary to reevaluate the current assumptions used in determining the labor-related share. We ran regressions applying the previous specifications to more recent data (FY 2001 and FY 2002), and, as described below, we ran regressions using alternative specifications. Once again we encourage comments on this research and any information that is available to help determine the most appropriate measure.

The first step in our regression analysis to determine the proportion of hospitals' costs that varied with labor-related costs was to edit the data, which had significant outliers in some of the variables we used in the regressions. We originally began with an edit that excluded the top and bottom 5 percent of reports based on average Medicare cost per discharge and number of discharges. We also used edits to exclude reports that did not meet basic criteria for use, such as having costs greater than zero for total, operating, and capital for the overall facility and just the Medicare proportion. We also required that the hospital occupancy rate, length-of-stay, number of beds, FTEs, and overall and Medicare discharges be greater than zero. Finally, we excluded reports with occupancy rates greater than one.

Our regression specification (in log form) was Medicare operating cost per Medicare discharge as the dependent variable (the same dependent variable we used in the regression analysis described in the May 9, 2002 Federal Register) with the independent variables being the compensation per FTE, the ratio of interns and residents per bed (as proxy for IME status), the occupancy rate, the number of hospital beds, a dummy variable that equals one if the hospital is privately owned and is zero otherwise, a dummy variable that equals one if the hospital is government-controlled and is zero otherwise, the Medicare length-of- stay, the number of FTEs per bed, the age of fixed assets, and a dummy variable that equals one if the hospital is located in a metropolitan area with a population of 1 million or more. This is a similar model to the one described in the May 9, 2002 Federal Register (67 FR 31447) as having the best fit, with two notable exceptions. First, the area wage index is replaced by compensation per FTE, where compensation is the sum of hospital wages and salaries, contract labor costs, and benefits. The area wage index is a payment variable computed by averaging wages across all hospitals within each MSA, whereas compensation per FTE differs from one hospital to the next. Second, the case-mix index is no longer included as a regressor because it is correlated with other independent variables in the regression. In other words, the other independent variables are capturing part of the effect of the case-mix index. We made these two specification changes in an attempt to only use cost variables to explain the variation in Medicare operating costs per discharge. We believe this is appropriate in order to compare to the results we are getting from the market basket methodology, which is based solely on cost data. As we will show below, the use of payment variables on the right-hand side of the equation appears to be producing less reasonable results when cost data are used.

The revised specification for FY 2002 produced a coefficient for all hospitals for compensation per FTE of 0.673 (which is roughly equivalent to the labor share and can be interpreted as an elasticity because of the log specification) with an adjusted R-squared of 63.7. The coefficient result for FY 2001 is 64.5, with an adjusted R-squared of 65.2. (For comparison, a separate regression for FY 2002 with the log area wage index and log case-mix index included in the set of regressors displays a log area wage index coefficient of 75.6 (adjusted R-squared = 67.7).) For FY 2001, the coefficient for the log area wage index is 72.3 (adjusted R-squared = 67.9). On the surface, these seem to be reasonable results. However, a closer look reveals some problems. In FY 2001, the coefficient for urban hospitals was 59.6 (adjusted R- squared = 57.3), and the coefficient for rural hospitals was 61.3 (adjusted R-squared = 50.6). On the other hand, in FY 2002, the coefficient for urban hospitals increased to 69.2 (adjusted R-squared = 55.9), and the coefficient for rural hospitals decreased to 58.2 (adjusted R squared = 46.0). The results for FY 2001 seem reasonable, but not when compared with the results for FY 2002. Furthermore, for FY 2002 the compensation share of costs for hospitals in rural areas was higher on average than the compensation share for hospitals in urban areas. Rural areas had an average compensation share of 63.3 percent, while urban areas had a share of 60.5 percent. This compares to a share of 61.2 percent for all hospitals.

Due to these problems, we do not believe the regression analysis is producing sound enough evidence at this point for us to make the decision to change from the current method for calculating the labor- related share. We continue to analyze these data and work on alternative specifications, including working with MedPAC, who in the past have done similar analysis in their studies of payment adequacy. Comments on this approach would be welcomed, given the difficulties we have encountered.

We also continue to look into ways to refine our market basket approach to more accurately account for the proportion of costs influenced by the local labor market. Specifically, we are looking at the professional fees and labor-intensive cost categories to determine if only a proportion of the costs in these categories should be considered labor-related, not the entire cost category. Professional fees include management and consulting fees, legal services, accounting services, and engineering services. Labor-intensive services are mostly building services, but also include other maintenance and repair services.

We conducted preliminary research into whether the various types of professional fees are more or less likely to be purchased in local labor markets. Through contact with a handful of hospitals in only two States, we asked for the percentages of their advertising, legal, and management and consulting services that they purchased in either local, regional, or national labor markets. The results were quite consistent across all of the hospitals, indicating most advertising and legal services are purchased in local or regional markets and nearly all management and consulting services are purchased in national labor markets. This suggested we may be appropriately reflecting advertising and legal services in the labor-related share, but we plan to investigate further whether management and consulting services are appropriately reflected. We do not believe that this limited effort produced enough evidence for us to change our methodology. However, we do plan to expand our efforts in this area to ensure we appropriately determine the labor-related share. We are soliciting data or studies that would be helpful in this analysis. We are unsure if we will be able to finish this analysis in time for inclusion in the FY 2006 IPPS final rule.

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As mentioned previously, we are proposing to continue to calculate the labor-related share by adding the relative weights of the operating cost categories that are related to, influenced by, or vary with the local labor markets. These categories include wages and salaries, fringe benefits, professional fees, contract labor and labor-intensive services. Since we no longer believe that postage costs meet our definition of labor-related, we are excluding them from the labor- related share. Using this methodology, we calculated a labor-related share of 69.731. Therefore, we are proposing a labor-related share of 69.731.

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

(If you choose to comment on issues in this section, please include the caption ``Excluded Hospital Market Basket'' at the beginning of your comment.) 1. Hospitals Paid Based on Their Reasonable Costs

On August 7, 2001, we published a final rule in the Federal Register (66 FR 41316) establishing the PPS for IRFs, effective for cost reporting periods beginning on or after January 1, 2002. On August 30, 2002, we published a final rule in the Federal Register (67 FR 55954) establishing the PPS for LTCHs, effective for cost reporting periods beginning on or after October 1, 2002. On November 15, 2004, we published a final rule in the Federal Register (69 FR 66922) establishing the PPS for the IPFs, effective for cost reporting periods beginning on or after January 1, 2005.

Prior to being paid under a PPS, IRFs, LTCHs, and IPFs were reimbursed solely under the reasonable cost-based system under Sec. 413.40 of the regulations, which impose rate-of-increase limits. Children's and cancer hospitals and religious nonmedical health care institutions (RNHCIs) are still reimbursed solely under the reasonable cost-based system, subject to the rate-of-increase limits. Under these limits, an annual target amount (expressed in terms of the inpatient operating cost per discharge) is set for each hospital based on the hospital's own historical cost experience trended forward by the applicable rate-of-increase percentages. To the extent a LTCH or IPF receives a blend of reasonable cost-based payment and the Federal prospective payment rate amount, the reasonable cost portion of the payment is also subject to the applicable rate-of-increase percentage. Section 1886(b)(3)(B)(ii) of the Act sets the percentage increase of the limits, which in certain years was based upon the market basket percentage increase. Beginning in FY 2003 and subsequent years, the applicable rate-of-increase is the market basket percentage increase. The market basket currently (and historically) used is the excluded hospital operating market basket, representing the cost structure of rehabilitation, long-term care, psychiatric, children's, and cancer hospitals (FY 2003 final rule, 67 FR 50042).

Because IRFs, LTCHs, and some IPFs are now paid under a PPS, we are considering developing a separate market basket for these hospitals that contains both operating and capital costs. We would publish any proposal to use a revised separate market basket for each of these types of hospitals when we propose the nest update of their respective PPS rates. Children's and cancer hospitals are two of the remaining three types of hospitals excluded from the IPPS that are still being paid based solely on their reasonable costs, subject to target amounts. (RNHCIs, the third type of IPPS-excluded entity still subject to target amounts, are reimbursed under Sec. 403.752(a) of the regulations.) Because there are a small number of children's and cancer hospitals and RNHCIs, which receive in total less than 1 percent of all Medicare payments to hospitals and because these hospitals provide limited Medicare cost report data, we are not proposing to create a separate market basket specifically for these hospitals. Under the broad authority in sections 1886(b)(3)(A) and (B), 1886(b)(3)(E), and 1871 of the Act, we are proposing to use the proposed FY 2002 IPPS operating market basket percentage increase to update the target amounts for children's and cancer hospitals reimbursed under sections 1886(b)(3)(A) and (b)(3)(E) of the Act and the market basket for RNHCIs under Sec. 403.752(a) of the regulations. This proposal reflects our belief that it is best to use an index that most closely represents the cost structure of children's and cancer hospitals and RNHCIs. The FY 2002 cost weights for wages and salaries, professional liability, and ``all other'' for children's and cancer hospitals are noticeably closer to those in the IPPS operating market basket than those in the excluded hospital market basket, which is based on the cost structure of IRFs, LTCHs, IPFs, and children's and cancer hospitals and RNHCIs. Therefore, we believe it is more appropriate to use the IPPS operating market basket for children's and cancer hospitals and RNHCIs. However, when we compare the weights for LTCHs and IPFs to the weights for IPPS hospitals, we did not find them comparable. Therefore, we do not believe it is appropriate to use the IPPS market basket for LTCHs and IPFs.

For similar reasons, we are considering at some other date proposing a separate market basket to update the adjusted Federal payment amount for IRFs, LTCHs, and IPFs. We expect that these changes would be proposed in separate proposed rules for each of these three hospital types. We envision that these changes should apply to the adjusted Federal payment rate, and not the portion of the payment that is based on a facility-specific (or reasonable cost) payment to the extent such a hospital or unit is paid under a blend methodology. In other words, to the extent any of these hospitals are paid under a blend methodology whereby a percentage of the payment is based on reasonable cost principles, we would not propose to make changes to the existing methodology for developing the market basket for the reasonable cost portion of the payment because this portion of the payment is being phased out, if it is not already a nonexistent feature of the PPSs for IRFs, LTCHs, and IPFs. We do not believe that it makes sense to propose to create an entirely new methodology for creating the market basket index which updates the ``reasonable cost'' portion of a blend methodology since the ``reasonable cost portion'' will last at most for just 1 or 3 additional years (1 year for LTCHs paid under a blend methodology since LTCHs only have 1 year remaining in their transition, and 3 years for IPFs since IPFs paid under a blend methodology only have 3 years remaining under a blend methodology). However, the same cannot be said for the adjusted Federal payment amount. In the case of the IRF PPS, all IRFs are paid at 100 percent of the adjusted Federal payment amount and will continue to be paid based on 100 percent of this amount for perpetuity. In the LTCH PPS, most LTCHs (98 percent) are already paid at 100 percent of the adjusted Federal payment amount. In the case of the few LTCHs that are paid under a blend methodology for cost reporting periods beginning on or after October 1, 2006, payment will be based entirely on the adjusted Federal prospective payment rate. In the case of IPFs, new IPFs (as defined in Sec. 412.426(c)) will be paid at 100 percent of the adjusted Federal prospective payment rate (the Federal per diem payment amount), while all others will

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continue to transition to 100 percent of the Federal per diem payment amount. In any event, even those transitioning will be at 100 percent of the adjusted Federal prospective payment rate in 3 years.

Chart 5 compares the updates for the FY 2002-based IPPS operating market basket, our proposed index used to update the target amounts for children's and cancer hospitals, and RNHCIs, with a FY 2002-based excluded hospital market basket that is based on the current methodology (that is, based on the cost structure of IRFs, LTCHs, IPFs, and children's and cancer hospitals). Although the percent change in the IPPS operating market basket is typically lower than the percent change in the FY 2002-based excluded hospital market basket (see charts), we believe it is important to propose using the market basket that most closely reflects the cost structure of children's and cancer hospitals. We invite comments on our proposal to use the proposed FY 2002 IPPS operating market basket to update the target amounts for children's and cancer hospitals reimbursed under sections 1886(b)(3)(A) and (b)(3)(E) of the Act and the market basket for RNHCIs under Sec. 403.752(a) of the regulations.

Chart 5 shows the historical and forecasted updates under both the proposed FY 2002-based IPPS operating market basket and the proposed FY 2002-based excluded hospital market basket. The forecasts are based on Global Insight, Inc. 4th quarter, 2004 forecast with historical data through the 3rd quarter of 2004. Global Insight, Inc. is a nationally recognized economic and financial forecasting firm that contracts with CMS to forecast the components of the market baskets.

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2. Excluded Hospitals Paid Under a Blend Methodology

As we discuss in greater detail in Appendix B to this proposed rule, in the past, hospitals and hospital units excluded from the IPPS have been paid based on their reasonable costs, subject to TEFRA limits. However, some of these categories of excluded hospitals and hospital units are now paid under their own PPSs. Specifically, some LTCHs and most IPFs are or will be transitioning from reasonable cost- based payments (subject to the TEFRA limits) to prospective payments under their respective PPSs. Under the respective transition period methodologies for the LTCH PPS and the IPF PPS, which are described below, payment is based, in part, on a decreasing percentage of the reasonable cost-based payment amount, which is subject to the TEFRA limits and an increasing percentage of the Federal prospective payment rate. For those LTCHs and IPFs whose PPS payment is comprised in part of a reasonable cost-based payment will have those reasonable cost- based payment amounts limited by the hospital's TEFRA ceiling.

Effective for cost reporting periods beginning on or after October 1, 2002, LTCHs are paid under the LTCH PPS,

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which was implemented with a 5-year transition period, transitioning existing LTCHs to a payment based on the fully Federal prospective payment rate (August 30, 2002; 67 FR 55954). However, a LTCH may elect to be paid at 100 percent of the Federal prospective rate at the start of any of its cost reporting periods during the 5-year transition period. A ``new'' LTCH, as defined in Sec. 412.23(e)(4), are paid based on 100 percent of the standard Federal rate. Effective for cost reporting periods beginning on or after January 1, 2005, IPFs are paid under the IPF PPS under which they receive payment based on a prospectively determined Federal per diem rate that is based on the sum of the average routine operating, ancillary, and capital costs for each patient day of psychiatric care in an IPF, adjusted for budget neutrality. During a 3-year transition period, existing IPFs are paid based on a blend of the reasonable cost-based payments and the Federal prospective per diem base rate. For cost reporting periods beginning on or after January 1, 2008, existing IPFs are to be paid based on 100 percent of the Federal per diem rate. A ``new'' IPF, as defined in Sec. 412.426(c), are paid based on 100 percent of the Federal per diem payment amount. Any LTCHs or IPFs that receive a PPS payment that includes a reasonable cost-based payment during its respective transition period will have that portion of its payment subject to the TEFRA limits.

Under the broad authority of section 1886(b)(3)(A) and (b)(3)(B) of the Act, for LTCHs and IPFs that are transitioning to the fully Federal prospective payment rate, we are proposing to use the rebased FY 2002 based-excluded hospital market basket to update the reasonable cost- based portion of their payments. The proposed market basket update is described in detail below. We do not believe the IPPS operating market basket should be used for the proposed update to the reasonable cost- based portion of the payments to LTCHs or IPFs because this market basket does not reflect the cost structure of LTCHs and IPFs. 3. Development of Cost Categories and Weights for the Proposed FY 2002- Based Excluded Hospital Market Basket a. Medicare Cost Reports

The major source of expenditure data for developing the proposed rebased and revised excluded hospital market basket cost weights is the FY 2002 Medicare cost reports. We choose FY 2002 as the base year because we believe this is the most recent, relatively complete year (with a 90-percent reporting rate) of Medicare cost report data. These cost reports are from rehabilitation, psychiatric, long-term care, children's, cancer, and religious nonmedical excluded hospitals. They do not reflect data from IPPS hospitals or CAHs. These are the same hospitals included in the FY 1997-based excluded hospital market basket, except for religious nonmedical hospitals. Due to insufficient Medicare cost report data for these excluded hospitals, their cost reports yield only four major expenditure or cost categories: Wages and salaries, pharmaceuticals, professional liability insurance (malpractice), and a residual ``all other.''

Since the cost weights for the FY 2002-based excluded hospital market basket are based on facility costs, we are proposing to use those cost reports for IRFs, LTCHs, and children's, cancer, and RNHCIs whose Medicare average length of stay is within 15 percent (that is, 15 percent higher or lower) of the total facility average length of stay for the hospital. We are proposing to use a less stringent edit for Medicare length of stay for IPFs, requiring the average length of stay to be within 30 or 50 percent (depending on the total facility average length of stay) of the total facility length of stay. This allows us to increase our sample size by over 150 reports and produce a cost weight more consistent with the overall facility. The edit we applied to IPFs when developing the FY 1997-based excluded hospital market basket was based on the best available data at the time.

We believe that limiting our sample to hospitals with a Medicare average length of stay within a comparable range of the total facility average length of stay provides a more accurate reflection of the structure of costs for Medicare treatments. Our method results in including in our data set hospitals with a share of Medicare patient days relative to total patient days that was approximately three times greater than for those hospitals excluded from our sample. Our goal is to measure cost shares that are reflective of case-mix and practice patterns associated with providing services to Medicare beneficiaries.

Cost weights for benefits, contract labor and blood and blood products were derived using the proposed FY 2002-based IPPS market basket. This is necessary because these data are poorly reported in the cost reports for non-IPPS hospitals. For example, the ratio of the benefit cost weight to the wages and salaries cost weight was applied to the proposed excluded hospital wages and salaries cost weight to derive a benefit cost weight for the proposed excluded hospital market basket.

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b. Other Data Sources

In addition to the Medicare cost reports, the other source of data used in developing the excluded hospital market basket weights is the Benchmark Input-Output Tables (I-Os) created by the Bureau of Economic Analysis, U.S. Department of Commerce.

New data for this source are scheduled for publication every 5 years, but often take up to 7 years after the reference year. Only an Annual I-O is produced each year, but the Annual I-O contains less industry detail than does the Benchmark I-O. When we rebased the excluded hospital market basket using FY 1997 data in the FY 2003 IPPS final rule, the 1997 Benchmark I-O was not yet available. Therefore, we did not incorporate data from that source into the FY 1997-based excluded hospital market basket (67 FR 50033). However, we did use a secondary source the 1997 Annual Input-Output tables. The third source of data, the 1997 Business Expenditure Survey (now known as the Business Expenses Survey), was used to develop weights for the utilities and telephone services categories.

The 1997 Benchmark I-O data are a much more comprehensive and complete set of data than the 1997 Annual I-O estimates. The 1997 Annual I-O is an update of the 1992 I-O tables, while the 1997 Benchmark I-O is an entirely new set of numbers derived from the 1997 Economic Census. The 2002 Benchmark Input-Output tables are not yet available. Therefore, we are proposing to use the 1997 Benchmark I-O data in the proposed FY 2002-based excluded hospital market basket, to be effective for FY 2006. Instead of using the less detailed, less accurate Annual I-O data, we aged the 1997 Benchmark I-O data forward to FY 2002. The methodology we used to age the data involves applying the annual price changes from the price proxies to the appropriate cost categories. We repeat this practice for each year.

The ``all other'' cost category is further divided into other hospital expenditure category shares using the 1997 Benchmark Input- Output tables. Therefore, the ``all other'' cost category expenditure shares are proportional to their relationship to ``all other'' totals in the I-O tables. For instance, if the cost for telephone services were to represent 10 percent of the sum of the ``all other'' I-O (see below) hospital expenditures, then telephone services would represent 10 percent of the market basket's ``all other'' cost category. The remaining detailed cost categories under the residual ``all other'' cost category were derived using the 1997 Benchmark Input-Output Tables aged to FY 2002 using relative price changes. 4. Proposed 2002-Based Excluded Hospital Market Basket--Selection of Price Proxies

After computing the FY 2002 cost weights for the proposed rebased excluded hospital market basket, it is necessary to select appropriate wage and price proxies to reflect the rate-of-price change for each expenditure category. With the exception of the Professional Liability proxy, all the indicators are based on Bureau of Labor Statistics (BLS) data and are grouped into one of the following BLS categories:

Producer Price Indexes--Producer Price Indexes (PPIs) measure price changes for goods sold in other than retail markets. PPIs are preferable price proxies for goods that hospitals purchase as inputs in producing their outputs because the PPIs would better reflect the prices faced by hospitals. For example, we use a special PPI for prescription drugs, rather than the Consumer Price Index (CPI) for prescription drugs because hospitals generally purchase drugs directly from the wholesaler. The PPIs that we use measure price change at the final stage of production.

Consumer Price Indexes--Consumer Price Indexes (CPIs) measure change in the prices of final goods and services bought by the typical consumer. Because they may not represent the price faced by a producer, we used CPIs only if an appropriate PPI was not available, or if the expenditures were more similar to those of retail consumers in general rather than purchases at the wholesale level. For example, the CPI for food purchased away from home is used as a proxy for contracted food services.

Employment Cost Indexes--Employment Cost Indexes (ECIs) measure the rate of change in employee wage rates and employer costs for employee benefits per hour worked. These indexes are fixed-weight indexes and strictly measure the change in wage rates and employee benefits per hour. Appropriately, they are not affected by shifts in employment mix.

We evaluated the price proxies using the criteria of reliability, timeliness, availability, and relevance. Reliability indicates that the index is based on valid statistical methods and has low sampling variability. Timeliness implies that the proxy is published regularly, at least once a quarter. Availability means that the proxy is publicly available. Finally, relevance means that the proxy is applicable and representative of the cost category weight to which it is applied. The CPIs, PPIs, and ECIs selected meet these criteria and, therefore, we believe they continue to be the best measure of price changes for the cost categories to which they are applied.

Chart 7 sets forth the complete proposed FY 2002-based excluded hospital market basket including cost categories, weights, and price proxies. For comparison purposes, the corresponding FY 1997-based excluded hospital market basket is listed as well. A summary outlining the choice of the various proxies follows the charts. BILLING CODE 4120-01-P

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BILLING CODE 4120-01-C a. Wages and Salaries

For measuring the price growth of wages in the proposed FY 2002- based excluded hospital market basket, we are proposing to use the ECI for wages and salaries for civilian hospital workers as the proxy for wages. This same proxy was used for the FY 1997-based excluded hospital market basket. b. Employee Benefits

The proposed FY 2002-based excluded hospital market basket uses the ECI for employee benefits for civilian hospital workers. This is the same proxy that was used in the FY 1997-based excluded hospital market basket. c. Nonmedical Professional Fees

The ECI for compensation for professional and technical workers in private industry is applied to this category because it includes occupations such as management and consulting, legal, accounting and engineering services. The same proxy was used in the FY 1997-based excluded hospital market basket.

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d. Fuel, Oil, and Gasoline

The percentage change in the price of gas fuels as measured by the PPI (Commodity Code 0552) is applied to this component. The same proxy was used in the FY 1997-based excluded hospital market basket. e. Electricity

The percentage change in the price of commercial electric power as measured by the PPI (Commodity Code 0542) is applied to this component. The same proxy was used in the FY 1997-based excluded hospital market basket. f. Water and Sewerage

The percentage change in the price of water and sewerage maintenance as measured by the CPI for all urban consumers (CPI Code CUUR0000SEHG01) is applied to this component. The same proxy was used in the FY 1997-based excluded hospital market basket. g. Professional Liability Insurance

The proposed FY 2002-based excluded hospital market basket uses the percentage change in the hospital professional liability insurance (PLI) premiums as estimated by the CMS Hospital Professional Liability Index for the proxy of this category. Similar to the Physicians Professional Liability Index, we attempt to collect commercial insurance premiums for a fixed level of coverage, holding nonprice factors constant (such as a change in the level of coverage). In the FY 1997-based excluded hospital market basket, the same price proxy was used.

We continue to research options for improving our proxy for professional liability insurance. This research includes exploring various options for expanding our current survey, including the identification of another entity that would be willing to work with us to collect more complete and comprehensive data. We are also exploring other options such as third party or industry data that might assist us in creating a more precise measure of PLI premiums. At this time, we have not yet identified a preferred option. Therefore, we are not proposing to make any changes to the proxy in this proposed rule. h. Pharmaceuticals

The percentage change in the price of prescription drugs as measured by the PPI (PPI Code PPI283DRX) is used as a proxy for this category. This is a special index produced by BLS and is the same proxy used in the FY 1997-based excluded hospital market basket. i. Food: Direct Purchases

The percentage change in the price of processed foods and feeds as measured by the PPI (Commodity Code 02) is applied to this component. The same proxy was used in the FY 1997-based excluded hospital market basket. j. Food: Contract Services

The percentage change in the price of food purchased away from home as measured by the CPI for all urban consumers (CPI Code CUUR0000SEFV) is applied to this component. The same proxy was used in the FY 1997-based excluded hospital market basket. k. Chemicals

The percentage change in the price of industrial chemical products as measured by the PPI (Commodity Code 061) is applied to this component. While the chemicals hospitals purchase include industrial as well as other types of chemicals, the industrial chemicals component constitutes the largest proportion by far. Thus, we believe that Commodity Code 061 is the appropriate proxy. The same proxy was used in the FY 1997-based excluded hospital market basket. l. Medical Instruments

The percentage change in the price of medical and surgical instruments as measured by the PPI (Commodity Code 1562) is applied to this component. The same proxy was used in the FY 1997-based excluded hospital market basket. m. Photographic Supplies

The percentage change in the price of photographic supplies as measured by the PPI (Commodity Code 1542) is applied to this component. The same proxy was used in the FY 1997-based excluded hospital market basket. n. Rubber and Plastics

The percentage change in the price of rubber and plastic products as measured by the PPI (Commodity Code 07) is applied to this component. The same proxy was used in the FY 1997-based excluded hospital market basket. o. Paper Products

The percentage change in the price of converted paper and paperboard products as measured by the PPI (Commodity Code 0915) is used. The same proxy was used in the FY 1997-based excluded hospital market basket. p. Apparel

The percentage change in the price of apparel as measured by the PPI (Commodity Code 381) is applied to this component. The same proxy was used in the FY 1997-based excluded hospital market basket. q. Machinery and Equipment

The percentage change in the price of machinery and equipment as measured by the PPI (Commodity Code 11) is applied to this component. The same proxy was used in the FY 1997-based excluded hospital market basket. r. Miscellaneous Products

The percentage change in the price of all finished goods less food and energy as measured by the PPI (Commodity Code SOP3500) is applied to this component. Using this index removes the double-counting of food and energy prices, which are already captured elsewhere in the market basket. The same proxy was used in the FY 1997-based excluded hospital market basket. The weight for this cost category is higher than in the FY 1997-based index because it also includes blood and blood products. In the FY 1997-based excluded hospital market basket, we included a separate cost category for blood and blood products, using the BLS PPI (Commodity Code 063711) for blood and derivatives as a price proxy. A review of recent trends in the PPI for blood and derivatives suggests that its movements may not be consistent with the trends in blood costs faced by hospitals. While this proxy did not match exactly with the product hospitals are buying, its trend over time appears to be reflective of the historical price changes of blood purchased by hospitals. However, an apparent divergence over recent periods led us to reevaluate whether the PPI for blood and derivatives was an appropriate measure of the changing price of blood. We ran test market baskets classifying blood in three separate cost categories: blood and blood products, contained within chemicals as was done for the FY 1992-based index, and within miscellaneous products. These categories use as proxies the following PPIs: the PPI for blood and blood products, the PPI for chemicals, and the PPI for finished goods less food and energy, respectively. Of these three proxies, the PPI for finished goods less food and energy moved most like the recent blood cost and price trends. In addition, the impact on the overall market basket by using different proxies for blood was negligible, mostly due to the relatively small weight for blood in the market basket. Therefore, we chose the PPI for finished goods less food and energy for the blood proxy because we believe it will best be able to proxy price

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changes (not quantities or required tests) associated with blood purchased by hospitals. We will continue to evaluate this proxy for its appropriateness and will explore the development of alternative price indexes to proxy the price changes associated with this cost. s. Telephone

The percentage change in the price of telephone services as measured by the CPI for all urban consumers (CPI Code CUUR0000SEED) is applied to this component. The same proxy was used in the FY 1997-based excluded hospital market basket. t. Postage

The percentage change in the price of postage as measured by the CPI for all urban consumers (CPI Code CUUR0000SEEC01) is applied to this component. The same proxy was used in the FY 1997-based excluded hospital market basket. u. All Other Services: Labor Intensive

The percentage change in the ECI for compensation paid to service workers employed in private industry is applied to this component. The same proxy was used in the FY 1997-based excluded hospital market basket. v. All Other Services: Nonlabor Intensive

The percentage change in the all-items component of the CPI for all urban consumers (CPI Code CUUR0000SA0) is applied to this component. The same proxy was used in the FY 1997-based excluded hospital market basket.

For further discussion of the rationale for choosing many of the specific price proxies, we refer the reader to the August 1, 2002 final rule (67 FR 50037).

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D. Frequency of Updates of Weights in IPPS Hospital Market Basket

Section 404 of Pub. L. 108-173 (MMA) requires CMS to report in this proposed rule the research that has been done to determine a new frequency for rebasing the hospital market basket. Specifically, section 404 states:

``(a) More frequent updates in weights. After revising the weights used in the hospital market basket under section 1886(b)(3)(B)(iii) of the Social Security Act (42 U.S.C. 1395ww(b)(3)(B)(iii)) to reflect the most current data available, the Secretary shall establish a frequency for revising such weights, including the labor share, in such market basket to reflect the most current data available more frequently than once every 5 years; and

``(b) Incorporation of explanation in rulemaking. The Secretary shall include in the publication of the final rule for payment for inpatient hospitals services under section 1886(d) of the Social Security Act (42 U.S.C. 1395ww(d)) for fiscal year 2006, an explanation of the reasons for, and options considered, in determining the frequency established under subsection (a).''

This section of the proposed rule discusses the research we have done to fulfill this requirement, and proposes a rebasing frequency that makes optimal use of available data.

Our past practice has been to monitor the appropriateness of the market basket on a consistent basis in order to rebase and revise the index when necessary. The decision to rebase and revise the index has been driven in large part by the availability of the data necessary to produce a complete index. In the past, we have supplemented the Medicare cost report data that are available on an annual basis with Bureau of the Census hospital expense data that are typically available only every 5 years (usually in years ending in 2 and 7). Because of this, we have generally rebased the index every 5 years. However, prior to the requirement associated with section 404 of Pub. L. 108-173, there was no legislative requirement regarding the timing of rebasing the hospital market basket nor was there a hard rule that we

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used in determining this frequency. ProPAC, one of MedPAC's predecessor organizations, did a report to the Secretary on April 1, 1985, that supported periodic rebasing at least every 5 years.

The most recent rebasing of the hospital market basket was just 3 years ago, for the FY 2003 update. Since its inception with the hospital PPS in FY 1984, the hospital market basket has been rebased several times (FY 1987 update, FY 1991 update, FY 1997 update, FY 1998 update, and FY 2003 update). One of the reasons we believe it appropriate to rebase the index on a periodic basis is that rebasing (as opposed to revising, as explained in section IV.A. of this preamble) tends to have only a minor impact on the actual percentage increase applied to the PPS update. There are two major reasons for this: (1) The cost category weights tend to be relatively stable over shorter term periods (3 to 5 years); and (2) the update is based on a forecast, which means the individual price series tend not to grow as differently as they have in some historical periods.

We focused our research in two major areas. First, we reviewed the frequency and availability of the data needed to produce the market basket. Second, we analyzed the impact on the market basket of determining the market basket weights under various frequencies. We did this by developing market baskets that had base years for every year between 1997 and 2002, and then analyzed how different the market basket percent changes were over various periods. We used the results from these areas of research to assist in our determination of a new rebasing frequency. Based on this analysis, we are proposing to rebase the hospital market basket every 4 years. This would mean the next rebasing would occur for the FY 2010 update.

As we have described in numerous Federal Register documents over the past few decades, the hospital market basket weights are the compilation of data from more than one data source. When we are discussing rebasing the weights in the hospital market basket, there are two major data sources: (1) The Medicare cost reports; and (2) expense surveys from the Bureau of the Census (the Economic Census is used to develop data for the Bureau of Economic Analysis' input-output series). We will explore the future availability of each of these data sources.

Each Medicare-participating hospital submits a Medicare cost report to CMS on an annual basis. It takes roughly 2 years before ``nearly complete'' Medicare cost report data are available. For example, approximately 90 percent of FY 2002 Medicare cost report data were available in October 2004 (only 50 percent of FY 2003 data was available), although only 20 percent of these reports were settled. We choose FY 2002 as the base year because we believe this is the most recent, relatively complete year (with a 90 percent reporting rate) of Medicare cost report data. In developing the hospital market basket weights, we have used the Medicare cost reports to determine the weights for six major cost categories (wages, benefits, contract labor, pharmaceuticals, professional liability, and blood). In FY 2002, these six categories accounted for 68.5 percent of the hospital market basket. Therefore, it is possible to develop a new set of market basket weights for these categories on an annual basis, but with a substantial lag (for the FY 2006 update, we consider the latest year of historical data to be FY 2002).

The second source of data is the U.S. Department of Commerce, Bureau of Economic Analysis' Benchmark Input-Output (I-O) table. These data are published every 5 years with a more significant lag than the Medicare cost reports. For example, the 1997 Benchmark I-O tables were not published until the beginning of 2003. We have sometimes used data from a third data source, the Bureau of the Census' Business Expenses Survey (BES), which is also published every 5 years. The BES data are used as an input into the I-O data, and thus are published a few months prior to the release of the I-O. However, the BES contains only a fraction of the detail contained in the I-O.

Chart 9 below takes into consideration the expected availability of these major data sources and summarizes how they could be incorporated into the development of future market basket weights.

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It would be necessary to age the I-O or BES data to the year for which cost report data are available using the price changes between those periods. While not a preferred method in developing the market basket weights, we have done this in the past when rebasing the index. We are proposing to age the 1997 Benchmark I-O data for this proposed rule.

As the table clearly indicates, the most optimal rebasing frequency from a data availability standpoint is every 5 years. That is, if we were to next rebase for the FY 2011 update, we could use the 2002 Benchmark I-O data that would recently be available. In order to match the Medicare cost report data that would be available at that time (FY 2007 data), we would have to age the I-O data to FY 2007. However, this would be aging the data only 5 years, whereas if the rebasing frequency was determined to be every 4 years, we would have to age 1997 I-O data to FY 2006. While aging data over 5 years is problematic (there can be significant utilization and intensity changes over that length period, as opposed to only a year or two), it would be significantly worse to age data over an 8-year or 9-year period. If we were on a 5-year rebasing frequency, for the FY 2016 update, we would use cost report data for FY 2012 and the newly available 2007 I-O data. Again, the I-O data would have to be aged only 5 years to match the cost report data.

We can look at the implications of determining a rebasing frequency of every 3 or 4 years. Considering a frequency of 3 years first, we would next rebase for the FY 2009 update using FY 2005 Medicare cost report data and 1997 I-O data (the same data currently being used in the proposed FY 2002-based market basket). This is problematic because the 1997 I-O data would need to be aged 8 years to match the cost report data. The next two rebasings would be for the FY 2012 update (using FY 2008 cost report data and 2002 I-O data) and FY 2015 (using FY 2011 cost report data and 2002 I-O data). This means that while we are making optimal use of the Medicare cost report data, we would be forced to use the same I-O data in consecutive rebasings and would have to age that data as much as 9 years to use the same year as the cost report data.

For a rebasing frequency of every 4 years, our next rebasing would be for the FY 2010 update using FY 2006 Medicare cost report data and 1997 I-O data. This is also problematic because the 1997 I-O data would need to be aged 9 years to match the cost report data. The next two rebasings would be for the FY 2014 update (using FY 2010 cost report data and 2002 I-O data) and FY 2018 (using FY 2014 cost report data and 2007 I-O data). Again, this frequency would make optimal use of the Medicare cost report data but would require aging of the I-O data between 7 and 9 years in order to match the cost report data.

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It is clear from this analysis that neither the 3-year nor 4-year rebasing frequencies makes as good use of all the data as rebasing every 5 years. In addition, when comparing the 3-year and 4-year rebasing frequencies, no one method stands out as being significantly improved over another. Thus, this analysis does not lead us to draw any definitive conclusions as to a rebasing frequency more appropriate than every 5 years.

Our second area of research in determining a new rebasing frequency was to analyze the impact on the market basket of determining the market basket weights under various frequencies. We did this by using the current historical data that are available (both Medicare cost report and I-O) to develop market baskets with base year weights for each year between FY 1997 and FY 2002. We then analyzed how differently the market baskets moved over various historical periods.

Approaching the analysis this way allowed us to develop six hypothetical market baskets with different base years (FY 1997, FY 1998, FY 1999, FY 2000, FY 2001, and FY 2002). As we have done when developing the official market baskets, we used Medicare cost report data where available. Thus, cost report data were used to determine the weights for wages and salaries, benefits, contract labor, pharmaceuticals, blood and blood products, and all other costs. We used the 1997 Benchmark I-O data to fill out the remainder of the market basket weights (note that this produces a different index for FY 1997 than the official FY 1997-based hospital market basket that used the Annual 1997 I-O data), aging the data to the appropriate year to match the cost report data. This means the FY 2002-based index used in this analysis matches the FY 2002-based market basket we are proposing in this rule. Chart 10 shows the weights from these hypothetical market baskets:

[[Continued on page 23405]]

From the Federal Register Online via GPO Access [wais.access.gpo.gov] ]

[[pp. 23405-23454]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2006 Rates

[[Continued from page 23404]]

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Note that the weights remain relatively stable between periods. It is for this reason that we believe defining the market basket as a Laspeyres-type, fixed-weight index is appropriate. Because the weights in the market basket are generally for aggregated costs (for example, wages and salaries for all employees), there is not much volatility in the weights between periods, especially over shorter time spans. As the results of this analysis will show, it is for this reason that rebasing the market basket more frequently than every 5 years is expected to have little impact on the overall percent change in the hospital market basket.

Using these hypothetical market baskets, we can produce market basket percent changes over historical periods to determine what is the impact of using various base periods. In our analysis, we consider the hypothetical FY 1997-based index to be the benchmark measure and the other indexes to indicate the impact of rebasing over various frequencies. The hypothetical FY 2000-based index would reflect the impact of rebasing every 3 years, the hypothetical FY 2001-based index would reflect the impact of rebasing every 4 years, and the hypothetical FY 2002-based index would reflect the

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impact of rebasing every 5 years. Chart 11 shows the results of these comparisons.

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It is clear from this comparison that there is little difference between the indexes, and, for some FYs, there would be no difference in the market basket update factor if we had rebased the market basket more frequently. In particular, there is no difference in the hypothetical indexes based between FY 2000 and FY 2002. This suggests that setting the rebasing frequency to 3, 4, or 5 years will have little or no impact on the resulting market basket. As we found when analyzing data availability, this portion of our research does not suggest that rebasing the market basket more frequently than every 5 years results in an improved market basket or that there is any noticeable difference between rebasing every 3 or 4 years.

Market basket rebasing is a 1-year to 2-year long process that includes data processing, analytical work, methodology reevaluation, and regulatory process. After developing a rebased and revised market basket, there are extensive internal review processes that a rule must undergo, both in proposed and final form. Once the proposed rule has been published, there is a 60-day comment period set aside for the public to respond to the proposed rule. After comments are received, we then need adequate time to research and reply to all comments submitted. The last part of the regulatory process is the 60-day requirement--the final rule must be published 60 days before the provisions of the rule can become effective.

We would like to rebase all of our indexes (PPS operating, PPS capital, excluded hospital with capital, SNFs, HHAs, and Medicare Economic Index) on a regular schedule. Therefore, if we were to choose a 3-year rebasing schedule, we would have to rebase more than one index at a time. This may potentially limit the amount of time we could devote to the market basket rebasing process. In addition, we recognize that, in the future, we may be required to develop additional market baskets that would require frequent rebasing.

Given the number of market baskets we are responsible for rebasing and revising, the regulatory process for each, and the availability of source data, we believe that while it is not necessary, rebasing and revising the hospital market baskets every 4 years is the most appropriate frequency to meet the legislative requirement.

E. Capital Input Price Index Section

The Capital Input Price Index (CIPI) was originally described in the September 1, 1992 Federal Register (57 FR 40016). There have been subsequent discussions of the CIPI presented in the May 26, 1993 (58 FR 30448), September 1, 1993 (58 FR 46490), May 27, 1994 (59 FR 27876), September 1, 1994 (59 FR 45517), June 2, 1995 (60 FR 29229), September 1, 1995 (60 FR 45815), May 31, 1996 (61 FR 27466), and August 30, 1996 (61 FR 46196) issues of the Federal Register. The August 1, 2002 (67 FR 50032) rule discussed the most recent revision and rebasing of the CIPI to a FY 1997 base year, which reflects the capital cost structure facing hospitals in that year.

We are proposing to revise and rebase the CIPI to a FY 2002 base year to reflect the more recent structure of capital costs in hospitals. Unlike the PPS operating market basket, we do not have FY 2002 Medicare cost report data available for the development of the capital cost weights, due to a change in the FY 2002 cost reporting requirements. Rather, we used hospital capital expenditure data for the capital cost categories of depreciation, interest, and other capital expenses for FY 2001 and aged these data to a FY 2002 base year using the relevant vintage-weighted price proxies. As with the FY 1997-based index, we have developed two sets of weights in order to calculate the proposed FY 2002-based CIPI. The first set of proposed weights identifies the proportion of hospital capital expenditures attributable to each expenditure category, while the second set of proposed weights is a set of relative vintage weights for depreciation

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and interest. The set of vintage weights is used to identify the proportion of capital expenditures within a cost category that is attributable to each year over the useful life of the capital assets in that category. A more thorough discussion of vintage weights is provided later in this section.

Both sets of proposed weights are developed using the best data sources available. In reviewing source data, we determined that the Medicare cost reports provided accurate data for all capital expenditure cost categories. We are proposing to use the FY 2001 Medicare cost reports for PPS hospitals, aged to FY 2002, excluding expenses from hospital-based subproviders, to determine weights for all three cost categories: depreciation, interest, and other capital expenses. We compared the weights determined from the Medicare cost reports to the 2002 Bureau of the Census' Business Expenses Survey and found the weights to be similar to those developed from the Medicare cost reports.

Lease expenses are not broken out as a separate cost category in the CIPI, but are distributed among the cost categories of depreciation, interest, and other, reflecting the assumption that the underlying cost structure of leases is similar to capital costs in general. As was done in previous rebasings of the CIPI, we assumed 10 percent of lease expenses are overhead and assigned them to the other capital expenses cost category as overhead. The remaining lease expenses were distributed to the three cost categories based on the proportion of depreciation, interest, and other capital expenses to total capital costs excluding lease expenses.

Depreciation contains two subcategories: building and fixed equipment and movable equipment. The split between building and fixed equipment and movable equipment was determined using the Medicare cost reports. This methodology was also used to compute the FY 1997-based index.

Total interest expense cost category is split between government/ nonprofit and profit interest. The FY 1997-based CIPI allocated 85 percent of the total interest cost weight to government/nonprofit interest, proxied by average yield on domestic municipal bonds, and 15 percent to for-profit interest, proxied by average yield on Moody's Aaa bonds (67 FR 50044). The methodology used to derive this split is explained in the June 2, 1995 issue of the Federal Register (60 FR 29233). We are proposing to derive the split using the relative FY 2001 Medicare cost report data on interest expenses for government/nonprofit and profit hospitals. Based on these data, we are proposing a 75/25 split between government/nonprofit and profit interest. We believe it is important that this split reflects the latest relative cost structure of interest expenses. The proposed split of 75/25 had little (less than 0.1 percent in any given year) or no effect on the annual capital market basket percent change in both the historical and forecasted periods.

Chart 12 presents a comparison of the proposed FY 2002-based CIPI capital cost weights and the FY 1997-based CIPI capital cost weights.

[GRAPHIC] [TIFF OMITTED] TP04MY05.045

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Because capital is acquired and paid for over time, capital expenses in any given year are determined by both past and present purchases of physical and financial capital. The vintage-weighted CIPI is intended to capture the long-term consumption of capital, using vintage weights for depreciation (physical capital) and interest (financial capital). These vintage weights reflect the proportion of capital purchases attributable to each year of the expected life of building and fixed equipment, movable equipment, and interest. We used the vintage weights to compute vintage-weighted price changes associated with depreciation and interest expense.

Vintage weights are an integral part of the CIPI. Capital costs are inherently complicated and are determined by complex capital purchasing decisions, over time, based on such factors as interest rates and debt financing. In addition, capital is depreciated over time instead of being consumed in the same period it is purchased. The CIPI accurately reflects the annual price changes associated with capital costs, and is a useful simplification of the actual capital investment process. By accounting for the vintage nature of capital, we are able to provide an accurate, stable annual measure of price changes. Annual nonvintage price changes for capital are unstable due to the volatility of interest rate changes and, therefore, do not reflect the actual annual price changes for Medicare capital-related costs. CMS' CIPI reflects the underlying stability of the capital acquisition process and provides hospitals with the ability to plan for changes in capital payments.

To calculate the vintage weights for depreciation and interest expenses, we needed a time series of capital purchases for building and fixed equipment and movable equipment. We found no single source that provides the best time series of capital purchases by hospitals for all of the above components of capital purchases. The early Medicare cost reports did not have sufficient capital data to meet this need. While the AHA Panel Survey provided a consistent database back to 1963, it did not provide annual capital purchases. The AHA Panel Survey provided a time series of depreciation expenses through 1997 which could be used to infer capital purchases over time. From 1998 to 2001, hospital depreciation expenses were calculated by multiplying the AHA Annual Survey total hospital expenses by the ratio of depreciation to total hospital expenses from the Medicare cost reports. Beginning in 2001, the AHA Annual Survey began collecting depreciation expenses. We hope to be able to use these data in future rebasings.

In order to estimate capital purchases from AHA data on depreciation expenses, the expected life for each cost category (building and fixed equipment, movable equipment, and interest) is needed to calculate vintage weights. We used FY 2001 Medicare cost reports to determine the expected life of building and fixed equipment and movable equipment. The expected life of any piece of equipment can be determined by dividing the value of the asset (excluding fully depreciated assets) by its current year depreciation amount. This calculation yields the estimated useful life of an asset if depreciation were to continue at current year levels, assuming straight-line depreciation. From the FY 2001 cost reports, the expected life of building and fixed equipment was determined to be 23 years, and the expected life of movable equipment was determined to be 11 years. The FY 1997-based CIPI showed the same expected life for the two categories of depreciation.

Although we are proposing to use this methodology for deriving the useful life of an asset, we intend to conduct a further review of the methodology between the publication of this proposed rule and the final rule. We plan to review alternate data sources, if available, and analyze in more detail the hospital's capital cost structure reported in the Medicare cost reports.

We are proposing to use the building and fixed equipment and movable equipment weights derived from FY 2001 Medicare cost reports to separate the depreciation expenses into annual amounts of building and fixed equipment depreciation and movable equipment depreciation. Year- end asset costs for building and fixed equipment and movable equipment were determined by multiplying the annual depreciation amounts by the expected life calculations from the FY 2001 Medicare cost reports. We then calculated a time series back to 1963 of annual capital purchases by subtracting the previous year asset costs from the current year asset costs. From this capital purchase time series, we were able to calculate the vintage weights for building and fixed equipment and movable equipment. Each of these sets of vintage weights is explained in detail below.

For building and fixed equipment vintage weights, the real annual capital purchase amounts for building and fixed equipment derived from the AHA Panel Survey were used. The real annual purchase amount was used to capture the actual amount of the physical acquisition, net of the effect of price inflation. This real annual purchase amount for building and fixed equipment was produced by deflating the nominal annual purchase amount by the building and fixed equipment price proxy, the Boeckh Institutional Construction Index. Because building and fixed equipment have an expected life of 23 years, the vintage weights for building and fixed equipment are deemed to represent the average purchase pattern of building and fixed equipment over 23-year periods. With real building and fixed equipment purchase estimates available back to 1963, we averaged sixteen 23-year periods to determine the average vintage weights for building and fixed equipment that are representative of average building and fixed equipment purchase patterns over time. Vintage weights for each 23-year period are calculated by dividing the real building and fixed capital purchase amount in any given year by the total amount of purchases in the 23- year period. This calculation is done for each year in the 23-year period, and for each of the sixteen 23-year periods. We are proposing to use the average of each year across the sixteen 23-year periods to determine the 2002 average building and fixed equipment vintage weights for the FY 2002-based CIPI.

For movable equipment vintage weights, the real annual capital purchase amounts for movable equipment derived from the AHA Panel Survey were used to capture the actual amount of the physical acquisition, net of price inflation. This real annual purchase amount for movable equipment was calculated by deflating the nominal annual purchase amount by the movable equipment price proxy, the PPI for Machinery and Equipment. Based on our determination that movable equipment has an expected life of 11 years, the vintage weights for movable equipment represent the average expenditure for movable equipment over an 11-year period. With real movable equipment purchase estimates available back to 1963, twenty-eight 11-year periods were averaged to determine the average vintage weights for movable equipment that are representative of average movable equipment purchase patterns over time. Vintage weights for each 11-year period are calculated by dividing the real movable capital purchase amount for any given year by the total amount of purchases in the 11-year period. This calculation was done for each year in the 11-year period, and for

[[Page 23409]]

each of the twenty-eight 11-year periods. We are proposing to use the average of each year across the twenty-eight 11-year periods to determine the average movable equipment vintage weights for the FY 2002-based CIPI.

For interest vintage weights, the nominal annual capital purchase amounts for total equipment (building and fixed, and movable) derived from the AHA Panel and Annual Surveys were used. Nominal annual purchase amounts were used to capture the value of the debt instrument. Because we have determined that hospital debt instruments have an expected life of 23 years, the vintage weights for interest are deemed to represent the average purchase pattern of total equipment over 23- year periods. With nominal total equipment purchase estimates available back to 1963, sixteen 23-year periods were averaged to determine the average vintage weights for interest that are representative of average capital purchase patterns over time. Vintage weights for each 23-year period are calculated by dividing the nominal total capital purchase amount for any given year by the total amount of purchases in the 23- year period. This calculation is done for each year in the 23-year period and for each of the sixteen 23-year periods. We are proposing to use the average of each year across the sixteen 23-year periods to determine the average interest vintage weights for the FY 2002-based CIPI. The vintage weights for the FY 1997 CIPI and the proposed FY 2002 CIPI are presented in Chart 13.

[GRAPHIC] [TIFF OMITTED] TP04MY05.046

After the capital cost category weights were computed, it was necessary to select appropriate price proxies to reflect the rate of increase for each expenditure category. Our proposed price proxies for the FY 2002-based CIPI are the same as those used in the FY 1997-based CIPI. We still believe these are the most appropriate proxies for

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hospital capital costs that meet our selection criteria of relevance, timeliness, availability, and reliability. We ran the proposed FY 2002- based index using the Moody's Aaa bonds average yield and then using the Moody's Baa bonds average yield as proxy for the for-profit interest cost category. There was no difference in the two sets of index percent changes either historically or forecasted. The rationale for selecting these price proxies is explained more fully in the August 30, 1996 final rule (61 FR 46196). The proposed proxies are presented in Chart 14.

[GRAPHIC] [TIFF OMITTED] TP04MY05.047

Global Insight, Inc. forecasts a 0.7 percent increase in the FY 2002-based CIPI for 2006, as shown in Chart 15. This is the result of a 1.3 percent increase in projected depreciation prices (building and fixed equipment, and movable equipment) and a 2.7 percent increase in other capital expense prices, partially offset by a 2.3 percent decrease in vintage-weighted interest rates in FY 2006, as indicated in Chart 15. Accordingly, we are proposing a 0.7 percent increase in the CIPI.

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[GRAPHIC] [TIFF OMITTED] TP04MY05.048

Rebasing the CIPI from FY 1997 to FY 2002 decreased the percent change in the FY 2006 forecast by 0.1 percentage point, from 0.8 to 0.7, as shown in Chart 12. The difference is caused mostly by changes in the relationships between the cost category weights within depreciation and interest. The fixed depreciation cost weight relative to the movable depreciation cost weight and the nonprofit/government interest cost weight relative to the for-profit interest cost weight are both less in the FY 2002-based CIPI. The changes in these relationships have a small effect on the FY 2002-based CIPI percent changes. However, when added together, they are responsible for a negative one-tenth percentage point difference between the FY 2002- based CIPI and the FY 1997-based CIPI.

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

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

(If you choose to comment on issues in this section, please include the caption ``Postacute Care Transfers'' at the beginning of your comment.) 1. Background

Existing regulations at Sec. 412.4(a) define discharges under the IPPS as situations in which a patient is formally released from an acute care hospital or dies in the hospital. Section 412.4(b) defines transfers from one acute care hospital to another, and Sec. 412.4(c) defines transfers to certain postacute care providers. Our policy provides that, in transfer situations, full payment is made to the final discharging hospital and each transferring hospital is paid a per diem rate for each day of the stay, not to exceed the full DRG payment that would have been made if the patient had been discharged without being transferred.

The per diem rate paid to a transferring hospital is calculated by dividing the full DRG payment by the geometric mean length of stay for the DRG. Based on an analysis that showed that the first day of hospitalization is the most expensive (60 FR 45804), our policy provides for payment that is double the per diem amount for the first day (Sec. 412.4(f)(1)). Transfer cases are also eligible for outlier payments. The outlier threshold for transfer cases is equal to the fixed-loss outlier threshold for nontransfer cases, divided by the geometric mean length of stay for the DRG, multiplied by the length of stay for the case, plus one day. The purpose of the IPPS transfer payment policy is to avoid providing an incentive for a hospital to transfer patients to another hospital early in the patients' stay in order to minimize costs while still receiving the full DRG payment. The transfer policy adjusts the payments to approximate the reduced costs of transfer cases.

2. Changes to DRGs Subject to the Postacute Care Transfer Policy (Sec. Sec. 412.4(c) and (d))

Section 1886(d)(5)(J) of the Act provides that, effective for discharges on or after October 1, 1998, a ``qualified discharge'' from one of 10 DRGs selected by the Secretary to a postacute care provider would be treated as a transfer case. This section required the Secretary to define and pay as transfers all cases assigned to one of 10 DRGs selected by the Secretary, if the

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individuals are discharged to one of the following postacute care settings:

A hospital or hospital unit that is not a subsection 1886(d) hospital. (Section 1886(d)(1)(B) of the Act identifies the hospitals and hospital units that are excluded from the term ``subsection (d) hospital'' as psychiatric hospitals and units, rehabilitation hospitals and units, children's hospitals, long-term care hospitals, and cancer hospitals.)

A SNF (as defined at section 1819(a) of the Act).

Home health services provided by a home health agency, if the services relate to the condition or diagnosis for which the individual received inpatient hospital services, and if the home health services are provided within an appropriate period (as determined by the Secretary).

In the July 31, 1998 IPPS final rule (63 FR 40975 through 40976), we specified that a patient discharged to home would be considered transferred to postacute care if the patient received home health services within 3 days after the date of discharge. In addition, in the July 31, 1998 final rule, we did not include patients transferred to a swing-bed for skilled nursing care in the definition of postacute care transfer cases (63 FR 40977).

Section 1886(d)(5)(J) of the Act directed the Secretary to select 10 DRGs based upon a high volume of discharges to postacute care and a disproportionate use of postacute care services. As discussed in the July 31, 1998 final rule, these 10 DRGs were selected in 1998 based on the MedPAR data from FY 1996. Using that information, we identified and selected the first 20 DRGs that had the largest proportion of discharges to postacute care (and at least 14,000 such transfer cases). In order to select 10 DRGs from the 20 DRGs on our list, we considered the volume and percentage of discharges to postacute care that occurred before the mean length of stay and whether the discharges occurring early in the stay were more likely to receive postacute care. We identified 10 DRGs to be subject to the postacute care transfer rule starting in FY 1999.

Section 1886(d)(5)(J)(iv) of the Act authorizes the Secretary to expand the postacute care transfer policy for FY 2001 or subsequent fiscal years to additional DRGs based on a high volume of discharges to postacute care facilities and a disproportionate use of postacute care services. In the FY 2004 IPPS final rule (68 FR 45412), we expanded the postacute care transfer policy to include additional DRGs. We established the following criteria that a DRG must meet, for both of the 2 most recent years for which data are available, in order to be included under the postacute care transfer policy:

At least 14,000 postacute care transfer cases;

At least 10 percent of its postacute care transfers occurring before the geometric mean length of stay;

A geometric mean length of stay of at least 3 days; and

If a DRG is not already included in the policy, a decline in its geometric mean length of stay during the most recent 5-year period of at least 7 percent.

In the FY 2004 IPPS final rule, we identified 21 new DRGs that met these criteria. We also determined that one DRG from the original group of 10 DRGs (DRG 263) no longer met the volume criterion of 14,000 transfer cases. Therefore, we removed DRGs 263 and 264 (DRG 264 is paired with DRG 263) from the policy and expanded the postacute care transfer policy to include payments for transfer cases in the new 21 DRGs, effective October 1, 2003. As a result, a total of 29 DRGs were subject to the postacute care transfer policy in FY 2004. In the FY 2004 IPPS final rule, we indicated that we would review and update this list periodically to assess whether additional DRGs should be added or existing DRGs should be removed (68 FR 45413).

For FY 2005, we analyzed the available data from the FY 2003 MedPAR file. For the 2 most recent years of available data (FY 2002 and FY 2003), we found that no additional DRGs qualified under the four criteria set forth in the IPPS final rule for FY 2004. We also analyzed the DRGs included under the policy for FY 2004 to determine if they still met the criteria to remain under the policy. In addition, we analyzed the special circumstances arising from a change to one of the DRGs included under the policy in FY 2004.

In the FY 2005 IPPS final rule (69 FR 48942), we deleted DRG 483 (Tracheostomy With Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth, and Neck Diagnosis) and established the following new DRGs as replacements: DRG 541 (Tracheostomy With Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck Diagnoses With Major O.R. Procedure) and DRG 542 (Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck Diagnoses Without Major O.R. Procedure). Cases in the existing DRG 483 were assigned to the new DRGs 541 and 542 based on the presence or absence of a major O.R. procedure, in addition to the tracheostomy code that was previously required for assignment to DRG 483. Specifically, if the patient's case involves a major O.R. procedure (a procedure whose code is included on the list that is assigned to DRG 468 (Extensive O.R. Procedure Unrelated to Principal Diagnosis), except for tracheostomy codes 31.21 and 31.29), the case is assigned to the DRG 541. If the patient does not have an additional major O.R. procedure (that is, if there is only a tracheostomy code assigned to the case), the case is assigned to DRG 542.

Based on data analysis, we determined that neither DRG 541 nor DRG 542 would have enough cases to meet the existing threshold of 14,000 transfer cases for inclusion in the postacute care transfer policy. Nevertheless, we believed the cases that would be incorporated into these two DRGs remained appropriate candidates for application of the postacute care transfer policy and that the subdivision of DRG 483 should not change the original application of the postacute care transfer policy to the cases once included in that DRG. Therefore, for FY 2005, we proposed alternate criteria to be applied in cases where DRGs do not satisfy the existing criteria, for discharges occurring on or after October 1, 2004 (69 FR 28273 and 28374). The proposed new criteria were designed to address situations such as those posed by the split of DRG 483, where there remain substantial grounds for inclusion of cases within the postacute care transfer policy, although one or more of the original criteria may no longer apply. Under the proposed alternate criteria, DRGs 430, 541, and 542 would have qualified for inclusion in the postacute care transfer policy.

In the response to comments on our FY 2005 proposal, we decided not to adopt the proposed alternate criteria for including DRGs under the postacute care transfer policy in the FY 2005 IPPS final rule. Instead we adopted the policy of simply grandfathering, for a period of 2 years, any cases that were previously included within a DRG that has split, when the split DRG qualified for inclusion in the postacute care transfer policy for both of the previous 2 years. Under this policy, the cases that were previously assigned to DRG 483 and that now fall into DRGs 541 and 542 continue to be subject to the policy. Therefore, effective for discharges on or after October 1, 2004, 30 DRGs, including new DRGs 541 and 542, are subject to the postacute care transfer policy. We indicated that we would monitor the frequency with which these

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cases are transferred to postacute care settings and the percentage of these cases that are short-stay transfer cases. Because we did not adopt the proposed alternate criteria for DRG inclusion in the postacute care transfer policy, DRG 430 (Psychoses) did not meet the criteria for inclusion and has not been subject to the postacute care transfer policy for FY 2005. We also invited comments on how to treat the cases formerly included in a split DRG after the grandfathering period.

We note that some commenters also suggested that, in place of the proposed alternate criteria, we should adopt a policy of permanently applying the postacute care transfer policy to a DRG once it has initially qualified for inclusion in the policy. These commenters noted that removing DRGs from the postacute care transfer policy makes the payment system less stable and results in inconsistent incentives over time. They also argued that ``a drop in the number of transfers to postacute care settings is to be expected after the transfer policy is applied to a DRG, but the frequency of transfers may well rise again if the DRG is removed from the policy.'' We indicated that we would consider adopting this general policy once we had evaluated the experience with the specific cases that are subject to the grandfathering policy for FY 2005 and FY 2006.

In the May 18, 2004 proposed rule, we also called attention to the data concerning DRG 263, which was subject to the postacute care transfer policy until FY 2004. We removed DRG 263 from the postacute care transfer policy for FY 2004 because it did not have the minimum number of cases (14,000) transferred to postacute care (13,588 transfer cases in FY 2002, with more than 50 percent of transfer cases being short-stay transfers). The FY 2003 MedPAR data show that there were 15,602 transfer cases in the DRG in FY 2003, of which 46 percent were short-stay transfers. Because we removed the DRG from the postacute care transfer policy in FY 2004, it must meet all criteria to be included under the policy in subsequent fiscal years. Because the geometric mean length of stay for DRG 263 showed only a 6-percent decrease since 1999, DRG 263 did not qualify to be added to the policy for FY 2005 under the existing criteria that were included in last year's rule. DRG 263 would have qualified under the volume threshold and percent of short-stay transfer cases under the proposed new alternate criteria contained in the FY 2005 proposed rule. However, it still would not have met the proposed required decline in length of stay to qualify to be added to the policy for FY 2005. We indicated that we would continue to monitor the experience with DRG 263, especially in light of the comment that recommended a general policy of grandfathering cases that qualify under the criteria for inclusion in the postacute care transfer policy.

The table below displays the 30 DRGs that are included in the postacute care transfer policy, effective for discharges occurring on or after October 1, 2004.

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[GRAPHIC] [TIFF OMITTED] TP04MY05.049

For this year's proposed rule, we have conducted an extensive analysis of the FY 2003 and FY 2004 MedPAR data to monitor the effects of the postacute care transfer policy. We have also conducted an overall assessment of the postacute care transfer policy since its inception in FY 1999. Specifically, we have examined the relationship between rates of postacute care utilization and the geometric mean length of stay and the relationship between a high volume and a high proportion of postacute care transfers within a DRG in light of experience under the current policy. Specifically, we examined whether a decline in the geometric mean length of stay is associated with an increase in the volume and proportion of total cases in a DRG that are discharges to postacute care. We analyzed these data as part of determining whether to retain the criteria that a DRG must have a decline in the geometric mean length of stay of

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at least 7 percent in the previous 5-year period to be included under the postacute care transfer policy.

Our current criteria for inclusion in the postacute care transfer policy include a requirement that, if a DRG is not already included in the policy, there must be a decline of at least 7 percent in the DRG's geometric mean length of stay during the most recent 5-year period. It has come to our attention that not all DRGs that experience an increase in postacute care utilization also experience a decrease in geometric mean length of stay. In fact, some DRGs with increases in postacute care utilization during the past several years have also experienced an increase in the geometric mean length of stay. The table below lists a number of DRGs that experienced increases in postacute care utilization and increases in the geometric mean length of stay from FY 2002 through FY 2004:

[GRAPHIC] [TIFF OMITTED] TP04MY05.050

Our current criteria also include a requirement that a DRG have at least 14,000 total postacute care transfer cases in order to be included in the policy. We have examined the data on the numbers of transfers and the percentage of postacute care transfer cases across DRGs. Among the 30 DRGs currently included within the postacute care transfer policy, the percentage of postacute care transfer cases ranges from a low of 15 percent to a high of 76 percent. Among DRGs that are not currently included within the policy, many have a relatively high percentage of postacute care transfer cases in proportion to the total volume of cases for the DRG or a relatively high volume of discharges to postacute care facilities, or both. For this reason, we reviewed the data for all DRGs before proposing a change to the postacute care transfer payment policy. As part of this review, we found that:

Of 550 DRGs, 26 have been deactivated and 17 have no cases in the FY 2004 MedPAR files. We are not proposing any changes for these DRGs because application of the postacute care transfer policy to them would have no effect.

Of the remaining 507 DRGs, 220 have geometric mean lengths of stay that are less than 3.0 days. Because the transfer payment policy provides 2 times the per diem rate for the first day of care (due to the large proportion of charges incurred on the first day of a patient's treatment), including these DRGs in the transfer policy would be relatively meaningless as they would all receive a full DRG payment. For this reason, we are not proposing any

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changes to the postacute care transfer policy for these DRGs.

Of the remaining 287 DRGs, 64 have fewer than 100 short- stay transfer cases. In addition, 39 of these 64 DRGs have fewer than 50 short-stay transfer cases. Consistent with the statutory guidance, we are not proposing any change to how we apply the postacute care transfer payment policy to these DRGs because we believe that these DRGs do not have a high volume of discharges to postacute care facilities or involve a disproportionate use of postacute care services.

Once we eliminated the DRGs cited above from consideration for the postacute care transfer policy, we examined the characteristics of the remaining 223 DRGs. We found that these DRGs had three common characteristics:

The DRG had at least 2,000 total postacute care transfer cases.

At least 20 percent of all cases in the DRG were discharged to postacute care settings.

10 percent of all discharges to postacute care were prior to the geometric mean length of stay for the DRG.

Consistent with the statutory guidance giving the Secretary the authority to make a DRG subject to the postacute care transfer policy based on a high volume of discharges to postacute care facilities and a disproportionate use of postacute care services, we believe these DRGs have characteristics that make them appropriate for inclusion in the postacute care transfer policy.

As a result of our analysis, we believe that it is appropriate to consider major revisions to the criteria for including a DRG within the postacute care transfer policy. First, our analysis calls into question the requirement that a DRG experience a decline in the geometric mean length of stay over the most recent 5-year period. Our findings that some DRGs with increases in postacute care utilization during the past several years have also experienced increases in geometric mean length of stay indicate that this criterion is no longer effective to identify those DRGs that should be subject to the postacute care transfer policy. In addition, our findings about the number of DRGs with relatively high volumes (at least 2,000 cases) and relatively high proportions (at least 20 percent) of postacute care utilization suggest that we should revise the requirement that a DRG have at least 14,000 total postacute care transfer cases to be included within the postacute care transfer policy.

Our analysis does confirm that it is appropriate to maintain the requirement that a DRG must have a geometric mean length of stay of at least 3.0 days in order to be included within the postacute care transfer policy. We believe that this policy should be retained because, under the transfer payment methodology, hospitals receive the entire payment for cases in these DRGs in the first 2 days of the stay. Lowering the limit below 3.0 days would, therefore, have no effect on payment for DRGs with geometric mean lengths-of-stay in this range. For the reasons discussed in the May 19, 2003 proposed rule (68 FR 27199) and because it is a common characteristic of DRGs with a large number of cases discharged to postacute care, we also continue to believe that it is appropriate to retain the criterion that at least 10 percent of all cases that are transferred to postacure care should be short-stay cases where the patient is transferred before the geometric mean length of stay for the DRG. We also continue to believe that both DRGs in a CC/non-CC pair should be subject to the postacute care transfer policy if one of the DRGs meets the criteria for inclusion. By including both DRGs in a CC/non-CC pair, our policy will preclude an incentive for hospitals to code cases in ways designed to avoid triggering the application of the policy, for example, by excluding codes that would identify a complicating or comorbid condition in order to assign a case to a non-CC DRG that is not subject to the policy.

Therefore, we are considering substantial revisions to the four criteria that are currently used to determine whether a DRG qualifies for inclusion in the postacute care transfer policy. The current criteria provide that, in order to be included within the policy, a DRG must have, for both of the 2 most recent years for which data are available:

At least 14,000 total postacute care transfer cases;

At least 10 percent of its postacute care transfers occurring before the geometric mean length of stay;

A geometric mean length of stay of at least 3 days;

If a DRG is not already included in the policy, a decline in its geometric mean length of stay during the most recent 5-year period of at least 7 percent; and

If the DRG is one of a paired set of DRGs based on the presence or absence of a comorbidity or complication, both paired DRGs are included if either one meets the first three criteria above.

As a result of our analysis, we considered two options for revising the current criteria. Option 1 is to include all DRGs within the postacute care transfer policy. This option has the advantage of providing consistent treatment of all DRGs. However, as we discussed above, our analysis tends to indicate that, at a minimum, it may be appropriate to maintain the requirement that a DRG must have a geometric mean length of stay of at least 3.0 days because, under the transfer payment methodology, hospitals receive the entire payment for these DRGs in the first 2 days of the stay. Lowering the limit below 3.0 days, would therefore have little or no effect on payment for DRGs with geometric mean lengths of stay in this range.

Option 2 that we considered is to expand the application of the postacute care transfer policy by applying the policy to any DRG that meets the following criteria:

The DRG has at least 2,000 postacute care transfer cases;

At least 20 percent of the cases in the DRG are discharged to postacute care;

Out of the cases discharged to postacute care, at least 10 percent occur before the geometric mean length of stay for the DRG;.

The DRG has a geometric mean length of stay of at least 3.0 days;

If the DRG is one of a paired set of DRGs based on the presence or absence of a comorbidity or complication, both paired DRGs are included if either one meets the first three criteria above.

Option 2 would expand the application of the postacute care transfer policy to 223 DRGs that have both a relatively high volume and a relatively high proportion of postacute care utilization. The proposed change would also avoid applying the postacute care transfer policy to DRGs with only a small number or proportion of cases transferred to postacute care. The table below shows the DRGs that would be included in the postacute care transfer policy under this option:

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We believe that the analysis that we have conducted suggest that substantial revisions to the criteria for including a DRG within the postacute care transfer policy are warranted. In this proposed rule, we are formally proposing Option 2 as presented above. However, we invite comments on both of these options and on the analysis that we have presented.

The impact section in Appendix A of this proposed rule discusses our findings on the effects of adopting Option 2. The proposed DRG relative weights included in Tables 5 and 7 of the Addendum to this proposed rule also include the effect of changing the postacute care transfer policy as described in Option 2 above. We note that if we adopt either option discussed above, or a variation based on comments submitted, we would follow procedures similar to those that are currently followed for treating cases identified as transfers in the DRG recalibration process. That is, as described in the discussion of DRG recalibration in section II.C. of the preamble to this proposed rule, additional transfer cases would be counted as a fraction of a case based on the ratio of a hospital's transfer payment under the per diem payment methodology to the full DRG payment for nontransfer cases.

Section 1886(d)(5)(J)(i) of the Act recognizes that, in some cases, a substantial portion of the cost of care is incurred in the early days of the inpatient stay. Similar to the policy for

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transfers between two acute care hospitals, transferring hospitals receive twice the per diem rate for the first day of treatment and the per diem rate for each following day of the stay before the transfer, up to the full DRG payment, for cases discharged to postacute care. However, three of the DRGs subject to the postacute care transfer policy exhibit an even higher share of costs very early in the hospital stay in postacute care transfer situations. For these DRGs, hospitals receive 50 percent of the full DRG payment plus the single per diem (rather than double the per diem) for the first day of the stay and 50 percent of the per diem for the remaining days of the stay, up to the full DRG payment.

In previous years, we determined that DRGs 209 and 211 met this cost threshold and qualified to receive this special payment methodology. Because DRG 210 is paired with DRG 211, we include payment for cases in that DRG for the same reason we include paired DRGs in the postacute care transfer policy (to eliminate any incentive to code incorrectly in order to receive higher payment for those cases). The FY 2004 MedPAR data show that DRGs 209 and 211 continue to have charges on the first day of the stay that are higher than 50 percent of the average charges in the DRGs. In addition, several of the DRGs that may be added to the postacute care transfer policy under the options that we are considering may also meet the 50 percent threshold in their average charges. We have identified those additional DRGs that are subject to the special payment methodology in Tables 5 and 7 of the Addendum to this proposed rule.

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

(If you choose to comment on issues in this section, please include the caption ``Hospital Quality Data'' at the beginning of your document.) 1. Background

Section 1886(b)(3)(B)(vii) of the Act, as added by section 501(b) of Pub. L. 108-173 revised the mechanism used to update the standardized amount of payment for inpatient hospital operating costs. Specifically, the statute provides for a reduction of 0.4 percentage points to the update percentage increase (also known as the market basket update) for each of FYs 2005 through 2007 for any ``subsection (d) hospital'' that does not submit data on a set of 10 quality indicators established by the Secretary as of November 1, 2003. The statute also provides that any reduction will apply only to the fiscal year involved, and will not be taken into account in computing the applicable percentage increase for a subsequent fiscal year. This measure establishes an incentive for IPPS hospitals to submit data on the quality measures established by the Secretary.

We initially implemented section 1886(b)(3)(B)(vii) of the Act in the FY 2005 IPPS final rule (August 11, 2004, 69 FR 49078) in continuity with the Department's Hospital Quality Initiative as described at the CMS Web site: http://www.cms.hhs.gov/quality/hospitals. At a press conference on December 12, 2002, the Secretary of

the Department of Health and Human Services (HHS) announced a series of steps that HHS and its collaborators were taking to promote public reporting of hospital quality information. These collaborators include the American Hospital Association, the Federation of American Hospitals, the Association of American Medical Colleges, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the National Quality Forum, the American Medical Association, the Consumer- Purchaser Disclosure Project, the American Association of Retired Persons, the American Federation of Labor-Congress of Industrial Organizations, the Agency for Healthcare Research and Quality, as well as CMS, Quality Improvement Organizations (QIOs), and others.

In July 2003, CMS began the National Voluntary Hospital Reporting Initiative (NVHRI), now known as the Hospital Quality Alliance (HQA): Improving Care through Information. Data from this initiative have been used to populate a professional Web site providing data to healthcare professionals. This website will be followed by the development of a consumer Web site in an easy-to-use format. The consumer Web site is intended to be an important tool for individuals to use in making decisions about health care options. This information will assist beneficiaries by providing comparison information for consumers who need to select a hospital. It will also serve as a way to encourage accountability of hospitals for the care they provide to patients.

The 10 measures that were employed in this voluntary initiative as of November 1, 2003, are:

Heart Attack (Acute Myocardial Infarction)

Was aspirin given to the patient upon arrival to the hospital?

Was aspirin prescribed when the patient was discharged?

Was a beta-blocker given to the patient upon arrival to the hospital?

Was a beta-blocker prescribed when the patient was discharged?

Was an ACE inhibitor given for the patient with heart failure? Heart failure

Did the patient get an assessment of his or her heart function?

Was an ACE inhibitor given to the patient? Pneumonia

Was an antibiotic given to the patient in a timely way?

Had a patient received a pneumococcal vaccination?

Was the patient's oxygen level assessed?

These measures have been endorsed by the National Quality Forum (NQF) and are a subset of the same measures currently collected for the JCAHO by its accredited hospitals. The Secretary adopted collection of data on these 10 quality measures in order to: (1) provide useful and valid information about hospital quality to the public; (2) provide hospitals with a sense of predictability about public reporting expectations; (3) begin to standardize data and data collection mechanisms; and (4) foster hospital quality improvement. Many hospitals are currently participating in the National Voluntary Hospital Reporting Initiative (NVHRI), and are submitting data to the QIO Clinical Warehouse for that purpose.

Over the next several years, hospitals are encouraged to take steps toward the adoption of electronic medical records (EMRs) that will allow for reporting of clinical quality data from the electronic record directly to a CMS data repository. CMS intends to begin working toward creating measures specifications and a system or mechanism, or both, that will accept the data directly without requiring the transfer of the raw data into an XML file as currently exists. The Department is presently working cooperatively with other Federal agencies in the development of Federal health architecture data standards. CMS encourages hospitals that are developing systems to conform them to both industry standards and the Federal health architecture data standards, and to ensure that they would capture the data necessary for quality measures. Ideally, such systems will also provide point-of-care decision support that enables high levels of performance on the measures. Hospitals using EMRs to produce data on quality measures will be held to the same performance expectations as hospitals not using EMRs. We are exploring requirements for the submission of electronically produced data and other options to encourage the submission of such data, and invite comments on this issue.

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2. Requirements for Hospital Reporting of Quality Data

The procedures for participating in the Reporting Hospital Quality Data for the Annual Payment Update (RHQDAPU) program created in accordance with section 501(b) of Pub. L. 108-173 can be found on the QualityNet Exchange at the Web site: http://www.qnetexchange.org in the

``Reporting Hospital Quality Data for Annual Payment Update Reference Checklist''. This checklist also contains all of the forms to be completed by hospitals participating in the program. In order to participate in the hospital reporting initiative, hospitals must follow these steps:

The hospital must identify a QualityNet Exchange Administrator who follows the registration process and submits the information through the QIO. This must be done regardless of whether the hospital uses a vendor for transmission of data.

All participants must first register with the QualityNet Exchange, regardless of the method used for data submission. If a hospital is currently participating in the voluntary reporting initiative, re-registration on QualityNet Exchange is unnecessary. However, the hospital must complete the Reporting Hospital Quality Data for Annual Payment Update Notice of Participation form. All hospitals must send this form to their QIOs.

The hospital must collect data for all 10 measures and submit the data to the QIO Clinical Warehouse either using the CMS Abstraction & Reporting Tool (CART), the JCAHO Oryx Core Measures Performance Measurement System (PMS), or another third-party vendor that has met the measurement specification requirements for data transmission to QualityNet Exchange. The QIO Clinical Warehouse will submit the data to CMS on behalf of the hospitals. The submission will be done through QualityNet Exchange, which is a secure site that voluntarily meets or exceeds all current Health Insurance Portability and Accountability Act (HIPAA) requirements, while maintaining QIO confidentiality as required under the relevant regulations and statutes. The information in the Clinical Warehouse is considered QIO data and, therefore, is subject to the stringent QIO confidentiality regulations in 42 CFR Part 480.

For the first year of the program, FY 2005, hospitals were required to begin the submission of data by July 1, 2004, under the provisions of section 1886(b)(3)(B)(vii)(II) of the Act, as added by section 501(b) of Pub. L. 108-173. Because section 501(b) of Pub. L. 108-173 granted a 30-day grace period for submission of data for purposes of the FY 2005 update, hospitals were given until August 1, 2004, for completed submissions to be successfully accepted into the QIO Clinical Warehouse. Hospitals were required to submit data for the first calendar quarter of 2004. We received data from over 98 percent of the eligible hospitals.

For FY 2006, we are proposing that hospitals must continuously submit the required 10 measures each quarter according to the schedule found on the Web site at http://www.qnetexchange.org. New facilities

must submit the data using the same schedule, as dictated by the quarter they begin discharging patients. We will expect that all hospitals will have submitted data to the QIO Clinical Warehouse for discharges through the fourth quarter of calendar year 2004 (October to December 2004). Hospitals have 4\1/2\ months from the end of the fourth quarter until the closing of the warehouse (from December 31, 2004, until May 15, 2005) to make sure there are no errors in the submitted data. The warehouse is closed at that time in order to draw the validation sample and to begin preparing the public file for Hospital Compare public reporting. Data from fourth quarter 2004 discharges (October through December 2004) will be the last quarter of data with a submission deadline (May 15, 2005) that precedes our deadline for certifying the hospitals eligible to receive the full update for FY 2006. As we required for FY 2005, the data for each quarter must be submitted on time and pass all of the edits and consistency checks required in the clinical warehouse. Hospitals that do not treat a condition or have very few discharges will not be penalized and will receive the full annual payment update if they submit all the data they do possess.

New hospitals should begin collecting and reporting data immediately and complete the registration requirements for the RHQDAPU. New hospitals will be held to the same standard as established facilities when determining the expected number of discharges for the calendar quarters covered for each fiscal year. The annual payment updates would be based on the successful submission of data to CMS via the QIO Clinical Warehouse by the established deadlines.

For FY 2005, hospitals could withdraw from RHQDAPU at any time up to August 1, 2004. Hospitals withdrawing from the program did not receive the full market basket update and, instead, received a reduction of 0.4 percentage points in their update. By law, a hospital's actions each year will not affect its update in a subsequent year. Therefore, a hospital must meet the requirements for RHQDAPU each year the program is in effect. Failure of a hospital to receive the full update in one year does not affect its update in a succeeding year.

For the first year, FY 2005, there were no chart-audit validation criteria in place. Based upon our experience from the FY 2005 submissions, and upon our requirement for reliable and valid data, we are proposing to place the following additional requirements on hospitals for the data for the FY 2006 payment update. These requirements, as well as additional information on validation requirements, will be placed on QualityNet Exchange.

The hospital must have passed our validation requirement of a minimum of 80 percent reliability, based upon our chart-audit validation process, for the third quarter data of calendar year 2004 in order to receive the full market basket update in FY 2006. These data were due to the clinical warehouse by February 15, 2005. We will use appropriate confidence intervals to determine if a hospital has achieved an 80-percent reliability. The use of confidence intervals will allow us to establish an appropriate range below the 80-percent reliability threshold that will demonstrate a sufficient level of validity to allow the data to still be considered valid. We will estimate the percent reliability based upon a review of five charts and then calculate the upper 95 percent confidence limit for that estimate. If this upper limit is above the required 80 percent, the hospital data will be considered validated. We are proposing to use the design specific estimate of the variance for the confidence interval calculation, which, in this case, is a single stage cluster sample, with unequal cluster sizes. (For reference, see Cochran, William G. (1977) Sampling Techniques, John Wiley & Sons, New York, chapter 3, section 3.12.)

We will use a two-step process to determine if a hospital is submitting valid data. At the first step, we will calculate the percent agreement for all of the variables submitted in all of the charts, whether or not they are related to the 10 measures. If a hospital falls below the 80 percent cutoff, we will then restrict the comparison to those variables associated with the 10 measures required under section 501(b) of Pub. L. 108-173. We will recalculate the percent agreement and the estimated 95 percent confidence interval and again compare to the 80 percent cutoff

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point. If a hospital passes under this restricted set of variables, the hospital will be considered to be submitting valid data for purposes of this proposed rule.

Under the standard appeal process, all hospitals are given the detailed results of the Clinical Data Abstraction Center (CDAC) reabstraction along with their estimated percent reliability and the upper bound of the 95 percent confidence interval. If a hospital disagrees with any of the abstraction results from the CDAC, the hospital has 10 days to appeal these results to their QIO. The QIO will review the appeal with the hospital and, if the QIO review agrees with the hospitals original abstraction, the QIO will forward the appeal to the CDAC for a final determination. If the QIO does not agree with the hospital's appeal, then the original results stand. When the CDAC has made its final determination, the new results will be provided to the hospital through the usual processes and the validation described previously will be repeated. This process is described in detail at the following Web site: http://www.qnetexchange.org. Hospitals that fail to

receive the required 80-percent reliability after the standard appeals process may ask that CMS accept the fourth quarter of calendar year 2004 validation results as a final attempt to present evidence of reliability. However, in order to process the fourth quarter data in time to meet our internal deadlines, these hospitals will need to submit the charts requested for reabstraction as soon as possible, but no later than August 1, 2005, in order for us to guarantee consideration of this information. Hospitals that make the early submission of these data and pass the 80-percent reliability minimum level will satisfy this requirement. In reviewing the data for these hospitals, we plan to combine the 5 cases from the third quarter and the 5 cases from the fourth quarter into a single sample to determine whether the 80 percent reliability level is met. This gives us the greatest accuracy when estimating the reliability level. The confidence interval approach accounts for the variation in coding among the 5 charts pulled each quarter and for the entire year around the overall hospital mean score (on all individual data elements compared). The closer each case's reliability score is to the hospital mean score, the tighter the confidence interval established for that hospital. A hospital may code each chart equally inaccurately, achieve a tight confidence interval, and fail to pass even though its overall score is just below the passing threshold (75 percent, for example). A hospital with more variation among charts will achieve a broader confidence interval, which may allow it to pass even though some charts score very low and others very high. As we gain experience with this system, we will adjust it as appropriate over time as we build our sample of validated cases and learn more about hospital performance against the thresholds we establish.

We believe we have adopted the most suitable statistical tests for the hospital data we are trying to validate, but we invite public comments on this and any other approaches hospitals choose to comment on. We are particularly interested in comments from hospitals on the initial starting points for the passing threshold, the confidence interval established, and the sampling approach. Because we will be receiving data each quarter from hospitals, our information on the sampling methodology will improve with each quarter's submissions. We will analyze this information to determine if any changes in our methodology are required. We will make any necessary revisions to the sampling methodology and the statistical approach through manual issuances and other guidance to hospitals.

The hospital must have two consecutive quarters of publishable data. The information collected by CMS through this rule will be displayed for public viewing on the Internet. Prior to this display, hospitals are permitted to preview their information as we have it recorded. In our previous experience, a number of hospitals requested that this information not be displayed due to errors in the submitted data that were not of the sort that could be detected by the normal edit and consistency checks. We acquiesced to these requests in the public interest and because of our own desire to present correct data. However, we still believe that the hospital bears the responsibility of submitting correct data that can serve as valid and reliable information. Therefore, in order to receive the full market basket update for IPPS, we are proposing to establish a requirement for two consecutive quarters of publishable data. We published the first quarter of calendar year 2004 data in November 2004. The first two quarters of calendar year 2004 data were published in March 2005. Our plans are to publish the first three quarters of calendar year 2004 in August 2005. For the FY 2006 update, we will expect that all hospitals receiving the full market basket update for FY 2006 to have published data for all of the required 10 measures for both the March and August 2005 publications. Allowances would be made for hospitals that do not treat a particular condition and for new hospitals that have not had the opportunity to provide the required data.

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

(If you choose to comment on issues in this section, please include the caption ``Sole Community Hospitals and Medicare Dependent Hospitals'' at the beginning of your comments.) 1. Background

Under the IPPS, special payment protections are provided to a sole community hospital (SCH). Section 1886(d)(5)(D)(iii) of the Act defines an SCH as a hospital that, by reason of factors such as isolated location, weather conditions, travel conditions, absence of other like hospitals (as determined by the Secretary), or historical designation by the Secretary as an essential access community hospital, is the sole source of inpatient hospital services reasonably available to Medicare beneficiaries. The regulations that set forth the criteria that a hospital must meet to be classified as an SCH are located in Sec. 412.92 of the regulations. Although SCHs and MDHs are paid under a special payment methodology, they are hospitals that are paid under section 1886(d) of the Act. Like all IPPS hospitals paid under section 1886(d) of the Act, SCHs and MDHs are paid for their discharges based on the DRG weights calculated under section 1886(d)(4) of the Act.

Effective with hospital cost reporting periods beginning on or after October 1, 2000, section 1886(d)(5)(D)(i) of the Act (as amended by section 6003(e) of Pub. L. 101-239) and section 1886(b)(3)(I) of the Act (as added by section 405 of Pub. L. 106-113 and further amended by section 213 of Pub. L. 106-554), provide that SCHs are paid based on whichever of the following rates yields the greatest aggregate payment to the hospital for the cost reporting period:

The Federal rate applicable to the hospital;

The updated hospital-specific rate based on FY 1982 costs per discharge;

The updated hospital-specific rate based on FY 1987 costs per discharge; or

The updated hospital-specific rate based on FY 1996 costs per discharge.

For purposes of payment to SCHs for which the FY 1996 hospital- specific rate yields the greatest aggregate payment, payments for discharges during FYs 2001, 2002, and 2003 were based on a

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blend of the FY 1996 hospital-specific rate and the greater of the Federal rate or the updated FY 1982 or FY 1987 hospital-specific rate. For discharges during FY 2004 and subsequent fiscal years, payments based on the FY 1996 hospital-specific rate are 100 percent of the updated FY 1996 hospital-specific rate.

For each cost reporting period, the fiscal intermediary determines which of the payment options will yield the highest rate of payment. Payments are automatically made at the highest rate using the best data available at the time the fiscal intermediary makes the determination. However, it may not be possible for the fiscal intermediary to determine in advance precisely which of the rates will yield the highest payment by year's end. In many instances, it is not possible to forecast the outlier payments, the amount of the DSH adjustment, or the IME adjustment, all of which are applicable only to payments based on the Federal rate. The fiscal intermediary makes a final adjustment at the close of the cost reporting period to determine precisely which of the payment rates would yield the highest payment to the hospital.

If a hospital disagrees with the fiscal intermediary's determination regarding the final amount of program payment to which it is entitled, it has the right to appeal the fiscal intermediary's decision in accordance with the procedures set forth in subpart R of part 400, which concern provider payment determinations and appeals.

Under section 1886(d)(5)(G) of the Act, Medicare dependent hospitals (MDHs) are paid based on the Federal national rate or, if higher, the Federal national rate plus 50 percent of the difference between the Federal national rate and the updated hospital-specific rate based on FY 1982 or FY 1987 costs per discharge, whichever is higher. MDHs do not have the option to use their FY 1996 hospital- specific rate. The regulations that set forth the criteria that a hospital must meet to be classified as an MDH are located in Sec. 412.108. 2. Budget Neutrality Adjustment to Hospital Payments Based on Hospital- Specific Rate

Under section 1886(d)(4)(C)(i) of the Act, beginning in FY 1988 and for each fiscal year thereafter, the Secretary is required to adjust the DRG classifications and weighting factors established under sections 1886(d)(4)(A) and (d)(4)(B) of the Act to reflect changes in treatment patterns, technology, and other factors that may change the use of hospital resources. For discharges beginning in FY 1991, section 1886(d)(4)(C)(iii) of the Act requires the Secretary to ensure that adjustments to DRG classifications and weighting factors result in aggregate DRG payments that are budget neutral (not greater or less than the aggregate payments without the adjustments). In addition, section 1886(d)(3)(E) of the Act requires the Secretary to update the hospital wage index annually in a manner that does not affect aggregate payments to hospitals under section 1886(d) of the Act.

As discussed in the May 9, 1990 IPPS proposed rule (55 FR 19466), we normalize the proposed recalibrated DRG weights by an adjustment factor so that the average case weight after recalibration is equal to the average case weight prior to recalibration. While this adjustment is intended to ensure that recalibration does not affect total payments to hospitals under section 1886(d) of the Act, our analysis has indicated that the normalization adjustment does not achieve budget neutrality with respect to aggregate payments to hospitals under section 1886(d) of the Act. In order to comply with the requirement of section 1886(d)(4)(C)(iii) of the Act that the DRG reclassification changes and recalibration of the relative weights be budget neutral and the requirement of section 1886(d)(3)(E) of the Act that the updated wage index be implemented in a budget neutral manner, we compare the estimated aggregate payments using the current year's relative weights and wage index factors to aggregate payments using the prior year's weights and factors. Based on this comparison, we compute a budget neutrality adjustment factor. This budget neutrality adjustment factor is then applied to the standardized per discharge payment amount. Beginning in FY 1994, in applying the current year's budget neutrality adjustment factor to both the standard Federal rate and hospital- specific rates, we do not remove the prior years' budget neutrality adjustment factors because estimated aggregate payments after the changes in the DRG relative weights and wage index factors must equal estimated aggregate payments prior to the changes. If we removed the prior year adjustment, we would not satisfy this condition. (58 FR 30269)

We are bound by the Act to ensure that aggregate payments to hospitals under section 1886(d) of the Act are projected to neither increase nor decrease as a result of the annual updates to the DRG classifications and weighting factors and for the updated wage indices. However, we have broad authority under the statute to determine the method for implementing budget neutrality. We have maintained since 1991 that the budget neutrality adjustment is applied, as described above, to all hospitals paid under section 1886(d) of the Act, including those that are paid based on a hospital-specific rate. Thus, the budget neutrality factor applies to payments to SCHs and MDHs.

Hospitals that are paid under section 1886(d) of the Act based on a hospital-specific rate are subject to the DRG reclassification and recalibration factor component of the budget neutrality adjustment because, as IPPS hospitals, they are paid based on DRGs. As described above, changes in DRG relative weights from one year to the next affect aggregate SCH and MDH payments, which in turn affect total Medicare payments to hospitals under section 1886(d) of the Act. Because SCHs and MDHs are paid under section 1886(d) of the Act, we believe their DRG payments should be factored into the DRG reclassification and recalibration factor component of the budget neutrality adjustment to ensure that recalibration does not affect total payments to hospitals under section 1886(d) of the Act. Therefore, we continue to believe it is appropriate to apply the DRG reclassification and recalibration factor component of the budget neutrality adjustment to SCHs and MDHs. Furthermore, consistent with the requirement of section 1886(d)(4)(C)(iii) of the Act that DRG reclassification changes and recalibration of relative weights be budget neutral, we continue to believe it is appropriate to apply this adjustment without removing the previous year's adjustment factor.

In the May 9, 1990 proposed rule (55 FR 19466), we discussed the rationale behind our decision to apply the wage index portion of the budget neutrality adjustment factors to hospitals that are paid under section 1886(d) of the Act based on a hospital-specific rate. We described how, even though the wage index is only applicable to those hospitals that are paid based on the Federal rate, the changes in wage index can cause changes in the payment basis for some SCHs, and MDHs. That is, depending on the size of the increase in their wage index values, some hospitals that had been paid based on the hospital- specific rate could now be paid based on the Federal rate when the wage index-adjusted Federal rate exceeds the hospital-specific rate. In some instances, hospitals that had previously been paid based on the Federal rate may be paid based on the hospital-specific rate if the Federal rate is adjusted by a lower wage

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index and the hospital-specific rate now exceeds the Federal rate. These shifts in the payment basis affect aggregate program payments and, therefore, are taken into account in the budget neutrality adjustment. In addition, we maintained that because we apply the adjustment to all hospitals paid based on the Federal rate under section 1886(d) of the Act, it would be fair to apply it to hospitals that are paid under section 1886(d) of the Act based on hospital- specific rates. We believed that if we did not apply the budget neutrality factor to hospitals paid based on their hospital-specific rate, hospitals that are paid on the Federal rate would be subject to larger reductions to make up for not adjusting payments to hospitals that are paid based on hospital-specific rates.

Concerns have been raised that hospitals under section 1886(d) of the Act whose reimbursement is based on a hospital-specific rate should not be subject to the wage index component of the budget neutrality adjustment. Hospital-specific rates reflect the effects of hospitals' area wage levels and, therefore, are not adjusted by an area wage index. Accordingly, the concern is that a budget neutrality factor for changes in the wage index should not be applied to hospitals that are paid based on a hospital-specific rate. In addition, it has been suggested that the budget neutrality adjustment that CMS applies to hospitals paid on a hospital-specific rate should be similar to the budget neutrality adjustment made to hospitals in Puerto Rico. Hospitals in Puerto Rico that are paid under the IPPS are paid based on a blend of the national prospective payment rate and the Puerto Rico- specific prospective payment rate (42 CFR 412.212). Beginning in FY 1991, the Puerto Rico-specific standardized amount became subject to a budget neutrality adjustment. This budget neutrality adjustment included both the DRG reclassification and recalibration factor component and the wage index component. However, beginning in FY 1998, the Puerto Rico-specific rate has been subject only to the DRG reclassification and recalibration factor component of the budget neutrality adjustment (62 FR 46038) and not to the wage index component of the budget neutrality adjustment. In other words, beginning in FY 1998, the budget neutrality adjustment for the Puerto Rico-specific rate reflects only the DRG reclassification and recalibration factor component. This adjustment is computed, as described above, for all hospitals paid under section 1886(d) of the Act, without removing the previous year's budget neutrality adjustment.

We have considered the concern that it is inappropriate to apply a budget neutrality factor that includes a component for changes in the wage index to a hospital with a payment rate that is not adjusted by a wage index adjustment. In cases in which a hospital's payments are ultimately based on a hospital-specific rate, that portion of the payment is not adjusted by a wage index. We believe that our current policy is valid, for the reasons indicated above and in previous rulemaking documents, but we recognize that there are also valid grounds to review the regulations and consider other approaches. Accordingly, we are revisiting this policy. After further consideration of these issues, we are proposing to remove the wage index component from the budget neutrality adjustment applied to the hospital-specific rate for hospitals paid under section 1886(d) of the Act. The DRG reclassification and recalibration factor component of the budget neutrality adjustment would still apply to these hospitals, as payments to SCHs and MDHs are based on DRGs and affect total Medicare payments to hospitals under section 1886(d) of the Act. In applying this budget neutrality adjustment factor, which would include only the DRG reclassification and recalibration factor component, to the hospital- specific rate, we would not remove the prior years' budget neutrality adjustment factors. This would satisfy the statutory requirement that estimated aggregate payments after the changes in the DRG relative weights equal estimated aggregate payments prior to the changes. We are proposing that the wage index portion of the budget neutrality adjustment would not be applied to hospital-specific amounts, as these amounts are not adjusted by an area wage index. While this may result in a slightly higher budget neutrality adjustment applied to all other IPPS hospitals, because these hospitals actually are paid based on the revised wage indices and are affected by wage index changes, we believe this is appropriate. In addition, we note that in FY 1990 when this policy was first discussed, we did not calculate a budget neutrality factor that reflected only the DRG changes. Because we now calculate such a budget neutrality factor for Puerto Rico hospitals, it would not be administratively burdensome to apply the same budget neutrality factor to SCHs and MDHs.

We are proposing to add a new paragraph (f) to Sec. 412.73, a new paragraph (i) to Sec. 412.75, and a new paragraph (j) to Sec. 412.77 relating to the computation of the hospital-specific rate to clarify our longstanding policy that CMS makes an adjustment to the hospital- specific rate to ensure that changes to the DRG reclassifications and recalibrations of the DRG relative weights are made in a manner so that aggregate payments to hospitals under section 1886(d) of the Act are not affected, and that this adjustment is made without removing the budget neutrality adjustment for the prior year. These provisions are cross-referenced in Sec. 412.92 for SCHs and Sec. 412.108 for MDHs for purposes of computing the hospital-specific rates for these hospitals. This proposed regulatory text will reflect the proposed changes to the way CMS applies the budget neutrality adjustment to hospitals paid under section 1886(d) of the Act based on the hospital- specific rate. Specifically, it would indicate that the budget neutrality adjustment made to hospitals paid under section 1886(d) of the Act based on the hospital-specific rate will only account for the DRG reclassification and recallibration factor component. The budget neutrality adjustment would no longer include the wage index factor component. 3. Technical Change

In the September 4, 1990 IPPS final rule (55 FR 36056), we made changes to the regulations at Sec. 412.92 to incorporate the provisions of section 6003(e) of Pub. L. 101-239. Section 6003(e) of Pub. L. 101-239 provided for a permanent payment methodology for SCHs that recognized distortions in operating costs in years subsequent to the implementation of the IPPS and provided for opportunity for payment based on a new base year. As a result of this legislation, we deleted from the regulations a special provision that we had included under Sec. 412.92(g) that provided for a payment adjustment to compensate SCHs reasonably for the increased operating costs resulting from the addition of new services or facilities.

We have discovered that, in making the changes to Sec. 412.92 in the September 4, 1990 final rule to remove paragraph (g), we inadvertently failed to make a conforming change to paragraph (d)(3) that references the provisions of paragraph (g) relating to a payment adjustment for significant increases in a SCH's operating costs. In this proposed rule, we are proposing to make this technical correction by revising paragraph (d)(3).

D. Rural Referral Centers (Sec. 412.96)

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

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caption ``Rural Referral Centers'' at the beginning of your document.)

Under the authority of section 1886(d)(5)(C)(i) of the Act, the regulations at Sec. 412.96 set forth the criteria that a hospital must meet in order to qualify under the IPPS as a rural referral center. For discharges occurring before October 1, 1994, rural referral centers received the benefit of payment based on the other urban standardized amount rather than the rural standardized amount. Although the other urban and rural standardized amounts are the same for discharges occurring on or after October 1, 1994, rural referral centers continue to receive special treatment under both the DSH payment adjustment and the criteria for geographic reclassification.

Section 402 of Pub. L. 108-173 raised the DSH adjustment for other rural hospitals with less than 500 beds and rural referral centers. Other rural hospitals with less than 500 beds are subject to a 12- percent cap on DSH payments. Rural referral centers are not subject to the 12.0 percent cap on DSH payments that is applicable to other rural hospitals (with the exception of rural hospitals with 500 or more beds). Rural referral centers are not subject to the proximity criteria when applying for geographic reclassification, and they do not have to meet the requirement that a hospital's average hourly wage must exceed 106 percent of the average hourly wage of the labor market area where the hospital is located.

Section 4202(b) of Pub. L. 105-33 states, in part, ``[a]ny hospital classified as a rural referral center by the Secretary * * * for fiscal year 1991 shall be classified as such a rural referral center for fiscal year 1998 and each subsequent year.'' In the August 29, 1997 final rule with comment period (62 FR 45999), we also reinstated rural referral center status for all hospitals that lost the status due to triennial review or MGCRB reclassification, but not to hospitals that lost rural referral center status because they were now urban for all purposes because of the OMB designation of their geographic area as urban. However, subsequently, in the August 1, 2000 final rule (65 FR 47089), we indicated that we were revisiting that decision. Specifically, we stated that we would permit hospitals that previously qualified as a rural referral center and lost their status due to OMB redesignation of the county in which they are located from rural to urban to be reinstated as a rural referral center. Otherwise, a hospital seeking rural referral center status must satisfy the applicable criteria. For FYs 1984 through 2004, we used the definitions of ``urban'' and ``rural'' in Sec. 412.63. For FY 2005 and subsequent years, the revised definitions of ``urban'' and ``rural'' in Sec. 412.64 apply.

One of the criteria under which a hospital may qualify as a rural referral center is to have 275 or more beds available for use (Sec. 412.96(b)(1)(ii)). A rural hospital that does not meet the bed size requirement can qualify as a rural referral center if the hospital meets two mandatory prerequisites (a minimum case-mix index and a minimum number of discharges) and at least one of three optional criteria (relating to specialty composition of medical staff, source of inpatients, or referral volume) (Sec. 412.96(c)(1) through (c)(5)). (See also the September 30, 1988 Federal Register (53 FR 38513)). With respect to the two mandatory prerequisites, a hospital may be classified as a rural referral center if--

The hospital's case-mix index is at least equal to the lower of the median case-mix index for urban hospitals in its census region, excluding hospitals with approved teaching programs, or the median case-mix index for all urban hospitals nationally; and

The hospital's number of discharges is at least 5,000 per year, or, if fewer, the median number of discharges for urban hospitals in the census region in which the hospital is located. (The number of discharges criterion for an osteopathic hospital is at least 3,000 discharges per year, as specified in section 1886(d)(5)(C)(i) of the Act.) 1. Case-Mix Index

Section 412.96(c)(1) provides that CMS will establish updated national and regional case-mix index values in each year's annual notice of prospective payment rates for purposes of determining rural referral center status. The methodology we use to determine the proposed national and regional case-mix index values is set forth in regulations at Sec. 412.96(c)(1)(ii). The proposed national median case-mix index value for FY 2006 includes all urban hospitals nationwide, and the proposed regional values for FY 2006 are the median values of urban hospitals within each census region, excluding those hospitals with approved teaching programs (that is, those hospitals receiving indirect medical education payments as provided in Sec. 412.105). These proposed values are based on discharges occurring during FY 2004 (October 1, 2003 through September 30, 2004) and include bills posted to CMS' records through December 2004.

We are proposing that, in addition to meeting other criteria, if they are to qualify for initial rural referral center status for cost reporting periods beginning on or after October 1, 2005, rural hospitals with fewer than 275 beds must have a case-mix index value for FY 2004 that is at least--

1.3659; or

The median case-mix index value (not transfer-adjusted) for urban hospitals (excluding hospitals with approved teaching programs as identified in Sec. 412.105) calculated by CMS for the census region in which the hospital is located.

The proposed median case-mix index values by region are set forth in the following table:

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[GRAPHIC] [TIFF OMITTED] TP04MY05.058

The preceding numbers will be revised in the final rule to the extent required to reflect the updated FY 2004 MedPAR file, which will contain data from additional bills through March 31, 2005.

Hospitals seeking to qualify as rural referral centers or those wishing to know how their case-mix index value compares to the criteria should obtain hospital-specific case-mix index values (not transfer- adjusted) from their fiscal intermediaries. Data are available on the Provider Statistical and Reimbursement (PS&R) System. In keeping with our policy on discharges, these case-mix index values are computed based on all Medicare patient discharges subject to DRG-based payment. 2. Discharges

Section 412.96(c)(2)(i) provides that CMS will set forth the national and regional numbers of discharges in each year's annual notice of prospective payment rates for purposes of determining rural referral center status. As specified in section 1886(d)(5)(C)(ii) of the Act, the national standard is set at 5,000 discharges. We are proposing to update the regional standards based on discharges for urban hospitals' cost reporting periods that began during FY 2002 (that is, October 1, 2001 through September 30, 2002), which is the latest available cost report data we have at this time.

Therefore, we are proposing that, in addition to meeting other criteria, a hospital, if it is to qualify for initial rural referral center status for cost reporting periods beginning on or after October 1, 2005, must have as the number of discharges for its cost reporting period that began during FY 2002 a figure that is at least--

5,000 (3,000 for an osteopathic hospital); or

The median number of discharges for urban hospitals in the census region in which the hospital is located, as indicated in the following table:

[GRAPHIC] [TIFF OMITTED] TP04MY05.059

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These numbers will be revised in the final rule based on the latest available cost report data.

We reiterate that if an osteopathic hospital is to qualify for rural referral center status for cost reporting periods beginning on or after October 1, 2005, the hospital would be required to have at least 3,000 discharges for its cost reporting period that began during FY 2002. 3. Technical Change

In the FY 1998 IPPS final rule (62 FR 46028), we removed paragraph (f) from Sec. 412.96. Paragraph (f) was removed when the requirement for triennial reviews of rural referral centers was terminated (62 FR 45998 through 45600, 46028 through 46029). However, we inadvertently failed to address all of the related cross-references to paragraph (f) in the entire Sec. 412.96. Therefore, we are proposing to revise Sec. 412.96 to remove paragraphs (h)(4) and (i)(4), consistent with the removal of paragraph (f).

E. Payment Adjustment for Low-Volume Hospitals (Sec. 412.101)

(If you choose to comment on issues in this section, please include the caption ``Low-Volume Hospital Payment Adjustment'' at the beginning of your comment.)

Section 1886(d)(12) of the Act, as added by section 406 of Pub. L. 108-173, provides for a payment adjustment to account for the higher costs per discharge of low-volume hospitals under the IPPS. Section 1886(d)(12)(C)(i) of the Act defines a low-volume hospital as a ``subsection (d) hospital * * * that the Secretary determines is located more than 25 road miles from another subsection (d) hospital and that has less than 800 discharges during the fiscal year.'' Section 1886(d)(12)(C)(ii) of the Act further stipulates that the term ``discharge'' refers to total discharges, and not merely to Medicare discharges. Specifically, the term refers to the ``inpatient acute care discharge of an individual regardless of whether the individual is entitled to benefits under part A.'' Finally, the provision requires the Secretary to determine an applicable percentage increase for these low-volume hospitals based on the ``empirical relationship'' between ``the standardized cost-per-case for such hospitals and the total number of discharges of these hospitals and the amount of the additional incremental costs (if any) that are associated with such number of discharges.'' The statute thus mandates the Secretary to develop an empirically justifiable adjustment based on the relationship between costs and discharges for these low-volume hospitals. The statute also limits the adjustment to no more than 25 percent.

According to the analysis conducted for the FY 2005 IPPS final rule (69 FR 49099 through 49102), a 25 percent low-volume adjustment to all qualifying hospitals with less than 200 discharges was found to be most consistent with the statutory requirement to provide relief to low- volume hospitals where there is empirical evidence that higher incremental costs are associated with low numbers of total discharges. However, we acknowledged that the empirical evidence did not provide robust support for that conclusion and indicated that we would reexamine the empirical evidence for the FY 2006 IPPS final rule with the intention of modifying or even eliminating the adjustment if the empirical evidence indicates that it is appropriate to do so.

In the FY 2005 IPPS final rule (69 FR 49102), we indicated that our analysis showed that there are fewer than 100 hospitals with less than 200 total discharges. At that time, we were unable to determine how many of these hospitals also meet the requirement that a low-volume hospital be more than 25 road miles from the nearest IPPS hospital in order to qualify for the adjustment. Our data systems currently indicate that 10 hospitals are receiving the low-volume adjustment.

As indicated in the FY 2005 IPPS final rule, we have now conducted a more detailed multivariate analysis on the empirical basis for a low- volume adjustment for FY 2006. In order to further evaluate the need for a proposed change in the development of the low-volume adjustment, we replicated much of the analysis conducted for the FY 2005 IPPS final rule, using updated data. We again empirically modeled the relationship between hospital costs-per-case and total discharges in several ways. We used both regression analysis and straight-line statistics to examine this relationship.

We conducted three different regression analyses. For all of the analyses, we simulated the FY 2005 cost environment by inflating FY 2002 and FY 2003 hospital cost report data to FY 2005 using the full hospital market basket updates. We note that, at the time of this analysis, we only had cost report data from FY 2003 for approximately 57 percent of the IPPS hospitals. Therefore, we have placed a greater weight on the results from the simulated FY 2002 cost data, which are significantly more complete. We again simulated the FY 2005 payment environment because payments have undergone several changes between FY 2002 and FY 2003 and FY 2005, making the results of the earlier data less relevant. Furthermore, many of these policy changes may already have helped increase payments to low-volume hospitals. We were unable to simulate the FY 2006 environment because payment factors for FY 2006 were not available at the time of our analysis.

In the first regression analysis, we used a dummy variable approach to model the relationship between standardized costs and total discharges. Using FY 2002 cost data, we found some evidence for a low- volume payment adjustment for hospitals with up to 199 discharges, consistent with our current policy. Using FY 2003 cost data, the empirical evidence only supported an adjustment for hospitals with up to 99 total discharges.

We also used a descriptive analysis approach to understand empirically the relationship between costs and total discharges. We grouped all hospitals by their total discharges and compared the mean Medicare per discharge payment to Medicare per discharge cost ratios. Hospitals with less than 800 total discharges were split into 24 cohorts based on increments of 25 discharges. When using the FY 2002 cost report data, the mean payment-to-cost ratios were below one (implying that Medicare per discharge costs exceeded Medicare per discharge payments) for all cohorts of hospitals with less than 200 discharges, after which the ratio was consistently above one. When using the FY 2003 cost report data, the mean payment-to-cost ratios were below one for all but two cohorts up to those with less than 175 total discharges, after which the ratio was consistently above one. No obvious increasing trend in the ratios, from which it would be possible to infer a formula to generate adjustments for hospitals based upon the number of discharges, was evident. Because more than 70 percent of hospitals with less than 200 discharges had ratios below 0.80, this analysis supports applying the highest payment adjustment to all providers with less than 200 discharges that are eligible for the low- volume adjustment.

The second regression analysis modeled the Medicare per discharge cost to Medicare per discharge payment ratio as a function of total discharges. The cost-to-payment ratio model more explicitly accounts for the relative values of per discharge costs and per discharge payments. These models provided some evidence for a statistically significant negative relationship between the cost-to-payment ratio and total discharges. However, that result was limited to FY

[[Page 23432]]

2002 data. FY 2003 data displayed no significant relationship between the cost-to-payment ratio and total discharges.

The third regression analysis employed per discharge costs minus per discharge payments as the dependent variable and total discharges as an explanatory variable. The results of this analysis were similar to the other regression analyses: some evidence was provided for an adjustment with the FY 2002 data, but not with the FY 2003 data, simulated for FY 2005. In fact, the FY 2003 data results suggest (with a positive intercept and positive coefficient on total discharges) that payments are greater than costs for all hospitals, including the low- volume hospitals.

Based upon these multivariate analyses using the FY 2002 cost report data, a case can be made that hospitals with fewer than 200 total discharges have per discharge costs that are statistically significantly higher relative to their Medicare per discharge payments in comparison to hospitals with 200 or more total discharges. Therefore, we are proposing to extend the existing low-volume adjustment for FY 2006. That is, a low-volume adjustment would again be provided for qualifying hospitals with less than 200 discharges. As noted above, the descriptive data do not reveal any pattern that could provide a formula for calculating an adjustment in relation to the number of discharges. However, the descriptive analysis of the data does indicate that, for a large majority of the hospitals with less than 200 discharges, the maximum adjustment of 25 percent would be appropriate because, for example, the payment-to-cost ratios for more than 70 percent of these hospitals are 0.80 or less. The maximum adjustment of 25 percent would still leave most of these hospitals with payment-to-cost ratios below 1.00. Because a large majority of hospitals with less than 200 discharges have payment-to-cost ratios below 1.00, we are proposing to again provide hospitals with less than 200 total discharges in the most recent submitted cost report an adjustment of 25 percent on each Medicare discharge. This policy is consistent with the existing language in Sec. 412.101(a) and (b).

However, the initial analysis of the FY 2003 data does not seem to provide strong empirical evidence for a relationship between Medicare per discharge costs and total discharges. Therefore, we will reevaluate the appropriateness of the low-volume adjustment in the FY 2007 proposed rule.

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

(If you choose to comment on issues in this section, please include the caption ``IME Adjustment'' at the beginning of your comment.) 1. Background

Section 1886(d)(5)(B) of the Act provides that prospective payment hospitals that have residents in an approved graduate medical education (GME) program receive an additional payment to reflect the higher indirect costs of teaching hospitals relative to nonteaching hospitals. The regulations regarding the calculation of this additional payment, known as the indirect medical education (IME) adjustment, are located at Sec. 412.105. The IME adjustment to the DRG payment is based in part on the applicable IME adjustment factor. The IME adjustment factor is calculated using a hospital's ratio of residents to beds, which is represented as r, and a formula multiplier, which is represented as c, in the following equation: c x [{1 + r{time} \.405\ - 1]. The formula is traditionally described in terms of a certain percentage increase in payment for every 10-percent increase in the resident-to-bed ratio. 2. IME Adjustment for TEFRA Hospitals Converting to IPPS Hospitals

The Balanced Budget Act of 1997 (Pub. L. 105-33) established a limit on the number of allopathic and osteopathic residents that a hospital may include in its full-time equivalent (FTE) count for direct GME and IME payment purposes. Under section 1886(h)(4)(F) of the Act, a hospital's unweighted FTE count of residents may not exceed the hospital's unweighted FTE count for its most recent cost reporting period ending on or before December 31, 1996. Under section 1886(d)(5)(B)(v) of the Act, the limit on the FTE resident count for IME purposes is effective for discharges occurring on or after October 1, 1997. A similar limit is effective for direct GME purposes for cost reporting periods beginning on or after October 1, 1997.

When these provisions were enacted, hospitals reported their weighted FTE resident count for direct GME and their unweighted FTE resident count for IME on the Medicare cost report. The cost report was subsequently modified to require reporting of unweighted FTE resident counts for both direct GME and IME. However, for cost reporting periods ending on or before December 31, 1996 (the cost report on which the FTE limit is based), hospitals were not required to report unweighted FTE resident counts for direct GME purposes. Therefore, a separate data collection effort was required to obtain the unweighted FTE resident counts. The fiscal intermediaries worked with hospitals to determine the unweighted FTE resident counts for direct GME for cost reporting periods ending on or before December 31, 1996, for purposes of implementing the FTE cap.

During this process, the fiscal intermediaries did not determine IME FTE resident counts for hospitals that were excluded from the IPPS (that is, psychiatric hospitals, LTCHs, rehabilitation hospitals, children's hospitals, and cancer hospitals) because these hospitals were not paid under the IPPS and, therefore, did not receive any IME payment adjustments. Only the FTE resident data related to direct GME payments were relevant for these excluded hospitals and, therefore, only those data were collected. However, it has come to our attention that some hospitals that were excluded from the IPPS during the cost reporting period ending on or before December 31, 1996 (that is, the cost reporting period during which the hospital's FTE resident limit was established under section 1886(h)(4)(F) of the Act for purposes of direct GME payments) have either failed to continue to qualify for exclusion from the IPPS or deliberately changed their operations in a way to become subject to the IPPS and, as a result, have subsequently become subject to the IME payment adjustment provisions of the IPPS. For example, a provider that was a rehabilitation hospital during its cost reporting period ending on December 31, 1996, but no longer meets the regulatory criteria to qualify as a rehabilitation hospital would become subject to the IPPS and be able to receive IME payments. However, because no IME FTE resident count for the cost reporting period ending on or before December 31, 1996, was determined, such a hospital does not have an unweighted FTE resident limit for IME.

To address this situation, we are proposing to incorporate in the regulations (proposed Sec. 412.105(f)(1)(xiii)) CMS' existing policy in such situations which provides for the establishment of an IME FTE cap for a hospital that was excluded from the IPPS during its base year and that subsequently became subject to the IPPS. We are clarifying and proposing to adopt into regulations our existing policy that, in such a situation, the fiscal intermediary would determine an IME FTE cap for the hospital, applicable beginning with the

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hospital's payments under the IPPS, based on the FTE count of residents during the cost reporting period(s) used to determine the hospital's direct GME FTE cap in accordance with existing Sec. 412.105(f) of the regulations. The new IPPS hospital's IME FTE cap would be subject to the same rules and adjustments as any IPPS hospital's IME FTE cap in accordance with Sec. 412.105(f) of the regulations.

While calculation of the IME FTE cap for a TEFRA hospital that converts to an IPPS hospital may require that fiscal intermediaries obtain information from cost reporting periods that are closed, allowing a fiscal intermediary to obtain this information should not be understood as allowing a fiscal intermediary to reopen closed cost reports that are beyond the normal reopening period in order to carry out the provisions of this proposed regulation.

Finally, there may be situations where the data necessary to carry out this policy are not available. For example, under this proposal, if a children's hospital converts to an IPPS hospital on July 1, 2007, the fiscal intermediary may need to determine the count of FTE residents for IME purposes training at the hospital during the most recent cost reporting period ending on or before December 31, 1996, in order to establish an IME FTE cap for the hospital, effective for discharges occurring on or after October 1, 2007. However, the count of FTE residents for IME purposes from the cost reporting period ending on or before December 31, 1996, may no longer be available, as the minimum time that hospitals are required to retain records is 5 years from the date the hospital submits the cost report. We believe this problem may not occur with sufficient frequency to warrant specific regulatory action. We are specifically soliciting comments as to whether and how hospitals believe this is a problem that needs to be addressed.

In some cases, a hospital that was previously excluded from the IPPS may become subject to the IPPS as a result of a merger between two or more hospitals where the surviving hospital is subject to the IPPS (and not creating an IPPS hospital with an excluded unit). In such cases, CMS policy is that the FTE resident cap for the surviving hospital should reflect the combined FTE resident caps for the hospitals that merged. If two or more hospitals merge after the conclusion of each hospital's base year for purposes of calculating resident FTE caps, the surviving hospital's FTE resident cap is an aggregation of the FTE resident cap for each hospital participating in the merger. When a merger involves an IPPS-excluded hospital, the base year IME FTE count for the IPPS-excluded hospital has not been determined. We are clarifying and proposing to codify in regulations our existing policy that, in such cases, the fiscal intermediary would determine an IME FTE cap for the IPPS-excluded hospital for purposes of determining the merged hospital's IME FTE cap in accordance with Sec. 412.105(f) of the regulations. Once this cap is determined, the aggregate IME FTE cap of the surviving entity may be calculated in accordance with existing CMS policy for mergers.

We note that we would compute an IME cap for an IPPS-excluded hospital only in cases of a merger between an IPPS-excluded hospital and an acute care IPPS hospital, where the entire surviving entity is subject to the IPPS. No such IME FTE cap would be computed for an IPPS- excluded hospital in instances where an IPPS-excluded hospital and an acute care IPPS hospital agree to form a Medicare GME affiliated group for purposes of aggregating FTE resident caps. In cases where an IPPS- excluded hospital enters into a Medicare GME affiliation agreement with other IPPS hospitals, the IPPS-excluded hospital can contribute only its direct GME FTE cap to the aggregate FTE cap for the group. This is because, as long as a hospital remains excluded from the IPPS, that hospital will not have an FTE resident cap established for purposes of IME. Under no circumstances may an IPPS-excluded hospital be considered to contribute any FTE residents to a Medicare GME affiliation group for purposes of the aggregate IME FTE resident cap. IPPS-excluded hospitals do not currently, and would not under this proposed policy, have an IME FTE resident cap. 3. Section 1886(d)(8)(E) Teaching Hospitals That Withdraw Rural Reclassification

In section V.I. of this preamble, we discuss situations in which an urban hospital may become rural under a reclassification request under section 1886(d)(8)(E) of the Act. Under section 1886(d)(8)(E) of the Act, an urban hospital may file an application to be treated as being located in a rural area. Becoming rural under this provision affects only payments under section 1886(d) of the Act. If the hospital is a teaching hospital, the hospital could not receive adjustments to its direct GME FTE cap because payments for direct GME are made under section 1886(h) of the Act and the section 1886(d)(8)(E) reclassifications affect only the payments that are made under section 1886(d) of the Act. Therefore, an urban hospital that reclassifies as rural under this provision may receive the 130-percent adjustment to its IME FTE resident cap. In addition, its IME FTE cap may be adjusted for any new programs (similar to a hospital that is actually located in an area designated as rural) under section 1886(d)(5)(B)(v) of the Act, as amended by section 407 of Pub. L. 106-113 (BBRA).

An urban hospital treated as rural under section 1886(d)(8)(E) of the Act may subsequently withdraw its election and return to its urban status under the regulations at Sec. 412.103. We are proposing that, effective with discharges occurring on or after October 1, 2005, hospitals that rescind their section 1886(d)(8)(E) reclassifications and return to being urban would not be eligible for permanent increases in their IME caps. Rather, any adjustments the hospitals received to their IME caps due to their rural status would be forfeited upon returning to urban status. Although we read the relevant IME FTE cap provisions in section 1886(d)(5)(B) of the Act as effecting a permanent increase to the FTE cap, we believe we have the statutory authority under section 1886(d)(5)(I) of the Act to make necessary adjustments to these caps that we believe are appropriate. Section 1886(d)(5)(I)(i) of the Act grants the Secretary authority to provide by regulation for ``such other exceptions and adjustments to such payment amounts under this subsection as the Secretary deems appropriate.'' We believe it is appropriate that a section 1886(d)(8)(E) hospital forfeit the adjustments it received solely due to its reclassification to rural status when it returns to being urban. Otherwise, urban hospitals might reclassify to rural areas under section 1886(d)(8)(E) of the Act for a short period of time solely as a means of receiving an increase to their IME FTE caps. These hospitals could reclassify for as little as one year, simply in order to receive a permanent increase to their IME FTE caps. Because section 1886(d)(8)(E) hospitals have control over when they switch in and out of rural status, we believe any other policy would be subject to gaming and inappropriate usage of the section 1886(d)(8)(E) authority. In contrast, hospitals that become urban due to the OMB-revised labor area designations have no control in the matter, and therefore would not be subject to the same type of manipulation of payment rates we believe would exist with the section 1886(d)(8)(E) hospitals.

(We note that the above proposed policy would have no effect on rural track resident training programs.

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Section 1886(h)(4)(H)(iv) of the Act, which governs direct GME, provides that an urban hospital may receive adjustments to its FTE caps for establishing ``separately accredited approved medical residency training programs (or rural tracks) in an [sic] rural area.'' The provisions governing IME state that ``Rules similar to the rules of subsection (h)(4)(H) shall apply for purposes of'' determining FTE resident caps (section 1886(d)(5)(B)(viii) of the Act). Since the requirement that the hospital be located in a rural area is found in the provisions governing direct GME (section 1886(h) of the Act), not the provision governing IME, and since hospitals cannot reclassify as rural for purposes of section 1886(h) of the Act, we believe that, as provided in section 1886(h) of the Act, the hospital with which the urban hospital establishes the rural track must be physically located in an area designated as rural. We do not believe we would be properly incorporating the rules of section 1886(h) of the Act or creating a rule similar to that used in section 1886(h) of the Act if we were to allow counting of such reclassified hospitals.)

For the reasons stated above, we are proposing to amend the regulations at Sec. 412.105 by adding a new paragraph (f)(1)(xiv) to provide that a hospital that rescinds its section 1886(d)(8)(E) reclassification will forfeit any adjustments to its IME FTE cap it received due to its rural status. Thus, for example, a hospital that reclassified as rural under section 1886(d)(8)(e) of the Act with an IME FTE cap of 10 would have received a 130 percent adjustment to its IME cap (that is, 10 FTEs x 1.3). Furthermore, if this hospital, while reclassified as rural, started a new 3-year residency program with 2 residents in each program year, its FTE cap would have been increased by an additional 6 FTEs to 19 FTEs (that is, 13 FTEs + 6 FTEs). However, once this hospital rescinds its reclassification under section 1886(d)(8)(E) of the Act to become urban again, its IME FTE cap would return to 10 FTEs (its original pre-reclassification IME FTE cap).

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

(If you choose to comment on issues in this section, please include the caption ``DSH Adjustment Data'' at the beginning of your comment.) 1. Background

Section 1886(d)(5)(F) of the Act provides for additional payments to subsection (d) hospitals that serve a disproportionate share of low- income patients. The Act specifies two methods for a hospital to qualify for the Medicare disproportionate share hospital (DSH) adjustment. Under the first method, hospitals that are located in an urban area and have 100 or more beds may receive a DSH payment adjustment if the hospital can demonstrate that, during its cost reporting period, more than 30 percent of its net inpatient care revenues are derived from State and local government payments for care furnished to indigent patients. These hospitals are commonly known as ``Pickle hospitals.'' The second method, which is also the most commonly used method for a hospital to qualify, is based on a complex statutory formula under which payment adjustments are based on the level of the hospital's DSH patient percentage, which is the sum of two fractions: the ``Medicare fraction'' and the ``Medicaid fraction.'' The Medicare fraction is computed by dividing the number of patient days that are furnished to patients who were entitled to both Medicare Part A and Supplemental Security Income (SSI) benefits by the total number of patient days furnished to patients entitled to benefits under Medicare Part A. The Medicaid fraction is computed by dividing the number of patient days furnished to patients who, for those days, were eligible for Medicaid but were not entitled to benefits under Medicare Part A by the number of total hospital patient days in the same period.

[GRAPHIC] [TIFF OMITTED] TP04MY05.088

2. Implementation of Section 951 of Pub. L. 108-173 (MMA)

Section 951 of Pub. L. 108-173 requires the Secretary to arrange to furnish the data necessary for hospitals to compute the number of patient days used in calculating the disproportionate patient percentages. The provision is not specific as to whether it applies to the patient day data used to determine the Medicare fraction or the Medicaid fraction. We are interpreting section 951 to require the Secretary to arrange to furnish to hospitals the data necessary to calculate both the Medicare and Medicaid fractions. With respect to both the Medicare and Medicaid fractions, we also are interpreting section 951 to require CMS to arrange to furnish the personally identifiable information that would enable a hospital to compare and verify its records, in the case of the Medicare fraction, against the CMS' records, and in the case of the Medicaid fraction, against the State Medicaid agency's records. Currently, as explained in more detail below, CMS provides the Medicare SSI days to certain hospitals that request these data. Hospitals are currently required under the regulation at Sec. 412.106(b)(4)(iii) to provide the data adequate to prove eligibility for the Medicaid, non-Medicare days.

As indicated above, the numerator of the Medicare fraction includes the number of patient days furnished by the hospital to patients who were entitled to both Medicare Part A and SSI benefits. This number is divided by the hospital's total number of patient days furnished to patients entitled to benefits under Medicare Part A. In order to determine the numerator of this fraction for each hospital, CMS obtains a data file from the Social Security Administration (SSA). CMS matches personally identifiable information from the SSI file against its Medicare Part A entitlement information for the fiscal year to determine the number of Medicare SSI days for each hospital during each fiscal year. These data are maintained in the MedPAR Limited Data Set (LDS) as described in more detail below and discussed in a notice published on August 18, 2000 in the Federal Register (65 FR 50548). The number of patient days furnished by the hospital to Medicare beneficiaries entitled to SSI is divided by the hospital's total number of Medicare days (the denominator of the Medicare fraction). CMS determines this number from Medicare claims data; hospitals also have this information in their records. The Medicare fraction for each hospital is posted on the CMS Web site (http://www.cms.hhs.gov) under

the SSI/Medicare Part A Disproportionate Share Percentage File. Under current regulations at Sec. 412.106(b)(3), a hospital may request to have its Medicare fraction recomputed based on the hospital's cost reporting period if that year differs from the Federal fiscal year. This request may be made only once per

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cost reporting period, and the hospital must accept the resulting DSH percentage for that year, whether or not it is a more favorable number than the DSH percentage based on the Federal fiscal year.

In accordance with section 951 of Pub. L. 108-173, we are proposing to change the process that we use to make Medicare data used in the DSH calculation available to hospitals. Currently, as stated above, CMS calculates the Medicare fraction for each section 1886(d) hospital using data from the MedPAR LDS (as established in a notice published in the August 18, 2000 Federal Register (65 FR 50548)). The MedPAR LDS contains a summary of all services furnished to a Medicare beneficiary, from the time of admission through discharge, for a stay in an inpatient hospital or skilled nursing facility, or both; SSI eligibility information; and enrollment data on Medicare beneficiaries. The MedPAR LDS is protected by the Privacy Act of 1974 (5 U.S.C. 552a) and the Privacy Rule of the Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104-191). The Privacy Act allows us to disclose information without an individual's consent if the information is to be used for a purpose that is compatible with the purpose(s) for which the information was collected. Any such compatible use of data is known as a ``routine use.'' In order to obtain this privacy-protected data, the hospital must qualify under the routine use that was described in the August 18, 2000 Federal Register. Currently, a hospital qualifies under the routine use if it has an appeal properly pending before the Provider Reimbursement Review Board (PRRB) or before an intermediary on the issue of whether it is entitled to DSH payments, or the amount of such payments. Once determined eligible to receive the data under the routine use, the hospital is then required to sign a data use agreement with CMS to ensure that the data are appropriately used and protected, and pay the requisite fee.

Beginning with cost reporting periods that include December 8, 2004 (within one year of the date of enactment of Pub. L. 108-173), we are proposing to furnish MedPAR LDS data for a hospital's patients eligible for both SSI and Medicare at the hospital's request, regardless of whether there is a properly pending appeal relating to DSH payments. We are proposing to make the information available for either the Federal fiscal year or, if the hospital's fiscal year differs from the Federal fiscal year, for the months included in the two Federal fiscal years that encompass the hospital's cost reporting period. Under our proposal, the hospital could use these data to calculate and verify its Medicare fraction, and to decide whether it prefers to have the fraction determined on the basis of its fiscal year rather than a Federal fiscal year. The data set made available to hospitals would be the same data set CMS uses to calculate the Medicare fractions for the Federal fiscal year.

Because we interpret section 951 to require the Secretary to arrange to furnish these data, we do not believe that it will continue to be appropriate to charge hospitals to access the data. These proposed changes would require CMS to modify the current routine use for the MedPAR LDS to reflect changes in the data provided and the circumstances under which they are made available to hospitals. In a future Federal Register document, we will publish the details of any necessary modifications to the current routine use to implement section 951 of Pub. L. 108-173. We welcome comments on all aspects of these proposed changes.

The numerator of the Medicaid fraction includes hospital inpatient days that are furnished to patients who, for those days, were eligible for Medicaid but were not entitled to benefits under Medicare Part A. Under the regulation at Sec. 412.106(b)(4)(iii), hospitals are responsible for proving Medicaid eligibility for each Medicaid patient day and verifying with the State that patients were eligible for Medicaid on the claimed days. The number of Medicaid, non-Medicare days is divided by the hospital's total number of inpatient days in the same period. Total inpatient days are reported on the Medicare cost report. (This number is also available in the hospital's own records.)

Much of the data used to calculate the Medicaid fraction of the DSH patient percentage are available to hospitals from their own records or from the States. We recognize that Medicaid State plans are only permitted to use and disclose information concerning applicants and recipients for ``purposes directly connected with the administration of the [State] plan'' under section 1902(a)(7) of the Act. Regulations at 42 CFR 431.302 define these purposes to include establishing eligibility (Sec. 431.302(a)) and determining the amount of medical assistance (Sec. 431.302(b)). Thus, State plans are permitted under the currently applicable statutory and regulatory provisions governing the disclosure of individually identifiable data on Medicaid applicants and recipients to provide hospitals the data needed to meet their obligation under Sec. 412.106(b)(4)(iii) in the context of either an ``eligibility inquiry'' with the State plan or in order to assist the hospital, and thus the State plan, in determining the amount of medical assistance.

In the process of developing a plan for implementing section 951 with respect to the data necessary to calculate the Medicaid fraction, we asked our regional offices to report on the availability of this information to hospitals and on any problems that hospitals face in obtaining the information that they need. The information we received suggested that, in the vast majority of cases, there are established procedures for hospitals or their authorized representatives to obtain the information needed for hospitals to meet their obligation under Sec. 412.106(b)(4)(iii) and to calculate their Medicaid fraction. There is no uniform national method for hospitals to verify Medicaid eligibility for a specific patient on a specific day. For instance, some States, such as Arizona, have secure online systems that providers may use to check eligibility information. However, in most States, providers send a list of patients to the State Medicaid office for verification. Other States, such as Hawaii, employ a third party private company to maintain the Medicaid database and run eligibility matches for providers. The information that providers submit to State plans (or third party contractors) differs among States as well. Most States require the patient's name, date of birth, gender, social security number, Medicaid identification, and admission and discharge dates. States or the third parties may respond with either ``Yes/No'' or with more detailed Medicaid enrollment and eligibility information such as whether or not the patient is a dual-eligible, whether the patient is enrolled in a fee-for-service or HMO plan, and under which State assistance category the individual qualified for Medicaid.\4\

\4\ Bear in mind that States and hospitals should, in keeping with the HIPAA Privacy Rule, limit the data exchanged in the context of these inquiries and responses to the minimum necessary to accomplish the task

We note that we have been made aware of at least one instance in which a State is concerned about providing hospitals with the requisite eligibility data. We understand that the basis for the State's objections is section 1902(a)(7) of the Act. The State is concerned that section 1902(a)(7) of the Act prohibits the State from providing eligibility data for any purpose other than a purpose related to State plan

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administration. However, as described above, we believe that States are permitted to verify Medicaid eligibility for hospitals as a purpose directly related to State plan administration under Sec. 431.302.

In addition, we believe it is reasonable to continue to place the burden of furnishing the data adequate to prove eligibility for each Medicaid patient day claimed for DSH percentage calculation purposes on hospitals because, since they have provided inpatient care to these patients for which they billed the relevant payors, including the State Medicaid plan, they will necessarily already be in possession of much of this information. We continue to believe hospitals are best situated to provide and verify Medicaid eligibility information. Although we believe the mechanisms are currently in place to enable hospitals to obtain the data necessary to calculate their Medicaid fraction of the DSH patient percentage, there is currently no mandatory requirement imposed upon State Medicaid agencies to verify eligibility for hospitals. At this point, we believe there is no need to modify the Medicaid State plan regulations to require that State plans verify Medicaid eligibility for hospitals. However, should we find that States are not voluntarily providing or verifying Medicaid eligibility information for hospitals, we will consider amending the State plan regulations to add a requirement that State plans provide certain eligibility information to hospitals.

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

(If you choose to comment on issues in this section, please include the caption ``Geographic Reclassifications'' at the beginning of your comment.) 1. Background

With the creation of the MGCRB, beginning in FY 1991, under section 1886(d)(10) of the Act, hospitals could request reclassification from one geographic location to another for the purpose of using the other area's standardized amount for inpatient operating costs or the wage index value, or both (September 6, 1990 interim final rule with comment period (55 FR 36754), June 4, 1991 final rule with comment period (56 FR 25458), and June 4, 1992 proposed rule (57 FR 23631)). As a result of legislative changes under section 402(b) of Pub. L. 108-7, Pub. L. 108-89, and section 401 of Pub. L. 108-173, the standardized amount reclassification criterion for large urban and other areas is no longer necessary or appropriate and has been removed from our reclassification policy (69 FR 49103). We implemented this provision in the FY 2005 IPPS final rule (69 FR 49103). As a result, hospitals can request reclassification for the purposes of the wage index only and not the standardized amount. Implementing regulations in Subpart L of Part 412 (Sec. Sec. 412.230 et seq.) set forth criteria and conditions for reclassifications for purposes of the wage index from rural to urban, rural to rural, or from an urban area to another urban area, with special rules for SCHs and rural referral centers.

Under section 1886(d)(8)(E) of the Act, an urban hospital may file an application to be treated as being located in a rural area if certain conditions are met. The regulations implementing this provision are located under Sec. 412.103.

Effective with reclassifications for FY 2003, section 1886(d)(10)(D)(vi)(II) of the Act provides that the MGCRB must use the average of the 3 years of hourly wage data from the most recently published data for the hospital when evaluating a hospital's request for reclassification. The regulations at Sec. 412.230(d)(2)(ii) stipulate that the wage data are taken from the CMS hospital wage survey used to construct the wage index in effect for prospective payment purposes. To evaluate applications for wage index reclassifications for FY 2006, the MGCRB used the 3-year average hourly wages published in Table 2 of the August 11, 2004 IPPS final rule (69 FR 49295). These average hourly wages are taken from data used to calculate the wage indexes for FY 2003, FY 2004, and FY 2005, based on cost reporting periods beginning during FY 1999, FY 2000, and FY 2001, respectively. 2. Multicampus Hospitals (Sec. 412.230)

As discussed in section III.B. of this preamble, on June 6, 2003, the OMB announced the new CBSAs, comprised of Metropolitan Statistical Areas (MSAs) and Micropolitan Statistical Areas, based on Census 2000 data. Effective October 1, 2004, for the IPPS, we implemented new labor market areas based on the CBSA definitions of MSAs. In some cases, the new CBSAs resulted in previously existing MSAs being divided into two or more separate labor market areas. In the FY 2005 IPPS final rule (69 FR 48916), we acknowledged that the implementation of the new MSAs would have a considerable impact on hospitals. Therefore, we made every effort to implement transitional provisions that would mitigate the negative effects of the new labor market areas on hospitals that request reclassification to another area for purposes of the wage index and on all hospitals.

Subsequent to the publication of the FY 2005 IPPS final rule, we became aware of a situation in which, as a result of the new labor market areas, a multicampus hospital previously located in a single MSA is now located in more than one CBSA. Under our current policy, a multicampus hospital with campuses located in the same labor market area receives a single wage index. However, if the campuses are located in more than one labor market area, payment for each discharge is determined using the wage index value for the MSA (or metropolitan division, where applicable) in which the campus of the hospital is located. In addition, the current provision set forth in section 2779F of the Medicare State Operations Manual provides that, in the case of a merger of hospitals, if the merged facilities operate as a single institution, the institution must submit a single cost report, which necessitates a single provider identification number. This provision does not differentiate between merged facilities in a single wage index area or in multiple wage index areas. As a result, the wage index data for the merged facility is reported for the entire entity on a single cost report.

The current criteria for a hospital being reclassified to another wage area by the MGCRB do not address the circumstances under which a single campus of a multicampus hospital may seek reclassification. That is, a hospital must provide data from the CMS hospital wage survey for the average hourly wage comparison that is used to support a request for reclassification. However, because a multicampus hospital is required to report data for the entire entity on a single cost report, there is no wage survey data for the individual hospital campus that can be used in a reclassification application. In an effort to remedy this situation, for FY 2007 and subsequent year reclassifications, we are proposing to allow a campus of a multicampus hospital system that wishes to seek geographic reclassification to another labor market area to report campus-specific wage data using a supplemental Form S-3 (CMS' manual version of Worksheet S-3) for purposes of the wage data comparison. These data would then constitute the appropriate wage data under Sec. 412.232(d)(2) for purposes of comparing the hospital's wages to the wages of hospitals in the area to which it seeks reclassification as well as the area in which it is located. Before the data could be used in a reclassification application, the

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hospital's fiscal intermediary would have to review the allocation of the entire hospital's wage data among the individual campuses.

For FY 2006 reclassification applications, we are proposing to allow a campus of a multicampus hospital system to use the average hourly wage data submitted for the entire multicampus hospital system as its appropriate wage data under Sec. 412.232(d)(2). We are establishing this special rule for FY 2006 reclassifications because the deadline for submitting an application to the MGCRB was September 1, 2004, and there no longer is an opportunity to provide a Supplemental Form S-3 that allocates the wage data by individual hospital campus. This special rule will be applied only to an individual campus of a multicampus hospital system that made an application for reclassification for FY 2006 and that otherwise meets all of the reclassification criteria. We do not believe that the special rule is necessary for reclassifications for FY 2007 because the deadline for making those applications has not yet passed and a hospital seeking reclassification will be able to provide the Supplemental Form S-3 that allocates the wage data by individual hospital campus. We are proposing to apply these new criteria to geographic reclassification applications that were received by September 1, 2004, and that will take effect for FY 2006.

We are proposing to revise the regulations at Sec. 412.230(d)(2) by redesignating paragraph (d)(2)(iii) as paragraph (d)(2)(v) and adding new paragraph (d)(2))(iii) and (d)(2)(iv) to incorporate the proposed new criteria for multicampus hospitals. 3. Urban Group Hospital Reclassifications

In FY 2005 IPPS final rule (69 FR 49104), we set forth, under Sec. 412.234(a)(3)(ii), revised criteria for urban hospitals to be reclassified as a group. After the publication of the final rule, we became aware that portions of our policy discussion with respect to the implementing decision were inadvertently omitted. This policy was corrected in the October 7, 2004, correction to the final rule (69 FR 60248). The correction specified that ``hospitals located in counties that are in the same Combined Statistical Area (under the MSA definitions announced by the OMB on June 6, 2003); or in the same Consolidated Metropolitan Statistical Area (CMSA) (under the standards published by the OMB on March 30, 1990) as the urban area to which they seek redesignation qualify as meeting the proximity requirement for reclassification to the urban area to which they seek redesignation.''

In making the determination to revise our urban group reclassification policy, we took into consideration the magnitude of the changes that would have resulted from our adoption of the new labor market areas. The resulting policy was intended to preserve the reclassification opportunities for urban county groups; in other words, an eligible urban county group would have to meet either the CSA or CMSA criteria, but not both to be eligible for consideration.

As a result of adopting the new labor market area definitions, we reexamined the appropriateness of the FY 2005 changes with emphasis on determining whether including ``* * * or in the same Consolidated Metropolitan Statistical Area (CMSA) (under the standards published by the OMB on March 30, 1990)'' as a qualifying criterion, is necessary or consistent with our plans to fully implement the new labor area market definitions.

Based on our experiences now that the new labor market areas are in effect and since we revised the urban county group regulations, we no longer think it is necessary to retain use of a 1990-based standard as a criterion for determining whether an urban county group is eligible for reclassification. We believe it is reasonable to use the area definitions that are based on the most recent statistics; in other words, the CSA standard. Therefore, we are proposing to delete Sec. 412.234(a)(3)(ii) to remove reference to the CMSA eligibility criterion. Beginning with FY 2006, we are proposing to require that hospitals must be located in counties that are in the same Combined Statistical Area (under the MSA definitions announced by the OMB on June 6, 2003) as the urban area to which they seek redesignation to qualify as meeting the proximity requirement for reclassification to the urban area to which they seek redesignation. We believe that this proposed change would improve the overall consistency of our policies by using a single labor market area definition for all aspects of the wage index and reclassification. 4. Clarification of Goldsmith Modification Criterion for Urban Hospitals Seeking Reclassification as Rural

Under section 1886(d)(8)(E) of the Act, certain urban hospitals may file an application for reclassification as rural if the hospital meets certain criteria. One of these criteria is that the hospital is located in a rural census tract of a CBSA, as determined under the most recent version of the Goldsmith Modification as determined by the Office of Rural Health Policy. This provision is implemented in our regulations at Sec. 412.103(a)(1).

The original Goldsmith Modification was developed using data from the 1980 census. In order to more accurately reflect current demographic and geographic characteristics of the Nation, the Office of Rural Health Policy, in partnership with the Department of Agriculture's Economic Research Service and the University of Washington, has developed the Rural-Urban Commuting Area codes (RUCAs) (69 FR 47518 through 47529, August 5, 2004). Rather than being limited to large area metropolitan counties (LAMCs), RUCAs use urbanization, population density, and daily commuting data to categorize every census tract in the country. RUCAs are the updated version of the Goldsmith Modification and are used to identify rural census tracts in all metropolitan counties.

We are proposing to update the Medicare regulations at Sec. 412.103(a)(1) to incorporate this change in the identification of rural census tracts. We are also proposing to update the website and the agency location at which the RUCA codes are accessible. 5. Cross-Reference Changes

In the FY 2005 IPPS final rule, in conjunction with changes made by various sections of Pub. L. 108-173 and changes in the OMB standards for defining labor market areas, we established a new Sec. 412.64 governing rules for establishing Federal rates for inpatient operating costs for FY 2005 and subsequent years. In this new section, we included definitions of ``urban'' and ``rural'' for the purpose of determining the geographic location or classification of hospitals under the IPPS. These definitions were previous located in Sec. 412.63(b), applicable to FYs 1985 through 2004, and in Sec. 412.62(f), applicable to FY 1984. References to the definitions under Sec. 412.62(f) and Sec. 412.63(b), appear throughout 42 CFR Chapter IV. However, when we finalized the provisions of Sec. 412.64, we inadvertently omitted updating some of these cross-references to reflect the change in the location of the two definitions for FYs 2005 and subsequent years. We are proposing to change the cross-references to the definitions of ``urban'' and ``rural'' to reflect their current locations in Subpart D of Part 412, as applicable.

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

(If you choose to comment on issues in this section, please include the caption ``Graduate Medical Education'' at the beginning of your comment.) 1. Background

Section 1886(h) of the Act, as added by section 9202 of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (Pub. L. 99-272) and implemented in regulations at existing Sec. Sec. 413.75 through 413.83, establishes a methodology for determining payments to hospitals for the costs of approved graduate medical education (GME) programs. Section 1886(h)(2) of the Act, as added by COBRA, sets forth a payment methodology for the determination of a hospital-specific, base-period per resident amount (PRA) that is calculated by dividing a hospital's allowable costs of GME for a base period by its number of residents in the base period. The base period is, for most hospitals, the hospital's cost reporting period beginning in FY 1984 (that is, the period of beginning between October 1, 1983, through September 30, 1984). Medicare direct GME payments are calculated by multiplying the PRA times the weighted number of full-time equivalent (FTE) residents working in all areas of the hospital (and nonhospital sites, when applicable), and the hospital's Medicare share of total inpatient days. In addition, as specified in section 1886(h)(2)(D)(ii) of the Act, for cost reporting periods beginning on or after October 1, 1993, through September 30, 1995, each hospital-specific PRA for the previous cost reporting period is not updated for inflation for any FTE residents who are not either a primary care or an obstetrics and gynecology resident. As a result, hospitals that train primary care and obstetrics and gynecology residents, as well as nonprimary care residents in FY 1994 or FY 1995, have two separate PRAs: One for primary care and obstetrics and gynecology residents and one for nonprimary care residents.

Pub. L. 106-113 amended section 1886(h)(2) of the Act to establish a methodology for the use of a national average PRA in computing direct GME payments for cost reporting periods beginning on or after October 1, 2000, and on or before September 30, 2005. Pub. L. 106-113 established a ``floor'' for hospital-specific PRAs equal to 70 percent of the locality-adjusted national average PRA. In addition, the BBRA established a ``ceiling'' that limited the annual adjustment to a hospital-specific PRA if the PRA exceeded 140 percent of the locality- adjusted national average PRA. Section 511 of the BIPA (Pub. L. 106- 554) increased the floor established by the BBRA to equal 85 percent of the locality-adjusted national average PRA. Existing regulations at Sec. 413.77(d)(2)(iii) specify that, for purposes of calculating direct GME payments, each hospital-specific PRA is compared to the floor and the ceiling to determine whether a hospital-specific PRA should be revised.

Section 1886(h)(4)(F) of the Act established limits on the number of allopathic and osteopathic residents that hospitals may count for purposes of calculating direct GME payments. For most hospitals, the limits were the number of allopathic and osteopathic FTE residents training in the hospital's most recent cost reporting period ending on or before December 31, 1996. 2. Direct GME Initial Residency Period (IRP) Sec. 413.79(a)(10) a. Background

As we have generally described above, the amount of direct GME payment to a hospital is based in part on the number of FTE residents the hospital is allowed to count for direct GME purposes during a year. The number of FTE residents, and thus the amount of direct GME payment to a hospital, is directly affected by CMS policy on how ``initial residency periods'' are determined for residents. Section 1886(h)(4)(C)(ii) of the Act, implemented at Sec. 413.79(b)(1), provides that while a resident is in the ``initial residency period'' (IRP), the resident is weighted at 1.00. Section 1886(h)(4)(C)(iii) of the Act, implemented at Sec. 413.79(b)(2), requires that if a resident is not in the resident's IRP, the resident is weighted at .50 FTE resident.

Section 1886(h)(5)(F) of the Act defines ``initial residency period'' as the ``period of board eligibility,'' and, subject to specific exceptions, limits the initial residency period to an ``aggregate period of formal training'' of no more than 5 years for any individual. Section 1886(h)(5)(G) of the Act generally defines ``period of board eligibility'' for a resident as ``the minimum number of years of formal training necessary to satisfy the requirements for initial board eligibility in the particular specialty for which the resident is training.'' Existing Sec. 413.79(a) of the regulations generally defines ``initial residency period'' as the ``minimum number of years required for board eligibility.'' Existing Sec. 413.79(a)(5) provides that ``time spent in residency programs that do not lead to certification in a specialty or subspecialty, but that otherwise meet the definition of approved programs * * * is counted toward the initial residency period limitation.'' Section 1886(h)(5)(F) of the Act further provides that ``the initial residency period shall be determined, with respect to a resident, as of the time the resident enters the residency training program.''

The IRP is determined as of the time the resident enters the ``initial'' or first residency training program and is based on the period of board eligibility associated with that medical specialty. Thus, these provisions limit the amount of FTE resident time that may be counted for a resident who, after entering a training program in one specialty, switches to a program in a specialty with a longer period of board eligibility or completes training in one specialty training program and then continues training in a subspecialty (for example, cardiology and gastroenterology are subspecialties of internal medicine). b. Direct GME Initial Residency Period Limitation: Simultaneous Match

We understand that there are numerous programs, including anesthesiology, dermatology, psychiatry, and radiology, that require a year of generalized clinical training to be used as a prerequisite for the subsequent training in the particular specialty. For example, in order to become board eligible in anesthesiology, a resident must first complete a generalized training year and then complete 3 years of training in anesthesiology. This first year of generalized residency training is commonly known as the ``clinical base year.'' Often, the clinical base year requirement is fulfilled by completing either a preliminary year in internal medicine (although the preliminary year can also be in other specialties such as general surgery or family practice), or a transitional year program (which is not associated with any particular medical specialty).

In many cases, during the final year of medical school, medical students apply for training in specialty residency training programs. Typically, a medical student who wants to train to become a specialist is ``matched'' to both the clinical base year program and the specialty residency training program at the same time. For example, the medical student who wants to become an anesthesiologist will apply and ``match'' simultaneously for a clinical base year in an internal medicine program for year 1 and for an anesthesiology training program beginning in year 2.

Prior to October 1, 2004, CMS' policy was that the IRP is determined for a

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resident based on the program in which he or she participates in the resident's first year of training, without regard to the specialty in which the resident ultimately seeks board certification. Therefore, for example, a resident who chooses to fulfill the clinical base year requirement for an anesthesiology program with a preliminary year in an internal medicine program will be ``labeled'' with the IRP associated with internal medicine, that is, 3 years (3 years of training are required to become board eligible in internal medicine), even though the resident may seek board certification in anesthesiology, which requires a minimum of 4 years of training to become board eligible. As a result, this resident would have an IRP of 3 years and, therefore, be weighted at 0.5 FTE in his or her fourth year of anesthesiology training for purposes of direct GME payment.

Effective with cost reporting periods beginning on or after October 1, 2004, to address programs that require a clinical base year, we revised our policy in the FY 2005 IPPS final rule (69 FR 49170 through 49174) concerning the IRP. Specifically, under the revised policy, if a hospital can document that a particular resident matches simultaneously for a first year of training in a clinical base year in one medical specialty, and for additional year(s) of training in a different specialty program, the resident's IRP will be based on the period of board eligibility associated with the specialty program in which the resident matches for the subsequent year(s) of training and not on the period of board eligibility associated with the clinical base year program. This change in policy is codified at Sec. 413.79(a)(10) of the regulations.

This policy applies regardless of whether the resident completes the first year of training in a separately accredited transitional year program or in a preliminary (or first) year in another residency training program such as internal medicine.

In addition, because programs that require a clinical base year are nonprimary care specialties, we specified in Sec. 413.79(a)(10) that the nonprimary care PRA would apply for the entire duration of the initial residency period. By treating the first year as part of a nonprimary care specialty program, the hospital will be paid at the lower nonprimary care PRA rather than the higher primary care PRA, even if the residents are training in a primary care program during the clinical base year.

In the FY 2005 IPPS final rule (69 FR 49170 and 49171), we also defined ``residency match'' to mean, for purposes of direct GME, a national process by which applicants to approved medical residency programs are paired with programs on the basis of preferences expressed by both the applicants and the program directors.

These policy changes, which were effective October 1, 2004, are only applicable to residents that simultaneously match in both a clinical base year program and a longer specialty residency program. We have become aware of situations where residents, upon completion of medical school, only match for a program beginning in the second residency year in an advanced specialty training program but fail to match for a clinical base year of training. Residents that match into an advanced program but fail to match into a clinical base year program may independently pursue unfilled residency positions in preliminary year programs after the match process is complete. However, because these residents do not ``simultaneously match'' into both a preliminary year and an advanced program, currently their IRP cannot be determined based on the period of board eligibility associated with the advanced program, as specified in Sec. 413.79(a)(10). Rather, the IRP for such residents would continue to be determined based on the specialty associated with the preliminary year program. For example, a student in the final year of medical school may match into a radiology program that begins in the second residency year, but not match with any clinical base year program. Under our current policy, if subsequent to conclusion of the match process, this resident secured a preliminary year position in an internal medicine program, the resident would not have met the requirements at Sec. 413.79(a)(10) for a simultaneous match and the IRP for this resident would be based on the length of time required to complete an internal medicine program (3 years) rather than the length of the radiology program (4 years).

The intent of the ``simultaneous match'' provision of Sec. 413.79(a)(10) is to identify in a verifiable manner the specialty associated with the program in which the resident will initially train and seek board certification. It is also the intent of Sec. 413.79(a)(10) that a resident's IRP would not change if the resident, after initially entering a training program in one specialty, changes programs to train in another medical specialty. The ``simultaneous match'' provisions of Sec. 413.79(a)(10) allow CMS to both identify the specialty associated with the program in which the resident is ultimately expected to train and seek board certification and prevent inappropriate revision of the IRP in cases where a resident changes specialties subsequent to beginning residency training. However, we note that when a medical student in his or her final year of medical school matches into an advanced program (for example, anesthesiology) for the second program year, but fails to match in a clinical base year, and obtains a preliminary year position outside the match process, we can still identify the specialty associated with the program in which the resident is ultimately expected to train and seek board certification and prevent inappropriate changes to the IRP if the resident changes specialties subsequent to beginning residency training.

Therefore, we are proposing to revise Sec. 413.79(a)(10) to state that, when a hospital can document that a resident matched in an advanced residency training program beginning in the second residency year prior to commencement of any residency training, the resident's IRP will be determined based on the period of board eligibility for the specialty associated with the advanced program, without regard to the fact that the resident had not matched for a clinical base year training program.

We note that this proposed policy change would not result in a policy to determine the IRP for all residents who must complete a clinical base year during the second residency training year based on the specialty associated with that second residency training year. That is, we are not proposing that, for any resident whose first year of training is completed in a program that provides a general clinical base year as required by the ACGME for certain specialties, an IRP should be assigned in the second year based on the specialty the resident enters in the second year of training. As we stated in the FY 2005 IPPS final rule (69 FR 49172), a ``second year'' policy would not allow CMS to distinguish between those residents who, in their second year of training, match in a specialty program prior to their first year of training, those residents who participated in a clinical base year in a specialty and then continued training in that specialty, and those residents who simply switched specialties in their second year. Rather, we are proposing that, if a hospital can document that a particular resident had matched in an advanced specialty program that requires completion of a clinical base year prior to the resident's first year of training, the IRP would not be determined based on the period of board eligibility for the specialty associated with the clinical base year

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program, for purposes of direct GME payment. Rather, under those circumstances, the IRP would be determined based upon the period of board eligibility associated with the specialty program in which the resident has matched and is expected to begin training in the second program year. 3. New Teaching Hospitals' Participation in Medicare GME Affiliated Groups (Sec. 413.79(e)(1))

In the August 29, 1997 final rule (62 FR 46005 through 46006) and the May 12, 1998 final rule (63 FR 26331 through 23336), we established rules for applying the FTE resident limit (or ``FTE cap'') for calculating Medicare direct GME and IME payments to hospitals. We added regulations, currently at Sec. 413.79(e), to provide for an adjustment to the FTE cap for certain hospitals that begin training residents in new medical residency training programs. For purposes of this provision, a new program is one that receives initial accreditation or begins training residents on or after January 1, 1995. Although we refer only to the direct GME provision throughout the remainder of this discussion, a similar cap adjustment is made under Sec. 412.105(f) for IME purposes. Therefore, this proposal applies to both IME and direct GME.

A new teaching hospital is one that had no allopathic or osteopathic residents in its most recent cost reporting period ending on or before December 31, 1996. Under Sec. 413.79(e)(1), if a new teaching hospital establishes one or more new medical residency training programs, the hospital's unweighted FTE caps for both direct GME and IME will be based on the product of the highest number of FTE residents in any program year in the third year of the hospital's first new program and the number of years in which residents are expected to complete the program(s), based on the minimum number of years of training that are accredited for the type of program(s).

The regulations at Sec. 413.79(e)(1)(iv) specify that hospitals in urban areas that qualify for an FTE cap adjustment for residents in newly approved programs under Sec. 413.79(e)(1) are not permitted to be part of a Medicare GME affiliated group for purposes of establishing an aggregate FTE cap. (A Medicare GME affiliated group is defined in the regulations at Sec. 413.75(b).) We established this policy because of our concern that hospitals with existing medical residency training programs could otherwise, with the cooperation of new teaching hospitals, circumvent the statutory FTE resident caps by establishing new medical residency programs in the new teaching hospitals solely for the purpose of affiliating with the new teaching hospitals to receive an upward adjustment to their FTE cap under an affiliation agreement. This would effectively allow existing teaching hospitals to achieve an increase in their FTE resident caps beyond the number allowed by their statutory caps.

In contrast, hospitals in rural areas that qualify for an adjustment under Sec. 413.79(e)(1)(v) are allowed to enter into a Medicare GME affiliation. Although we recognize that rural hospitals would not be immune from the kind of ``gaming'' arrangement described above, we allow new rural teaching hospitals that begin training residents in new programs, and thereby increase their FTE cap, to affiliate because we understand that rural hospitals may not have a sufficient volume of patient care utilization at the rural hospital site to be able to support a training program that meets accreditation standards. Securing sufficient patient volumes to meet accreditation requirements may necessitate rotations of the residents to another hospital. Accordingly, the regulations allow new teaching hospitals in rural areas to enter into Medicare GME affiliation agreements. However, an affiliation is only permitted if the rural hospital provides training for at least one-third of the FTE residents participating in all of the joint programs of the affiliated hospitals because, as we stated in the May 12, 1998 Federal Register (63 FR 26333), we believe that requiring at least one-third of the training to take place in the rural area allows operation of programs that focus on, but are not exclusively limited to, training in rural areas.

Through comment and feedback from industry trade groups and hospitals, we understand that, while these rules were meant to prevent gaming on the part of existing teaching hospitals, they could also preclude affiliations that clearly are designed to facilitate additional training at the new teaching hospital.

For example, Hospital A had no allopathic or osteopathic residents in its most recent cost reporting period ending on or before December 31, 1996. As such, Hospital A's caps for direct GME and IME are both zero. Hospital A and Hospital B enter into a Medicare GME affiliation for the academic year beginning on July 1, 2003, and ending on June 30, 2004. On July 1, 2003, Hospital A begins training residents from an existing family medicine program located at Hospital B. This rotation will result in 5 FTE residents training at Hospital A. Through the affiliation agreement, Hospital A receives a positive adjustment of 5 FTE's for both its direct GME and IME caps. Hospital B receives a corresponding negative adjustment of 5 FTEs under the affiliation agreement. Hospital A's Board of Directors is interested in starting a new residency program in Internal Medicine that would begin training residents at Hospital A on July 1, 2005. If Hospital A establishes the new program, under existing Medicare regulations, Hospital A will have its direct GME and IME caps (which were both previously established at zero) permanently adjusted to reflect the additional residents training in the newly approved program in accordance with Sec. 413.79(e)(1). However, under existing regulations, Hospital A may no longer enter into an affiliation with Hospital B after it receives the adjustment to its FTE caps under Sec. 413.79(e)(1).

We are proposing to revise Sec. 413.79(e)(1)(iv) so that new urban teaching hospitals that qualify for an adjustment under Sec. 413.79(e)(1) may enter into a Medicare GME affiliation agreement under certain circumstances. Specifically, a new urban teaching hospital that qualifies for an adjustment to its FTE caps for a newly approved program may enter into a Medicare GME affiliation agreement, but only if the resulting adjustments to its direct GME and IME caps are ``positive adjustments.'' ``Positive adjustment'' means, for the purpose of this policy, that there is an increase in the new teaching hospital's caps as a result of the affiliation agreement. At no time would the caps of a hospital located in an urban area that qualifies for adjustment to its FTE caps for a new program under Sec. 413.79(e)(1), be allowed to decrease as a result of a Medicare GME affiliation agreement. We believe this proposed policy change would allow new urban teaching hospitals flexibility to start new teaching programs without jeopardizing their ability to count additional FTE residents training at the hospital under an affiliation agreement.

We remain concerned that hospitals with existing medical residency training programs could cooperate with a new teaching hospital to circumvent the statutory FTE caps by establishing new programs at the new teaching hospital, and, through a Medicare GME affiliation agreement, moving most or all of the new residency program to its own hospital, thereby receiving an upward adjustment to its FTE caps. For this reason, we are proposing to revise

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Sec. 413.79(e)(1)(iv) of the regulations to provide that a hospital that qualifies for an adjustment to its caps under Sec. 413.79(e)(1) would not be permitted to enter into an affiliation agreement that would produce a negative adjustment to its FTE resident cap.

Continuing the example shown above, under the proposed change in policy, Hospital A and Hospital B would be able to continue the Medicare GME affiliation agreement under which Hospital A trained residents from Hospital B's family practice program because Hospital A would receive an increase in its direct GME or IME caps under an affiliation after qualifying for a new program adjustment under Sec. 413.79(e)(1). However, Hospital B would not be able to receive an increase in its caps as a result of a Medicare GME affiliation agreement with Hospital A.

Thus, we are proposing the above policy change to provide some flexibility to hospitals that are currently prohibited from entering into a Medicare GME affiliation agreement, while continuing to protect the statutory FTE resident caps from being undermined by gaming. We solicit comments on the proposed change. 4. GME FTE Cap Adjustment for Rural Hospitals (Sec. 413.79(c) and (k))

As stated earlier under section V.I.1. of this preamble, Medicare makes both direct and indirect GME payments to hospitals for the training of residents. Direct GME payments are made in accordance with section 1886(h) of the Act, based generally on the hospital-specific PRA, the number of FTE residents a hospital trains, and the hospital's percentage of Medicare inpatient utilization. Indirect GME payments (referred to as IME) are made in accordance with section 1886(d)(5)(B) of the Act as an adjustment to DRG payment and are based generally on the ratio of the hospital's FTE residents to the number of hospital beds. It is well-established that the calculation of both direct GME and IME payments is affected by the number of FTE residents a hospital is allowed to count; generally, the greater the number of FTE residents a hospital counts, the greater the amount of Medicare direct GME and IME payments the hospital will receive.

Effective October 1, 1997, Congress instituted caps on the number of allopathic and osteopathic residents a hospital is allowed to count for direct GME and IME purposes at sections 1886(h)(4)(F) (direct GME) and 1886(d)(5)(B)(v) (IME) of the Act. These caps were instituted in an attempt to end the implicit incentive for hospitals to increase the number of FTE residents. Dental and podiatric residents were not included in these statutorily mandated caps.

Congress provided certain exceptions for rural hospitals when establishing the 1996 caps ``with the intent of encouraging physician training and practice in rural areas'' (65 FR 47032). For example, the statute states at section 1886(h)(4)(H)(i) that, in promulgating rules regarding application of the FTE caps to training programs established after January 1, 1995, ``the Secretary shall give special consideration to facilities that meet the needs of underserved rural areas.'' Accordingly, in implementing this provision, we provided in the regulations under Sec. 413.86(g)(6)(i)(C) (now Sec. 413.79(e)(1)(iii)) that ``except for rural hospitals, the cap will not be adjusted for new programs established more than 3 years after the first program begins training residents. In other words, only hospitals located in rural areas (that is, areas that are not designated as an MSA), receive adjustments to their unweighted FTE caps to reflect residents in new medical residency training programs past the third year after the first residency program began training in that hospital (62 FR 46006).

Section 413.79(e)(1) specifies the new program adjustment as the ``product of the highest number of residents in any program year during the third year of the * * * program's existence * * * and the number of years in which residents are expected to complete the program based on the minimum accredited length for the type of program.'' The regulation applies only to new programs (as defined under Sec. 413.79(1)) established by rural hospitals, not for expansion of previously existing programs. For example, if a rural hospital has an unweighted FTE cap for direct GME of 100 and begins training residents in a new 3- year residency program that has 10 residents in each of its first 3 program years (for a total of 30 residents in the entire program in the program's third year), the hospital's direct GME FTE cap of 100 would be permanently adjusted at the conclusion of the third program year by 30, and the hospital's new FTE cap would be 130. A similar adjustment would be made to the hospital's FTE cap for IME in accordance with the regulations at Sec. 412.105(f)(1)(iv)(A). However, the rural hospital would not be able to receive adjustments to its FTE cap for any expansion of a preexisting program.

In 1999, Congress passed an additional provision under section 407 of Pub. L. 106-113 (BBRA) to promote physician training in rural areas. Section 407 of the Pub. L. 106-113 amended the FTE caps provision at sections 1886(h)(4)(F) and 1886(d)(5)(B)(v) of the Act to provide that ``effective for cost reporting periods beginning on or after April 1, 2000, [a rural hospital's FTE cap] is 130 percent of the unweighted FTE count * * * for those residents for the most recent cost reporting period ending on or before December 31, 1996.'' In other words, the otherwise applicable FTE caps for rural hospitals were multiplied by 1.3 to encourage rural hospitals to expand preexisting residency programs. (As described above, even prior to the BBRA change, rural hospitals were able to receive FTE cap adjustments for new programs.) For example, a hospital that was rural as of April 1, 2000, and had a direct GME cap of 100 FTEs would receive a permanent cap adjustment of 30 FTEs (100 FTEs x 1.3 = 130 FTEs) and effective for cost reporting periods beginning on or after April 1, 2000, its FTE for direct GME would be 130. (A similar adjustment would be made to the FTE cap for IME for discharges occurring on or after April 1, 2000.)

We recently received questions regarding the application of the 130-percent FTE cap adjustment and the new program adjustment for rural hospitals in instances in which a rural teaching hospital is later redesignated as an urban hospital or reclassifies back to being an urban hospital after having been classified as rural. We are aware of two circumstances when a rural hospital may subsequently be reclassified as urban. The first circumstance involves labor market area changes, and the second involves urban hospitals, after having been reclassified as rural through section 1886(d)(8)(E) of the Act, that elect to be considered urban again. In both situations, if the hospital in question was a teaching hospital, its FTE caps would have been subject to the 130 percent and new program FTE cap adjustments while it was designated or classified as rural. The issue is whether the adjusted caps would continue to apply after the hospital becomes urban or returns to being treated as urban. Below we first address hospitals that lost their status as urban hospitals due to new labor market areas. We then address hospitals that rescinded their section 1886(d)(8)(E) reclassifications. (We note that reclassification by the MGCRB under section 1886(d)(10) of the Act, as well as reclassifications under section 1886(d)(8)(B) of the Act, are effective only for purposes of the wage index and would not affect the hospital's IME or direct GME payments).

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a. Formerly Rural Hospitals That Became Urban Due to the New CBSA Labor Market Areas

In the FY 2005 IPPS final rule, we adopted the new CBSA-based labor market areas announced by OMB on June 6, 2003, and these areas became effective October 1, 2004. As a result of these new labor market areas, a number of hospitals that previously were located outside of an MSA and therefore considered rural are now located in a CBSA that is designated as urban and considered urban.

We believe that previously rural hospitals that received adjustments due to establishing new medical training programs should not now be required to forego such adjustments simply because they have now been redesignated as urban. Such hospitals added and received accreditation for new medical training programs under the assumption that such programs would effect a permanent increase in their FTE caps. Indeed, we believe it would be nonsensical to view the fact that these hospitals are now urban as causing them to lose the adjustments that stemmed directly from the permissible and encouraged establishment of new medical training programs. Such hospitals cannot reach back into the past and alter whether they added the new programs or not. Nor would it be reasonable to prohibit them from counting FTE residents training in new programs that they worked to accredit. (We note that the hospitals would not be required to close the programs. Rather, if they were not permitted to retain the adjustments to their FTE caps they received as a result of having established new programs, they would no longer be permitted to count FTE residents that exceeded their original, preadjustment FTE caps for purposes of direct GME and IME payments. The effect might be that the hospital would have to close the program(s) as a result of decreased Medicare funding, but the hospital would be free to continue to operate the programs(s).)

For these reasons, we believe the best reading of our regulation at Sec. 413.79(e)(3), which states that if a hospital ``is located in a rural area,'' it may adjust its FTE cap to reflect residents training in new programs, is that hospitals were permitted to receive a permanent adjustment to their FTE caps if, at the time of adding a new program, the hospitals were rural. A hospital's subsequent designation as urban or rural due to labor market area changes becomes irrelevant, because the central question is whether the hospital is rural at the time it adds the new programs. Therefore, we are clarifying in this proposed rule our policy that hospitals that became urban in FY 2005 due to the new labor market areas would nevertheless be permitted to retain the adjustments they received for new programs as long as they were rural at the time they received them. (Once such hospitals receive a designation as ``urban,'' they may no longer seek FTE cap adjustments relating to new training programs; they may only retain the adjustments they received for the new programs they added when they were rural.)

Similarly, we believe that rural hospitals that received the statutorily mandated 130 percent adjustment to their FTE caps would be disadvantaged if we were to rescind this adjustment due to new urban designation. Such hospitals expanded their already existing training programs under the assumption that these expansions would cause a permanent increase in their FTE caps. Many of these hospitals expanded their programs only once the BBRA became effective (in 2000). Thus, they have had only a few years to expand their programs and receive the cap adjustment mandated by statute. For these reasons, we believe it is permissible to read sections 1886(h)(4)(F)(i) and 1886(d)(5)(B)(v) of the Act as permitting a permanent adjustment to the FTE caps at the time a rural hospital adds residents to its already existing program(s). The language states that the total number of FTE residents with respect to a ``hospital's approved medical residency training program in the fields of allopathic medicine and osteopathic medicine may not exceed the number (or, 130 percent of such number in the case of a hospital located in a rural area) of such full-time equivalent residents for the hospital's most recent cost reporting period ending on or before December 31, 1996.'' As with the addition of new programs, we interpret the language ``130 percent of such number in the case of a hospital located in a rural area,'' as meaning only that the hospital was required to be rural at the time it received the 30-percent increase. Once the hospital received such increase, the increase became a permanent increase in the FTE cap and should not be rescinded based on subsequent designation as an urban hospital.

We believe our interpretations are consistent with legislative intent. Congress provided for these FTE cap adjustments for rural hospitals with the intent of encouraging physician training and practice in rural areas. If rural hospitals had believed that new CBSAs would cause them to lose the adjustments, they would not have had the incentives Congress wished to increase the number of FTE residents training in their programs. These hospitals might have feared losing the adjustments as a result of new labor market areas, and therefore not carried out Congress' intent to expand their already existing residency training programs or add new residency training programs.

To provide an example of the how the above statutory interpretations would be applied, a hospital located in a rural area prior to October 1, 2004, with an unweighted direct GME FTE cap of 100 would have received a 30-percent increase in its FTE cap so that its adjusted cap was 130 FTEs. The rural hospital also could have received an adjustment for any new medical residency program. If this hospital, while rural, started a new 3-year residency program with 10 residents in each program year, its FTE cap would have been increased by an additional 30 FTEs to 160 FTEs (that is, (100 FTEs x 1.3) + 30 FTEs = 160 FTEs). Under our reading of the statute, if this hospital is now located in an urban area due to the new CBSAs, it would retain this cap of 160 FTEs.

We also believe that the statute should be interpreted as permitting urban hospitals with rural track training programs to retain the adjustment they received for such programs at Sec. 413.79(k), even if the ``rural'' tracks as of October 1, 2004, are now located in urban areas due to the new OMB labor market areas. As explained in the FY 2001 IPPS final rule (66 FR 47033), we provided that an urban hospital that establishes a separately accredited medical residency training program in a rural area (that is, a rural track) may receive an adjustment to reflect the number of residents in that program (existing Sec. 413.79(k)). Section 1886(h)(4)(H)(iv) of the Act states: ``In the case of a hospital that is not located in a rural area but establishes separately accredited approved medical residency training programs (or rural tracks) in an (sic) rural area or has an accredited training program with an integrated rural track, the Secretary shall adjust the limitation under subparagraph (F) in an appropriate manner insofar as it applies to such programs in such rural areas in order to encourage the training of physicians in rural areas.''

Again, we believe that the reading that best carries out Congressional intent is one that allows the adjustment for rural tracks to remain permanent as long as the rural track training programs continue, even if the once-rural tracks

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are now urban due to new labor market area boundaries. Congress clearly intended to encourage the training of physicians in the rural tracks identified by the statute. However, if the FTE cap adjustments were merely temporary, and hospitals could not rely on retaining the adjustments relating to the rural training programs in which they invested, then Congress' wishes to encourage rural training programs might not have been realized. Hospitals would always need to speculate as to whether the FTE cap adjustments relating to the rural track programs they established would be lost each time new labor market areas were adopted (which normally occurs once every 10 years). Thus, we believe the statutory language should be interpreted as allowing an urban hospital to retain its FTE cap adjustment for rural track programs as long as the tracks were actually located in rural areas at the time the urban hospital received its adjustment. However, if the urban hospital wants to receive a cap adjustment for a new rural track residency program, the rural track must involve rural hospitals that are located in rural areas based on the most recent OMB labor market designations as specified in the FY 2005 IPPS final rule. We are proposing to add a new paragraph (k)(7) to Sec. 413.79 to incorporate this proposal. b. Section 1886(d)(8)(E) Hospitals

As stated above, a second situation exists where a hospital that is treated as rural returns to being urban under section 1886(d)(8)(E) of the Act (Sec. 412.103 of the regulations). Under this provision, an urban hospital may file an application to be treated as being located in a rural area. A hospital's reclassification as located in a rural area under this provision affects only payments under section 1886(d) of the Act. Accordingly, a hospital that is treated as rural under this provision can receive the FTE cap adjustments that any other rural hospital receives, but only to the FTE cap that applies for purposes of IME payments, which are made under section 1886(d) of the Act. The hospital could not receive adjustments to its direct GME FTE cap because payments for direct GME are made under section 1886(h) of the Act and the section 1886(d)(8)(E) reclassifications affect only the payments that are made under that section 1886(d) of the Act. Therefore, a hospital that reclassifies as rural under section 1886(d)(8)(E) of the Act may receive the 130-percent adjustment to its IME FTE cap and its IME FTE cap may be adjusted for any new programs, similar to hospitals that are actually located in a rural location. A hospital treated as rural under section 1886(d)(8)(E) of the Act may subsequently withdraw its election and return to its urban status under the regulations at Sec. 412.103. We are proposing that, effective with discharges occurring on or after October 1, 2005, a different policy should apply for hospitals that reclassify under section 1886(d)(8)(E) of the Act than the policy that applies to rural hospitals redesignated as urban due to changes in labor market areas, as discussed in section IV.F.3 of this preamble. 5. Technical Changes: Cross References

In the FY 2005 IPPS final rule (69 FR 49234), we redesignated the contents of Sec. 413.86 as Sec. Sec. 413.75 through 413.83. We also updated cross-references to Sec. 413.86 that were located in various sections under 42 CFR Parts 400 through 499. We inadvertently did not capture all of the needed cross-reference changes. In this proposed rule, we are proposing to correct the additional cross-references in 42 CFR Parts 405, 412, 413, 415, 419, and 422 that were not made in the August 11, 2004 final rule.

When we redesignated Sec. 413.86 as Sec. Sec. 413.75 through 413.83 in the FY 2005 IPPS final rule, we also made a corresponding redesignation of Sec. 413.80 as Sec. 413.89. We are proposing to correct cross-references to Sec. 413.80 in 42 CFR Parts 412, 413, 417, and 419 to reflect the redesignation of this section as Sec. 413.89.

J. Provider-Based Status of Facilities and Organizations Under Medicare

(If you choose to comment on issues in this section, please include the caption ``Provider-Based Entities'' at the beginning of your comment.) 1. Background

Since the beginning of the Medicare program, some providers, which we refer to as ``main providers,'' have functioned as a single entity while owning and operating multiple provider-based departments, locations, and facilities that were treated as part of the main provider for Medicare purposes. Having clear criteria for provider- based status is important because this designation can result in additional Medicare payments for services furnished at the provider- based facility, and may also increase the coinsurance liability of Medicare beneficiaries for those services.

To set forth Medicare policies with regard to the provider-based status of facilities and organizations, we have published a number of Federal Register documents as follows:

In a proposed rule published in the Federal Register on September 8, 1998 (63 FR 47552), we proposed specific and comprehensive criteria for determining whether a facility or organization is provider-based. In the preamble to the proposed rule, we explained why we believed meeting each criterion would be necessary to a finding that a facility or organization qualifies for provider-based status. After considering public comments on the September 8, 1998 proposed rule and making appropriate revisions, on April 7, 2000 (65 FR 18504), we published a final rule setting forth the provider-based regulations at 42 CFR 413.65.

Before the regulations that were issued on April 7, 2000 could be implemented, Congress enacted the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA), Pub. L. 106-544. Section 404 of BIPA delayed implementation of the April 7, 2000 provider-based rules with respect to many providers, and mandated changes in the criteria at Sec. 413.65 for determining provider-based status.

In order to conform our regulations to the requirements of section 404 of BIPA and to codify certain clarifications of provider- based policy that had previously been posted on the CMS Web site, we published another proposed rule on August 24, 2001 (66 FR 44672). After considering public comments on the August 24, 2001 proposed rule and making appropriate revisions, we published a final rule on November 30, 2001 setting forth the provider-based regulations (66 FR 59909).

On May 9, 2002, we proposed further significant revisions to the provider-based regulations at Sec. 413.65 (67 FR 31480). After considering public comments on the May 9, 2002 proposed rule and making appropriate revisions, on August 1, 2002, we published a final rule specifying the criteria that must be met to qualify for provider-based status (67 FR 50078). These regulations remain in effect and continue to be codified at Sec. 413.65.

Following is a discussion of the major provisions of the provider- based regulations: Section 413.65(a) of the regulations describes the scope of that section and provides definitions of key terms used in the regulations. Paragraph (b) describes the procedure for making provider- based determinations, and paragraph (c) imposes requirements for reporting material changes in relationships between main providers and provider-based facilities or organizations. In paragraph (d), we

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specify the requirements that are applicable to all facilities or organizations seeking provider-based status, and in paragraph (e), we describe the additional requirements applicable to off-campus facilities or organizations (generally, those located more than 250 yards from the provider's main buildings). Paragraphs (f) through (o) set forth policies regarding joint ventures, obligations of provider- based facilities, facilities operated under management contracts or providing all services under arrangements, procedures in connection with certain provider-based determinations, and specific types of facilities such as Indian Health Service (IHS) and Tribal facilities and Federally qualified health centers (FQHCs). 2. Limits on the Scope of the Provider-Based Regulations--Facilities for Which Provider-Based Determinations Will Not Be Made

In Sec. 413.65(a) (1)(ii), we list specific types of facilities and organizations for which determinations of provider-based status will not be made. We previously concluded that provider-based determinations should not be made for these facilities because the outcome of the determination (that is, whether a facility, unit, or department is found to be freestanding or provider-based) would not affect the methodology used to make Medicare or Medicaid payment, the scope of benefits available to a Medicare beneficiary in or at the facility, or the deductible or coinsurance liability of a Medicare beneficiary in or at the facility.

We have now concluded that, under the principle stated above, rural health clinics affiliated with hospitals having 50 or more beds should be added to the list of facilities for which provider-based status determinations are not made. Therefore, we are proposing to revise Sec. 413.65(a)(1)(ii) to add rural health clinics with hospitals having 50 or more beds to the listing of the types of facilities for which a provider-based status determination will not be made. We believe this proposed revision to Sec. 413.65(a)(1)(ii) is appropriate because all rural health clinics affiliated with hospitals having 50 or more beds are paid on the same basis as rural health clinics not affiliated with any hospital, and the scope of Medicare Part B benefits and beneficiary liability for Medicare Part B deductible and coinsurance amounts would be the same, regardless of whether the rural health clinic was found to be provider-based or freestanding.

In setting forth this proposal, we recognize that rural health clinics affiliated with hospitals report their costs using the hospital's cost report rather than by filing a separate rural health clinic cost report, and that whether or not a rural health clinic is hospital-affiliated will affect the selection of a fiscal intermediary for the clinic. However, we do not believe these administrative differences provide a sufficient reason to make provider-based determinations for such rural health clinics. 3. Location Requirement for Off-Campus Facilities: Application to Certain Neonatal Intensive Care Units

As we stated in the preamble to May 9, 2002 proposed rule for changes in the provider-based rules (67 FR 31485), we recognize that provider-based status is not limited to on-campus facilities or organizations and that facilities or organizations located off the main provider campus may also be sufficiently integrated with the main provider to justify a provider-based designation. However, the off- campus location of the facilities or organizations may make such integration harder to achieve, and such integration should not simply be presumed to exist. Therefore, to ensure that off-campus facilities or organizations seeking provider-based status are appropriately integrated, we have adopted certain requirements regarding the location of off-campus facilities or organizations. These requirements are set forth in Sec. 413.65(e)(3). Section 413.65(e)(3) specifies that a facility or organization not located on the main campus of the potential main provider can qualify for provider-based status only if it is located within a 35-mile radius of the campus of the hospital or CAH that is the potential main provider, or meets any one of the following requirements.

The facility or organization is owned and operated by a hospital or CAH that has a disproportionate share adjustment (as determined under Sec. 412.106) greater than 11.75 percent or is described in Sec. 412.106(c)(2) of the regulations which implement section 1886(e)(5)(F)(i)(II) of the Act and is--

--Owned or operated by a unit of State or local government; --A public or nonprofit corporation that is formally granted governmental powers by a unit of State or local government; or --A private hospital that has a contract with a State or local government that includes the operation of clinics located off the main campus of the hospital to assure access in a well-defined service area to health care services for low-income individuals who are not entitled to benefits under Medicare (or medical assistance under a Medicaid State plan). (Sec. 413.65(e)(3)(i))

The facility or organization demonstrates a high level of integration with the main provider by showing that it meets all of the other provider-based criteria and demonstrates that it serves the same patient population as the main provider, by submitting records showing that, during the 12-month period immediately preceding the first day of the month in which the application for provider-based status is filed with CMS, and for each subsequent 12-month period--

--At least 75 percent of the patients served by the facility or organization reside in the same zip code areas as at least 75 percent of the patients served by the main provider (Sec. 413.65(e)(3)(ii)(A)); or --At least 75 percent of the patients served by the facility or organization who required the type of care furnished by the main provider received that care from that provider (for example, at least 75 percent of the patients of a rural health clinic seeking provider- based status received inpatient hospital services from the hospital that is the main provider (Sec. 413.65(e)(3)(ii)(B)).

Section 413.65(e)(3)(ii)(C) of the regulations allows new facilities or organizations to qualify as provider-based entities. Under this section, if a facility or organization is unable to meet the criteria in Sec. 413.65(e)(3)(ii)(A) or (e)(3)(ii)(B) because it was not in operation during all of the 12-month period before the start of the period for which provider-based status is sought, the facility or organization may nevertheless meet the location requirement of paragraph (e)(3) of Sec. 413.65 if it is located in a zip code area included among those that, during all of the 12-month period before the start of the period for which provider-based status is sought, accounted for at least 75 percent of the patients served by the main provider.

CMS has been advised that, in some cases, the location requirements in current regulations may inadvertently impede the delivery of intensive care services to newborn infants in areas where there is no nearby children's hospital with a neonatal intensive care unit (NICU). According to those who expressed this concern, hospitals participating in the Medicare program as children's hospitals establish off-site neonatal intensive care units (NICUs) which they operate and staff but which are located in space leased from other hospitals. The hospitals in which the offsite NICUs are housed typically are

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short-term, acute care hospitals located in rural areas. According to comments that CMS has received, the nearest children's hospital in a rural area is usually located a considerable distance from individual rural communities, which prevents infants in these rural communities from having ready access to the specialized care offered by NICUs.

We have received a suggestion that this configuration (that of a hospital participating in the Medicare program as a hospital whose inpatients are predominantly individuals under 18 years of age under section 1886(d)(1)(B)(iii) of the Act, establishing an offsite NICU which it operates and staffs but which is located in space leased from another hospital) can be very helpful in making neonatal intensive care more quickly available in areas where community hospitals are located. In addition, this configuration can offer relief to families who otherwise would be required to travel long distances to obtain this care for their infants. However, offsite NICUs would not be able to qualify for provider-based status under the location criteria in our current regulations if they are located more than 35 miles from the children's hospital that would be the main provider, are not owned and operated by a hospital meeting the requirements of Sec. 413.65(e)(3)(i), and cannot meet either of the ``75 percent tests'' for service to the same patient population as the potential main provider that are specified in existing Sec. 413.65(e)(3)(ii)(A) and Sec. 413.65(e)(3)(ii)(B).

We understand the concern that requiring a patient to be transported to an NICU located on the campus of a distant children's hospital could create an unacceptable medical risk to the life of a newborn at a most critical time. To help us better understand this issue and determine what action, if any, CMS should take on it, we are soliciting specific public comment on the following question:

Is the problem as described above actually occurring and, if so, in what locations? We are particularly interested in learning which areas of which States are experiencing such a problem, and in receiving specific information, such as the rates of transfer of newborns from community hospitals to children's hospital on-campus NICUs relative to adult or non-neonatal pediatric transfers for intensive care services, which describe the problem objectively. Such objective information will be much more useful than expressions of opinion or anecdotes.

We also wish to ask those who believe such a problem is currently occurring to comment on which of the following approaches would be most effective in resolving it. The proposed approaches on which we are soliciting specific comments are:

[s] A change in the Medicare provider- based regulations to create an exception to the location requirements for NICUs located in community hospitals that are more than 35 miles from the children's hospital that is the potential main provider. The exception might take the form of a more generous mileage allowance (such as being within 50 miles of the potential main provider) or could require other criteria to be met. However, the exception would be available only if there is no other NICU within 35 miles of the community hospital.

[s] A change in the national Medicaid regulations to allow off-campus NICUs that meet other provider-based requirements under Sec. 413.65 to qualify as provider-based for purposes of payment under Medicaid, even though those facilities would not qualify as provider-based under Medicare. (We note that under 42 CFR 440.10(a)(3)(iii), services are considered to be ``inpatient hospital services'' under the Medicaid program only if they are furnished in an institution that meets the requirements for participation in Medicare as a hospital. Because of the age of the patients they serve, NICUs typically have no Medicare utilization but a substantial proportion of their patients may be Medicaid patients.)

[s] A change in individual State's Medicaid plans that would provide enhanced financial incentives for community hospitals to establish NICUs, possibly in collaboration with children's hospitals.

[s] The establishment of children's hospitals that meet the requirements for being hospitals-within- hospitals under 42 CFR 412.22(e). (We note that this option, unlike the three above, would not require any revision of Medicare or Medicaid regulations or individual State Medicaid plans).

We also welcome suggestions for specific options other than those listed above. 4. Technical and Clarifying Changes to Sec. 413.65

a. Definitions. In paragraph (a)(2) of Sec. 413.65, we state that the term ``Provider-based entity'' means a provider of health care services, or an RHC as defined in Sec. 405.2401(b), that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of a different type from those of the main provider under the name, ownership and administrative and financial control of the main provider, in accordance with the provisions of Sec. 413.65. In recognition of the fact that provider- based entities, unlike departments of a provider, offer a type of services different from those of the main provider and participate separately in Medicare, we are proposing to revise this requirement by deleting the word ``name'' from this definition. This change would simplify compliance with the provider-based criteria since entities that do not now operate under the potential main provider's name will not be obligated to change their names in order to be treated as provider-based.

b. Provider-based determinations. In paragraph (b)(3)(ii) of Sec. 413.65, we state that, in the case of a facility not located on the campus of the potential main provider, the provider seeking a determination would be required to submit an attestation stating that the facility meets the criteria in paragraphs (d) and (e) of Sec. 413.65, and if the facility is operated as a joint venture or under a management contract, the requirements of paragraph (f) or paragraph (h) of Sec. 413.65, as applicable. However, paragraph (f), which sets forth rules regarding provider-based status for joint ventures, states clearly that a facility or organization operated as a joint venture may qualify for provider-based status only if it is located on the main campus of the potential main provider. To avoid any misunderstanding regarding the content of attestations for off-campus facilities, we are proposing to revise paragraph (b)(3)(ii) by removing the reference to compliance with requirements in paragraph (f) for joint ventures. We also are proposing to add a sentence to paragraph (b)(3)(i), regarding attestations for on-campus facilities, to state that if the facility is operated as a joint venture, the attestation by the potential main provider regarding that facility would also have to include a statement that the provider will comply with the requirements of paragraph (f) of Sec. 413.65.

c. Additional requirements applicable to off-campus facilities or organizations--Operation under the ownership and control of the main provider. In paragraph (e)(1)(i), regarding 100 percent ownership by the main provider of the business enterprise that constitutes the facility or organization seeking provider-bases status, we are proposing to add the word ``main'' before the word ``provider'', to clarify that the main provider must own and control the facility or organization seeking provider-based status. We are also proposing, for purposes of

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clarifying the requirements in paragraph (e)(1), to add the word ``main'' before the word ``provider'' in paragraphs (e)(1)(ii) and (e)(1)(iii).

d. Additional requirements applicable to off-campus facilities or organizations--Location. We are proposing several clarifying changes to this paragraph, as follows:

Currently, the opening sentence of Sec. 413.65(e)(3) states that a facility or organization for which provider-based status is sought must be located within a 35-mile radius of the campus of the hospital or CAH that is the potential main provider, except when the requirements in paragraph (e)(3)(i), (e)(3)(ii), or (e)(3)(iii) of that section are met. However, the regulation text that follows does not contain a paragraph designation as paragraph (e)(3)(iii). We are proposing to correct this error by redesignating existing paragraph (e)(3)(ii)(C) as paragraph (e)(3)(iv). We are also proposing to revise this sentence to state that the facility or organization must meet the requirements in paragraph (e)(3)(i), (e)(3)(ii), (e)(3)(iii), (e)(3)(iv) or, in the case of an RHC, paragraph (e)(3)(v) of Sec. 413.65 and the requirements in paragraph (e)(3)(vi) of Sec. 413.65.

We are proposing to revise the opening sentence of Sec. 413.65(e)(3) to reflect the changes in the coding of this paragraph as described above.

We are also proposing to redesignate paragraph (v) of Sec. 413.65(e)(3) as paragraph (e)(3)(vi) and correct a drafting error by adding the word ``that'' before ``has fewer than 50 beds''. This proposed addition is a grammatical change that is intended only to clarify the size of the hospital with which a rural health clinic must have a provider-based relationship in order to qualify under the special location requirement in that paragraph.

e. Paragraph (g)--Obligations of hospital outpatient departments and hospital-based entities. We are proposing to revise the first sentence of paragraph (g)(7), regarding beneficiary notices of coinsurance liability, to clarify that notice must be given only if the service is one for which the beneficiary will incur a coinsurance liability for both an outpatient visit to the hospital and the physician service. This should help to make it clear that notice is not required for visits that do not result in additional coinsurance liability. In addition, we are proposing to reorganize the subsequent paragraphs of that section for clarity.

K. Rural Community Hospital Demonstration Program

(If you choose to comment on issues in this section, please include the caption ``Rural Community Hospital Demonstration Program'' at the beginning of your comments.)

In accordance with the requirements of section 410A(a) of Pub. L. 108-173, the Secretary has established a 5-year demonstration (beginning with selected hospitals' first cost reporting period beginning on or after October 1, 2004) to test the feasibility and advisability of establishing ``rural community hospitals'' for Medicare payment purposes for covered inpatient hospital services furnished to Medicare beneficiaries. A rural community hospital, as defined in section 410A(f)(1), is a hospital that--

Is located in a rural area (as defined in section 1886(d)(2)(D) of the Act) or treated as being so located under section 1886(d)(8)(E) of the Act;

Has fewer than 51 beds (excluding beds in a distinct part psychiatric or rehabilitation unit) as reported in its most recent cost report;

Provides 24-hour emergency care services; and

Is not designated or eligible for designation as a CAH.

As we indicated in the FY 2005 IPPS final rule (69 FR 49078), in accordance with sections 410A(a)(2) and (4) of Pub. L. 108-173 and using 2002 data from the U.S. Census Bureau, we identified 10 States with the lowest population density from which to select hospitals: Alaska, Idaho, Montana, Nebraska, Nevada, New Mexico, North Dakota, South Dakota, Utah, and Wyoming. (Source: U.S. Census Bureau Statistical Abstract of the United States: 2003) Thirteen rural community hospitals located within these States are participating in the demonstration.

Under the demonstration, participating hospitals are paid the reasonable costs of providing covered inpatient hospital services (other than services furnished by a psychiatric or rehabilitation unit of a hospital that is a distinct part), applicable for discharges occurring in the first cost reporting period beginning on or after the October 1, 2004 implementation date of the demonstration program. Payment will be the lesser amount of reasonable cost or a target amount in subsequent cost reporting periods. The target amount in the second cost reporting period is defined as the reasonable costs of providing covered inpatient hospital services in the first cost reporting period, increased by the inpatient prospective payment update factor (as defined in section 1886(b)(3)(B) of the Act) for that particular cost reporting period. The target amount in subsequent cost reporting periods is defined as the preceding cost reporting period's target amount, increased by the inpatient prospective payment update factor (as defined in section 1886(b)(3)(B) of the Act) for that particular cost reporting period.

Covered inpatient hospital services means inpatient hospital services (defined in section 1861(b) of the Act) and includes extended care services furnished under an agreement under section 1883 of the Act.

Section 410A of Pub. L. 108-173 requires that ``in conducting the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented.'' Generally, when CMS implements a demonstration on a budget neutral basis, the demonstration is budget neutral in its own terms; in other words, aggregate payments to the participating providers do not exceed the amount that would be paid to those same providers in the absence of the demonstration. This form of budget neutrality is viable when, by changing payments or aligning incentives to improve overall efficiency, or both, a demonstration may reduce the use of some services or eliminate the need for others, resulting in reduced expenditures for the demonstration participants. These reduced expenditures offset increased payments elsewhere under the demonstration, thus ensuring that the demonstration as a whole is budget neutral or yields savings. However, the small scale of this demonstration, in conjunction with the payment methodology, makes it extremely unlikely that this demonstration could be viable under the usual form of budget neutrality. Specifically, cost-based payments to 13 small rural hospitals are likely to increase Medicare outlays without producing any offsetting reduction in Medicare expenditures elsewhere. Therefore, a rural community hospital's participation in this demonstration is unlikely to yield benefits to the participant if budget neutrality were to be implemented by reducing other payments for these providers.

In order to achieve budget neutrality for this demonstration, we are proposing to adjust national inpatient PPS rates by an amount sufficient to account for the added costs of this demonstration. In other words, we apply budget neutrality

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across the payment system as a whole rather than merely across the participants of this demonstration. As we discussed in the FY 2005 IPPS final rule (69 FR 49183), we believe that the language of the statutory budget neutrality requirements permits the agency to implement the budget neutrality provision in this manner. For FY 2006, using the most recent cost report data (that is, data for FY 2003), adjusted for increased estimated cost for the 13 participating hospitals, we are proposing that the estimated adjusted amount would be $12,706,334. This adjusted amount reflects the estimated difference between cost and IPPS payment based on data from hospitals' cost reports. We discuss the proposed payment rate adjustment that would be required to ensure the budget neutrality of the demonstration in section II.A.4. of the Addendum to this proposed rule.

The data collection instrument for the demonstration has been approved by OMB under the title ``Medicare Waiver Demonstration Application,'' under OMB approval number 0938-0880, with a current expiration date of July 30, 2006.

L. Definition of a Hospital in Connection With Specialty Hospitals

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

Section 1861(e) of the Act provides a definition for a ``hospital'' for purposes of participating in the Medicare program. In order to be a Medicare-participating hospital, an institution must, among other things, be primarily engaged in furnishing services to inpatients. This requirement is incorporated in our regulations on conditions of participation for hospitals at 42 CFR 482.1. An institution that applies for a Medicare provider agreement as a hospital but is unable to meet this requirement will have its application denied in accordance with our authority at 42 CFR 489.12. In addition, institutions that have a Medicare hospital provider agreement but are no longer primarily engaging in furnishing services to inpatients are subject to having their provider agreements terminated pursuant to 42 CFR 489.53. Although compliance with this requirement is not problematic for most hospitals, the issue of whether an institution is primarily engaged in providing care to inpatients has recently come to our attention in two arisen two contexts. First, an institution has applied to be certified as an ``emergency hospital,'' yet the institution has 29 outpatient beds for emergency patients, including observation and post-anesthesia care, and only 2 inpatient beds. Emergency treatment by nature does not usually involve overnight stays. Second, the issue has also arisen in the area of ``specialty hospitals.'' (For purposes of this discussion, ``specialty hospitals'' are those hospitals specifically defined as such in section 507 of Pub. L. 108-173 (MMA), that is, those hospitals that are primarily or exclusively engaged in the care and treatment of:

(i) Patients with a cardiac condition; (ii) patients with an orthopedic condition; or (iii) patients receiving a surgical procedure.)

``Specialty hospitals'' are of interest partly because of section 507 of Pub. L. 108-173, which amended the hospital ownership exception to the physician self-referral prohibition statute, section 1877 of the Act. Prior to the enactment of Pub. L. 108-173, the ``whole hospital'' exception contained in section 1877(d)(3) of the Act allowed a physician to refer Medicare patients to a hospital in which the physician (or an immediate family member of the physician) had an ownership or investment interest, if the physician was authorized to perform services at the hospital and the ownership or investment interest was in the entire hospital and not a subdivision of the hospital. Section 507 of Pub. L. 108-173 added an additional criterion to the whole hospital exception, specifying that for the 18-month period beginning on December 8, 2003 and ending on June 8, 2005, physician ownership and investment interests in ``specialty hospitals'' would not qualify for the whole hospital exception. The term ``specialty hospital'' does not include any hospital determined by the Secretary to be in operation or ``under development'' as of November 18, 2003.

In our advisory opinions that we issue as to whether a requesting entity is subject to the 18-month moratorium described above, we inform the requesting entity that, among other things, it must meet the definition of a hospital that is contained in section 1861(e) of the Act. It has come to our attention that some institutions entities that describe themselves as surgical or orthopedic specialty hospitals may be primarily primarily engaged in furnishing services to outpatients, and thus would might not meet the definition of a hospital as contained in section 1861(e) of the Act. Therefore, although an institution entity may satisfy the ``under development'' criteria for purposes of being excepted from the moratorium on physician-owner referrals to specialty hospitals, if we were to determine such entity is not primarily engaged in inpatient care at the time it seeks certification to participate in the Medicare program, its application for a provider agreement as a hospital would will be denied and it would not be eligible for the whole hospital exception to the prohibition on physician self-referrals. Further, if we were to determine that a specialty hospital that is operating under an existing Medicare provider agreement but is not, or is no longer, primarily engaged in treating inpatients, the hospital is subject to having its provider agreement terminated; in this event, it could no longer take advantage of and lose the protection of the whole hospital exception.

VI. PPS for Capital-Related Costs

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

In this proposed rule, we are not proposing any changes in the policies governing the determination of the payment rates for capital- related costs for short-term acute care hospitals under the IPPS. However, for the readers' benefit, we are providing a summary of the statutory basis for the PPS for hospital capital-related costs and the methodology used to determine capital-related payments to hospitals. A discussion of the proposed rates and factors for FY 2006 (determined under our established methodology) can be found in section III. of the Addendum of this proposed rule.

Section 1886(g) of the Act requires the Secretary to pay for the capital-related costs of inpatient acute hospital services ``in accordance with a PPS established by the Secretary.'' Under the statute, the Secretary has broad authority in establishing and implementing the PPS for hospital inpatient capital-related costs. We initially implemented the PPS for capital-related costs in the August 30, 1991 IPPS final rule (56 FR 43358), in which we established a 10- year transition period to change the payment methodology for Medicare hospital inpatient capital-related costs from a reasonable cost-based methodology to a prospective methodology (based fully on the Federal rate).

Federal fiscal year (FY) 2001 was the last year of the 10-year transition period established to phase in the PPS for hospital inpatient capital-related costs. For cost reporting periods beginning in FY 2002, capital PPS payments are based solely on the Federal rate for most acute care hospitals (other than certain new hospitals and hospitals receiving certain exception payments). The basic

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methodology for determining capital prospective payments using the Federal rate is set forth in Sec. 412.312. For the purpose of calculating payments for each discharge, the standard Federal rate is adjusted as follows:

(Standard Federal Rate) x (DRG Weight) x (Geographic Adjustment Factor (GAF)) x (Large Urban Add-on, if applicable) x (COLA Adjustment for hospitals located in Alaska and Hawaii) x (1 + Capital DSH Adjustment Factor + Capital IME Adjustment Factor, if applicable)

Hospitals also may receive outlier payments for those cases that qualify under the thresholds established for each fiscal year as specified in Sec. 412.312(c) of the regulations.

The regulations at Sec. 412.348(f) provide that a hospital may request an additional payment if the hospital incurs unanticipated capital expenditures in excess of $5 million due to extraordinary circumstances beyond the hospital's control. This policy was originally established for hospitals during the 10-year transition period, but as we discussed in the August 1, 2002 IPPS final rule (67 FR 50102), we revised the regulations at Sec. 412.312 to specify that payments for extraordinary circumstances are also made for cost reporting periods after the transition period (that is, cost reporting periods beginning on or after October 1, 2001). Additional information on the exceptions payment for extraordinary circumstances in Sec. 412.348(f) can be found in the FY 2005 IPPS final rule (69 FR 49185 through 49186).

During the transition period, under Sec. Sec. 412.348(b) through (e), eligible hospitals could receive regular exception payments. These exception payments guaranteed a hospital a minimum payment percentage of its Medicare allowable capital-related costs depending on the class of hospital (Sec. 412.348(c)), but were available only during the 10- year transition period. After the end of the transition period, eligible hospitals can no longer receive this exception payment. However, even after the transition period, eligible hospitals receive additional payments under the special exceptions provisions at Sec. 412.348(g), which guarantees all eligible hospitals a minimum payment of 70 percent of its Medicare allowable capital-related costs provided that special exceptions payments do not exceed 10 percent of total capital IPPS payments. Special exceptions payments may be made only for the 10 years from the cost reporting year in which the hospital completes its qualifying project, and the hospital must have completed the project no later than the hospital's cost reporting period beginning before October 1, 2001. Thus, an eligible hospital may receive special exceptions payments for up to 10 years beyond the end of the capital PPS transition period. Hospitals eligible for special exceptions payments were required to submit documentation to the intermediary indicating the completion date of their project. (For more detailed information regarding the special exceptions policy under Sec. 412.348(g), refer to the August 1, 2001 IPPS final rule (66 FR 39911 through 39914) and the August 1, 2002 IPPS final rule (67 FR 50102).)

Under the PPS for capital-related costs, Sec. 412.300(b) of the regulations defines a new hospital as a hospital that has operated (under current or previous ownership) for less than 2 years. (For more detailed information see the August 30, 1991 final rule (56 FR 43418).) During the 10-year transition period, a new hospital was exempt from the capital PPS for its first 2 years of operation and was paid 85 percent of its reasonable costs during that period. Originally, this provision was effective only through the transition period and, therefore, ended with cost reporting periods beginning in FY 2002. Because we believe that special protection to new hospitals is also appropriate even after the transition period, as discussed in the August 1, 2002 IPPS final rule (67 FR 50101), we revised the regulations at Sec. 412.304(c)(2) to provide that, for cost reporting periods beginning on or after October 1, 2002, a new hospital (defined under Sec. 412.300(b)) is paid 85 percent of its allowable Medicare inpatient hospital capital-related costs through its first 2 years of operation, unless the new hospital elects to receive fully-prospective payment based on 100 percent of the Federal rate. (Refer to the August 1, 2001 IPPS final rule (66 FR 39910) for a detailed discussion of the statutory basis for the system, the development and evolution of the system, the methodology used to determine capital-related payments to hospitals both during and after the transition period, and the policy for providing exception payments.)

Section 412.374 provides for the use of a blended payment amount for prospective payments for capital-related costs to hospitals located in Puerto Rico. Accordingly, under the capital PPS, we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capital- related costs. In general, hospitals located in Puerto Rico are paid a blend of the applicable capital PPS Puerto Rico rate and the applicable capital PPS Federal rate.

Prior to FY 1998, hospitals in Puerto Rico were paid a blended capital PPS rate that consisted of 75 percent of the applicable capital PPS Puerto Rico specific rate and 25 percent of the applicable capital PPS Federal rate. However, effective October 1, 1997 (FY 1998), in conjunction with the change to the operating PPS blend percentage for Puerto Rico hospitals required by section 4406 of Pub. L. 105-33, we revised the methodology for computing capital PPS payments to hospitals in Puerto Rico to be based on a blend of 50 percent of the Puerto Rico rate and 50 percent of the Federal rate. Similarly, effective beginning in FY 2005, in conjunction with the change in operating PPS payments to hospitals in Puerto Rico for FY 2005 required by section 504 of Pub. L. 108-173, we again revised the methodology for computing capital PPS payments to hospitals in Puerto Rico to be based on a blend of 25 percent of the Puerto Rico rate and 75 percent of the Federal rate for discharges occurring on or after October 1, 2004.

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

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

A. Payments to Existing Hospitals and Hospital Units (Sec. Sec. 413.40(c), (d), and (f))

1. Payments to Existing Excluded Hospitals and Hospital Units

Section 1886(b)(3)(H) of the Act (as amended by section 4414 of Pub. L. 105-33) established caps on the target amounts for cost reporting periods beginning on or after October 1, 1997 through September 30, 2002, for certain existing hospitals and hospital units excluded from the IPPS. Section 413.40(c)(4)(iii) of the implementing regulations states that ``In the case of a psychiatric hospital or unit, rehabilitation hospital or unit, or long-term care hospital, the target amount is the lower of amounts specified in paragraph (c)(4)(iii)(A) or (c)(4)(iii)(B) of this section.'' Accordingly, in general, for hospitals and units within these three classes of providers for the applicable 5-year period, the target amount is the lower of either: the hospital-specific target amount (Sec. 413.40(c)(4)(iii)(A)) or the 75th percentile cap (Sec. 413.40(c)(4)(iii)(B)). (We note that, in the case of LTCHs, for cost reporting periods beginning during

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FY 2001, the hospital-specific target amount is the net allowable cost in a base period increased by the applicable update factors multiplied by 1.25.)

Questions have been raised as to whether Sec. 413.40(c)(4)(iii) (specifically paragraph (c)(4)(iii)(A)) continues to apply beyond FY 2002. In order to clarify the policy for periods after FY 2002, we note that Sec. 413.40(c)(4)(iii) applies only to cost reporting periods beginning on or after October 1, 1997 through September 30, 2002, for psychiatric hospitals and units, rehabilitation hospitals and units, and LTCHs. We discussed this applicable time period in the May 12, 1998 Federal Register (63 FR 26344) when we discussed implementing the caps. Specifically, we clarified our regulations to indicate that the target amount for FYs 1998 through 2002 is equal to the lower of the hospital- specific target amount or the 75th percentile of target amounts for hospitals in the same class for cost reporting periods ending during FY 1996, increased by the applicable market basket percentage for the subject period. We did not intend for the provisions of Sec. 413.40(c)(4)(iii) to apply beyond FY 2002, as we specifically included an ending date; that is, we stated that the target amount calculation provisions were for FYs 1998 through 2002. More recently, in the FY 2003 IPPS final rule (67 FR 50103), we clarified again how the target amount for FY 2003 was to be determined by stating that: ``* * * for cost reporting periods beginning in FY 2003, the hospital or unit should use its previous year's target amount, updated by the appropriate rate-of-increase percentage.'' Thus, the time-limited provision of Sec. 413.40(c)(4)(iii) is neither a new policy nor a change in policy.

For cost reporting periods beginning on or after October 1, 2002, to the extent one of the above-mentioned excluded hospitals or units has all or a portion of its payment determined under reasonable cost principles, the target amounts for the reasonable cost-based portion of the payment are determined in accordance with section 1886(b)(3)(A)(ii) of the Act and the regulations at Sec. 413.40(c)(4)(ii). Section 413.40(c)(4)(ii) states, ``Subject to the provisions of [Sec. 413.40] paragraph (c)(4)(iii) of this section, for subsequent cost reporting periods, the target amount equals the hospital's target amount for the previous cost reporting period increased by the update factor for the subject cost reporting period unless the provisions of [Sec. 413.40] paragraph (c)(5)(ii) of this section apply.'' Thus, since Sec. 413.40(c)(4)(ii) indicates that the provisions of that paragraph are subject to the provisions of Sec. 413.40(c)(4)(iii), which are applicable only for cost reporting periods beginning on or after October 1, 1997 through September 30, 2002, the target amount for FY 2003 is determined by updating the target amount for FY 2002 (the target amount from the previous period) by the applicable update factor. Accordingly, we are proposing to make a change to the language in Sec. 413.40(c)(4)(iii) to clarify that the provisions of this paragraph relating to the caps on target amounts are for a specific period of time only, that is, cost reporting periods beginning on or after October 1, 1997, and before October 1, 2002.

The inpatient operating costs of children's hospitals and cancer hospitals that are excluded from the IPPS are subject to the rate-of- increase limits established under the authority of section 1886(b) of the Act and implemented in the regulations at Sec. 413.40. Under these limits, an annual target amount (expressed in terms of the inpatient operating cost per discharge) is set for each hospital, based on the hospital's own historical cost experience, trended forward by the applicable percentage increase. This target amount is applied as a ceiling on the allowable costs per discharge for the hospital's cost reporting period. (We note that, in accordance with Sec. 403.752(a) of the regulations, RNHCIs are also subject to the rate-of-increase limits established under Sec. 413.40 of the regulations.) 2. Updated Caps for New Excluded Hospitals and Units

Section 1886(b)(7) of the Act established the method for determining the payment amount for new rehabilitation hospitals and units, psychiatric hospitals and units, and LTCHs that first received payment as a hospital or unit excluded from the IPPS on or after October 1, 1997. However, effective for cost reporting periods beginning on or after October 1, 2002, this payment amount (or ``new provider cap'') no longer applies to any new rehabilitation hospital or unit because they now are paid 100 percent of the Federal prospective rate under the IRF PPS.

In addition, LTCHs that meet the definition of a new LTCH under Sec. 412.23(e)(4) are also paid 100 percent of the fully Federal prospective payment rate under the LTCH PPS. In contrast, those ``new'' LTCHs that meet the criteria under Sec. 413.40(f)(2)(ii) (that is, that were not paid as an excluded hospital prior to October 1, 1997), but were paid as a LTCH before October 1, 2002, may be paid under the LTCH PPS transition methodology with the reasonable cost portion of the payment subject to Sec. 413.40(f)(2)(ii). Finally, LTCHs that existed prior to October 1, 1997, may also be paid under the LTCH PPS transition methodology with the reasonable cost portion of the payment subject to Sec. 413.40(c)(4)(ii). (The last LTCHs that were subject to the payment amount limitation for ``new'' LTCHs were new LTCHs that had their first cost reporting period beginning on September 30, 2002. In that case, the payment amount limitation remained applicable for the next 2 years--September 30, 2002 through September 29, 2003, and September 30, 2003 through September 29, 2004. This is because, under existing regulations at Sec. 413.40(f)(2)(ii), a ``new hospital'' would be subject to the same payment (target amount) in its second cost reporting period that was applicable to the LTCH in its first cost reporting period. Accordingly, for these hospitals, the updated payment amount limitation that we published in the FY 2003 IPPS final rule (67 FR 50103) applied through September 29, 2004. Consequently, there is no longer a need to publish updated payment amounts for new (Sec. 413.40(f)(2)(ii)) LTCHs. A discussion of how the payment limitations were calculated can be found in the August 29, 1997 final rule with comment period (62 FR 46019); the May 12, 1998 final rule (63 FR 26344); the July 31, 1998 final rule (63 FR 41000); and the July 30, 1999 final rule (64 FR 41529).

A freestanding inpatient rehabilitation hospital, an inpatient rehabilitation unit of an acute care hospital, and an inpatient rehabilitation unit of a CAH are referred to as IRFs. Effective for cost reporting periods beginning on or after October 1, 2002, this payment limitation is also no longer applicable to new rehabilitation hospitals and units because they are paid 100 percent of the Federal prospective rate under the IRF PPS. Therefore, it is also no longer necessary to update the payment limitation for new rehabilitation hospitals or units.

For psychiatric hospitals and units, under the IPF PPS, there is a 3-year transition period during which existing IPFs will receive a blended payment of the Federal per diem payment amount and the payment amount that IPFs would receive under the reasonable cost-based payment (TEFRA) methodology. However, new IPFs (those facilities that under present or previous ownership (or both) have their first cost reporting period as an IPF begin on or after January 1, 2005, are paid the fully Federal per diem payment amount rather than a blended payment amount.

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(See section VII.A.5. of the preamble of this proposed rule for further discussion of the IPF PPS.) Thus, the payment limitations under the TEFRA payment system are not applicable for new IPFs that meet the definition in Sec. 412.426(c).

However, ``new'' IPFs that meet the criteria under Sec. 413.40(f)(2)(ii) (that is, that were not paid as an excluded hospital prior to October 1, 1997), but were paid as an IPF before January 1, 2005, are paid under the IPF PPS transition methodology with the reasonable cost portion of the payment determined according to Sec. 413.40(f)(2)(ii), that is, subject to the payment amount limitation. The last ``new'' IPFs that were subject to the payment amount limitation were IPFs that had their first cost reporting period beginning on December 31, 2004. For these hospitals, the payment amount limitation that was published in the FY 2005 IPPS final rule (69 FR 49189) for cost reporting periods beginning on or after October 1, 2004, and before January 1, 2005, remains applicable for the IPF's first two cost reporting periods. IPFs with a first cost reporting period beginning on or after January 1, 2005, are paid 100 percent of the Federal rate and are not subject to the payment amount limitation. Therefore, since the last IPFs eligible for a blended payment have a cost reporting period beginning on December 31, 2004, the payment limitation published for FY 2005 remains applicable for these IPFs, and publication of the updated payment amount limitation is no longer needed. We note that IPFs that existed prior to October 1, 1997, may also be paid under the IPF transition methodology with the reasonable cost portion of the payment subject to Sec. 413.40(c)(4)(ii).

The payment limitations for new hospitals under TEFRA do not apply to new LTCHs, IRFs, or IPFs, that is, these hospitals with their first cost reporting period beginning on or after the date that the particular class of hospitals implemented their respective PPS. Therefore, for the reasons noted above, we are proposing to discontinue publishing Tables 4G and 4H (Pre-Reclassified Wage Index for Urban and Rural Areas, respectively) in the annual proposed and final IPPS rules. 3. Implementation of a PPS for IRFs

Section 1886(j) of the Act, as added by section 4421(a) of Pub. L. 105-33, provided for the phase-in of a case-mix adjusted PPS for inpatient hospital services furnished by a rehabilitation hospital or a rehabilitation hospital unit (referred to in the statute as rehabilitation facilities) for cost reporting periods beginning on or after October 1, 2000, and before October 1, 2002, with payments based entirely on the adjusted Federal prospective payment for cost reporting periods beginning on or after October 1, 2002. Section 1886(j) of the Act was amended by section 125 of Pub. L. 106-113 to require the Secretary to use a discharge as the payment unit under the PPS for inpatient hospital services furnished by rehabilitation facilities and to establish classes of patient discharges by functional-related groups. Section 305 of Pub. L. 106-554 further amended section 1886(j) of the Act to allow rehabilitation facilities, subject to the blend methodology, to elect to be paid the full Federal prospective payment rather than the transitional period payments specified in the Act.

On August 7, 2001, we issued a final rule in the Federal Register (66 FR 41316) establishing the PPS for inpatient rehabilitation facilities, effective for cost reporting periods beginning on or after January 1, 2002. There was a transition period for cost reporting periods beginning on or after January 1, 2002 and ending before October 1, 2002. For cost reporting periods beginning on or after October 1, 2002, payments are based entirely on the Federal prospective payment rate determined under the IRF PPS. 4. Implementation of a PPS for LTCHs

In accordance with the requirements of section 123 of Pub. L. 106- 113, as modified by section 307(b) of Pub. L. 106-554, we established a per discharge, DRG-based PPS for LTCHs as described in section 1886(d)(1)(B)(iv) of the Act for cost reporting periods beginning on or after October 1, 2002, in a final rule issued on August 30, 2002 (67 FR 55954). The LTCH PPS uses information from LTCH hospital patient records to classify patients into distinct LTC-DRGs based on clinical characteristics and expected resource needs. Separate payments are calculated for each LTC-DRG with additional adjustments applied.

We published in the Federal Register on May 7, 2004, a final rule (69 FR 25673) that updated the payment rates for the upcoming rate year LTCH PPS and made policy changes effective as of July 1, 2004. The 5- year transition period to the fully Federal prospective rate will end with cost reporting periods beginning on or after October 1, 2005 and before October 1, 2006. For cost reporting periods beginning on or after October 1, 2006, payment is based entirely on the adjusted Federal prospective payment rate. However, existing hospitals can elect payment under 100 percent of the adjusted Federal prospective payment rate. Moreover, LTCHs as defined in Sec. 412.23(e)(4) are paid under 100 percent of the adjusted Federal prospective payment rate. 5. Implementation of a PPS for IPFs

In accordance with section 124 of the BBRA and section 405(g)(2) of Pub. L. 108-173, we established a PPS for inpatient hospital services furnished in psychiatric hospitals and psychiatric units of acute care hospitals and CAHs (inpatient psychiatric facilities (IPFs)). On November 15, 2004, we issued in the Federal Register a final rule (69 FR 66922) that established the IPF PPS, effective for IPF cost reporting periods beginning on or after January 1, 2005. Under the final rule, we compute a Federal per diem base rate to be paid to all IPFs for inpatient psychiatric services based on the sum of the average routine operating, ancillary, and capital costs for each patient day of psychiatric care in an IPF, adjusted for budget neutrality. The Federal per diem base rate is adjusted to reflect certain patient characteristics, including age, specified DRGs, selected high-cost comorbidities, and day of the stay, and certain facility characteristics, including a wage index adjustment, rural location, indirect teaching costs, the presence of a full-service emergency department, and cost-of-living adjustments for IPFs located in Alaska and Hawaii. We have established a 3-year transition period during which IPFs will be paid based on a blend of reasonable cost-based payment and IPF PPS payments. For cost reporting periods beginning on or after January 1, 2008, IPFs will be paid 100 percent of the Federal per diem payment amount.

B. Critical Access Hospitals (CAHs)

(If you choose to comment on issues in this section, please include the caption ``Critical Access Hospitals'' at the beginning of your comment.) 1. Background

Section 1820 of the Act provides for the establishment of Medicare Rural Hospital Flexibility Programs (MRHFPs), under which individual States may designate certain facilities as critical access hospitals (CAHs). Facilities that are so designated and meet the CAH conditions of participation (CoPs) under 42 CFR Part 485, Subpart F, will be certified as CAHs by CMS. Regulations governing payments to CAHs for services to Medicare beneficiaries are located in 42 CFR Part 413.

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2. Proposed Policy Change Relating to Continued Participation by CAHs in Lugar Counties

Criteria for the designation of a CAH under the MRHFP at section 1820(c)(2)(b)(i) of the Act require that a hospital be located in a rural area as defined in section 1886(d)(2)(D) of the Act or be treated as being located in a rural area in accordance with section 1886(d)(8)(E) of the Act. The regulations at Sec. 485.610 further define ``rural area'' for purposes of being a CAH. Under Sec. 485.610(b), a CAH must meet any one of the following three location requirements. First, a CAH must not be located in an MSA as defined by the Office of Management and Budget, not be deemed to be located in an urban area under 42 CFR 412.63(b), and not be reclassified by CMS or the MGCRB as urban for purposes of the standardized payment amount, nor be a member of a group of hospitals reclassified to an urban area under 42 CFR 412.232. Second, if a CAH does not meet the first criterion, if located in an MSA, a CAH will be treated as rural if it has reclassified under 42 CFR 412.103. Third, as we stated in the FY 2005 IPPS final rule, if the CAH cannot meet either of the first two requirements and is located in a revised labor market area (CBSA) under the standards announced by OMB on June 6, 2003 and adopted by CMS effective October 1, 2004, it has until September 30, 2006, to meet one of the other classification requirements without losing its CAH status.

Under section 1886(d)(8)(B) of the Act, hospitals that are located in a rural county that is adjacent to one or more urban counties are considered to be located in the urban MSA to which the greatest number of workers in the county commute, if certain conditions, specified in section 1886(d)(8)(B) of the Act, are met. Regulations implementing this provision are set forth in 42 CFR 412.62(f)(1) (for FY 1984), 42 CFR 412.63(b)(3) (for FYs 1985 through 2004), and at 42 CFR 412.64(b)(3) (for FY 2005 and subsequent fiscal years). The provision (section 1886(d)(8)(B) of the Act) is referred to as the ``Lugar provision'' and the counties described by it are referred to as the ``Lugar counties.''

As explained more fully in the FY 2005 IPPS final rule (69 FR 48916), certain counties that previously were not considered Lugar counties were, effective October 1, 2004, redesignated as Lugar counties as a result of the most recent census data and the new labor market area definitions announced by OMB on June 6, 2003. Some CAHs located in these newly designated Lugar counties are now unable to meet the rural location requirements described above, even though they were in full compliance with the location requirements in effect at the time they converted from short-term acute care hospital to CAH status.

We have received comments that suggest that it would be inappropriate for a facility to be required to terminate participation as a CAH and resume participating as a short-term acute care hospital because of a change in county classification that did not result from any change in functioning by the CAH. After consideration of these comments, we are clarifying our policy with respect to facilities located in Lugar counties. As we noted in the FY 2005 IPPS final rule, we believe it is appropriate to allow facilities located in counties that began to be considered part of MSAs effective October 1, 2004, as a result of data from the 2000 census and implementation of the new labor market area definitions announced by OMB on June 6, 2003, an opportunity to obtain rural designations under applicable State law or regulations from their State legislatures or regulatory agencies. Similarly, we believe that when a CAH's status as being located in a Lugar county occurs as a result of changes that the CAH did not originate and that were beyond its control, such as a change in the OMB standards for labor market area definitions, it is appropriate for the CAH to be allowed a reasonable opportunity to reclassify to rural status. Thus, we are clarifying our policy to note that CAHs in counties that were designated as Lugar counties effective October 1, 2004, because of implementation of the new labor market area definitions announced by OMB on June 6, 2003, are to be given the same reclassification opportunity. Of course, the opportunity to reclassify would not be available to a CAH if the CAH itself were to initiate some change, such as a redesignation as urban rather than rural under State law or regulations, which would invalidate a prior Sec. 412.103 reclassification. As a result, we are proposing to make changes to Sec. 485.610(b) of the regulations that would permit CAHs located in a county that, in FY 2004, was not part of a Lugar county, but as of FY 2005 was included in such a county as a result of the new labor market area definitions, to maintain their CAH status until September 30, 2006. These changes, if adopted in final form, would permit CAHs in newly designated Lugar counties to continue participating in Medicare as CAHs until September 30, 2006. We expect that this will provide these CAHs with sufficient time to seek reclassification as rural facilities under the current regulations at Sec. 412.103. In other words, after October 1, 2006, these facilities must meet at least one of the criteria in Sec. 412.103(a)(1) through (a)(3) to be eligible to reclassify from urban to rural status. Once the Sec. 412.103 reclassification is approved, the facilities would meet the CAH rural location requirements in Sec. 485.610(b)(2). In addition, consistent with the clarification of the policy, we are proposing to amend the regulations at Sec. 412.103(a)(4) to reflect the proposed change in the text of the CAH location regulations at Sec. 485.610(b)(3).

In addition, we are making a technical amendment to Sec. 485.610(b)(1)(ii) by replacing the reference to 42 CFR 412.63(b) with 42 CFR 412.64(b). This proposed technical amendment would conform the regulations to reflect the rules governing geographic reclassification (found at Sec. 412.64) that are already in place for fiscal years beginning on or after October 1, 2004 (69 FR 49242). 3. Proposed Policy Change Relating to Designation of CAHs as Necessary Providers

Section 405(h) of Pub. L. 108-173 amended section 1820(c)(2)(B)(i)(II) of the Act by adding language that terminated a State's authority to waive the location requirement for a CAH by designating the CAH as a necessary provider, effective January 1, 2006. Currently, a CAH is required to be located more than a 35-mile drive (or in the case of mountainous terrain or secondary roads, a 15-mile drive) from a hospital or another CAH, unless the CAH is certified by the State as a necessary provider of health care services to residents in the area. Under this provision, after January 1, 2006, States will no longer be able to designate a CAH based upon a determination that it is a necessary provider of health care. In addition, section 405(h) of Pub. L. 108-173 amended section 1820(h) of the Act to include a grandfathering provision for CAHs that are certified as necessary providers prior to January 1, 2006. In the FY 2005 IPPS final rule (69 FR 49220), we incorporated these amendments in our regulations at Sec. 485.610 (c). Under that regulation, any CAH that is designated as a necessary provider in its State rural health plan prior to January 1, 2006, will be permitted to maintain its necessary provider designation. However, the regulations are limited to CAHs that were necessary providers as of January 1, 2006, and does not address the

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situation where the CAH is no longer the same facility due to relocation, cessation of business, or a substitute facility. Currently, CMS Regional Offices make the decision for continued certification following relocation of a certified facility on a case-by-case basis.

The criteria used to qualify a CAH as a necessary provider were established by each State in its MRHFP. The State's MRHFP defined those CAHs that provide necessary services to a particular patient community in the event that the facility did not meet the required 35-mile (or 15-mile with stated exceptions) distance requirement from the nearest hospital or CAH. Each State's criteria are different, but the criteria share certain similarities and all define a necessary provider related to the facility location. Therefore, it becomes crucial to define whether the necessary provider designation remains pertinent in the event the certified CAH builds in a different location. Accordingly, the first step of this process is to determine whether building a new CAH facility in a different location is a replacement of an existing facility in essentially the same location, a relocation of the facility in a new location, or a cessation of business at one location and establishment of new business at another location. a. Determination of the Relocation Status of a CAH

(1) Replacement in the same location. Under this approach, we are proposing that, if the CAH is constructing renovation of the same building in the same location, the renovation is considered to be a replacement of the same provider and not relocation. We would consider a construction of the CAH to be a replacement if construction was undertaken within 250 yards of the current building, as set by prior precedence in defining a hospital campus. In addition, if the replacement is constructed on land that is contiguous to the current CAH, and that land was owned by the CAH prior to enactment of Pub. L. 108-173, and the CAH is operating under a State-issued necessary provider waiver that is grandfathered by Pub. L. 108-173, we would consider that construction to be a replacement of the existing provider and the provisions of the grandfathered necessary provider designation would continue to apply regardless of when the construction or renovation work commenced and was completed.

(2) Relocation of a CAH. Under our proposed approach, if the CAH is constructing a new facility in a location that does not qualify the construction as replacement of an existing facility in the same location under the criteria in the preceding paragraph, we would need to determine if this building would be a relocation of the current provider or a cessation of business at one location and establishment of a new business at another location. In the event of relocation, the CAH must ensure that the provider is functioning as essentially the same provider in order to operate under the same provider agreement. A provider that is changing location is considered to have closed the old facility if the original community or service area can no longer be expected to be served at the new location. The distance of the moved CAH from its old location will be considered, but it will not be the sole determining factor in granting the relocation of a CAH under the same provider agreement. For example, a specialty hospital may move a considerable distance and still care for generally the same inpatient population, while the relocation of a CAH at a relatively short distance within a rural area may greatly affect the community served.

In the event that CMS determines the rebuilding of the CAH in a different location to be a relocation, the provider agreement would continue to apply to the CAH at the new location. In addition to the relocation being within the same service area, serving the same population, the CAH would need to be providing essentially the same services with the same staff; that is, at least 75 percent of the same staff and 75 percent of the range of services are maintained in the new location as the same provider of services. We are proposing the use of a 75-percent threshold because we believe it indicates that the CAH that is relocating demonstrates that it will maintain a high level of involvement, as opposed to just a majority involvement, in the current community. We note that CMS has also used a 75-percent threshold in other provider designation policies such as the provider-based policies at Sec. 413.65(e)(3)(ii).

In all cases of relocation, the CAH must continue to meet all of the CoPs found at 42 CFR Part 485, Subpart F, including location in a rural area as provided for at Sec. 485.610.

(3) Cessation of business at one location. Under existing CMS policy, if the CAH relocation results in the cessation of furnishing services to the same community, we would not consider this to be a relocation, but instead would consider such a scenario a cessation of business at one location and establishment of a new business at another location. Cessation of business is a basis for voluntary termination of the provider agreement under 42 CFR Part 489. If the proposed move constitutes a cessation of business, the CMS Regional Office may assist the provider in obtaining an agreement to participate under a new provider number. Furthermore, in such a situation, the regulations require the provider to give advanced notice to CMS and the public regarding its intent to stop providing medical services to the community. There is no appeals process for a voluntary termination. Under our current policies, the cessation of business by a CAH automatically terminates the CAH designation, regardless of whether the designation was obtained through a necessary provider determination. b. Relocation of a CAH Using a Necessary Provider Designation To Meet the CoP for Distance

Once it has been determined that constructing a new facility will cause the CAH to relocate, the second step is to determine if the CAH that has a necessary provider designation can maintain this designation after relocating.

We recognize that Sec. 485.610(c) relating to location relative to other facilities or necessary provider certification states that, after January 1, 2006, the ``necessary provider'' designation will no longer be used to waive the mileage requirements. In addition, CMS policy regarding a change of size or location of a provider states that there may be situations where the facility relocation is so far removed from the originally approved site that we would conclude that this is a different provider or supplier, for example, it has different employees, services, and patients. Furthermore, the language of section 1820(c)(2)(i) of the Act allows a State to waive the mileage requirement and designate a facility as a necessary provider of health care services to residents in the area. We have interpreted ``services to residents in the area'' to mean that the necessary provider designation does not automatically follow the provider if the facility relocates to a different location because it is no longer furnishing ``services to patients'' in the area determined to need a necessary provider.

We do not intend to change this policy. Our proposal, noted below, is intended to establish a methodology to be used by all CMS Regional Offices in making such a decision consistent with the statutory provisions concerning necessary provider designation.

In this proposed rule, we are proposing to amend the regulations at Sec. 485.610 to set forth the criteria by

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which those relocated CAHs designated as necessary providers that embarked on a replacement facility project before the sunset provision was enacted on December 8, 2003, but find that they cannot be operational in the replacement facility by January 1, 2006, can retain their necessary provider status. As required by statute, no additional CAHs will be certified as a necessary provider on or after January 1, 2006. We recognize that the statute refers to a facility designated as a CAH while relocation of a facility may result in a different building. However, to provide flexibility for a facility designated as a CAH whose location may change, but is essentially the same facility in a different location, we are proposing to amend the regulations to account for this scenario. Essentially, we recognize that the necessary provider designation may need to be applied to certain relocated CAHs. To this end, we are proposing to use the specified relocation criteria as the initial step to determine continuing necessary provider status. Specifically, in this proposed rule, we are proposing that, when a CAH is determined to have relocated, it may nonetheless continue to operate under its necessary provider designation that exempts the distance from other providers only if the following conditions are met:

(1) The relocated CAH has submitted an application to the State agency for relocation prior to the January 1, 2006, sunset date. If the CAH is applying under a grandfathered status under section 1820(h)(3) of the Act, the following items would need to be included in the application:

A demonstration that the CAH will meet the same State criteria for the necessary provider designation that were established when the waiver was originally issued. For example, if the location waiver was granted because the CAH was located in a health professional shortage area (HPSA), the CAH must remain in that HPSA.

Assurance that, after the relocation, the CAH will be servicing the same community and will be operating essentially the same services with essentially the same staff (that is, a demonstration that it is serving at least 75 percent of the same service area, with 75 percent of the same services offered, and staffed by 75 percent of the same staff, including medical staff, contracted staff, and employees). This is essentially the same criteria used in determining whether the CAH has relocated.

Assurance that the CAH will remain in compliance with all of the CoPs at 42 CFR Part 485 in the new location. Compliance will be established with a full survey in the new location to include the Life Safety Code and would include any off-site locations and rehabilitation or psychiatric distinct part units.

A demonstration that construction plans were ``under development'' prior to the effective date of Pub. L. 108-173 (December 8, 2003) in the application the CAH submits to continue using a necessary provider designation. Supporting documentation could include the drafting of architectural specifications, the letting of bids for construction, the purchase of land and building supplies, documented efforts to secure financing for construction, expenditure of funds for construction, and compliance with state requirements for construction such as zoning requirements, application for a certificate of need, and architectural review. However, we recognize that it may not have been feasible for a CAH to have completed all of these activities noted above as examples prior to December 8, 2003. Thus, we expect the CMS Regional Offices to consider all of the criteria and make case-by-case determinations of whether a relocated CAH continues to warrant necessary provider status. We note that we have also used the above documentation guidelines in Publication 100-20 for grandfathered specialty hospitals to determine if construction plans were ``under development.''

In proposing these criteria, our intent in clarifying the sunset of the necessary provider designation provision is to allow CAHs to complete construction projects that were initiated prior to the enactment of Pub. L. 108-173, which we believe is consistent with the statutory language of section 405(h) of Pub. L. 108-173.

(2) In the application, the CAH demonstrates that the replacement will facilitate the access to care and improve the delivery of services to Medicare beneficiaries. We are soliciting comments on how a necessary provider CAH should demonstrate that the replacement will improve access to care.

These guidelines are meant to be applied to the relocated CAH that meets the CoP in the new location and wishes to maintain a necessary provider designation in order to meet the distance requirement at Sec. 485.610(c). They are not meant to preclude a CAH from relocating at any time if the CAH does not seek to maintain the necessary provider designation. Any CAH may relocate at any time if the CAH meets the definition of relocation and can meet all the CoPs at 42 CFR part 485, subpart F, as determined by the CMS Regional Offices on a case-by-case basis.

Accordingly, we are proposing to revise Sec. 485.610 of the regulations by adding a new paragraph (d) to incorporate this proposal. Specifically, the proposed new paragraph (d) would specify that a CAH may maintain its necessary provider certification provided for under Sec. 485.610(c) if the new facility meets the requirements for either a replacement facility that is constructed within 250 yards of the current building or contiguous to the current CAH on land owned by the CAH prior to December 8, 2003; or as a relocated CAH if, at the relocated site, the CAH provides essentially (75 percent) the same services to the same service area with essentially the same staff. The CAH that plans to relocate must provide documentation demonstrating that its plans to rebuild in the relocated area were undertaken prior to December 8, 2003. We are also proposing that if a CAH that has a necessary provider certification from the State places a new facility in service on or after January 1, 2006, and does not meet either the requirements for a replacement facility or a relocated facility, as specified in the regulations, the action will be considered a cessation of business.

VIII. Payment for Blood Clotting Factor Administered to Hemophilia Inpatients

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

Section 1886(a)(4) of the Act excludes the costs of administering blood clotting factors to individuals with hemophilia from the definition of ``operating costs of inpatient hospital services.'' Section 6011(b) of Pub. L. 101-239 (the Omnibus Budget Reconciliation Act of 1989) states that the Secretary of Health and Human Services shall determine the payment amount made to hospitals under Part A of Title XVIII of the Act for the costs of administering blood clotting factors to individuals with hemophilia by multiplying a predetermined price per unit of blood clotting factor by the number of units provided to the individual. The regulations governing payment for blood clotting factor furnished to hospital inpatients are located in Sec. Sec. 412.2(f)(8) and 412.115(b).

Consistent with the rates paid under section 1842(o) of the Act for Medicare Part B drugs (including blood clotting factor furnished to individuals who are not inpatients), in FY 2005, we made payments for blood clotting factors furnished to inpatients at 95 percent of average wholesale price (AWP). Section 303 of Pub. L. 108-173 established

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section 1847A of the Act which requires that almost all Medicare Part B drugs not paid on a cost or prospective basis be paid at 106 percent of average sales price (ASP) and provided for payment of a furnishing fee for blood clotting factor, effective January 1, 2005. On November 15, 2004, we issued regulations in the Federal Register (69 FR 66299) that implemented the provisions of section 1847A for payment for Medicare Part B drugs using the 106 percent of ASP payment methodology and for payment of the furnishing fee. These regulations are codified at 42 CFR 410.63 and subpart K of Part 414.

To ensure consistency in payment for Medicare Part A and Medicare Part B drugs, we are proposing to revise Sec. Sec. 412.2(f)(8) and 412.115(b) of the regulations governing the IPPS to specify that, for discharges occurring on or after October 1, 2005, the additional payment for the blood clotting factor administered to hemophilia inpatients is made based on the average sales price methodology specified in subpart K of 42 CFR part 414 and the furnishing fee specified in Sec. 410.63.

The proposed payment amount per unit and the unit payment for the furnishing fee for blood clotting factor administered to hospital inpatients who have hemophilia that we are proposing to apply under the IPPS for FY 2006 are specified in section V. of the Addendum to this proposed rule.

IX. MedPAC Recommendations

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

We are required by section 1886(e)(4)(B) of the Act to respond to MedPAC's IPPS recommendations in our annual proposed IPPS rule. In March 2005, MedPAC released the following two reports to Congress, which included IPPS recommendations: ``Report to Congress: Medicare Payment Policy'' and ``Report to Congress: Physician-Owned Specialty Hospitals.'' We have reviewed each of these reports and have given them careful consideration in conjunction with the policies set forth in this document. These recommendations and our responses are set forth below. For further information relating specifically to the MedPAC reports or to obtain a copy of the reports, contact MedPAC at (202) 653-7220, or visit MedPAC's Web site at: http://www.medpac.gov.

A. Medicare Payment Policy

MedPAC's Recommendation 2A-1 concerning the update factor for inpatient hospital operating costs and for hospitals and distinct-part hospital units excluded from the IPPS is discussed in Appendix B to this proposed rule.

Recommendation 4A: The Congress should establish a quality incentive payment policy for hospitals in Medicare.

Response: We are exploring provider payment policies that link quality to Medicare reimbursement in a cost neutral manner under our demonstration authority. We currently have demonstrations underway that will identify and examine the components of such a policy.

B. Physician-Owned Specialty Hospitals

Recommendation 1: The Secretary should improve payment accuracy in the hospital inpatient PPS by:

Refining the current DRGs to more fully capture differences in severity of illness among patients.

Basing the DRG relative weights on the estimated cost of providing care rather than on charges.

Basing the weights on the national average of hospitals' relative values in each DRG.

In making this recommendation, MedPAC recognized several implementation issues regarding potential low volume DRGs and potential changes in hospital coding and reporting behavior. In particular, MedPAC recommended that the Secretary project the likely effect of reporting improvements on total payments and make an offsetting adjustment to the standardized amounts.

Response: We expect to make changes to the DRGs to better reflect severity of illness. The following discussion briefly describes some of the options we are considering. As we discussed in section II.B. of this preamble, there is a standard list of diagnoses that are considered complications or comorbidities (CC). These conditions, when present as a secondary diagnosis, may result in payment using a higher weighted DRG. Currently, 3,285 diagnosis codes on this list, and 121- paired DRGs are differentiated based on the presence or absence of a CC. Our analysis indicates that the majority of cases assigned to these DRGs fall into the ``with CC'' DRGs. We believe that it is possible that the CC distinction has lost much of its ability to differentiate the resource needs of patients, given the long period of time since the original CC list was developed and the incremental nature of subsequent changes in an environment of major changes in the way inpatient care is delivered.

We are planning a comprehensive and systematic review of the CC list for the IPPS rule for FY 2007. As part of this process, we will consider revising the standard for determining when a condition is a CC. For instance, we expect to use an alternative to the current method of classifying a condition as a CC based on how it affects the length of stay of a case. Similar to other aspects of the DRG system, we expect to consider the effect of a specific secondary diagnosis on the charges or costs of a case to evaluate whether to include the condition on the CC list.

Another option we are considering is a selective review of the specific DRGs, such as cardiac, orthopedic, and surgical DRGs, that are alleged to be overpaid and that create incentives for physicians to form specialty hospitals. We expect to selectively review particular DRGs based on statistical criteria such as the range or standard deviation among charges for cases included within the DRG. It is possible specific DRGs have high variation in resource costs and that a better recognition of severity would reduce incentives for hospitals to select the least costly and most profitable patients within these DRGs. Any analysis we perform would balance the goal of making payment based on an accurate coding system that recognizes severity of illness with the premise that the IPPS is a system of payment based on averages. We agree with MedPAC that, in refining the DRGs, we must continue to be mindful of issues such as the instability of small volume DRGs and the potential impact of changes in hospital coding and reporting behavior. As MedPAC noted, previous refinements to DRG definitions have led to unanticipated increases in payment because of more complete reporting of patients' diagnoses and procedures. As part of our analysis of possible refinements to the DRGs, we have concerns with our ability to account for the effect of changes in coding behavior on payment.

We are also considering the use of alternative DRG systems such as the all patient refined diagnosis related groups (APR-DRGs) in place of Medicare's current DRG system. The APR-DRGs have a greater number of DRGs that could relate payment rates more closely to patient resource needs, and thus reduce the advantages of selection of desirable patients within DRGs by specialty hospitals. However, any large change to the DRGs could have substantial effects across all hospitals. Therefore, we believe we must thoroughly analyze such options and

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From the Federal Register Online via GPO Access [wais.access.gpo.gov] ]

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their impacts on the various types of hospitals before making any proposal. In addition, as noted above, we are concerned about our ability to account for the effect of changes in coding behavior on payment if we were to significantly expand the number of DRGs. Therefore, in light of the above, we must consider how to mitigate the risk of paying significantly more for the alternatives discussed above while measuring the benefit for Medicare beneficiaries.

In response to MedPAC's recommendation that we improve payment accuracy by basing the DRG relative weights on the estimated cost of providing care rather than on charges, we note that we do not have access to any information that would provide a direct measure of the costs of individual discharges. Claims filed by hospitals do provide information on the charges for individual cases. At present, we use this information to set the relative weights for the DRGs. We obtain information on costs from the hospital cost reports, but this information is at best at the department level; it does not include information about the costs of individual cases. Consequently, the most straightforward way to estimate costs of an individual case is to calculate a cost-to-charge ratio for some body of claims (for example, for a hospital's radiology department), and then apply this ratio to the charges for that department.

However, this procedure is not without disadvantages because assignment of costs to departments is not uniform from hospital to hospital, given the variability of hospital accounting systems, and because cost information is not available until a year or more after claims information. In addition, the application of a cost-to-charge ratio that is uniform across any body of claims may result in biased estimates of individual costs if hospital charging behavior is not uniform. Thus, it is alleged that hospitals mark up lower cost services less than higher cost services, and to the extent they do so, application of a uniform cost-to-charge ratio will result in underestimates of the costs of higher cost services and vice versa. We use estimated costs, based on hospital-specific, department-level cost- to-charge ratios, in the hospital outpatient prospective payment system. The accuracy of this procedure has generated some concern, and without further analysis, the extent to which accuracy of inpatient payments would be improved by adopting this method is not obvious.

We will closely analyze the impact of such a change from the current charge-based DRG weights to cost-based DRG weights. We note that such a change is complex and would require further analysis. With this in mind, CMS will consider the following issues in performing this analysis:

The effect of using cost-to-charge ratio data, which is frequently older than the claims data we use to set the charge-based weights, and the impact on these data of any changes in hospitals' charging behavior that resulted from the recent modifications to the outlier payment methodology (68 FR 34494; June 9, 2003);

Whether using this method has different effects on DRGs that have experienced substantial technological change compared to DRGs with more stable procedures for care;

The effect of using a routine cost-to-charge ratio and department-level ancillary cost-to-charge data as compared to either an overall hospital cost-to-charge ratio or a routine cost-to-charge ratio and an overall ancillary cost-to-charge ratio, particularly in considering earlier studies performed for the Prospective Payment Assessment Commission, the predecessor to MedPAC, indicating that an overall ancillary cost-to-charge ratio led to more accurate estimates of case level costs; \5\

\5\ Cost Accounting for Health Care Organizations, Technical Report Series, 1-93-01, ProPAC, March 1993, page 6. Using a cost report package, the contractor simulated single and multiple ancillary cost-to-charge ratios and found that inpatient ancillary costs were 2.5 percent understated relative to what hospitals thought their costs were with the single cost-to-charge ratio, and 4.9 percent understated with the multiple cost-to-charge ratios.

Whether developing relative weights by estimating costs from charges multiplied by cost-to-charge ratios versus whether the sole use of charges improves payment accuracy; and

How payments to hospitals would be affected by MedPAC's suggestion intended to simplify recalibration, to recalibrate weights based on costs every few years, and to calculate an adjustment to charge-based weights for the intervening periods.

In response to the recommendation that the Secretary should improve payment accuracy in the IPPS by basing the weights on the national average of hospitals' relative values in each DRG, we note that presently we set the relative weights using standardized charges (adjusted to remove the effects of differences in area wage costs and in IME and DSH payments). In contrast, MedPAC proposes that Medicare set the DRG relative weights using unstandardized, hospital-specific charges. Each hospital's unstandardized charges would become the basis for determining the relative weights for the DRGs for that hospital. These relative weights would be adjusted by the hospital's case-mix index when combining each hospital's relative weights to determine a national relative weight for all hospitals. This adjustment is designed to reduce the influence that a single hospital's charge structure could have on determining the relative weight when it provides a high proportion of the total, nationwide number of discharges in a particular DRG.

We will analyze the possibility of moving to hospital specific relative values while conducting the analysis outlined above in response to the recommendations regarding improved severity adjustment and using charges adjusted to estimated cost using cost-to-charge ratios to set the relative weights. We note that we use this method at present to set weights for the LTCH PPS. We use this method for LTCHs because of the small volume of providers and the possibility that only a few providers provide care for certain DRGs. The charges of one or a few hospitals could thus materially affect the relative weights for these DRGs. In this event, looking at relative values within hospitals first can smooth out the hospital-specific effects on DRG weights. A 1993 Rand Report on hospital specific relative values noted the possibility of DRG compression (or the undervaluing of high-cost cases and the overvaluing of low-cost cases) if we were to shift to a hospital-specific relative value method from the current method for determining DRG weights. We will need to consider whether the resultant level of compression is appropriate.

Recommendation 2: The Congress should amend the law to give the Secretary authority to adjust the DRG relative weights to account for differences in the prevalence of high-cost outlier cases.

Response: While MedPAC's language suggests that the law would need to be amended for us to adopt this suggestion, we believe the statute may give the Secretary broad discretion to consider all factors that change the relative use of hospital resources in calculating the DRG relative weights. We believe that MedPAC's recommendation springs from a concern that including high-charge outlier cases in the relative- weight calculation results in overvaluing DRGs that have a high prevalence of outlier cases. However, we believe that excluding outlier cases completely in calculating the relative weights would be inappropriate. Doing

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so would undervalue the relative weight for a DRG with a high percentage of outliers by not including that portion of hospital charges that is above the median but below the outlier threshold. We believe it would be preferable to adjust the charges used for calculating the relative weights to exclude the portion of charges above the outlier threshold but to include the charges up to the outlier threshold. At this time, we expect to further analyze these ideas as we consider the other changes recommended by MedPAC and welcome public comments on this issue.

Finally, we believe that the recommendations made by MedPAC, or some variants of them, have significant promise in improving the accuracy of rates in the inpatient payment prospective payment system. We agree with MedPAC that they should be pursued even in the absence of concerns about the proliferation of specialty hospitals. However, until we have completed further analysis of these options and their effects, we cannot predict the extent to which they will provide payment equity between specialty and general hospitals. In fact, we must caution that any system that groups cases and provides a standard payment for cases in the group (that is, the IPPS among other Medicare payment systems) will always present some opportunities for providers to specialize in cases where they believe margins may be better. Improving payment accuracy should reduce these opportunities, and it may do so to the extent that Medicare payments no longer provide a significant impetus to further development of specialty hospitals.

Recommendation 3: The Congress and the Secretary should implement the case-mix measurement and outlier policies over a transitional period.

Response: Before proposing any changes to the DRGs, we would need to model the impact of any specific proposal and our authority under the statute to determine whether any changes should be implemented immediately or over a period of time. We do note that with regard to revising the existing DRG system with a new DRG system that fully captures differences in severity, there would likely be unique complexities in creating a transition from one DRG system to another. Our payment would be a blend of two different relative weights that would have to be determined using two different systems of DRGs. The systems and legal implications of such a transition or any other major change to the DRGs could be significant.

C. Other MedPAC Recommendations

MedPAC also made the following recommendations that we will address in our Report to Congress on Specialty Hospitals:

Recommendation 4: The Congress should extend the current [Pub. L. 108-173] moratorium on physician-owned single specialty hospitals until January 1, 2007.

Recommendation 5: The Congress should grant the Secretary the authority to allow gainsharing arrangements between physicians and hospitals and to regulate those arrangements to protect the quality of care and minimize financial incentives that could affect physician referrals.

X. Other Required Information

A. Requests for Data From the Public

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

cost for each file, if applicable, are listed below. Anyone wishing to purchase data tapes, cartridges, or diskettes should submit a written request along with a company check or money order (payable to CMS-PUF) to cover the cost to the following address: Centers for Medicare & Medicaid Services, Public Use Files, Accounting Division, P.O. Box 7520, Baltimore, MD 21207-0520, (410) 786-3691. Files on the Internet may be downloaded without charge. 1. CMS Wage Data

This file contains the hospital hours and salaries for FY 2002 used to create the FY 2006 prospective payment system wage index. The file will be available by the beginning of February for the NPRM and the beginning of May for the final rule.

[GRAPHIC] [TIFF OMITTED] TP04MY05.060

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These files support the following:

NPRM published in the Federal Register.

Final Rule published in the Federal Register.

Media: Diskette/most recent year on the Internet.

File Cost: $165.00 per year.

Periods Available: FY 2006 PPS Update. 2. CMS Hospital Wages Indices (Formerly: Urban and Rural Wage Index Values Only)

This file contains a history of all wage indices since October 1, 1983.

Media: Diskette/most recent year on the Internet.

File Cost: $165.00 per year.

Periods Available: FY 2006 PPS Update. 3. FY 2006 Proposed Rule Occupational Mix Adjusted and Unadjusted AHW by Provider

This file includes each hospital's adjusted and unadjusted average hourly wage.

Media: Internet.

Periods Available: FY 2006 PPS Update. 4. FY 2006 Proposed Rule Occupational Mix Adjusted and Unadjusted AHW and Pre-Reclassified Wage Index by CBSA

This file includes each CBSA's adjusted and unadjusted average hourly wage.

Media: Internet.

Periods Available: FY 2006 PPS Update. 5. Provider Occupational Mix Adjustment Factors for Each Occupational Category

This file contains each hospital's occupational mix adjustment factors by occupational category.

Media: Internet.

Periods Available: FY 2006 PPS Update. 6. PPS SSA/FIPS MSA State and County Crosswalk.

This file contains a crosswalk of State and county codes used by the Social Security Administration (SSA) and the Federal Information Processing Standards (FIPS), county name, and a historical list of Metropolitan Statistical Areas (MSAs).

Media: Diskette/Internet.

File Cost: $165.00 per year.

Periods Available: FY 2006 PPS Update. 7. Reclassified Hospitals New Wage Index (Formerly: Reclassified Hospitals by Provider Only)

This file contains a list of hospitals that were reclassified for the purpose of assigning a new wage index. Two versions of these files are created each year. They support the following:

NPRM published in the Federal Register.

Final Rule published in the Federal Register.

Media: Diskette/Internet.

File Cost: $165.00 per year.

Periods Available: FY 2006 PPS Update. 8. PPS-IV to PPS-XII Minimum Data Set

The Minimum Data Set contains cost, statistical, financial, and other information from Medicare hospital cost reports. The data set includes only the most current cost report (as submitted, final settled, or reopened) submitted for a Medicare participating hospital by the Medicare fiscal intermediary to CMS. This data set is updated at the end of each calendar quarter and is available on the last day of the following month.

Media: Tape/Cartridge.

File Cost: $770.00 per year.

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(Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS- XVIII, and PPS-XIX Minimum Data Sets are part of the PPS-XIII, PPS- XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII, PPS-XIX, and PPS-XX Hospital Data Set Files (refer to item 7 below).) 9. PPS-IX to PPS-XII Capital Data Set

The Capital Data Set contains selected data for capital-related costs, interest expense and related information and complete balance sheet data from the Medicare hospital cost report. The data set includes only the most current cost report (as submitted, final settled or reopened) submitted for Medicare certified hospital by the Medicare fiscal intermediary to CMS. This data set is updated at the end of each calendar quarter and is available on the last day of the following month.

Media: Tape/Cartridge.

Fine Cost: $770.00 per year.

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(Note: The PPS-XIII, PPS-XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS- XVIII, and PPS-XIX Capital Data Sets are part of the PPS-XIII, PPS- XIV, PPS-XV, PPS-XVI, PPS-XVII, PPS-XVIII, PPS-XIX, and PPS-XX Hospital Data Set Files (refer to item 7 below).) 10. PPS-XIII to PPS-XX Capital Data Set

The file contains costs, statistical, financial, and other data from the Medicare Hospital Cost Report. The data set includes only the most current cost report (as submitted, final settled or reopened) submitted for Medicare-certified hospital by the Medicare fiscal intermediary to CMS. This data set is updated at the end of each calendar quarter and is available on the last day of the following month.

Media: Diskette/Internet.

Fine Cost: $2,500.00.

[GRAPHIC] [TIFF OMITTED] TP04MY05.063

11. Provider-Specific File

This file is a component of the PRICER program used in the fiscal intermediary's system to compute DRG payments for individual bills. The file contains records for all prospective payment system eligible hospitals, including hospitals in waiver States, and data elements used in the prospective payment system recalibration processes and related activities. Beginning with December 1988, the individual records were enlarged to include pass-through per diems and other elements.

Media: Diskette/Internet.

File Cost: $265.00.

Periods Available: FY 2006 PPS Update. 12. CMS Medicare Case-Mix Index File

This file contains the Medicare case-mix index by provider number as published in each year's update of the Medicare hospital inpatient prospective payment system. The case-mix index is a measure of the costliness of cases treated by a hospital relative to the cost of the national average of all Medicare hospital cases, using DRG weights as a measure of relative costliness of cases. Two versions of this file are created each year. They support the following:

NPRM published in the Federal Register.

Final rule published in the Federal Register.

Media: Diskette/most recent year on Internet.

Price: $165.00 per year/per file.

Periods Available: FY 1985 through FY 2006. 13. DRG Relative Weights (Formerly Table 5 DRG)

This file contains a listing of DRGs, DRG narrative description, relative weights, and geometric and arithmetic mean lengths of stay as published in the Federal Register. The hard copy image has been copied to diskette. There are two versions of this file as published in the Federal Register:

NPRM.

Final rule.

Media: Diskette/Internet.

File Cost: $165.00.

Periods Available: FY 2006 PPS Update. 14. PPS Payment Impact File

This file contains data used to estimate payments under Medicare's hospital inpatient prospective payment systems for operating and capital-related costs. The data are taken from various sources, including the Provider-Specific File, Minimum Data Sets, and prior impact files. The data set is abstracted from an internal file used for the impact analysis of the changes to the prospective payment systems published in the Federal Register. This file is available for release 1 month after the proposed and final rules are published in the Federal Register.

Media: Diskette/Internet.

File Cost: $165.00.

Periods Available: FY 2006 PPS Update. 15. AOR/BOR Tables

This file contains data used to develop the DRG relative weights. It contains mean, maximum, minimum, standard deviation, and coefficient of variation statistics by DRG for length of stay and standardized charges. The BOR tables are ``Before Outliers Removed'' and the AOR is ``After Outliers Removed.'' (Outliers refers to statistical outliers, not payment outliers.)

Two versions of this file are created each year. They support the following:

NPRM published in the Federal Register.

Final rule published in the Federal Register.

Media: Diskette/Internet.

File Cost: $165.00.

Periods Available: FY 2006 PPS Update.

[[Page 23459]]

16. Prospective Payment System (PPS) Standardizing File

This file contains information that standardizes the charges used to calculate relative weights to determine payments under the prospective payment system. Variables include wage index, cost-of- living adjustment (COLA), case-mix index, disproportionate share, and the Metropolitan Statistical Area (MSA). The file supports the following:

NPRM published in the Federal Register.

Final rule published in the Federal Register.

Media: Internet.

File Cost: No charge.

Periods Available: FY 2006 PPS Update.

For further information concerning these data tapes, contact the CMS Public Use Files Hotline at (410) 786-3691.

Commenters interested in obtaining or discussing any other data used in constructing this rule should contact Mark Hartstein at (410) 786-4548.

B. Collection of Information Requirements

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

The need for the information collection and its usefulness in carrying out the proper functions of our agency.

The accuracy of our estimate of the information collection burden.

The quality, utility, and clarity of the information to be collected.

Recommendations to minimize the information collection burden on the affected public, including automated collection techniques.

Therefore, we are soliciting public comments on each of these issues for the information collection requirements discussed below.

The following information collection requirements included in this proposed rule and their associated burdens are subject to the PRA. Section 412.64 Federal Rates for Inpatient Operating Costs for Federal Fiscal Year 2005 and Subsequent Fiscal Years

Section 412.64(d)(2) requires hospitals to submit quality data on a quarterly basis to CMS, as specified by CMS. In this document, we are setting out the specific requirements related to the data that must be submitted. The burden associated with this section is the time and effort associated with collecting, copying and submitting this data. We estimate that there will be approximately 4,000 respondents per year. Of this number, approximately 3,600 hospitals are JCAHO accredited and are currently collecting measures and submitting data to the JCAHO on a quarterly basis. Of the JCAHO accredited hospitals, approximately 3,300 are collecting the same measures CMS will be collecting for public reporting. Therefore, there will be no additional burden for these hospitals. Only approximately 300 of the JCAHO accredited hospitals will need to collect an additional topic in addition to the data already collected for maintaining JCAHO accreditation. In addition, there are approximately 400 hospitals that do not participate in the JCAHO accreditation process. These hospitals will have the additional burden of collecting data on all three topics.

For JCAHO accredited hospitals that are not already collecting all of the required measures, we estimate it will take 25 hours per month per topic for collection. We expect the burden for all of these hospitals to total 102,000 hours per year, including time allotted for overhead. For non-JCAHO accredited hospitals, we estimate the burden to be 136,000 hours per year. This estimate also includes overhead. The total number of burden hours for all hospitals combined is 238,000. The number of responders will vary according to the level of voluntary participation. One hundred percent of the data may be collected electronically.

In the preamble to this proposed rule, we are proposing additional validation criteria to ensure that the quality data being sent to CMS are accurate. Our validation process requires participating hospitals to submit five charts per quarter. The burden associated with this requirement is the time and effort associated with collecting, copying, and submitting these charts. It will take approximately 2 hours per hospital to submit the 5 charts per quarter. There will be a total of approximately 19,000 charts (3,800 hospitals x charts per hospital) submitted by the hospitals to CMS per quarter for a total burden of 7,600 hours per quarter and a total annual burden of 30,400 hours. Section 413.65 Requirements for a Determination That a Facility or an Organization Has Provider-Based Status

Proposed Sec. 413.65(b)(3)(i) requires potential main providers seeking a determination of provider-based status for a facility that is located on the campus of the potential main provider to submit an attestation stating that the facility meets the criteria in paragraph (d) of Sec. 413.65 and, if it is a hospital, to also attest that it will fulfill the obligations of hospital outpatient departments and hospital-based entities described in paragraph (g) of Sec. 413.65. We are also proposing to amend this paragraph to require that in the case of a facility that is operated as a joint venture, the potential main provider attest that it will comply with the requirements of paragraph (f) of Sec. 413.65.

Proposed Sec. 413.65(b)(3)(ii) provides that, if a facility is not located on the campus of the potential main provider, the potential main provider must submit an attestation stating that the facility meets the criteria in paragraph (d) and (e) of Sec. 413.65 and, if it is a hospital, to also attest that it will fulfill the obligations of hospital outpatient departments and hospital-based entities described in paragraph (g) of Sec. 413.65. If the facility is operated under a management contract, the potential main provider also attest that the facility meets the requirements of paragraph (h) of Sec. 413.65.

Proposed Sec. 413.65(e)(3) requires that a facility or organization for which provider-based status is sought that is not located on the campus of a potential main provider must (i) be located within a 35-mile radius of the campus of the hospital or CAH that is the potential main provider, or (ii) be owned and operated by a hospital or CAH that has a disproportionate share adjustment (as determined under Sec. 412.106 of this chapter) greater than 11.75 percent and is described in Sec. 412.106(c)(2) of this chapter implementing section 1886(e)(5)(F)(i)(II) of the Act and is (A) owned or operated by a unit of State or local government, (B) a public or nonprofit corporation formally granted governmental powers by a unit of State or local government; or (C) a private hospital having a contract with a State or local government that includes the operation of clinics located off the main campus of the hospital to assure access in a well- defined service area to health care services for low-income individuals who are not entitled to benefits under Medicare (or medical assistance under a Medicaid State plan), or (iii) demonstrate a high level of integration

[[Page 23460]]

with the main provider by showing that it meets all of the other provider-based criteria and demonstrate that it serves the same patient population as the main provider, by submitting certain records showing the information contained in paragraphs (e)(3)(iii)(A) and (e)(3)(iii)(B) of this section or (iv) if the facility or organization is unable to meet the criteria in paragraph (e)(3)(iii)(A) or paragraph (e)(3)(iii)(B) because it was not in operation during all of the 12- month period described in paragraph (e)(3)(iii), be located in a zip code area included among those that, during all of the 12-month period described in paragraph (e)(3)(iii), accounted for at least 75 percent of the patients served by the main provider, or (v) in the case of an RHC, (A) be an RHC that is otherwise qualified as a provider-based entity of a hospital that has fewer than 50 beds, and (B) the hospital with which the facility or organization has a provider-based relationship be located in a rural area, and (vi) be located in the same State as the main provider or, when consistent with the laws of both States, in adjacent States.

Section 413.65(g)(7) provides that when a Medicare beneficiary is treated in a hospital outpatient department that is not located on the main provider's campus, the treatment is not required to be provided by the antidumping rules of section 489.24, and the beneficiary will incur a coinsurance liability for an outpatient visit to the hospital, as well as for the physician service the hospital must provide written notice to the beneficiary, before delivery of services of the amount of the beneficiary's potential financial liability. If the exact type and extent of care is not known, the hospital must provide written notice to the beneficiary that explains that the beneficiary will incur a coinsurance liability to the hospital that he or she would not incur if the facility were not provider-based, an estimate based on typical or average charges for visits to the facility, and a statement that the patient's actual liability will depend upon the actual services furnished by the hospital.

While the information collection requirements contained in this section are subject to the PRA, the burden associated with this requirement is currently approved under OMB approval no. 0938-0798. Section 485.610 Condition of Participation: Status and Location

In order to be considered a relocation, we are proposing under Sec. 485.610(d)(2)(ii) to require a CAH to provide documentation demonstrating that its plans to rebuild in a relocated area were undertaken prior to December 8, 2003. This requirement does impose an information collection requirement. However, because this burden would be imposed on less than 10 CAHs, under 5 CFR 1320.2(c), these requirements are exempt from the PRA.

We have submitted a copy of this proposed rule to OMB for its review of the information collection requirements described above.

If you have any comments on the information collection and recordkeeping requirements, please mail the copies directly to the following:

Centers for Medicare & Medicaid Services, Office of Strategic Operations and Regulatory Affairs, Security and Standards Group, Regulations Development and Issuances Group, Room C4-24-02, 7500 Security Boulevard, Baltimore, MD 21244-1850, Attn.: James Wickliffe, CMS-1500-P. Office of Information and Regulatory Affairs, Office of Management and Budget, Room 3001, New Executive Office Building, Washington, DC 20503, Attn: Christopher Martin, CMS Desk Officer.

Comments submitted to OMB may also be e-mailed to the following address: Christopher_Martin@omb.eop.gov; or faxed to OMB at (202) 395- 6974 or (202) 395-5167. Attn.: CMS-1500-P.

C. Public Comments

Because of the large number of items of correspondence we normally receive on a proposed rule, we are not able to acknowledge or respond to them individually. However, in preparing the final rule, we will consider all comments concerning the provisions of this proposed rule that we receive by the date and time specified in the DATES section of this preamble and respond to those comments in the preamble to that rule. We emphasize that section 1886(e)(5) of the Act requires the final rule for FY 2006 to be published by August 1, 2005, and we will consider only those comments that deal specifically with the matters discussed in this proposed rule.

List of Subjects

42 CFR Part 405

Administrative practice and procedure, Health facilities, Health professions, Kidney diseases, Medicare, Reporting and recordkeeping requirements, Rural area, X-rays.

42 CFR Part 412

Administrative practice and procedure, Health facilities, Medicare, Puerto Rico, Reporting and recordkeeping requirements.

42 CFR Part 413

Health facilities, Kidney diseases, Medicare, Puerto Rico, Reporting and recordkeeping requirements.

42 CFR Part 415

Health facilities, Health professions, Medicare, and reporting and recordkeeping requirements.

42 CFR Part 419

Hospitals, Medicare, Reporting and recordkeeping requirements.

42 CFR Part 422

Health maintenance organizations (HMO), Medicare+Choice, Provider sponsored organizations (PSO).

42 CFR Part 485

Grant programs-health, Health facilities, Medicaid, Medicare, Reporting and recordkeeping requirements.

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

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

A. Part 405 is amended as follows:

1. The authority citation for Part 405 continues to read as follows:

Authority: Secs. 1102, 1861, 1862(a), 1871, 1874, 1881, and 1886(k) of the Social Security Act (42 U.S.C. 1302, 1395x, 1395y(a), 1395hh, 1395kk, 1395rr, and 1395ww(k)), and sec. 353 of the Public Health Service Act (42 U.S.C. 263a).

Sec. 405.2468 [Amended]

2. In Sec. 405.2468(f)(1), the reference ``Sec. 413.86(b)'' is removed and the reference ``Sec. 413.75(b)'' is added in its place.

PART 412--PROSPECTIVE PAYMENT SYSTEMS FOR INPATIENT HOSPITAL SERVICES

B. Part 412 is amended as follows:

1. The authority citation for Part 412 continues to read as follows:

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

Sec. 412.1 [Amended]

2. In Sec. 412.1(a)(1), the reference ``Sec. 413.86'' is removed and the reference ``Sec. Sec. 413.75 through 413.83'' is added in its place.

Sec. 412.2 [Amended]

3. In Sec. 412.2--

[[Page 23461]]

a. In paragraph (f)(7), remove the reference ``Sec. 413.86'' and add in its place the reference ``Sec. Sec. 413.75 through 413.83''.

b. At the end of paragraph (f)(8), add the following sentence: ``For discharges occurring on or after October 1, 2005, the additional payment is made based on the average sales price methodology specified in Subpart K, Part 414 of this subchapter and the furnishing fee specified in Sec. 410.63 of this subchapter.''

4. Section 412.64 is amended by revising paragraph (k)(2) to read as follows:

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

* * * * *

(k) Midyear corrections to the wage index. * * * * *

(2)(i) Except as provided in paragraph (k)(2)(ii) of this section, a midyear correction to the wage index is effective prospectively from the date the change is made to the wage index.

(ii) Effective October 1, 2005, a change to the wage index may be made retroactively to the beginning of the Federal fiscal year, if, for the fiscal year in question, CMS determines all of the following--

(A) The fiscal intermediary or CMS made an error in tabulating data used for the wage index calculation;

(B) The hospital knew about the error in its wage data and requested the fiscal intermediary and CMS to correct the error both within the established schedule for requesting corrections to the wage data (which is at least before the beginning of the fiscal year for the applicable update to the hospital inpatient prospective payment system) and using the established process; and

(C) CMS agreed before October 1 that the fiscal intermediary or CMS made an error in tabulating the hospital's wage data and the wage index should be corrected. * * * * *

5. Section 412.73 is amended by adding a new paragraph (f) to read as follows:

Sec. 412.73 Determination of the hospital-specific rate based on a Federal fiscal year 1982 base period.

* * * * *

(f) Maintaining budget neutrality. CMS makes an adjustment to the hospital-specific rate to ensure that changes to the DRG classifications and recalibrations of the DRG relative weights are made in a manner so that aggregate payments to section 1886(d) hospitals are not affected.

6. Section 412.75 is amended by adding a new paragraph (i) to read as follows:

Sec. 412.75 Determination of the hospital-specific rate for inpatient operating costs based on a Federal fiscal year 1987 base period.

* * * * *

(i) Maintaining budget neutrality. CMS makes an adjustment to the hospital-specific rate to ensure that changes to the DRG classifications and recalibrations of the DRG relative weights are made in a manner so that aggregate payments to section 1886(d) hospitals are not affected.

7. Section 412.77 is amended by--

a. Revising paragraph (a)(1).

b. Adding a new paragraph (j).

The revision and addition read as follows:

Sec. 412.77 Determination of the hospital-specific rate for inpatient operating costs for sole community hospitals based on a Federal fiscal year 1996 base period.

(a) Applicability. (1) This section applies to a hospital that has been designated as a sole community hospital, as described in Sec. 412.92. If the 1996 hospital-specific rate exceeds the rate that would otherwise apply, that is, either the Federal rate under Sec. 412.64 (or under Sec. 412.63 for periods prior to FY 2005) or the hospital- specific rates for either FY 1982 under Sec. 412.73 or FY 1987 under Sec. 412.75, this 1996 rate will be used in the payment formula set forth in Sec. 412.92(d)(1). * * * * *

(j) Maintaining budget neutrality. CMS makes an adjustment to the hospital-specific rate to ensure that changes to the DRG classifications and recalibrations of the DRG relative weights are made in a manner so that aggregate payments to section 1886(d) hospitals are not affected.

8. Section 412.90 is amended by revising paragraph (e)(1) to read as follows:

Sec. 412.90 General rules.

* * * * *

(e) Hospitals located in areas that are reclassified from urban to rural. (1) CMS adjusts the rural Federal payment amounts for inpatient operating costs for hospitals located in geographic areas that are reclassified from urban to rural as defined in subpart D of this part. This adjustment is set forth in Sec. 412.102. * * * * *

9. Section 412.92 is amended by--

a. In paragraph (a) introductory text, removing the reference ``Sec. 412.83(b)'' and adding in its place the reference ``Sec. 412.64''.

b. Revising paragraph (d)(1)(i).

c. Revising paragraph (d)(3).

The revisions and addition read as follows:

Sec. 412.92 Special treatment: Sole community hospitals.

* * * * *

(d) Determining prospective payment rates for inpatient operating costs for sole community hospitals. (1) * * *

(i) The Federal payment rate applicable to the hospitals as determined under subpart D of this part. * * * * *

(3) Adjustment to payments. A sole community hospital may receive an adjustment to its payments to take into account a significant decrease in the number of discharges, as described in paragraph (e) of this section. * * * * *

10. Section 412.96 is amended by--

a. Revising paragraph (b)(1) introductory text.

b. Revising paragraph (c) introductory text.

c. In paragraph (c)(1) introductory text, removing the reference ``paragraph (g)'' and adding in its place the reference ``paragraph (h)''.

d. In paragraph (c)(2)(i), removing the reference ``paragraph (h)'' and adding in its place the reference ``paragraph (i)''.

e. Revising paragraph (g)(1).

f. In the introductory text of paragraph (h), removing the phrase ``paragraphs (g)(1) through (g)(4)'' and adding in its place the phrase ``paragraphs (h)(1) through (h)(4)''.

g. In paragraph (h)(2), removing the reference ``(g)(1)'' and adding in its place the reference ``(h)(1)''.

h. Removing paragraph (h)(4).

i. In paragraph (i)(2), removing the reference ``(h)(1)'' and adding in its place the reference ``(i)(1)''.

j. Removing paragraph (i)(4).

The revisions read as follows:

Sec. 412.96 Special treatment: Referral centers.

* * * * *

(b) Criteria for cost reporting periods beginning on or after October 1, 1983.* * *

(1) The hospital is located in a rural area (as defined in subpart D of this part) and has the following number of beds, as determined under the provisions of Sec. 412.105(b) available for use: * * * * *

(c) Alternative criteria. For cost reporting periods beginning on or after October 1, 1985, a hospital that does not meet the criteria of paragraph (b) of this section is classified as a referral center if it is located in a rural area (as defined

[[Page 23462]]

in subpart D of this part) and meets the criteria specified in paragraphs (c)(1) and (c)(2) of this section and at least one of the three criteria specified in paragraphs (c)(3), (c)(4), and (c)(5) of this section. * * * * *

(g) Hospital cancellation of referral center status. (1) A hospital may at any time request cancellation of its status as a referral center and be paid prospective payments per discharge based on the applicable rural rate, as determined in accordance with subpart D of this part. * * * * *

11. Section 412.103 is amended by revising paragraphs (a)(1) and (a)(4) to read as follows:

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

(a) * * *

(1) The hospital is located in a rural census tract of a Metropolitan Statistical Area (MSA) as determined under the most recent version of the Goldsmith Modification, the Rural-Urban Commuting Area codes, as determined by the Office of Rural Health Policy (ORHP) of the Health Resources and Services Administration, which is available via the ORHP Web site at: http://www.ruralhealth.hrsa.gov or from the U.S.

Department of Health and Human Services, Health Resources and Services Administration, Office of Rural Health Policy, 5600 Fishers Lane, Room 9A-55, Rockville, MD 20857. * * * * *

(4) For any period after September 30, 2004 and before October 1, 2006, a CAH in a county that, in FY 2004, was not part of an MSA as defined by the Office of Management and Budget and was not considered to be urban under Sec. 412.64(b)(3) of this chapter, but as of FY 2005 was included as part of an MSA or was considered to be urban under Sec. 412.64(b)(3) of this chapter as a result of the most recent census data and implementation of the new MSA definitions announced by OMB on June 6, 2003, may be reclassified as being located in a rural area for purposes of meeting the rural location requirement under Sec. 485.610(b) of this chapter if it meets any of the requirements in paragraphs (a)(1), (a)(2), or (a)(3) of this section. * * * * *

12. Section 412.105 is amended by--

a. Adding a new paragraph (f)(1)(iv)(D).

b. Adding a new paragraph (f)(1)(xiii).

c. Adding a new paragraph (f)(1)(xiv).

The additions read as follows:

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

* * * * *

(f) Determining the total number of full-time equivalent residents for cost reporting periods beginning on or after July 1, 1991. (1) * * *

(iv) * * *

(D) A rural hospital redesignated as urban after September 30, 2004, as a result of the most recent census data and implementation of the new labor market area definitions announced by OMB on June 6, 2003, may retain the increases to its full-time equivalent resident cap that it received under paragraphs (f)(1)(iv)(A) and (f)(1)(vii) of this section while it was located in a rural area. * * * * *

(xiii) For a hospital that was excluded from the hospital inpatient prospective payment system under Part 413 of this chapter and that subsequently changed to a hospital subject to the hospital inpatient prospective payment system for cost reporting periods ending on or before December 31, 1996, the total number of full-time equivalent residents for payment purposes is determined in accordance with the provisions of this paragraph (f). In the case of a merger of two or more hospitals, for purposes of this paragraph, the surviving hospital's number of full-time equivalent residents for payment purposes is equal to the aggregate number of the full-time equivalent resident count of each of the merged hospitals as determined in accordance with the provisions of this paragraph (f).

(xiv) Effective for discharges occurring on or after October 1, 2005, an urban hospital that reclassifies to a rural area under Sec. 412.103 and then subsequently elects to revert back to urban classification will not be allowed to retain the adjustment to its IME FTE resident cap that it received as a result of being reclassified as rural. * * * * *

13. Section 412.108 is amended by revising paragraph (c)(1) to read as follows:

Sec. 412.108 Special treatment: Medicare-dependent, small rural hospitals.

* * * * *

(c) Payment methodology. * * *

(1) The Federal payment rate applicable to the hospital, as determined under subpart D of this part, subject to the regional floor defined in Sec. 412.70(c)(6). * * * * *

14. Section 412.109 is amended by revising paragraph (b)(2) to read as follows:

Sec. 412.109 Special treatment: Essential access community hospitals (EACHs).

* * * * *

(b) Location in a rural area. * * *

(2) Is not deemed to be located in an urban area under subpart D of this part. * * * * *

Sec. 412.113 [Amended]

15. In Sec. 412.113--

a. In paragraph (b)(2), the reference ``Sec. 413.86 of this chapter.'' is removed and the reference ``Sec. Sec. 413.75 through 413.83 of this subchapter.'' is added in its place.

b. In paragraph (b)(3), the reference ``Sec. 413.86(c) of this chapter,'' is removed and the reference ``Sec. 413.75(c) of this subchapter,'' is added in its place.

Sec. 412.115 [Amended]

16. In Sec. 412.115--

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

b. At the end of paragraph (b), add the following sentence: ``For discharges occurring on or after October 1, 2005, the additional payment is made based on the average sales price methodology specified in subpart K, part 414 of this chapter and the furnishing fee specified in Sec. 410.63 of this subchapter.''

17. Section 412.230 is amended by--

a. Redesignating paragraph (d)(2)(iii) as paragraph (d)(2)(v).

b. Adding new paragraphs (d)(2)(iii) and (d)(2)(iv).

The additions read as follows:

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

* * * * *

(d) Use of urban or other rural area's wage index.--* * *

(2) Appropriate wage data. * * *

(iii) For applications submitted for reclassifications effective in FY 2006, a campus of a multicampus hospital system may seek reclassification to another CBSA. As part of its reclassification request, the requesting entity may submit the composite wage data for the entire multicampus hospital system as its hospital-specific data.

(iv) For applications submitted for reclassifications effective in FY 2007 and subsequent years, a campus of a multicampus hospital system may seek reclassification to another CBSA. As part of its reclassification request, the requesting entity must submit campus- specific wage data for purposes of the wage index comparison. * * * * *

18. Section 412.234 is amended by--

a. In paragraph (a)(3)(ii), removing the phrase ``fiscal years 2006 and thereafter''

[[Page 23463]]

and adding in its place the phrase ``fiscal year 2006''.

b. Adding a new paragraph (a)(3)(iii).

c. In paragraph (b)(1), removing the phrase ``or NECMA''.

The addition reads as follows:

Sec. 412.234 Criteria for all hospitals in an urban county seeking redesignation to another urban area.

(a) * * *

(3) * * *

(iii) For Federal fiscal year 2007 and thereafter, hospitals located in counties that are in the same Consolidated Statistical Area (CSA) (under the MSA definitions announced by the OMB on June 6, 2003) as the urban area to which they seek redesignation qualify as meeting the proximity requirement for reclassification to the urban area to which they seek redesignation. * * * * *

Sec. 412.278 [Amended]

19. In Sec. 412.278(b)(1), the phrase ``Office of Payment Policy'' is removed and the phrase ``Hospital and Ambulatory Policy Group'' is added in its place.

20. Section 412.304 is amended by revising paragraph (a) to read as follows:

Sec. 412.304 Implementation of the capital prospective payment system.

(a) General rule. As described in Sec. Sec. 412.312 through 412.370, effective with cost reporting periods beginning on or after October 1, 1991, CMS pays an amount determined under the capital prospective payment system for each inpatient hospital discharge as defined in Sec. 412.4. This amount is in addition to the amount payable under the prospective payment system for inpatient hospital operating costs as determined under subpart D of this part. * * * * *

Sec. 412.521 [Amended]

21. In Sec. 412.521--

a. Under paragraph (b)(2)(i), the reference ``Sec. Sec. 413.85, 413.86, and 413.87 of this subchapter.'' is removed and the reference ``Sec. Sec. 413.75 through 413.83, 413.85, and 413.87 of this subchapter.'' is added in its place.

b. Under paragraph (b)(2)(ii), the reference ``Sec. 413.80'' is removed and the reference ``Sec. 413.89'' is added in its place.

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

C. Part 413 is amended as follows:

1. The authority citation for Part 413 continued to read as follows:

Authority: Secs. 1102, 1812(d), 1814(b), 1815, 1833(a), (i), and (n), 1871, 1881, 1883, and 1886 of the Social Security Act (42 U.S.C. 1302, 1395d(d), 1395f(b), 1395g, 1395l(a), (i), and (n), 1395hh, 1395rr, 1395tt, and 1395ww).

Sec. 413.13 [Amended]

2. In Sec. 413.13 (d)(1), the reference ``Sec. 413.80'' is removed and the reference ``Sec. 413.89'' is added in its place.

3. Section 413.40 is amended by--

a. In paragraph(a)(3), under the definition of ``Net inpatient operating costs'', removing the reference ``Sec. Sec. 413.85 and 413.86'' and adding in its place the reference ``Sec. Sec. 413.75 through 413.83 and 413.85''.

b. Revising paragraph (c)(4)(iii).

Sec. 413.40 Ceiling on the rate of increase in hospital inpatient costs.

* * * * *

(c) Costs subject to the ceiling--* * *

(4) Target amounts. * * *

(iii) For cost reporting periods beginning on or after October 1, 1997 through September 30, 2002, in the case of a psychiatric hospital or unit, rehabilitation hospital or unit, or long-term care hospital, the target amount is the lower of the amounts specified in paragraph (c)(4)(iii)(A) or paragraph (c)(4)(iii)(B) of this section. * * * * *

4. Section 413.65 is amended by--

a. Reprinting the introductory text of paragraph (a)(1)(ii) and adding a new paragraph (a)(1)(ii)(L).

b. Revising the definition of ``Provider-based entity'' under paragraph (a)(2).

c. Revising paragraphs (b)(3)(i) and (b)(3)(ii).

d. Revising paragraphs (e)(1) introductory text and (e)(1)(i).

e. Revising paragraph (e)(3).

f. Revising paragraph (g)(7).

The addition and revision read as follows:

Sec. 413.65 Requirements for a determination that a facility or an organization has provider-based status.

(a) Scope and definitions. * * *

(1) * * *

(ii) The determinations of provider-based status for payment purposes described in this section are not made as to whether the following facilities are provider-based: * * * * *

(L) Rural health clinics (RHCs) affiliated with hospitals having 50 or more beds. * * * * *

(2) Definitions. * * *

Provider-based entity means a provider of health care services, or an RHC as defined in Sec. 405.2401(b) of this chapter, that is either created by, or acquired by, a main provider for the purpose of furnishing health care services of a different type from those of the main provider under the ownership and administrative and financial control of the main provider, in accordance with the provisions of this section. A provider-based entity comprises both the specific physical facility that serves as the site of services of a type for which payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at that facility. A provider-based entity may, by itself, be qualified to participate in Medicare as a provider under Sec. 489.2 of this chapter, and the Medicare conditions of participation do apply to a provider-based entity as an independent entity. * * * * *

(b) Provider-based determinations.-- * * *

(3)(i) Except as specified in paragraphs (b)(2) and (b)(5) of this section, if a potential main provider seeks a determination of provider-based status for a facility that is located on the campus of the potential main provider, the provider would be required to submit an attestation stating that the facility meets the criteria in paragraph (d) of this section and, if it is a hospital, also attest that it will fulfill the obligations of hospital outpatient departments and hospital-based entities described in paragraph (g) of this section. The provider seeking such a determination would also be required to maintain documentation of the basis for its attestations and to make that documentation available to CMS and to CMS contractors upon request. If the facility is operated as a joint venture, the provider would also have to attest that it will comply with the requirements of paragraph (f) of this section.

(ii) If the facility is not located on the campus of the potential main provider, the provider seeking a determination would be required to submit an attestation stating that the facility meets the criteria in paragraphs (d) and (e) of this section, and if the facility is operated under a management contract, the requirements of paragraph (h) of this section. If the potential main provider is a hospital, the hospital also would be required to attest that it will fulfill the obligations of hospital outpatient departments and hospital-based entities described in paragraph (g) of this section. The provider would be required

[[Page 23464]]

to supply documentation of the basis for its attestations to CMS at the time it submits its attestations. * * * * *

(e) * * *

(1) Operation under the ownership and control of the main provider. The facility or organization seeking provider-based status is operated under the ownership and control of the main provider, as evidenced by the following:

(i) The business enterprise that constitutes the facility or organization is 100 percent owned by the main provider. * * * * *

(3) Location. The facility or organization meets the requirements in paragraph (e)(3)(i), (e)(3)(ii), (e)(3)(iii), (e)(3)(iv), or, in the case of an RHC, paragraph (e)(3)(v) of this section, and the requirements in paragraph (e)(3)(vi) of this section.

(i) The facility or organization is located within a 35-mile radius of the campus of the hospital or CAH that is the potential main provider.

(ii) The facility or organization is owned and operated by a hospital or CAH that has a disproportionate share adjustment (as determined under Sec. 412.106 of this chapter) greater than 11.75 percent and is described in Sec. 412.106(c)(2) of this chapter implementing section 1886(e)(5)(F)(i)(II) of the Act and is--

(A) Owned or operated by a unit of State or local government;

(B) A public or nonprofit corporation that is formally granted governmental powers by a unit of State or local government; or

(C) A private hospital that has a contract with a State or local government that includes the operation of clinics located off the main campus of the hospital to assure access in a well-defined service area to health care services for low-income individuals who are not entitled to benefits under Medicare (or medical assistance under a Medicaid State plan).

(iii) The facility or organization demonstrates a high level of integration with the main provider by showing that it meets all of the other provider-based criteria and demonstrates that it serves the same patient population as the main provider, by submitting records showing that, during the 12-month period immediately preceding the first day of the month in which the application for provider-based status is filed with CMS, and for each subsequent 12-month period--

(A) At least 75 percent of the patients served by the facility or organization reside in the same zip code areas as at least 75 percent of the patients served by the main provider; or

(B) At least 75 percent of the patients served by the facility or organization who required the type of care furnished by the main provider received that care from that provider (for example, at least 75 percent of the patients of an RHC seeking provider-based status received inpatient hospital services from the hospital that is the main provider).

(iv) If the facility or organization is unable to meet the criteria in paragraph (e)(3)(iii)(A) or paragraph (e)(3)(iii)(B) of this section because it was not in operation during all of the 12-month period described in paragraph (e)(3)(iii) of this section, the facility or organization is located in a zip code area included among those that, during all of the 12-month period described in paragraph (e)(3)(iii) of this section, accounted for at least 75 percent of the patients served by the main provider.

(v) Both of the following criteria are met:

(A) The facility or organization is an RHC that is otherwise qualified as a provider-based entity of a hospital that has fewer than 50 beds, as determined under Sec. 412.105(b) of this chapter; and

(B) The hospital with which the facility or organization has a provider-based relationship is located in a rural area, as defined in Subpart D of Part 412 of this subchapter.

(vi) A facility or organization may qualify for provider-based status under this section only if the facility or organization and the main provider are located in the same State or, when consistent with the laws of both States, in adjacent States. * * * * *

(g) Obligations. * * *

(7) When a Medicare beneficiary is treated in a hospital outpatient department that is not located on the main provider's campus, the treatment is not required to be provided by the antidumping rules in Sec. 489.24 of this chapter, and the beneficiary will incur a coinsurance liability for an outpatient visit to the hospital as well as for the physician service, the following requirements must be met:

(i) The hospital must provide written notice to the beneficiary, before the delivery of services, of--

(A) The amount of the beneficiary's potential financial liability; or

(B) If the exact type and extent of care needed are not known, an explanation that the beneficiary will incur a coinsurance liability to the hospital that he or she would not incur if the facility were not provider-based, an estimate based on typical or average charges for visits to the facility, and a statement that the patient's actual liability will depend upon the actual services furnished by the hospital.

(ii) The notice must be one that the beneficiary can read and understand.

(iii) If the beneficiary is unconscious, under great duress, or for any other reason unable to read a written notice and understand and act on his or her own rights, the notice must be provided, before the delivery of services, to the beneficiary's authorized representative.

(iv) In cases where a hospital outpatient department provides examination or treatment that is required to be provided by the antidumping rules of Sec. 489.24 of this chapter, notice, as described in this paragraph (g)(7), must be given as soon as possible after the existence of an emergency has been ruled out or the emergency condition has been stabilized. * * * * *

5. Section 413.75 is amended in paragraph (b) by revising paragraph (1) under the definition of ``Medicare GME affiliated group'' to read as follows:

Sec. 413.75 Direct GME payments: General requirements.

* * * * *

(b) * * *

Medicare GME affiliated group means--

(1) Two or more hospitals that are located in the same urban or rural area (as those terms are defined in subpart D of part 412 of this subchapter. * * * * *

Sec. 413.77 [Amended]

6. In Sec. 413.77, under paragraph (e)(1)(iii), the reference ``Sec. 412.62(f)(1)(i) of this chapter.'' is removed and the reference ``subpart D of part 412 of this subchapter''. is added in its place.

7. Section 413.79 is amended by--

a. Revising paragraph (a)(10).

b. Revising the introductory text of paragraph (c)(2).

c. In paragraph (c)(3)(i), removing the reference ``Sec. 412.62(f)(iii)'' and adding in its place the reference ``subpart D of part 412 of this subchapter''.

d. Adding a new paragraph (c)(6).

e. Revising paragraph (e)(1)(iv).

f. In the introductory text of paragraph (k), removing the reference ``(k)(6)'' and adding in its place the reference ``(k)(7)''.

g. Adding a new paragraph (k)(7).

The revisions and additions read as follows:

Sec. 413.79 Direct GME payments: Determination of the weighted number of FTE residents.

* * * * *

[[Page 23465]]

(a) * * *

(10) Effective for portions of cost reporting periods beginning on or after October 1, 2004, if a hospital can document that a resident simultaneously matched for one year of training in a particular specialty program, and for a subsequent year(s) of training in a different specialty program, the resident's initial residency period will be determined based on the period of board eligibility for the specialty associated with the program for which the resident matched for the subsequent year(s) of training. Effective for cost reporting periods beginning on or after October 1, 2005, if a hospital can document that a particular resident, prior to beginning the first year of residency training, matched in a specialty program for which training would begin at the conclusion of the first year of training, that resident's initial residency period will be determined in the resident's first year of training based on the period of board eligibility associated with the specialty program for which the resident matched for subsequent training year(s). * * * * *

(c) Unweighted FTE counts. * * *

(2) Determination of the FTE resident cap. Subject to the provisions of paragraphs (c)(3) through (c)(6) of this section and Sec. 413.81, for purposes of determining direct GME payment-- * * * * *

(6) FTE resident caps for rural hospitals that are reclassified as urban. A rural hospital redesignated as urban after September 30, 2004, as a result of the most recent census data and implementation of the new MSA definitions announced by OMB on June 6, 2003, may retain the increases to its FTE resident cap that it received under paragraphs (c)(2)(i), (e)(1)(iii), and (e)(3) of this section while it was located in a rural area. * * * * *

(e) New medical residency training programs. * * *

(1) * * *

(iv) An urban hospital that qualifies for an adjustment to its FTE cap under paragraph (e)(1) of this section is permitted to be part of a Medicare GME affiliated group for purposes of establishing an aggregate FTE cap only if the adjustment that results from the affiliation is an increase to the urban hospital's FTE cap. * * * * *

(k) Residents training in rural track programs. * * *

(7) If an urban hospital had established a rural track training program under the provisions of this paragraph (k) with a hospital located in a rural area and that rural area subsequently becomes an urban area due to the most recent census data and implementation of the new labor market area definitions announced by OMB on June 6, 2003, the urban hospital may continue to adjust its FTE resident limit in accordance with this paragraph (k) for the rural track programs established prior to the adoption of such new labor market area definitions. In order to receive an adjustment to its FTE resident cap for a new rural track residency program, the urban hospital must establish a rural track program with hospitals that are designated rural based on the most recent geographical location designations adopted by CMS. * * * * *

Sec. 413.87 [Amended]

8. In Sec. 413.87(d) introductory text, the reference ``Sec. 413.86(d)(4)'' is removed and the reference ``Sec. 413.76(d)(4)'' is added in its place.

Sec. 413.178 [Amended]

9. In Sec. 413.178--

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

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

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

D. Part 415 is amended as follows:

1. The authority citation for part 415 continued to read as follows:

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

Sec. 415.55 [Amended]

2. In Sec. 415.55(a)(5), the reference ``Sec. 413.86'' is removed and the reference ``Sec. Sec. 413.75 through 413.83'' is added in its place.

Sec. 415.70 [Amended]

3. In Sec. 415.70(a)(2), the reference ``Sec. 413.86'' is removed and the reference ``Sec. Sec. 413.75 through 413.83'' is added in its place.

Sec. 415.102 [Amended]

4. In Sec. 415.102(c)(1), the reference ``Sec. 413.86'' is removed and the reference ``Sec. Sec. 413.75 through 413.83'' is added in its place.

Sec. 415.150 [Amended]

5. In Sec. 415.150(b), the reference ``Sec. 413.86'' is removed and the phrase ``Sec. Sec. 413.75 through 413.83'' is added in its place.

Sec. 415.152 [Amended]

6. In Sec. 415.152--

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

b. In the definition of ``Teaching setting'', the reference ``Sec. 413.86,'' is removed and the reference ``Sec. Sec. 413.75 through 413.83,'' is added in its place.

Sec. 415.160 [Amended]

7. In Sec. 415.160--

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

b. In paragraph (d)(2), the reference ``Sec. 413.86'' is removed and the reference ``Sec. Sec. 413.75 through 413.83'' is added in its place.

Sec. 415.174 [Amended]

8. In Sec. 415.174(a)(1), the reference ``Sec. 413.86.'' is removed and the phrase ``Sec. Sec. 413.75 through 413.83.'' is added in its place.

Sec. 415.200 [Amended]

9. In Sec. 415.200(a), the reference ``Sec. 413.86'' is removed and the reference ``Sec. Sec. 413.75 through 413.83'' is added in its place.

Sec. 415.204 [Amended]

10. In Sec. 415.204(a)(2), the reference ``Sec. 413.86'' is removed and the reference ``Sec. Sec. 413.75 through 413.83'' is added in its place.

Sec. 415.206 [Amended]

11. In Sec. 415.206(a), the reference ``Sec. 413.86(f)(1)(iii)'' is removed and the reference ``Sec. 413.78'' is added in its place.

Sec. 415.208 [Amended]

12. In Sec. 415.208--

a. In paragraph (b)(1), the reference ``Sec. 413.86'' is removed and the reference ``Sec. Sec. 413.75 through 413.83'' is added in its place.

b. In paragraph (b)(4), the reference ``Sec. 413.86'' is removed and the reference ``Sec. Sec. 413.75 through 413. 83'' is added in its place.

PART 419--PROSPECTIVE PAYMENT SYSTEM FOR OUTPATIENT DEPARTMENT SERVICES

F. Part 419 is amended as follows:

1. The authority citation for part 419 continues to read as follows:

Authority: Secs. 1102, 1833(t), and 1871 of the Social Security Act (42 U.S.C. 1302, 1395l(t), and 1395hh).

[[Page 23466]]

Sec. 419.2 [Amended]

2. In Sec. 419.2--

a. In paragraph (c)(1), the reference ``Sec. 413.86'' is removed and the reference ``Sec. Sec. 413.75 through 413.83'' is added in its place.

b. In paragraph (c)(6), the reference ``Sec. 413.80(b)'' is removed and the reference ``Sec. 413.89(b)'' is added in its place.

PART 422--SPECIAL RULES FOR SERVICES FURNISHED BY NONCONTRACT PROVIDERS

G. Part 422 is amended as follows:

1. The authority citation of part 422 continues to read as follows:

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

Sec. 422.214 [Amended]

2. In Sec. 422.214--

a. In paragraph (b), the phrase ``Sec. Sec. 412.105(g) and 413.86(d))'' is removed and the phrase ``Sec. Sec. 412.105(g) and 413.76))'' is added in its place.

b. In paragraph (b), the phrase ``Section 413.86 (d)'' is removed and the phrase ``Section 413.76'' is added in its place.

Sec. 422.216 [Amended]

3. In Sec. 422.216(a)(4), the reference ``Sec. Sec. 412.105(g) and 413.86(d)'' is removed and the reference ``Sec. Sec. 412.105(g) and 413.76'' is added in its place.

PART 485--CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS

G. Part 485 is amended as follows:

1. The authority citation for Part 485 continues to read as follows:

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

2. Section 485.610 is amended by--

a. In paragraph (b)(1)(i), removing the reference ``Sec. 412.62(f)'' and adding in its place the reference ``Sec. 412.64(b)''.

b. In paragraph (b)(1)(ii), removing the reference ``Sec. 412.63(b)'' and adding in its place the reference ``Sec. 412.64(b)''.

c. Revising paragraph (b)(3).

d. Adding a new paragraph (d).

The revisions and additions read as follows:

Sec. 485.610 Condition of participation: Status and location.

* * * * *

(b) * * *

(3) Effective only for October 1, 2004 through September 30, 2006, the CAH does not meet the location requirements in either paragraph (b)(1) or paragraph (b)(2) of this section and is located in a county that, in FY 2004, was not part of a Metropolitan Statistical Area as defined by the Office of Budget Management and was not considered to be urban under Sec. 412.63(b)(3) of this chapter, but as of FY 2005 was included as part of such an MSA or was considered to be urban under Sec. 412.64(b)(3) of this chapter, as a result of the most recent census data and implementation of the new MSA definitions announced by OMB on June 6, 2003. * * * * *

(d) Standard: Relocation of CAHs with a necessary provider designation. A CAH that has a necessary provider certification from the State and places a new facility in service after January 1, 2006, can continue to meet the location requirement of paragraph (c) of this section based on the necessary provider certification only if the new facility meets either the requirement for replacement in the same location in paragraph (d)(1) of this section or the requirement for a relocation of a CAH in paragraph (d)(2) of this section.

(1) A new construction of a CAH will be considered as a replacement facility if the construction is undertaken within 250 yards of the current building or contiguous to the current CAH on land owned by the CAH prior to December 8, 2003.

(2) A new facility CAH will be considered as a relocation of a CAH if, at the relocated site--

(i) The CAH serves at least 75 percent of the same service area that it served prior to its relocation, provides at least 75 percent of the same services that it provided prior to the relocation, and is staffed by 75 percent of the same staff (including medical staff, contracted staff, and employees); and

(ii) The CAH provides documentation demonstrating that its plans to rebuild in the relocated area were undertaken prior to December 8, 2003.

(3) If a CAH that has a necessary provider certification from the State places a new facility in service on or after January 1, 2006, and does not meet either the requirements in paragraph (d)(1) or paragraph (d)(2) of this section, the action will be considered a cessation of business as described in Sec. 489.52(b)(3).

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

Dated: April 19, 2005. Mark B. McClellan, Administrator, Centers for Medicare & Medicaid Services.

Dated: April 22, 2005. Michael O. Leavitt, Secretary.

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

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

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

I. Summary and Background

In this Addendum, we are setting forth the proposed amounts and factors for determining prospective payment rates for Medicare hospital inpatient operating costs and Medicare hospital inpatient capital-related costs. We are also setting forth the proposed rate- of-increase percentages for updating the target amounts for hospitals and hospital units excluded from the IPPS.

For discharges occurring on or after October 1, 2005, except for SCHs, MDHs, and hospitals located in Puerto Rico, each hospital's payment per discharge under the IPPS will be based on 100 percent of the Federal national rate, which will be based on the national adjusted standardized amount. This amount reflects the national average hospital costs per case from a base year, updated for inflation.

SCHs are paid based on whichever of the following rates yields the greatest aggregate payment: the Federal national rate; the updated hospital-specific rate based on FY 1982 costs per discharge; the updated hospital-specific rate based on FY 1987 costs per discharge; or the updated hospital-specific rate based on FY 1996 costs per discharge.

Under section 1886(d)(5)(G) of the Act, MDHs are paid based on the Federal national rate or, if higher, the Federal national rate plus 50 percent of the difference between the Federal national rate and the updated hospital-specific rate based on FY 1982 or FY 1987 costs per discharge, whichever is higher. MDHs do not have the option to use their FY 1996 hospital-specific rate.

For hospitals in Puerto Rico, the payment per discharge is based on the sum of 25 percent of a Puerto Rico rate that reflects base year average costs per case of Puerto Rico hospitals and 75 percent of the Federal national rate. (See section II.D.3. of this Addendum for a complete description.)

As discussed below in section II. of this Addendum, we are proposing to make changes in the determination of the prospective payment rates for Medicare inpatient operating costs for FY 2006. The proposed changes, to be applied

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prospectively effective with discharges occurring on or after October 1, 2005, affect the calculation of the Federal rates. In section III. of this Addendum, we discuss our proposed changes for determining the prospective payment rates for Medicare inpatient capital-related costs for FY 2006. Section IV. of this Addendum sets forth our proposed changes for determining the rate-of-increase limits for hospitals excluded from the IPPS for FY 2006. Section V. of this Addendum sets forth policies on payment for blood clotting factors administered to hemophilia patients. The tables to which we refer in the preamble of this proposed rule are presented in section VI. of this Addendum.

II. Proposed Changes to Prospective Payment Rates for Hospital Inpatient Operating Costs for FY 2006

The basic methodology for determining prospective payment rates for hospital inpatient operating costs for FY 2005 and subsequent fiscal years is set forth at Sec. 412.64. The basic methodology for determining the prospective payment rates for hospital inpatient operating costs for hospitals located in Puerto Rico for FY 2005 and subsequent fiscal years is set forth at Sec. Sec. 412.211 and 412.212. Below we discuss the factors used for determining the prospective payment rates.

In summary, the proposed standardized amounts set forth in Tables 1A, 1B, 1C, and 1D of section VI. of this Addendum reflect--

Equalization of the standardized amounts for urban and other areas at the level computed for large urban hospitals during FY 2004 and onward, as provided for under section 1886(d)(3)(A)(iv) of the Act, updated by the applicable percentage increase required under sections 1886(b)(3)(B)(i)(XIX) and 1886(b)(3)(B)(vii) of the Act.

The two labor-related shares that are applicable to the standardized amounts, depending on whether the hospital's payments would be higher with a lower (in the case of a wage index below 1.0000) or higher (in the case of a wage index above 1.0000) labor share, as provided for under sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act;

Updates of 3.2 percent for all areas (that is, the full market basket percentage increase of 3.2 percent, as required by section 1886(b)(3)(B)(i)(XIX) of the Act, and reflecting the requirements of section 1886(b)(3)(B)(vii) of the Act to reduce the applicable percentage increase by 0.4 percentage points for hospitals that fail to submit data, in a form and manner specified by the Secretary, relating to the quality of inpatient care furnished by the hospital;

An adjustment to ensure the proposed DRG recalibration and wage index update and changes are budget neutral, as provided for under sections 1886(d)(4)(C)(iii) and 1886(d)(3)(E) of the Act, by applying new budget neutrality adjustment factors to the standardized amount;

An adjustment to ensure the effects of the special transition measures adopted in relation to the implementation of new labor market areas are budget neutral;

An adjustment to ensure the effects of geographic reclassification are budget neutral, as provided for in section 1886(d)(8)(D) of the Act, by removing the FY 2005 budget neutrality factor and applying a revised factor;

An adjustment to apply the new outlier offset by removing the FY 2005 outlier offset and applying a new offset;

An adjustment to ensure the effects of the rural community hospital demonstration required under section 410A of Pub. L. 108-173 are budget neutral, as required under section 410A(c)(2) of Pub. L. 108-173.

A. Calculation of the Adjusted Standardized Amount

1. Standardization of Base-Year Costs or Target Amounts

The national standardized amount is based on per discharge averages of adjusted hospital costs from a base period (section 1886(d)(2)(A) of the Act) or, for Puerto Rico, adjusted target amounts from a base period (section 1886(d)(9)(B)(i) of the Act), updated and otherwise adjusted in accordance with the provisions of section 1886(d) of the Act. The September 1, 1983 interim final rule (48 FR 39763) contained a detailed explanation of how base-year cost data (from cost reporting periods ending during FY 1981) were established in the initial development of standardized amounts for the IPPS. The September 1, 1987 final rule (52 FR 33043 and 33066) contains a detailed explanation of how the target amounts were determined, and how they are used in computing the Puerto Rico rates.

Sections 1886(d)(2)(B) and (d)(2)(C) of the Act require us to update base-year per discharge costs for FY 1984 and then standardize the cost data in order to remove the effects of certain sources of cost variations among hospitals. These effects include case-mix, differences in area wage levels, cost-of-living adjustments for Alaska and Hawaii, indirect medical education costs, and costs to hospitals serving a disproportionate share of low- income patients.

Under section 1886(d)(3)(E) of the Act, the Secretary estimates, from time-to-time, the proportion of hospitals' costs that are attributable to wages and wage-related costs. The standardized amount is divided into labor-related and nonlabor-related amounts; only the proportion considered the labor-related amount is adjusted by the wage index. Section 403 of Pub. L. 108-173 revises the proportion of the standardized amount that is considered labor- related. Specifically, section 1886(d)(3)(E) of the Act (as amended by section 403 of Pub. L. 108-173) requires that 62 percent of the standardized amount be adjusted by the wage index, unless doing so would result in lower payments to a hospital than would otherwise be made. (Section 403(b) of Pub. L. 108-173 extended this provision to the Puerto Rico standardized amounts.) We are proposing to update the labor-related share to 69.7 percent for FY 2006, as discussed in section IV.B.3. of the preamble to this proposed rule. We note that the revised labor-related share that we are proposing for FY 2006 was determined to be 69.731, as discussed in section IV of the preamble to this proposed rule. We are proposing to continue with our previous methodology and round the labor-related share to 69.7 percent for purposes of establishing the labor-related and nonlabor- related portions of the standardized amount. As discussed in section IV. of the preamble to this proposed rule, we are also proposing to rebase the current labor-related share for the Puerto Rico-specific amounts for FY 2006. Since the proposed rebased Puerto Rico labor- related share has not yet been calculated, the proposed standardized amounts that appear in Table 1C of this Addendum for providers with a wage index greater than 1.0000 reflect the current (FY 2005) labor-related share for the Puerto Rico-specific amounts of 71.3 percent for FY 2006. However, in the final rule, if we adopt our proposal to rebase the labor-related share for Puerto Rico, these amounts would reflect this revised labor-related share. We are proposing to adjust 62 percent of the national standardized amount and 62 percent of the Puerto Rico-specific amount by the wage index for all hospitals whose wage indexes are less than or equal to 1.0000. For all hospitals whose wage values are greater than 1.0000, we are proposing to adjust the national standardized amount by a labor-related share of 69.7 percent.

2. Computing the Average Standardized Amount

Sections 1886(d)(3)(A)(iv) of the Act previously required the Secretary to compute the following two average standardized amounts for discharges occurring in a fiscal year: One for hospitals located in large urban areas and one for hospitals located in other areas. In accordance with section 1886(b)(3)(B)(i) of the Act, the large urban average standardized amount was 1.6 percent higher than the other area average standardized amount. In addition, under sections 1886(d)(9)(B)(iii) and 1886(d)(9)(C)(i) of the Act, the average standardized amounts per discharge were determined for hospitals located in urban and rural areas in Puerto Rico.

Section 402(b) of Pub. L. 108-7 required that, effective for discharges occurring on or after April 1, 2003, and before October 1, 2003, the Federal rate for all IPPS hospitals would be based on the large urban standardized amount. Subsequently, Pub. L. 108-89 extended section 402(b) of Pub. L. 108-7 beginning with discharges on or after October 1, 2003 and before March 31, 2004. Finally, section 401(a) of Pub. L. 108-173 amended section 1886(d)(3)(A)(iv) of the Act to require that, beginning with FY 2004 and thereafter, an equal standardized amount is to be computed for all hospitals at the level computed for large urban hospitals during FY 2003, updated by the applicable percentage update. This provision in effect makes permanent the equalization of the standardized amounts at the level of the previous standardized amount for large urban hospitals. Section 401(c) of Pub. L. 108-173 also amended section 1886(d)(9)(A) of the Act to equalize the Puerto Rico-specific urban and rural area rates. Accordingly, we are providing in this proposed rule for a single national standardized amount and a

[[Page 23468]]

single Puerto Rico standardized amount for FY 2006.

3. Updating the Average Standardized Amount

In accordance with section 1886(d)(3)(A)(iv)(II) of the Act, we are proposing to update the equalized standardized amount for FY 2006 by the full estimated market basket percentage increase for hospitals in all areas, as specified in section 1886(b)(3)(B)(i)(XIX) of the Act, as amended by section 501 of Pub. L. 108-173. The percentage change in the market basket reflects the average change in the price of goods and services purchased by hospitals to furnish inpatient care. The most recent forecast of the hospital market basket increase for FY 2006 is 3.2 percent. Thus, for FY 2006, the proposed update to the average standardized amount is 3.2 percent for hospitals in all areas.

Section 1886(b)(3)(B) of the Act specifies the mechanism used to update the standardized amount for payment for inpatient hospital operating costs. Section 1886(b)(3)(B)(vii) of the Act, as amended by section 501(b) of Pub. L. 108-173, provides for a reduction of 0.4 percentage points to the update percentage increase (also known as the market basket update) for each of FYs 2005 through 2007 for any ``subsection (d) hospital'' that does not submit data on a set of 10 quality indicators established by the Secretary as of November 1, 2003. The statute also provides that any reduction will apply only to the fiscal year involved, and will not be taken into account in computing the applicable percentage increase for a subsequent fiscal year. This measure establishes an incentive for hospitals to submit data on quality measures established by the Secretary. The proposed standardized amounts in Tables 1A through 1D of section VI. of this Addendum reflect these differential amounts.

Although the update factors for FY 2006 are set by law, we are required by section 1886(e)(3) of the Act to report to the Congress our initial recommendation of update factors for FY 2006 for both IPPS hospitals and hospitals and hospital units excluded from the IPPS. Our recommendation on the update factors (which is required by sections 1886(e)(4)(A) and (e)(5)(A) of the Act) is set forth as Appendix B of this proposed rule.

4. Other Adjustments to the Average Standardized Amount

As in the past, we are proposing to adjust the FY 2006 standardized amount to remove the effects of the FY 2005 geographic reclassifications and outlier payments before applying the FY 2006 updates. We then apply the new offsets for outliers and geographic reclassifications to the standardized amount for FY 2006.

We do not remove the prior year's budget neutrality adjustments for reclassification and recalibration of the DRG weights and for updated wage data because, in accordance with section 1886(d)(4)(C)(iii) of the Act, estimated aggregate payments after the changes in the DRG relative weights and wage index should equal estimated aggregate payments prior to the changes. If we removed the prior year adjustment, we would not satisfy this condition.

Budget neutrality is determined by comparing aggregate IPPS payments before and after making the changes that are required to be budget neutral (for example, reclassifying and recalibrating the DRGs, updating the wage data, and geographic reclassifications). We include outlier payments in the payment simulations because outliers may be affected by changes in these payment parameters.

We are also proposing to adjust the standardized amount this year by an amount estimated to ensure that aggregate IPPS payments do not exceed the amount of payments that would have been made in the absence of the rural community hospital demonstration required under section 410A of Pub. L. 108-173. This demonstration is required to be budget neutral under section 410A(c)(2) of Pub. L. 108-173.

a. Recalibration of DRG Weights and Updated Wage Index--Budget Neutrality Adjustment

Section 1886(d)(4)(C)(iii) of the Act specifies that, beginning in FY 1991, the annual DRG reclassification and recalibration of the relative weights must be made in a manner that ensures that aggregate payments to hospitals are not affected. As discussed in section II. of the preamble, we normalized the recalibrated DRG weights by an adjustment factor, so that the average case weight after recalibration is equal to the average case weight prior to recalibration. However, equating the average case weight after recalibration to the average case weight before recalibration does not necessarily achieve budget neutrality with respect to aggregate payments to hospitals because payments to hospitals are affected by factors other than average case weight. Therefore, as we have done in past years, we are proposing to make a budget neutrality adjustment to ensure that the requirement of section 1886(d)(4)(C)(iii) of the Act is met.

Section 1886(d)(3)(E) of the Act requires us to update the hospital wage index on an annual basis beginning October 1, 1993. This provision also requires us to make any updates or adjustments to the wage index in a manner that ensures that aggregate payments to hospitals are not affected by the change in the wage index. For FY 2006, we are proposing to continue to adjust 10 percent of the wage index factor for occupational mix. We describe the proposed occupational mix adjustment in section III.C. of the preamble to this proposed rule. Because section 1886(d)(3)(E) of the Act requires us to update the wage index on a budget neutral basis, we are including the effects of this proposed occupational mix adjustment on the wage index in our budget neutrality calculations.

In FY 2005, those urban hospitals that became rural under the new labor market area definitions were assigned the wage index of the urban area in which they were located under the previous labor market definitions for a 3-year period of FY 2005, FY 2006, and FY 2007. Because we are in the second year of this 3-year transition, we are proposing to adjust the standardized amounts for FY 2006 to ensure budget neutrality for this policy. We discuss this adjustment in section III.B. of the preamble to this proposed rule.

Section 4410 of Pub. L. 105-33 provides that, for discharges on or after October 1, 1997, the area wage index applicable to any hospital that is not located in a rural area may not be less than the area wage index applicable to hospitals located in rural areas in that State. This provision is required by section 4410(b) of Pub. L. 105-33 to be budget neutral. Therefore, we include the effects of this provision in our calculation of the wage update budget neutrality factor. As discussed in the FY 2005 IPPS final rule (69 FR 49110), we are in the second year of the 3-year provision that uses an imputed wage index floor for States that have no rural areas and States that have geographic rural areas, but that have no hospitals actually classified as rural. We are also adjusting for the effects of this provision in our calculation of the wage update budget neutrality factor.

To comply with the requirement that DRG reclassification and recalibration of the relative weights be budget neutral, and the requirement that the updated wage index be budget neutral, we used FY 2004 discharge data to simulate payments and compared aggregate payments using the FY 2005 relative weights and wage index to aggregate payments using the proposed FY 2006 relative weights and wage index. The same methodology was used for the FY 2005 budget neutrality adjustment.

Based on this comparison, we computed a proposed budget neutrality adjustment factor equal to 1.002494. We also are proposing to adjust the Puerto Rico-specific standardized amount for the effect of DRG reclassification and recalibration. We computed a proposed budget neutrality adjustment factor for the Puerto Rico- specific standardized amount equal to 0.999003. These proposed budget neutrality adjustment factors are applied to the standardized amounts without removing the effects of the FY 2005 budget neutrality adjustments. In addition, as discussed in section V.C.2. of the preamble to this proposed rule, we are proposing to apply the same DRG reclassification and recalibration budget neutrality factor of 0.999003 to the hospital-specific rates that are effective for cost reporting periods beginning on or after October 1, 2005.

Using the same data, we calculated a transition budget neutrality adjustment to account for the ``hold harmless'' policy under which urban hospitals that became rural under the new labor market area definitions were assigned the wage index of the urban area in which they were located under the previous labor market area definitions for a 3-year period of FY 2005, FY 2006, and FY 2007 (see Table 2 in section VI. of this Addendum). Using the prereclassified wage index, we simulated payments under the new labor market area definitions and compared them to simulated payments under the ``hold harmless'' policy. Based on this comparison, we computed a proposed transition budget neutrality adjustment of 0.999529.

b. Reclassified Hospitals--Budget Neutrality Adjustment

Section 1886(d)(8)(B) of the Act provides that, effective with discharges occurring on or after October 1, 1988, certain rural hospitals are deemed urban. In addition, section 1886(d)(10) of the Act provides for

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the reclassification of hospitals based on determinations by the MGCRB. Under section 1886(d)(10) of the Act, a hospital may be reclassified for purposes of the wage index.

Under section 1886(d)(8)(D) of the Act, the Secretary is required to adjust the standardized amount to ensure that aggregate payments under the IPPS after implementation of the provisions of sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the Act are equal to the aggregate prospective payments that would have been made absent these provisions. (We note that neither the wage index reclassifications provided under section 508 of Pub. L. 108-173 nor the wage index adjustments provided under section 505 of Pub. L. 108-173 are budget neutral. Section 508(b) of Pub. L. 108-173 provides that the wage index reclassifications approved under section 508(a) of Pub. L. 108-173 ``shall not be effected in a budget neutral manner.'' Section 505(a) of Pub. L. 108-173 similarly provides that any increase in a wage index under that section shall not be taken into account ``in applying any budget neutrality adjustment with respect to such index'' under section 1886(d)(8)(D) of the Act.) To calculate this proposed budget neutrality factor, we used FY 2004 discharge data to simulate payments, and compared total IPPS payments prior to any reclassifications under sections 1886(d)(8)(B) and (C) and 1886(d)(10) of the Act to total IPPS payments after such reclassifications. Based on these simulations, we are proposing to apply an adjustment factor of 0.992905 to ensure that the effects of this reclassification are budget neutral.

The proposed adjustment factor is applied to the standardized amount after removing the effects of the FY 2005 budget neutrality adjustment factor. We note that the proposed FY 2006 adjustment reflects FY 2006 wage index reclassifications approved by the MGCRB or the Administrator, and the effects of MGCRB reclassifications approved in FY 2004 and FY 2005 (section 1886(d)(10)(D)(v) of the Act makes wage index reclassifications effective for 3 years).

c. Outliers

Section 1886(d)(5)(A) of the Act provides for payments in addition to the basic prospective payments for ``outlier'' cases involving extraordinarily high costs. To qualify for outlier payments, a case must have costs above a fixed-loss cost threshold amount (a dollar amount by which the costs of a case must exceed payments in order to qualify for outlier payment). To determine whether the costs of a case exceed the fixed-loss threshold, a hospital's cost-to-charge ratio is applied to the total covered charges for the case to convert the charges to costs. Payments for eligible cases are then made based on a marginal cost factor, which is a percentage of the costs above the threshold.

In accordance with section 1886(d)(5)(A)(iv) of the Act, outlier payments for any year are projected to be not less than 5 percent nor more than 6 percent of total operating DRG payments plus outlier payments. Section 1886(d)(3)(B) of the Act requires the Secretary to reduce the average standardized amount by a factor to account for the estimated proportion of total DRG payments made to outlier cases. Similarly, section 1886(d)(9)(B)(iv) of the Act requires the Secretary to reduce the average standardized amounts applicable to hospitals in Puerto Rico to account for the estimated proportion of total DRG payments made to outlier cases. More information on outlier payments may be found on the CMS Web site at http://www.cms.hhs.gov/providers/hipps/ippsotlr.asp .

i. Proposed FY 2006 outlier fixed-loss threshold. For FY 2006, we are proposing a new methodology to calculate the outlier fixed- loss threshold. For FY 2004, we simulated outlier payments by applying FY 2004 rates and policies using cases from the FY 2002 MedPAR file. In order to determine the FY 2004 outlier fixed-loss threshold, it was necessary to inflate the charges on the MedPAR claims by 2 years, from FY 2002 to FY 2004. In order to determine the FY 2004 threshold, we used the 2-year average annual rate-of- change in charges per case to inflate FY 2002 charges to approximate FY 2004 charges. (We refer the reader to the FY 2004 IPPS final rule (67 FR 45476) for a complete discussion of the FY 2004 methodology.) In the IPPS proposed rule for FY 2005 (69 FR 28376), we proposed to use the same methodology we used for determining the FY 2004 outlier fix-loss threshold to determine the FY 2005 outlier threshold. We further noted that the rate-of-increase in the 2-year average annual rate-of-change in charges derived from the period before the changes we made to the policy affecting the applicable cost-to-charge ratios (68 FR 34494) and, therefore, they may have represented rates-of- increase that could be higher than the rates-of-increase under our new policy. As a result, we welcomed comments on the data we were using to update charges for purposes of the threshold and specifically encouraged commenters to provide recommendations for data that might better reflect current trends in charge increases.

In response to the many comments we received on this proposed FY 2005 methodology, in the IPPS final rule for FY 2005 (69 FR 49275), we revised that proposed methodology and used the following methodology to calculate the final FY 2005 outlier fixed-loss threshold. Instead of using the 2-year average annual rate-of-change in charges per case from FY 2001 to FY 2002 and FY 2002 to FY 2003, we used more recent data to determine the annual rate-of-change in charges for the FY 2005 outlier threshold. Specifically, we compared the rate-of-increase in charges from the first half-year of FY 2003 to the first half-year of FY 2004. We stated that we believed this methodology would result in a more accurate determination of the rate-of-change in charges per case between FY 2003 and FY 2005. Although a full year of data was available for FY 2003, we did not have a full year of FY 2004 data at the time we set the FY 2005 outlier threshold. Therefore, we stated that we believed it was optimal to employ comparable periods in determining the rate-of- change from one year to the next. We also stated that we believed this methodology was the best methodology for determining the rate- of-change in charges per case because it used the most recent charge data available. Using this methodology, we established a fixed-loss cost outlier threshold for FY 2005 equal to the prospective payment rate for the DRG, plus any IME and DSH payment, and any add-on payment for new technology, plus $25,800.

For FY 2006, we are proposing to use a new methodology to calculate the outlier threshold that will take into account the lower inflation in hospital charges that is occurring as a result of the June 9, 2003 outlier final rule (68 FR 34505), which changed our methodology for determining outlier payments by implementing the use of more current and accurate cost-to-charge ratios when paying for outliers. As we have done in the past, to calculate the proposed FY 2006 outlier thresholds, we simulated payments by applying proposed FY 2006 rates and policies using cases from the FY 2004 MedPAR files. Therefore, in order to determine the appropriate proposed FY 2006 outlier threshold, it was necessary to inflate the charges on the MedPAR claims by 2 years, from FY 2004 to FY 2006.

However, we are not proposing to inflate charges using a 2-year average annual rate-of-change in charges per case from FY 2002 to FY 2003 and FY 2003 to FY 2004 because of the distortion in FY 2002 and FY 2003 charge data caused by the exceptionally high rate of hospital charge inflation during those years. Instead, we are proposing to use more recent data that reflect changes under the new outlier policy. However, we will continue to consider other methodologies in the future when calculating the outlier threshold once we have 2 complete years of charge data under the new outlier policy.

Specifically, we are proposing to establish the proposed FY 2006 outlier threshold as follows: Using the latest data available, the 1-year average annualized rate-of-change in charges per case from the last quarter of FY 2003 in combination with the first quarter of FY 2004 (July 1, 2003 through December 31, 2003) to the last quarter of FY 2004 in combination with the first quarter of FY 2005 (July 1, 2004 through December 31, 2004) was 8.65 percent (1.0865), or 18.04 percent (1.1804) over 2 years. As we have done in the past, we are proposing to use hospital cost-to-charge ratios from the most recent Provider Specific File, in this case the December 2004 update, in establishing the proposed FY 2006 outlier threshold. This file includes cost-to-charge ratios that reflect implementation of the changes to the policy for determining the applicable cost-to-charge ratios that became effective August 8, 2003 (68 FR 34494).

Using this methodology, we are proposing to establish a fixed- loss cost outlier threshold for FY 2006 equal to the prospective payment rate for the DRG, plus any IME and DSH payments, and any add-on payments for new technology, plus $26,675. In addition, as stated in the June 9, 2003 outlier final rule (68 FR 34505), we believe the use of charge inflation is more appropriate than our previous methodology of cost inflation because charges tend to increase at a much faster rate than costs. Although charges have increased at a slower rate since the implementation of changes to our outlier payment methodology in 2003, we believe the use of charges is still appropriate because this trend is still evident.

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As we did in establishing the FY 2005 outlier threshold (69 FR 49278), we are not including in the calculation of the outlier threshold the possibility that hospitals' cost-to-charge ratios and outlier payments may be reconciled upon cost report settlement. We believe that, due to the policy implemented in the June 9, 2003 outlier final rule, cost-to-charge ratios will no longer fluctuate significantly and, therefore, few hospitals, if any, will actually have these ratios reconciled upon cost report settlement. In addition, it is difficult to predict which specific hospitals will have cost-to-charge ratios and outlier payments reconciled in their cost reports in any given year. We also note that reconciliation occurs because hospitals' actual cost-to-charge ratios for the cost reporting period are different than the interim cost-to-charge ratios used to calculate outlier payments when a bill is processed. Our simulations assume cost-to-charge ratios accurately measure hospital costs and, therefore, are more reflective of post- reconciliation than pre-reconciliation outlier payments. As a result, we omitted any assumptions about the effects of reconciliation from the outlier threshold calculation.

ii. Other changes concerning outliers. As stated in the September 1, 1993 final rule (58 FR 46348), we establish outlier thresholds that are applicable to both hospital inpatient operating costs and hospital inpatient capital-related costs. When we modeled the combined operating and capital outlier payments, we found that using a common set of thresholds resulted in a lower percentage of outlier payments for capital-related costs than for operating costs. We project that the proposed thresholds for FY 2006 will result in outlier payments equal to 5.1 percent of operating DRG payments and 5.03 percent of capital payments based on the Federal rate.

In accordance with section 1886(d)(3)(B) of the Act, we reduced the proposed FY 2005 standardized amount by the same percentage to account for the projected proportion of payments paid to outliers.

The proposed outlier adjustment factors that would be applied to the standardized amount for FY 2006 are as follows:

[GRAPHIC] [TIFF OMITTED] TP04MY05.064

We are proposing to apply the outlier adjustment factors to the FY 2006 rates after removing the effects of the FY 2005 outlier adjustment factors on the standardized amount.

To determine whether a case qualifies for outlier payments, we apply hospital-specific cost-to-charge ratios to the total covered charges for the case. Operating and capital costs for the case are calculated separately by applying separate operating and capital cost-to-charge ratios. These costs are then combined and compared with the fixed-loss outlier threshold.

The June 9, 2003 outlier final rule (68 FR 34494) eliminated the application of the statewide average for hospitals whose cost-to- charge ratios fall below 3 standard deviations from the national mean cost-to-charge ratio. However, for those hospitals for which the fiscal intermediary computes operating cost-to-charge ratios greater than 1.220 or capital cost-to-charge ratios greater than 0.169, or hospitals for whom the fiscal intermediary is unable to calculate a cost-to-charge ratio (as described at Sec. 412.84(i)(3) of our regulations), we are still using statewide average ratios to calculate costs to determine whether a hospital qualifies for outlier payments.\6\ Table 8A in section VI. of this Addendum contains the proposed statewide average operating cost-to-charge ratios for urban hospitals and for rural hospitals for which the fiscal intermediary is unable to compute a hospital-specific cost- to-charge ratio within the above range. Effective for discharges occurring on or after October 1, 2005, these proposed statewide average ratios would replace the ratios published in the IPPS final rule for FY 2005 (69 FR 49687). Table 8B in section VI. of this Addendum contains the proposed comparable statewide average capital cost-to-charge ratios. Again, the proposed cost-to-charge ratios in Tables 8A and 8B would be used during FY 2006 when hospital-specific cost-to-charge ratios based on the latest settled cost report are either not available or are outside the range noted above.

\6\ These figures represent 3.0 standard deviations from the mean of the log distribution of cost-to-charge ratios for all hospitals.

iii. FY 2004 and FY 2005 outlier payments. In the FY 2005 IPPS final rule, we stated that, based on available data, we estimated that actual FY 2004 outlier payments would be approximately 3.6 percent of actual total DRG payments (69 FR 49278, as corrected at 69 FR 60252). This estimate was computed based on simulations using the FY 2003 MedPAR file (discharge data for FY 2003 bills). That is, the estimate of actual outlier payments did not reflect actual FY 2004 bills, but instead reflected the application of FY 2004 rates and policies to available FY 2003 bills.

Our current estimate, using available FY 2004 bills, is that actual outlier payments for FY 2004 were approximately 3.5 percent of actual total DRG payments. Thus, the data indicate that, for FY 2004, the percentage of actual outlier payments relative to actual total payments is lower than we projected before FY 2004 (and, thus, is less than the percentage by which we reduced the standardized amounts for FY 2004). We note that, for FY 2005, the outlier threshold was lowered to $25,800 compared to $31,000 for FY 2004. The outlier threshold was lower in FY 2005 than FY 2004 as a result of slower growth in hospital charge inflation. We believe that this slower growth was due to changes in hospital charge practices following implementation of the outlier final rule published on June 9, 2003. Nevertheless, consistent with the policy and statutory interpretation we have maintained since the inception of the IPPS, we do not plan to make retroactive adjustments to outlier payments to ensure that total outlier payments for FY 2004 are equal to 5.1 percent of total DRG payments.

We currently estimate that actual outlier payments for FY 2005 will be approximately 4.4 percent of actual total DRG payments, 0.7 percentage points lower than the 5.1 percent we projected in setting outlier policies for FY 2005. This estimate is based on simulations using the FY 2004 MedPAR file (discharge data for FY 2004 bills). We used these data to calculate an estimate of the actual outlier percentage for FY 2005 by applying FY 2005 rates and policies, including an outlier threshold of $25,800 to available FY 2004 bills.

d. Rural Community Hospital Demonstration Program Adjustment (Section 410A of Pub. L. 108-173)

Section 410A of Pub. L. 108-173 requires the Secretary to establish a demonstration that will modify reimbursement for inpatient services for up to 15 small rural hospitals. Section 410A(c)(2) of Pub. L. 108-173 requires that ``in conducting the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented.'' As discussed in section V.K. of the preamble to this proposed rule, we are proposing to satisfy this requirement by adjusting national IPPS rates by a factor that is sufficient to account for the added costs of this demonstration. We estimate that the average additional annual payment that will be made to each participating hospital under the demonstration will be approximately $977,410. We based this estimate on the recent historical experience of the difference between inpatient cost and payment for hospitals that are participating in the demonstration. For 13 participating hospitals, the total annual impact of the demonstration program is estimated to be $12,706,334. The required adjustment to the Federal rate used in calculating Medicare inpatient prospective payments as a result of the demonstration is 0.999863.

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In order to achieve budget neutrality, we are proposing to adjust national IPPS rates by an amount sufficient to account for the added costs of this demonstration. In other words, we are proposing to apply budget neutrality across the payment system as a whole rather than merely across the participants of this demonstration. We believe that the language of the statutory budget neutrality requirement permits the agency to implement the budget neutrality provision in this manner. This is because the statutory language requires that ``aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration * * * was not implemented,'' but does not identify the range across which aggregate payments must be held equal.

5. Proposed FY 2006 Standardized Amount

The adjusted standardized amount is divided into labor-related and nonlabor-related portions. Tables 1A and 1B in section VI. of this Addendum contain the national standardized amount that we are proposing to apply to all hospitals, except hospitals in Puerto Rico. The amounts shown in the two tables differ only in that the labor-related share applied to the standardized amounts in Table 1A is 69.7 percent, and the labor-related share applied to the standardized amounts in Table 1B is 62 percent. In accordance with sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act, we are applying the labor-related share of 62 percent, unless the application of that percentage would result in lower payments to a hospital than would otherwise be made. The effect of this proposed application is that the labor-related share of the standardized amount is 62 percent for all hospitals whose wage indexes are less than or equal to 1.0000.

As discussed in section IV.B.3. of the preamble to this proposed rule (reflecting the Secretary's current estimate of the proportion of costs that are attributable to wages and wage-related costs), we are proposing to set the labor-related share of the standardized amount at 69.7 percent for hospitals whose wage indexes are greater than 1.0000. In addition, Tables 1A and 1B include proposed standardized amounts reflecting the full 3.2 percent update for FY 2006, and proposed standardized amounts reflecting the 0.4 percentage point reduction to the update applicable for hospitals that fail to submit quality data consistent with section 501(b) of Pub. L. 108-173. (Tables 1C and 1D show the proposed standardized amounts for Puerto Rico for FY 2006, reflecting the different labor- related shares that apply, that is, 71.3 percent or 62 percent.)

The following table illustrates the proposed changes from the FY 2005 national average standardized amount. The first column shows the proposed changes from the FY 2005 standardized amounts for hospitals that satisfy the quality data submission requirement for receiving the full update (3.2 percent). The second column shows the proposed changes for hospitals receiving the reduced update (2.8 percent). The first row of the table shows the proposed updated (through FY 2005) average standardized amount after restoring the FY 2005 offsets for outlier payments, demonstration budget neutrality, the wage index transition budget neutrality and geographic reclassification budget neutrality. The DRG reclassification and recalibration and wage index budget neutrality factor is cumulative. Therefore, the FY 2005 factor is not removed from the amount in the table. We have added separate rows to this table to reflect the different labor-related shares that apply to hospitals.

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Under section 1886(d)(9)(A)(ii) of the Act, the Federal portion of the Puerto Rico payment rate is based on the discharge-weighted average of the national large urban standardized amount (as set forth in Table 1A). The labor-related and nonlabor-related portions of the national average standardized amounts for Puerto Rico hospitals are set forth in Table 1C of section VI. of this Addendum. This table also includes the Puerto Rico standardized amounts. The labor-related share applied to the Puerto Rico standardized amount is 71.3 percent, or 62 percent, depending on which is more advantageous to the hospital. (Section 1886(d)(9)(C)(iv) of the Act, as amended by section 403(b) of Pub. L. 108-173, provides that the labor-related share for hospitals in Puerto Rico will be 62 percent, unless the application of that percentage would result in lower payments to the hospital.)

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

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

1. Adjustment for Area Wage Levels

Sections 1886(d)(3)(E) and 1886(d)(9)(C)(iv) of the Act require that we make an adjustment to the labor-related portion of the national and Puerto Rico prospective payment rates, respectively, to account for area differences in hospital wage levels. This adjustment is made by multiplying the labor-related portion of the adjusted standardized amounts by the appropriate wage index for the area in which the hospital is located. In section III. of the preamble to this proposed rule, we discuss the data and methodology for the proposed FY 2006 wage index. The proposed FY 2006 wage indexes are set forth in Tables 4A, 4B, 4C, and 4F of section VI. of this Addendum.

2. Adjustment for Cost-of-Living in Alaska and Hawaii

Section 1886(d)(5)(H) of the Act authorizes an adjustment to take into account the unique circumstances of hospitals in Alaska and Hawaii. Higher labor-related costs for these two States are taken into account in the adjustment for area wages described above. For FY 2006, we are proposing to adjust the payments for hospitals in Alaska and Hawaii by multiplying the nonlabor-related portion of the standardized amount by the appropriate adjustment factor contained in the table below. If the Office of Personnel Management releases revised cost-of-living adjustment factors before July 1, 2005, we will publish them in the final rule and use them in determining FY 2006 payments.

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C. DRG Relative Weights

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

D. Calculation of Proposed Prospective Payment Rates for FY 2006

General Formula for Calculation of Prospective Payment Rates for FY 2006

The proposed operating prospective payment rate for all hospitals paid under the IPPS located outside of Puerto Rico, except SCHs and MDHs, equals the Federal rate based on the corresponding amounts in Table 1A or Table 1B in section VI. of this Addendum.

The proposed prospective payment rate for SCHs equals the higher of the applicable Federal rate (from Table 1A or Table 1B) or the hospital-specific rate as described below. The proposed prospective payment rate for MDHs equals the higher of the Federal rate, or the Federal rate plus 50 percent of the difference between the Federal rate and the hospital-specific rate as described below. The proposed prospective payment rate for Puerto Rico equals 25 percent of the Puerto Rico rate plus 75 percent of the applicable national rate from Table 1C or Table 1D in section VI. of this Addendum.

1. Federal Rate

For discharges occurring on or after October 1, 2005 and before October 1, 2006, except for SCHs, MDHs, and hospitals in Puerto Rico, payment under the IPPS is based exclusively on the Federal rate.

The Federal rate is determined as follows:

Step 1--Select the appropriate average standardized amount considering the applicable wage index (Table 1A for wage indexes greater than 1.0000 and Table 1B for wage indexes less than or equal to 1.0000) and whether the hospital has submitted qualifying quality data (full update for qualifying hospitals, update minus 0.4 percentage points for nonqualifying hospitals).

Step 2--Multiply the labor-related portion of the standardized amount by the applicable wage index for the geographic area in which the hospital is located or the area to which the hospital is reclassified (see Tables 4A, 4B, and 4C of section VI. of this Addendum).

Step 3--For hospitals in Alaska and Hawaii, multiply the nonlabor-related portion of the standardized amount by the appropriate cost-of-living adjustment factor.

Step 4--Add the amount from Step 2 and the nonlabor-related portion of the standardized amount (adjusted, if appropriate, under Step 3).

Step 5--Multiply the final amount from Step 4 by the relative weight corresponding to the appropriate DRG (see Table 5 of section VI. of this Addendum).

The Federal rate as determined in Step 5 may then be further adjusted if the hospital qualifies for either the IME or DSH adjustment.

2. Hospital-Specific Rate (Applicable Only to SCHs and MDHs)

a. Calculation of Hospital-Specific Rate

Section 1886(b)(3)(C) of the Act provides that SCHs are paid based on whichever of the following rates yields the greatest aggregate payment: the Federal rate; the updated hospital-specific rate based on FY 1982 costs per discharge; the updated hospital- specific rate based on FY 1987 costs per discharge; or the updated hospital-specific rate based on FY 1996 costs per discharge.

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Section 1886(d)(5)(G) of the Act provides that MDHs are paid based on whichever of the following rates yields the greatest aggregate payment: The Federal rate or the Federal rate plus 50 percent of the difference between the Federal rate and the greater of the updated hospital-specific rates based on either FY 1982 or FY 1987 costs per discharge. MDHs do not have the option to use their FY 1996 hospital-specific rate.

Hospital-specific rates have been determined for each of these hospitals based on the FY 1982 costs per discharge, the FY 1987 costs per discharge, or, for SCHs, the FY 1996 costs per discharge. For a more detailed discussion of the calculation of the hospital- specific rates, we refer the reader to the September 1, 1983 interim final rule (48 FR 39772); the April 20, 1990 final rule with comment (55 FR 15150); the September 4, 1990 final rule (55 FR 35994); and the August 1, 2000 final rule (65 FR 47082). In addition, for both SCHs and MDHs, the hospital-specific rate is adjusted by the proposed budget neutrality adjustment factor (that is, by the recalibration budget neutrality factor of 0.999003) as discussed in section V.C.2. of the preamble to this proposed rule. The resulting rate would be used in determining the payment rate an SCH or MDH would receive for its discharges beginning on or after October 1, 2005.

b. Updating the FY 1982, FY 1987, and FY 1996 Hospital-Specific Rates for FY 2005

We are proposing to increase the hospital-specific rates by 3.2 percent (the hospital market basket percentage increase) for SCHs and MDHs for FY 2006. Section 1886(b)(3)(C)(iv) of the Act provides that the update factor applicable to the hospital-specific rates for SCHs is equal to the update factor provided under section 1886(b)(3)(B)(iv) of the Act, which, for SCHs in FY 2006, is the market basket rate of increase. Section 1886(b)(3)(D) of the Act provides that the update factor applicable to the hospital-specific rates for MDHs also equals the update factor provided under section 1886(b)(3)(B)(iv) of the Act, which, for FY 2006, is the market basket rate-of-increase.

3. General Formula for Calculation of Proposed Prospective Payment Rates for Hospitals Located in Puerto Rico Beginning On or After October 1, 2005 and Before October 1, 2006

Under section 504 of Pub. L. 108-173, effective for discharges occurring on or after October 1, 2004, hospitals located in Puerto Rico are paid based on a blend of 75 percent of the national prospective payment rate and 25 percent of the Puerto Rico-specific rate.

a. Puerto Rico Rate

The Puerto Rico prospective payment rate is determined as follows:

Step 1--Select the appropriate average standardized amount considering the applicable wage index (see Table 1C).

Step 2--Multiply the labor-related portion of the standardized amount by the appropriate Puerto Rico-specific wage index (see Table 4F of section VI. of the Addendum).

Step 3--Add the amount from Step 2 and the nonlabor-related portion of the standardized amount.

Step 4--Multiply the amount from Step 3 by the appropriate DRG relative weight.

Step 5--Multiply the result in Step 4 by 25 percent (see Table 5 of section VI. of the Addendum).

b. National Rate

The national prospective payment rate is determined as follows:

Step 1--Select the appropriate average standardized amount considering the applicable wage index (see Table 1C).

Step 2--Add the amount from Step 1 and the nonlabor-related portion of the national average standardized amount.

Step 3--Multiply the amount from Step 2 by the appropriate DRG relative weight (see Table 5 of section VI. of the Addendum).

Step 4--Multiply the result in Step 3 by 75 percent.

The sum of the Puerto Rico rate and the national rate computed above equals the prospective payment for a given discharge for a hospital located in Puerto Rico. This rate may then be further adjusted if the hospital qualifies for either the IME or DSH adjustment.

III. Proposed Changes to Payment Rates for Acute Care Hospital Inpatient Capital-Related Costs for FY 2006

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

The PPS for acute care hospital inpatient capital-related costs was implemented for cost reporting periods beginning on or after October 1, 1991. Effective with that cost reporting period, hospitals were paid during a 10-year transition period (which extended through FY 2001) to change the payment methodology for Medicare acute care hospital inpatient capital-related costs from a reasonable cost-based methodology to a prospective methodology (based fully on the Federal rate).

The basic methodology for determining Federal capital prospective rates is set forth in regulations at Sec. Sec. 412.308 through 412.352. Below we discuss the factors that we are proposing to use to determine the capital Federal rate for FY 2006, which would be effective for discharges occurring on or after October 1, 2005. The 10-year transition period ended with hospital cost reporting periods beginning on or after October 1, 2001 (FY 2002). Therefore, for cost reporting periods beginning in FY 2002, all hospitals (except ``new'' hospitals under Sec. 412.304(c)(2)) are paid based on 100 percent of the capital Federal rate. For FY 1992, we computed the standard Federal payment rate for capital-related costs under the IPPS by updating the FY 1989 Medicare inpatient capital cost per case by an actuarial estimate of the increase in Medicare inpatient capital costs per case. Each year after FY 1992, we update the capital standard Federal rate, as provided at Sec. 412.308(c)(1), to account for capital input price increases and other factors. The regulations at Sec. 412.308(c)(2) provide that the capital Federal rate is adjusted annually by a factor equal to the estimated proportion of outlier payments under the capital Federal rate to total capital payments under the capital Federal rate. In addition, Sec. 412.308(c)(3) requires that the capital Federal rate be reduced by an adjustment factor equal to the estimated proportion of payments for (regular and special) exceptions under Sec. 412.348. Section 412.308(c)(4)(ii) requires that the capital standard Federal rate be adjusted so that the effects of the annual DRG reclassification and the recalibration of DRG weights and changes in the geographic adjustment factor are budget neutral.

For FYs 1992 through 1995, Sec. 412.352 required that the capital Federal rate also be adjusted by a budget neutrality factor so that aggregate payments for inpatient hospital capital costs were projected to equal 90 percent of the payments that would have been made for capital-related costs on a reasonable cost basis during the fiscal year. That provision expired in FY 1996. Section 412.308(b)(2) describes the 7.4 percent reduction to the capital rate that was made in FY 1994, and Sec. 412.308(b)(3) describes the 0.28 percent reduction to the capital rate made in FY 1996 as a result of the revised policy of paying for transfers. In FY 1998, we implemented section 4402 of Pub. L. 105-33, which required that, for discharges occurring on or after October 1, 1997, and before October 1, 2002, the unadjusted capital standard Federal rate is reduced by 17.78 percent. As we discussed in the FY 2003 IPPS final rule (67 FR 50102) and implemented in Sec. 412.308(b)(6)), a small part of that reduction was restored effective October 1, 2002.

To determine the appropriate budget neutrality adjustment factor and the regular exceptions payment adjustment during the 10-year transition period, we developed a dynamic model of Medicare inpatient capital-related costs; that is, a model that projected changes in Medicare inpatient capital-related costs over time. With the expiration of the budget neutrality provision, the capital cost model was only used to estimate the regular exceptions payment adjustment and other factors during the transition period. As we explained in the FY 2002 IPPS final rule (66 FR 39911), beginning in FY 2002, an adjustment for regular exception payments is no longer necessary because regular exception payments were only made for cost reporting periods beginning on or after October 1, 1991, and before October 1, 2001 (see Sec. 412.348(b)). Because, effective with cost reporting periods beginning in FY 2002, payments are no longer being made under the regular exception policy, we no longer use the capital cost model. The capital cost model and its application during the transition period are described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099).

Section 412.374 provides for the use of a blended payment system for payments to Puerto Rico hospitals under the PPS for acute care hospital inpatient capital-related costs. Accordingly, under the capital PPS, we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capital-related costs. In

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accordance with section 1886(d)(9)(A) of the Act, under the IPPS for acute care hospital operating costs, hospitals located in Puerto Rico are paid for operating costs under a special payment formula. Prior to FY 1998, hospitals in Puerto Rico were paid a blended operating rate that consisted of 75 percent of the applicable standardized amount specific to Puerto Rico hospitals and 25 percent of the applicable national average standardized amount. Similarly, prior to FY 1998, hospitals in Puerto Rico were paid a blended capital rate that consisted of 75 percent of the applicable capital Puerto Rico specific rate and 25 percent of the applicable capital Federal rate. However, effective October 1, 1997, in accordance with section 4406 of Pub. L. 105-33, operating payments to hospitals in Puerto Rico were revised to be based on a blend of 50 percent of the applicable standardized amount specific to Puerto Rico hospitals and 50 percent of the applicable national average standardized amount. In conjunction with this change to the operating blend percentage, effective with discharges occurring on or after October 1, 1997, we also revised the methodology for computing capital payments to hospitals in Puerto Rico to be based on a blend of 50 percent of the Puerto Rico capital rate and 50 percent of the capital Federal rate.

As we discussed in the FY 2005 IPPS final rule (69 FR 49185), section 504 of Pub. L. 108-173 increased the national portion of the operating IPPS payments for Puerto Rico hospitals from 50 percent to 62.5 percent and decreased the Puerto Rico portion of the operating IPPS payments from 50 percent to 37.5 percent for discharges occurring on or after April 1, 2004 through September 30, 2004 (see the March 26, 2004 One-Time Notification (Change Request 3158)). In addition, section 504 of Pub. L. 108-173 provided that the national portion of operating IPPS payments for Puerto Rico hospitals is equal to 75 percent and the Puerto Rico portion of operating IPPS payments is equal to 25 percent for discharges occurring on or after October 1, 2004. Consistent with that change in operating IPPS payments to hospitals in Puerto Rico, for FY 2005 (as we discussed in the FY 2005 IPPS final rule), we revised the methodology for computing capital payments to hospitals located in Puerto Rico to be based on a blend of 25 percent of the Puerto Rico capital rate and 75 percent of the capital Federal rate for discharges occurring on or after October 1, 2004.

A. Determination of Proposed Federal Hospital Inpatient Capital- Related Prospective Payment Rate Update

In the FY 2005 IPPS final rule (69 FR 49283) and corrected in a December 30, 2004 correction notice (69 FR 78532), we established a capital Federal rate of $416.53 for FY 2005.

In the discussion that follows, we explain the factors that were used to determine the proposed FY 2006 capital Federal rate. In particular, we explain why the proposed FY 2006 capital Federal rate would increase 0.7 percent compared to the FY 2005 capital Federal rate. We also estimate aggregate capital payments would decrease by 0.1 percent during this same period. This decrease is due to several factors, including a projected decrease in the number of Medicare fee-for-service hospital admissions, and a decrease in the proposed geographic adjustment factor (GAF) values (which are based on the proposed wage index values). Our Office of the Actuary projects a decrease in Medicare fee-for-service Part A enrollment, in part, because of a projected increase in Medicare managed care enrollment as a result of the implementation of several provisions of Pub. L. 108-173. We are projecting a slight increase in the proposed GAF values (based on the proposed wage index) for some hospitals as a result of the completion of the transition to the CBSA-based labor market area definitions (as discussed in section III. of the preamble of this proposed rule). Thus, we are projecting that capital PPS payments would remain relatively unchanged from FY 2005 to FY 2006.

Total payments to hospitals under the IPPS are relatively unaffected by changes in the capital prospective payments. Since capital payments constitute about 10 percent of hospital payments, a 1-percent change in the capital Federal rate yields only about 0.1 percent change in actual payments to hospitals. Aggregate payments under the capital IPPS are estimated to decrease slightly in FY 2006 compared to FY 2005, as discussed above.

1. Projected Capital Standard Federal Rate Update

a. Description of the Update Framework

Under Sec. 412.308(c)(1), the capital standard Federal rate is updated on the basis of an analytical framework that takes into account changes in a capital input price index (CIPI) and several other policy adjustment factors. Specifically, we have adjusted the projected CIPI rate-of-increase as appropriate each year for case- mix index-related changes, for intensity, and for errors in previous CIPI forecasts. The proposed update factor for FY 2006 under that framework is 0.7 percent based on the best data available at this time. The proposed update factor is based on a projected 0.7 percent increase in the CIPI, a 0.0 percent adjustment for intensity, a 0.0 percent adjustment for case-mix, a 0.0 percent adjustment for the FY 2004 DRG reclassification and recalibration, and a forecast error correction of 0.0 percent. As discussed below in section III.C. of this Addendum, we believe that the CIPI is the most appropriate input price index for capital costs to measure capital price changes in a given year. We also explain the basis for the FY 2006 CIPI projection in that same section of this Addendum. Below we describe the proposed policy adjustments that have been applied.

The case-mix index is the measure of the average DRG weight for cases paid under the IPPS. Because the DRG weight determines the prospective payment for each case, any percentage increase in the case-mix index corresponds to an equal percentage increase in hospital payments.

The case-mix index can change for any of several reasons:

The average resource use of Medicare patients changes (``real'' case-mix change);

Changes in hospital coding of patient records result in higher weight DRG assignments (``coding effects''); and

The annual DRG reclassification and recalibration changes may not be budget neutral (``reclassification effect'').

We define real case-mix change as actual changes in the mix (and resource requirements) of Medicare patients as opposed to changes in coding behavior that result in assignment of cases to higher weighted DRGs but do not reflect higher resource requirements. The capital update framework includes the same case-mix index adjustment used in the former operating IPPS update framework (as discussed in the May 18, 2005 IPPS proposed rule for FY 2005 (69 FR 28816)). (We are no longer using an update framework in making a recommendation for updating the operating IPPS standardized amounts as discussed in section III. of Appendix B of this proposed rule.)

For FY 2006, we are projecting a 1.0 percent total increase in the case-mix index. We estimate that the real case-mix increase would also equal 1.0 percent in FY 2006. The net adjustment for change in case-mix is the difference between the projected increase in real case-mix and the projected total increase in real case-mix. Therefore, the net proposed adjustment for case-mix change in FY 2006 is 0.0 percentage points.

The capital update framework also contains an adjustment for the effects of DRG reclassification and recalibration. This adjustment is intended to remove the effect on total payments of prior year changes to the DRG classifications and relative weights, in order to retain budget neutrality for all case-mix index-related changes other than those due to patient severity. Due to the lag time in the availability of data, there is a 2-year lag in data used to determine the adjustment for the effects of DRG reclassification and recalibration. For example, we are adjusting for the effects of the FY 2004 DRG reclassification and recalibration as part of our proposed update for FY 2006. We estimate that FY 2004 DRG reclassification and recalibration would result in a 0.0 percent change in the case-mix when compared with the case-mix index that would have resulted if we had not made the reclassification and recalibration changes to the DRGs. Therefore, we are proposing to make a 0.0 percent adjustment for DRG reclassification and recalibration in the update for FY 2006 to maintain budget neutrality.

The capital update framework also contains an adjustment for forecast error. The input price index forecast is based on historical trends and relationships ascertainable at the time the update factor is established for the upcoming year. In any given year, there may be unanticipated price fluctuations that may result in differences between the actual increase in prices and the forecast used in calculating the update factors. In setting a prospective payment rate under the framework, we make an adjustment for forecast error only if our estimate of the change in the capital input price index for any year is off by 0.25 percentage points or more. There is a 2-year

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lag between the forecast and the measurement of the forecast error. A forecast error of -0.1 percentage points was calculated for the FY 2004 update. That is, current historical data indicate that the forecasted FY 2004 CIPI used in calculating the FY 2004 update factor (0.7 percent) slightly overstated the actual realized price increases (0.6 percent) by 0.1 percentage points. This slight overprediction was mostly due to a prediction of the cuts in the interest rate by the Federal Reserve Board in 2004. However, the Federal Reserve Board did not cut interest rates during 2004, which impacted the interest component of the CIPI. However, since this estimation of the change in the CIPI is less than 0.25 percentage points, it is not reflected in the update recommended under this framework. Therefore, we are proposing to make a 0.0 percent adjustment for forecast error in the update for FY 2006.

Under the capital IPPS system framework, we also make an adjustment for changes in intensity. We calculate this adjustment using the same methodology and data that are used in the framework for the operating PPS. The intensity factor for the operating update framework reflects how hospital services are utilized to produce the final product, that is, the discharge. This component accounts for changes in the use of quality-enhancing services, for changes in within-DRG severity, and for expected modification of practice patterns to remove noncost-effective services.

We calculate case-mix constant intensity as the change in total charges per admission, adjusted for price level changes (the CPI for hospital and related services) and changes in real case-mix. The use of total charges in the calculation of the intensity factor makes it a total intensity factor; that is, charges for capital services are already built into the calculation of the factor. Therefore, we have incorporated the intensity adjustment from the operating update framework into the capital update framework. Without reliable estimates of the proportions of the overall annual intensity increases that are due, respectively, to ineffective practice patterns and to the combination of quality-enhancing new technologies and within-DRG complexity, we assume, as in the operating update framework, that one-half of the annual increase is due to each of these factors. The capital update framework thus provides an add-on to the input price index rate of increase of one- half of the estimated annual increase in intensity, to allow for within-DRG severity increases and the adoption of quality-enhancing technology.

We have developed a Medicare-specific intensity measure based on a 5-year average. Past studies of case-mix change by the RAND Corporation (Has DRG Creep Crept Up? Decomposing the Case Mix Index Change Between 1987 and 1988 by G.M. Carter, J.P. Newhouse, and D.A. Relles, R-4098-HCFA/ProPAC (1991)) suggest that real case-mix change was not dependent on total change, but was usually a fairly steady 1.0 to 1.4 percent per year. We use 1.4 percent as the upper bound because the RAND study did not take into account that hospitals may have induced doctors to document medical records more completely in order to improve payment.

We calculate case-mix constant intensity as the change in total charges per admission, adjusted for price level changes (the CPI for hospital and related services), and changes in real case-mix. As we noted above, in accordance with Sec. 412.308(c)(1)(ii), we began updating the capital standard Federal rate in FY 1996 using an update framework that takes into account, among other things, allowable changes in the intensity of hospital services. For FYs 1996 through 2001, we found that case-mix constant intensity was declining and we established a 0.0 percent adjustment for intensity in each of those years. For FYs 2002 and 2003, we found that case- mix constant intensity was increasing and we established a 0.3 percent adjustment and 1.0 percent adjustment for intensity, respectively. For FYs 2004 and 2005, we found that the charge data appeared to be skewed (as discussed in greater detail below) and we established a 0.0 percent adjustment in each of those years. Furthermore, we stated that we would continue to apply a 0.0 percent adjustment for intensity until any increase in charges can be tied to intensity rather than attempts to maximize outlier payments.

Using the methodology described above, for FY 2006 we examined the change in total charges per admission, adjusted for price level changes (the CPI for hospital and related services), and changes in real case-mix for FYs 1999 through 2004. We found that, over this period and in particular the last 4 years of this period (FYs 2000 through 2003), the charge data appear to be skewed. More specifically, we found a dramatic increase in hospital charges for FYs 2000 through 2004 without a corresponding increase in the hospital case-mix index. These findings are similar to the considerable increase in hospitals' charges, which we found when we were determining the intensity factor in the FY 2004 and FY 2005 update recommendations as discussed in the FY 2004 IPPS final rule (68 FR 45482) and the FY 2005 IPPS final rule (69 FR 49285), respectively. If hospitals were treating new or different types of cases, which would result in an appropriate increase in charges per discharge, then we would expect hospitals' case-mix to increase proportionally.

As we discussed in the FY 2005 IPPS final rule (69 FR 49285), because our intensity calculation relies heavily upon charge data and we believe that these charge data may be inappropriately skewed, we established a 0.0 percent adjustment for intensity for FY 2005. We believed that it was appropriate to apply a zero intensity adjustment until we believe that any increase in charges can be tied to intensity rather than to attempts to maximize outlier payments. As discussed above, we believe that the most recently available charge data used to make this determination may still be inappropriately skewed. Therefore, we are proposing a 0.0 percent adjustment for intensity for FY 2006. In the past (FYs 1996 through 2001) when we found intensity to be declining, we believed a zero (rather than negative) intensity adjustment was appropriate. Similarly, we believe that it is appropriate to propose to apply a zero intensity adjustment for FY 2006 until any increase in charges can be tied to intensity rather than to attempts to maximize outlier payments.

Above we described the basis of the components used to develop the proposed 0.7 percent capital update factor for FY 2006 as shown in the table below.

[GRAPHIC] [TIFF OMITTED] TP04MY05.067

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b. Comparison of CMS and MedPAC Update Recommendation

In the past, MedPAC has included update recommendations for capital PPS in a Report to Congress. In its March 2005 Report to Congress, MedPAC did not make an update recommendation for capital PPS payments for FY 2006. However, in that same report, MedPAC made an update recommendation for hospital inpatient and outpatient services (page 40). MedPAC reviews inpatient and outpatient services together since they are so closely interrelated. MedPAC recommended an increase in the payment rate for the operating IPPS by the projected increase in the hospital market basket index, less 0.4 percent for FY 2006, based on their assessment of beneficiaries' access to care, volume of services, access to capital, quality of care, and the relationship of Medicare payments and costs. In addition, the Commission considered the efficient provision of services in making its FY 2006 update recommendations. (MedPAC's Report to the Congress: Medicare Payment Policy, March 2005, page 44.)

2. Proposed Outlier Payment Adjustment Factor

Section 412.312(c) establishes a unified outlier methodology for inpatient operating and inpatient capital-related costs. A single set of thresholds is used to identify outlier cases for both inpatient operating and inpatient capital-related payments. Section 412.308(c)(2) provides that the standard Federal rate for inpatient capital-related costs be reduced by an adjustment factor equal to the estimated proportion of capital related outlier payments to total inpatient capital-related PPS payments. The outlier thresholds are set so that operating outlier payments are projected to be 5.1 percent of total operating DRG payments.

In the FY 2005 IPPS final rule (69 FR 49286), we estimate that outlier payments for capital will equal 4.94 percent of inpatient capital-related payments based on the capital Federal rate in FY 2005. Based on the thresholds as set forth in section II.A.4.c. of this Addendum, we estimate that outlier payments for capital would equal 5.03 percent for inpatient capital-related payments based on the proposed Federal rate in FY 2006. Therefore, we are proposing to apply an outlier adjustment factor of 0.9497 to the capital Federal rate. Thus, the percentage of capital outlier payments to total capital standard payments for FY 2006 would be higher than the percentages for FY 2005.

The outlier reduction factors are not built permanently into the capital rates; that is, they are not applied cumulatively in determining the capital Federal rate. The proposed FY 2006 outlier adjustment of 0.9497 is a -0.09 percent change from the FY 2005 outlier adjustment of 0.9506. The net change in the proposed outlier adjustment to the capital Federal rate for FY 2006 is 0.9991 (0.9497/0.9506). Thus, the proposed outlier adjustment decreases the FY 2006 capital Federal rate by 0.09 percent compared with the FY 2005 outlier adjustment.

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

Section 412.308(c)(4)(ii) requires that the capital Federal rate be adjusted so that aggregate payments for the fiscal year based on the capital Federal rate after any changes resulting from the annual DRG reclassification and recalibration and changes in the GAF are projected to equal aggregate payments that would have been made on the basis of the capital Federal rate without such changes.

Since we implemented a separate GAF for Puerto Rico, we apply separate budget neutrality adjustments for the national GAF and the Puerto Rico GAF. We apply the same budget neutrality factor for DRG reclassifications and recalibration nationally and for Puerto Rico. Separate adjustments were unnecessary for FY 1998 and earlier because the GAF for Puerto Rico was implemented in FY 1998.

In the past, we used the actuarial capital cost model (described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099)) to estimate the aggregate payments that would have been made on the basis of the capital Federal rate with and without changes in the DRG classifications and weights and in the GAF to compute the adjustment required to maintain budget neutrality for changes in DRG weights and in the GAF. During the transition period, the capital cost model was also used to estimate the regular exception payment adjustment factor. As we explain in section III.A.4. of this Addendum, beginning in FY 2002, an adjustment for regular exception payments is no longer necessary. Therefore, we are no longer using the capital cost model. Instead, we are using historical data based on hospitals' actual cost experiences to determine the exceptions payment adjustment factor for special exceptions payments.

To determine the proposed factors for FY 2006, we compared (separately for the national capital rate and the Puerto Rico capital rate) estimated aggregate capital Federal rate payments based on the FY 2005 DRG relative weights and the average FY 2005 GAF (that is, the weighted average of the GAFs applied from October 2004 through December 2004 and the GAFs applied from January 2005 through September 2005) to estimated aggregate capital Federal rate payments based on the proposed FY 2006 relative weights and the proposed FY 2006 GAF. As we established in the FY 2005 IPPS final rule (69 FR 49287), the budget neutrality factors were 0.9914 for the national capital rate and 0.9895 for the Puerto Rico capital rate for discharges occurring on or after October 1, 2004 through December 31, 2004 (the first quarter of FY 2005). As a result of the corrections to the FY 2005 GAF values established in the December 30, 2004 correction notice (69 FR 78531), effective for January 1, 2005 through September 30, 2005 (the last three quarters of FY 2005), the budget neutrality factor for the national capital rate is 0.9912 and the budget neutrality factor for the Puerto Rico capital rate remained unchanged (0.9895). For FY 2005, the weighted average budget neutrality adjustment factors were 0.9912 (0.9914 x \1/4\ + 0.9912 x \3/4\) for the national capital rate (calculations were done on unrounded numbers) and 0.9895 for the Puerto Rico capital rate. In making the comparison, we set the regular and special exceptions reduction factors to 1.00. To achieve budget neutrality for the changes in the national GAF, based on calculations using updated data, we are proposing to apply an incremental budget neutrality adjustment of 1.0022 for FY 2006 to the weighted average of the previous cumulative FY 2005 adjustments of 0.9912 (yielding a proposed adjustment of 0.9934) through FY 2006 (calculations done on unrounded numbers). For the Puerto Rico GAF, we are proposing to apply an incremental budget neutrality adjustment of 1.0240 for FY 2006 to the previous cumulative FY 2005 adjustment of 0.9895, yielding a proposed cumulative adjustment of 1.0132 through FY 2006.

We then compared estimated aggregate capital Federal rate payments based on the FY 2005 DRG relative weights and the average FY 2005 GAF to estimated aggregate capital Federal rate payments based on the proposed FY 2006 DRG relative weights and the proposed FY 2006 GAF. The proposed incremental adjustment for DRG classifications and changes in relative weights is 0.9998 both nationally and for Puerto Rico. The proposed cumulative adjustments for DRG classifications and changes in relative weights and for changes in the GAF through FY 2005 are 0.9931 nationally and 1.013 for Puerto Rico. The following table summarizes the adjustment factors for each fiscal year:

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The methodology used to determine the proposed recalibration and geographic (DRG/GAF) budget neutrality adjustment factor for FY 2006 is similar to that used in establishing budget neutrality adjustments under the PPS for operating costs. One difference is that, under the operating PPS, the budget neutrality adjustments for the effect of geographic reclassifications are determined separately from the effects of other changes in the hospital wage index and the DRG relative weights. Under the capital PPS, there is a single DRG/ GAF budget neutrality adjustment factor (the national capital rate and the Puerto Rico capital rate are determined separately) for changes in the GAF (including geographic reclassification) and the DRG relative weights. In addition, there is no adjustment for the effects that geographic reclassification has on the other payment parameters, such as the payments for serving low-income patients, indirect medical education payments, or the large urban add-on payments.

In the FY 2005 IPPS final rule (69 FR 49288), we calculated a GAF/DRG budget neutrality factor of 1.0006 for FY 2005. As we noted above, as a result of the revisions to the GAF effective for discharges occurring on or after January 1, 2005 established in the December 30, 2004 correction notice (69 FR 78351), we calculated a GAF/DRG budget neutrality factor of 1.0004 for discharges occurring in the remainder of FY 2005. For FY 2006, we are proposing a GAF/DRG budget neutrality factor of 1.0019. The GAF/

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DRG budget neutrality factors are built permanently into the capital rates; that is, they are applied cumulatively in determining the capital Federal rate. This follows from the requirement that estimated aggregate payments each year be no more or less than they would have been in the absence of the annual DRG reclassification and recalibration and changes in the GAF. The proposed incremental change in the adjustment from the average from FY 2005 to FY 2006 is 1.0019. The proposed cumulative change in the capital Federal rate due to this adjustment is 0.9931 (the product of the incremental factors for FYs 1993 through 2005 and the proposed incremental factor of 1.0019 for FY 2006). (We note that averages of the incremental factors that were in effect during FYs 2004 and 2005, respectively, were used in the calculation of the proposed cumulative adjustment of 0.9931 for FY 2006.)

This proposed factor accounts for DRG reclassifications and recalibration and for changes in the GAF. It also incorporates the effects on the GAF of FY 2006 geographic reclassification decisions made by the MGCRB compared to FY 2005 decisions. However, it does not account for changes in payments due to changes in the DSH and IME adjustment factors or in the large urban add-on.

4. Proposed Exceptions Payment Adjustment Factor

Section 412.308(c)(3) requires that the capital standard Federal rate be reduced by an adjustment factor equal to the estimated proportion of additional payments for both regular exceptions and special exceptions under Sec. 412.348 relative to total capital PPS payments. In estimating the proportion of regular exception payments to total capital PPS payments during the transition period, we used the actuarial capital cost model originally developed for determining budget neutrality (described in Appendix B of the FY 2002 IPPS final rule (66 FR 40099)) to determine the exceptions payment adjustment factor, which was applied to both the Federal and hospital-specific capital rates.

An adjustment for regular exception payments is no longer necessary in determining the proposed FY 2006 capital Federal rate because, in accordance with Sec. 412.348(b), regular exception payments were only made for cost reporting periods beginning on or after October 1, 1991 and before October 1, 2001. Accordingly, as we explained in the FY 2002 IPPS final rule (66 FR 39949), in FY 2002 and subsequent fiscal years, no payments will be made under the regular exceptions provision. However, in accordance with Sec. 412.308(c), we still need to compute a budget neutrality adjustment for special exception payments under Sec. 412.348(g). We describe our methodology for determining the special exceptions adjustment used in calculating the proposed FY 2006 capital Federal rate below.

Under the special exceptions provision specified at Sec. 412.348(g)(1), eligible hospitals include SCHs, urban hospitals with at least 100 beds that have a disproportionate share percentage of at least 20.2 percent or qualify for DSH payments under Sec. 412.106(c)(2), and hospitals with a combined Medicare and Medicaid inpatient utilization of at least 70 percent. An eligible hospital may receive special exceptions payments if it meets (1) a project need requirement as described at Sec. 412.348(g)(2), which, in the case of certain urban hospitals, includes an excess capacity test as described at Sec. 412.348(g)(4); (2) an age of assets test as described at Sec. 412.348(g)(3); and (3) a project size requirement as described at Sec. 412.348(g)(5).

Based on information compiled from our fiscal intermediaries, six hospitals have qualified for special exceptions payments under Sec. 412.348(g). Since we have cost reports ending in FY 2004 for all of these hospitals, we calculated the proposed adjustment based on actual cost experience. Using data from cost reports ending in FY 2004 from the December 2004 update of the HCRIS data, we divided the capital special exceptions payment amounts for the six hospitals that qualified for special exceptions by the total capital PPS payment amounts (including special exception payments) for all hospitals. Based on the data from cost reports ending in FY 2004, this ratio is rounded to 0.0003. Because we have not received all cost reports ending in FY 2004, we also divided the FY 2004 special exceptions payments by the total capital PPS payment amounts for all hospitals with cost reports ending in FY 2003. This ratio also rounds to 0.0003. Because special exceptions are budget neutral, we are proposing to offset the capital Federal rate by 0.03 percent for special exceptions payments for FY 2006. Therefore, the proposed exceptions adjustment factor is equal to 0.9997 (1-0.0003) to account for special exceptions payments in FY 2006.

In the FY 2005 IPPS final rule (69 FR 49288), we estimated that total (special) exceptions payments for FY 2005 would equal 0.04 percent of aggregate payments based on the capital Federal rate. Therefore, we applied an exceptions adjustment factor of 0.9996 (1- 0.0004) in determining the FY 2005 capital Federal rate. As we stated above, we estimate that exceptions payments in FY 2006 would equal 0.03 percent of aggregate payments based on the proposed FY 2006 capital Federal rate. Therefore, we are proposing to apply an exceptions payment adjustment factor of 0.9997 to the capital Federal rate for FY 2006. The proposed exceptions adjustment factor for FY 2006 is 0.01 percent higher than the factor for FY 2005 published in the FY 2005 IPPS final rule (69 FR 49288). The exceptions reduction factors are not built permanently into the capital rates; that is, the factors are not applied cumulatively in determining the capital Federal rate. Therefore, the proposed net change in the exceptions adjustment factor used in determining the proposed FY 2006 capital Federal rate is 1.0001 (0.9997/0.9996).

5. Proposed Capital Standard Federal Rate for FY 2006

In the FY 2005 IPPS final rule (69 FR 49283) and corrected in a December 30, 2004 correction notice (69 FR 78532), we established a capital Federal rate of $416.53 for FY 2005. In this proposed rule, we are proposing to establish a capital Federal rate of $419.90 for FY 2006. The proposed capital Federal rate for FY 2006 was calculated as follows:

The proposed FY 2006 update factor is 1.0070; that is, the update is 0.7 percent.

The proposed FY 2006 budget neutrality adjustment factor that is applied to the capital standard Federal payment rate for changes in the DRG relative weights and in the GAF is 1.0019.

The proposed FY 2006 outlier adjustment factor is 0.9497.

The proposed FY 2006 (special) exceptions payment adjustment factor is 0.9997.

Because the proposed capital Federal rate has already been adjusted for differences in case-mix, wages, cost-of-living, indirect medical education costs, and payments to hospitals serving a disproportionate share of low-income patients, we are proposing to make no additional adjustments in the capital standard Federal rate for these factors, other than the budget neutrality factor for changes in the DRG relative weights and the GAF.

We are providing a chart that shows how each of the proposed factors and adjustments for FY 2006 affected the computation of the proposed FY 2006 capital Federal rate in comparison to the average FY 2005 capital Federal rate. The proposed FY 2006 update factor has the effect of increasing the capital Federal rate by 0.70 percent compared to the average FY 2005 Federal rate. The proposed GAF/DRG budget neutrality factor has the effect of increasing the capital Federal rate by 0.19 percent. The proposed FY 2006 outlier adjustment factor has the effect of decreasing the capital Federal rate by 0.09 percent compared to the average FY 2005 capital Federal rate, and the proposed FY 2006 exceptions payment adjustment factor has the effect of increasing the capital Federal rate by 0.01 percent compared to the exceptions payment adjustment factor for the FY 2005 capital Federal rate. The combined effect of all the proposed changes is to increase the capital Federal rate by 0.81 percent compared to the average FY 2005 capital Federal rate.

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6. Proposed Special Capital Rate for Puerto Rico Hospitals

Section 412.374 provides for the use of a blended payment system for payments to Puerto Rico hospitals under the PPS for acute care hospital inpatient capital-related costs. Accordingly, under the capital PPS, we compute a separate payment rate specific to Puerto Rico hospitals using the same methodology used to compute the national Federal rate for capital-related costs. Under the broad authority of section 1886(g) of the Act, as discussed in section VI. of the preamble of this proposed rule, beginning with discharges occurring on or after October 1, 2004, capital payments to hospitals in Puerto Rico are based on a blend of 25 percent of the Puerto Rico capital rate and 75 percent of the capital Federal rate. The Puerto Rico capital rate is derived from the costs of Puerto Rico hospitals only, while the capital Federal rate is derived from the costs of all acute care hospitals participating in the IPPS (including Puerto Rico).

To adjust hospitals' capital payments for geographic variations in capital costs, we apply a GAF to both portions of the blended capital rate. The GAF is calculated using the operating IPPS wage index and varies, depending on the labor market area or rural area in which the hospital is located. We use the Puerto Rico wage index to determine the GAF for the Puerto Rico part of the capital-blended rate and the national wage index to determine the GAF for the national part of the blended capital rate.

Because we implemented a separate GAF for Puerto Rico in FY 1998, we also apply separate budget neutrality adjustments for the national GAF and for the Puerto Rico GAF. However, we apply the same budget neutrality factor for DRG reclassifications and recalibration nationally and for Puerto Rico. As we stated above in section III.A.4. of this Addendum, for Puerto Rico, the proposed GAF budget neutrality factor is 1.0240, while the proposed DRG adjustment is 0.9998, for a combined cumulative adjustment of 1.0130.

In computing the payment for a particular Puerto Rico hospital, the Puerto Rico portion of the capital rate (25 percent) is multiplied by the Puerto Rico-specific GAF for the labor market area in which the hospital is located, and the national portion of the capital rate (75 percent) is multiplied by the national GAF for the labor market area in which the hospital is located (which is computed from national data for all hospitals in the United States and Puerto Rico). In FY 1998, we implemented a 17.78 percent reduction to the Puerto Rico capital rate as a result of Pub. L. 105-33. In FY 2003, a small part of that reduction was restored.

For FY 2005, before application of the GAF, the special capital rate for Puerto Rico hospitals was $199.01 for discharges occurring on or after October 1, 2004 through September 30, 2005. With the changes we are proposing to the factors used to determine the capital rate, the proposed FY 2006 special capital rate for Puerto Rico is $205.64.

B. Calculation of Proposed Inpatient Capital-Related Prospective Payments for FY 2006

Because the 10-year capital PPS transition period ended in FY 2001, all hospitals (except ``new'' hospitals under Sec. 412.324(b) and under Sec. 412.304(c)(2)) are paid based on 100 percent of the capital Federal rate in FY 2006. The applicable proposed capital Federal rate was determined by making adjustments as follows:

For outliers, by dividing the proposed capital standard Federal rate by the proposed outlier reduction factor for that fiscal year; and

For the payment adjustments applicable to the hospital, by multiplying the hospital's proposed GAF, disproportionate share adjustment factor, and IME adjustment factor, when appropriate.

For purposes of calculating payments for each discharge during FY 2006, the capital standard Federal rate is adjusted as follows: (Standard Federal Rate) x (DRG weight) x (GAF) x (Large Urban Add- on, if applicable) x (COLA adjustment for hospitals located in Alaska and Hawaii) x (1 + Disproportionate Share Adjustment Factor + IME Adjustment Factor, if applicable). The result is the adjusted capital Federal rate.

Hospitals also may receive outlier payments for those cases that qualify under the thresholds established for each fiscal year. Section 412.312(c) provides for a single set of thresholds to identify outlier cases for both inpatient operating and inpatient capital-related payments. The proposed outlier thresholds for FY 2006 are in section II.A.4.c. of this Addendum. For FY 2006, a case qualifies as a cost outlier if the cost for the case plus the IME and DSH payments is greater than the prospective payment rate for the DRG plus $26,675.

An eligible hospital may also qualify for a special exceptions payment under Sec. 412.348(g) for up through the 10th year beyond the end of the capital transition period if it meets: (1) A project need requirement described at Sec. 412.348(g)(2), which in the case of certain urban hospitals includes an excess capacity test as described at Sec. 412.348(g)(4); and (2) a project size requirement as described at Sec. 412.348(g)(5). Eligible hospitals include SCHs, urban hospitals with at least 100 beds that have a DSH patient percentage of at least 20.2 percent or qualify for DSH payments under Sec. 412.106(c)(2), and hospitals that have a combined Medicare and Medicaid inpatient utilization of at least 70 percent. Under Sec. 412.348(g)(8), the amount of a special exceptions payment is determined by comparing the cumulative payments made to the hospital under the capital PPS to the cumulative minimum payment level. This amount is offset by: (1) Any amount by which a hospital's cumulative capital payments exceed its cumulative minimum payment levels applicable under the regular exceptions process for cost reporting periods

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beginning during which the hospital has been subject to the capital PPS; and (2) any amount by which a hospital's current year operating and capital payments (excluding 75 percent of operating DSH payments) exceed its operating and capital costs. Under Sec. 412.348(g)(6), the minimum payment level is 70 percent for all eligible hospitals.

During the transition period, new hospitals (as defined under Sec. 412.300) were exempt from the capital PPS for their first 2 years of operation and were paid 85 percent of their reasonable costs during that period. Effective with the third year of operation through the remainder of the transition period, under Sec. 412.324(b), we paid the hospitals under the appropriate transition methodology. If the hold-harmless methodology were applicable, the hold-harmless payment for assets in use during the base period would extend for 8 years, even if the hold-harmless payments extend beyond the normal transition period. Under Sec. 412.304(c)(2), for cost reporting periods beginning on or after October 1, 2002, we pay a new hospital 85 percent of its reasonable costs during the first 2 years of operation unless it elects to receive payment based on 100 percent of the capital Federal rate. Effective with the third year of operation, we pay the hospital based on 100 percent of the capital Federal rate (that is, the same methodology used to pay all other hospitals subject to the capital PPS).

C. Capital Input Price Index

1. Background

Like the operating input price index, the capital input price index (CIPI) is a fixed-weight price index that measures the price changes associated with capital costs during a given year. The CIPI differs from the operating input price index in one important aspect--the CIPI reflects the vintage nature of capital, which is the acquisition and use of capital over time. Capital expenses in any given year are determined by the stock of capital in that year (that is, capital that remains on hand from all current and prior capital acquisitions). An index measuring capital price changes needs to reflect this vintage nature of capital. Therefore, the CIPI was developed to capture the vintage nature of capital by using a weighted-average of past capital purchase prices up to and including the current year.

We periodically update the base year for the operating and capital input prices to reflect the changing composition of inputs for operating and capital expenses. The CIPI was last rebased to FY 1997 in the FY 2003 IPPS final rule (67 FR 50044). (We note that we are proposing a rebasing to FY 2002 in section IV. of the preamble of this proposed rule.)

2. Forecast of the CIPI for FY 2006

Based on the latest forecast by Global Insight, Inc. (first quarter of 2005), we are forecasting the CIPI to increase 0.7 percent in FY 2006. This reflects a projected 1.3 percent increase in vintage-weighted depreciation prices (building and fixed equipment, and movable equipment) and a 2.7 percent increase in other capital expense prices in FY 2006, partially offset by a 2.3 percent decline in vintage-weighted interest expenses in FY 2006. The weighted average of these three factors produces the 0.7 percent increase for the CIPI as a whole in FY 2006.

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

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

A. Payments to Existing Excluded Hospitals and Units

As discussed in section VII. of the preamble of this proposed rule, in accordance with section 1886(b)(3)(H)(i) of the Act and effective for cost reporting periods beginning on or after October 1, 2002, payments to existing psychiatric hospitals and units, rehabilitation hospitals and units, and long-term care hospitals (LTCHs) excluded from the IPPS are no longer subject to a cap on a hospital-specific target amount (expressed in terms of the inpatient operating cost per discharge under TEFRA) that is set for each hospital, based on the hospital's own historical cost experience trended forward by the applicable percentage increase. However, the inpatient operating costs of children's hospitals and cancer hospitals that are excluded from the IPPS continue to be subject to the rate-of-increase limits established under the authority of section 1886(b) of the Act and Sec. 413.40 of the regulations. This target amount is applied as a ceiling on the allowable costs per discharge for the hospital's cost reporting period.

Effective for cost reporting periods beginning on or after October 1, 2002, rehabilitation hospitals and units are paid 100 percent of the adjusted Federal prospective payment rate under the IRP PPS. Effective for cost reporting periods beginning on or after October 1, 2002, LTCHs also are no longer paid on a reasonable cost basis, but are paid under a LTCH DRG-based PPS. In implementing the LTCH PPS for existing LTCHs, we established a 5-year transition period from reasonable cost-based payments (subject to the TEFRA limit) to fully Federal prospective payment amounts during which a LTCH may receive a blended payment consisting of two payment components--one based on reasonable cost under the TEFRA payment system, and the other based on the standard Federal prospective payment rate. However, an existing LTCH may elect to be paid based on 100 percent of the standard Federal prospective payment rate during the transition period.

IPFs that have their first cost reporting period beginning on or after January 1, 2005, are not paid on a reasonable cost basis but paid under a prospective per diem payment system. As part of the PPS for existing IPFs, we have established a 3-year transition period during which IPFs will be paid based on a blend of reasonable cost- based payment (subject to the TEFRA limit) and the prospective per diem payment rate. For cost reporting periods beginning on or after January l, 2008, IPFs will be paid 100 percent of the Federal prospective per diem payment amount.

Excluded psychiatric hospitals and units as well as LTCHs that are paid under a blended methodology will have the reasonable cost- based portion of their payment subject to a hospital target amount and, if applicable, the payment amount limitation.

B. Updated Caps for New Excluded Hospitals and Units

Section 1886(b)(7) of the Act established the method for determining the payment amount for new rehabilitation hospitals and units, psychiatric hospitals and units, and LTCHs that first received payment as a hospital or unit excluded from the IPPS on or after October 1, 1997. However, due to the implementation of the IRF PPS, effective for cost reporting periods beginning on or after October 1, 2002, this payment amount (or ``new provider cap'') no longer applies to any new rehabilitation hospital or unit because they now are paid 100 percent of the Federal prospective rate under the IRF PPS. In addition, LTCHs that meet the definition of a new LTCH under Sec. 412.23(e)(4) are paid 100 percent of the fully Federal prospective payment rate. In contrast, those ``new'' LTCHs that meet the criteria under Sec. 413.40(f)(2)(ii) (that is, that were not paid as an excluded hospital prior to October 1, 1997, but were paid as a LTCH before October 1, 2002), may be paid under the LTCH PPS transition methodology, with the reasonable cost portion of the payment subject to Sec. 413.40(f)(2)(ii). Finally, LTCHs that existed prior to October 1, 1997, may also be paid under the LTCH PPS transition methodology, with the reasonable cost portion subject to Sec. 413.40(c)(4)(ii). (The last LTCHs that were subject to the payment amount limitation for ``new'' LTCHs were new LTCHs that had their first cost reporting period beginning on September 30, 2002. In that case, the payment amount limitation remained applicable for the next 2 years--September 30, 2002 through September 29, 2003, and September 30, 2003 through September 29, 2004. This is because, under existing regulations at Sec. 413.40(f)(2)(ii), the ``new hospital'' would be subject to the same payment (target amount) in its second cost reporting period that was applicable to the LTCH in its first cost reporting period. Accordingly, for this hospital, the updated payment amount limitation that we published in the FY 2003 IPPS final rule (67 FR 50103) applied through September 29, 2004. Consequently, there is no longer a need to publish updated payment amounts for new (Sec. 413.40(f)(2)(ii)) LTCHs. A discussion of how the payment limitations were calculated can be found in the August 29, 1997 final rule with comment period (62 FR 46019); the May 12, 1998 final rule (63 FR 26344); the July 31, 1998 final rule (63 FR 41000); and the July 30, 1999 final rule (64 FR 41529).

With the implementation of the LTCH PPS, payment limitations do not apply to any new LTCHs that meet the definition at Sec. 412.23(e)(4) because they are paid 100 percent of the Federal prospective payment rate.

A freestanding inpatient rehabilitation hospital, an inpatient rehabilitation unit of an acute care hospital, and an inpatient rehabilitation unit of a CAH are referred to as IRFs. Effective for cost reporting periods beginning on or after October 1, 2002, this

[[Page 23482]]

payment limitation is also no longer applicable to new rehabilitation hospitals and units because they are paid 100 percent of the Federal prospective rate under the IRF PPS. Therefore, it is also no longer necessary to update the payment limitation for new rehabilitation hospitals or units.

Under the IPF PPS, there is a 3-year transition period during which existing IPFs will receive a blended payment of the Federal per diem payment amount and the payment amount that IPFs would receive under the reasonable cost-based payment (TEFRA) methodology. IPFs that were ``new'' under Sec. 413.40(f)(2)(ii) (that is, that were not paid as an excluded hospital prior to October 1, 1997, but were paid as an IPF prior to January 1, 2005), would have the reasonable cost portion of the transition period payment subject to the payment amount limitation as determined according to Sec. 413.40(f)(2)(ii). The last ``new'' IPFs that were subject to the payment amount limitation were IPFs that had their first cost reporting period beginning on December 31, 2004. For these hospitals, the payment amount limitation that was published in the FY 2005 IPPS final rule (69 FR 49189) for cost reporting periods beginning on or after October 1, 2004, and before January 1, 2005, remains applicable for the IPF's first two cost reporting periods. IPFs with a first cost reporting period beginning on or after January 1, 2005, are paid 100 percent of the Federal rate and are not subject to the payment amount limitation. Therefore, since the last IPFs eligible for a blended payment have a cost reporting period beginning on December 31, 2004, the payment limitation published for FY 2005 remains applicable for these IPFs, and publication of the updated payment amount limitation is no longer needed. We note that IPFs that existed prior to October 1, 1997, may also be paid under the IPF transition methodology with the reasonable cost portion of the payment subject to Sec. 413.40(c)(4)(ii).

The payment limitations for new hospitals under TEFRA do not apply to new LTCHs, IRFs, or IPFs, that is, these hospitals with their first cost reporting period beginning on or after the date that the particular class of hospitals implemented the respective PPS. Therefore, for the reasons noted above, we are proposing to discontinue publishing Tables 4G and 4H (Pre-Reclassified Wage Index for Urban and Rural Areas, respectively) in the annual proposed and final IPPS rules.

V. Payment for Blood Clotting Factor Administered to Hemophilia Inpatients

(If you choose to comment on issues in this section, please include the caption ``Payment for Blood Clotting Factor'' at the beginning of your comments.)

As discussed in section VIII. of the preamble to this proposed rule, section 1886(a)(4) of the Act excludes the costs of administering blood clotting factors to individuals with hemophilia from the definition of ``operating costs of inpatient hospital services.'' Section 6011(b) of Pub. L. 101-239 (the Omnibus Budget Reconciliation Act of 1989) provides that the Secretary shall determine the payment amount made to hospitals under Part A of Title XVIII of the Act for the costs of administering blood clotting factors to individuals with hemophilia by multiplying a predetermined price per unit of blood clotting factor by the number of units provided to the individual. Currently, we use the average wholesale price (AWP) methodology used to determine rates paid for Medicare Part B drugs to price blood clotting factors administered to inpatients who have hemophilia under Medicare Part A. Section 303 of Pub. L. 108-173 amended the Act by adding section 1847A, which changed the drug pricing system under Medicare Part B. Effective January 1, 2005, section 1847A of the Act established a payment methodology based on average sales price (ASP) under which almost all Medicare Part B drugs and biologicals not paid on a cost or prospective basis are paid at 106 percent of the ASP.

In the FY 2005 IPPS final rule (69 FR 49292), we had instructed the fiscal intermediaries for FY 2005 to continue to use the Single Drug Pricer (SDP) to establish the pricing limits for the blood clotting factor administered to hemophilia inpatients at 95 percent of the AWP. We did not use the new ASP pricing methodology for Part A blood clotting factor in FY 2005 because the IPPS final rule was published in advance of final regulations implementing the ASP payment methodology for Part B drugs and biologicals. Final regulations establishing the ASP methodology and the furnishing fee for blood clotting factor under Medicare Part B were published on November 15, 2004 (69 FR 66299). Therefore, we believe that a consistent methodology should be used to pay for blood clotting factor administered under both Medicare Part A and Part B. For this reason, we are proposing for FY 2006 that the fiscal intermediaries make payment for blood clotting factor using 106 percent of ASP and make payment for the furnishing fee at $0.14 per individual unit (I.U.) that is currently used for Medicare Part B drugs. The ASP will be updated quarterly. The furnishing fee will be updated annually based on the consumer price index.

VI. Tables

This section contains the tables referred to throughout the preamble to this proposed rule and in this Addendum. Tables 1A, 1B, 1C, 1D, 2, 3A, 3B, 4A, 4B, 4C, 4F, 4J, 5, 6A, 6B, 6C, 6D, 6E, 6F, 6G, 6H, 7A, 7B, 8A, 8B, 9A, 9B, 9C, 10, and 11 are presented below. The tables presented below are as follows:

Table 1A--National Adjusted Operating Standardized Amounts, Labor/ Nonlabor (69.7 Percent Labor Share/30.3 Percent Nonlabor Share If Wage Index Is Greater Than 1); Table 1B--National Adjusted Operating Standardized Amounts, Labor/ Nonlabor (62 Percent Labor Share/38 Percent Nonlabor Share If Wage Index Is Less Than or Equal To 1); Table 1C--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor; Table 1D--Capital Standard Federal Payment Rate; Table 2--Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2004; Hospital Average Hourly Wage for Federal Fiscal Years 2004 (2000 Wage Data), 2005 (2001 Wage Data), and 2006 (2002 Wage Data) Wage Indexes and 3-Year Average of Hospital Average Hourly Wages; Table 3A--FY 2006 3-Year Average Hourly Wage for Urban Areas by CBSA; Table 3B--FY 2006 and 3-Year Average Hourly Wage for Rural Areas by CBSA; Table 4A--Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas by CBSA; Table 4B--Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas by CBSA; Table 4C--Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA; Table 4F--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA; Table 4J--Out-Migration Adjustment--FY 2006; Table 5--List of Diagnosis Related Groups (DRGs), Relative Weighting Factors, Geometric and Arithmetic Mean Length of Stay; Table 6A--New Diagnosis Codes; Table 6B--New Procedure Codes; Table 6C--Invalid Diagnosis Codes; Table 6D--Invalid Procedure Codes; Table 6E--Revised Diagnosis Code Titles; Table 6F--Revised Procedure Code Titles; Table 6G--Additions to the CC Exclusions List; Table 6H--Deletions from the CC Exclusions List; Table 7A--Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 2004 MedPAR Update December 2004 GROUPER V22.0; Table 7B--Medicare Prospective Payment System Selected Percentile Lengths of Stay FY 2004 MedPAR Update December 2004 GROUPER V23.0; Table 8A--Statewide Average Operating Cost-to-Charge Ratios--March 2005; Table 8B--Statewide Average Capital Cost-to-Charge Ratios--March 2005; Table 9A--Hospital Reclassifications and Redesignations by Individual Hospital and CBSA--FY 2006; Table 9B--Hospital Reclassifications and Redesignations by Individual Hospital Under Section 508 of Pub. L. 108-173--FY 2006; Table 9C--Hospitals Redesignated as Rural under Section 1886(s)(8)(E) of the Act--FY 2006; Table 10--Geometric Mean Plus the Lesser of .75 of the National Adjusted Operating Standardized Payment Amount (Increased to Reflect the Difference Between Costs and Charges) or .75 of One Standard Deviation of Mean Charges by Diagnosis-Related Groups (DRGs)--March 2005; Table 11--Proposed FY 2006 LTC-DRGs, Relative Weights, Geometric Average Length of Stay, and 5/6ths of the Geometric Average Length of Stay.

[[Page 23483]]

Table 1A.--National Adjusted Operating Standardized Amounts, Labor/ NonLabor [69.7 Percent labor share/30.3 percent nonlabor share if wage index greater than 1]

Full update (3.2 Percent)

Reduced update (2.8 Percent)

Labor-related Nonlabor-related Labor-related Nonlabor-related

$3,286.14

$1,428.55

$3,273.40

$1,423.01

Table 1B.--National Adjusted Operating Standardized Amounts, Labor/ Nonlabor [62 Percent labor share/38 percent nonlabor share if wage index less than or equal to 1]

Full update (3.2 Percent)

Reduced update (2.8 Percent)

Labor-related Nonlabor-related Labor-related Nonlabor-related

$2,923.11

$1,791.58

$2,911.78

$1,784.63

Table 1C.--Adjusted Operating Standardized Amounts for Puerto Rico, Labor/Nonlabor

Rates if wage index less

than or equal to 1

Rates if wage index greater than 1

Labor Nonlabor Labor Nonlabor

National.................................................... $3,286.14 $1,428.55 $2,923.11 $1,791.58 uerto Rico.................................................. $1,608.99 $647.66 $1,431.24 $812.25

Table 1D.--Capital Standard Federal Payment Rate

Rate

National................................................... $419.90 Puerto Rico................................................ $205.64

Table 2.--Hospital Case-Mix Indexes for Discharges Occurring in Federal Fiscal Year 2004; Hospital Average Hourly Wage for Federal Fiscal Years 2004 (2000 Wage Data), 2005 (2001 Wage Data), and 2006 (2002 Wage Data) Wage Indexes and 3-Year Average of Hospital Average Hourly Wages

Average Case-mix Wage index Average Average Average hourly wage Provider number

index FY 2006 hourly wage hourly wage hourly wage ** (3 FY 2004 FY 2005 FY 2006 years)

010001............................ 1.4678 0.7743 19.4061 20.6563 21.3753 20.5001 010004............................

***

* 22.2674 22.7585

* 22.4801 010005 h.......................... 1.1407 0.8872 19.6063 20.4937 22.4906 20.9007 010006............................ 1.4394 0.8305 19.0976 21.0241 23.4823 21.1655 010007............................ 1.0619 0.7495 17.5462 16.8811 18.2430 17.5458 010008............................ 0.9712 0.8276 19.6573 23.8333 20.4591 21.3782 010009............................ 0.9770 0.8517 20.4309 21.6422 23.2229 21.7690 010010 h.......................... 1.0191 0.9124 19.2644 22.3021 22.3366 21.3489 010011............................ 1.5689 0.8979 25.8231 24.8166 27.4850 26.0626 010012............................ 1.2232 0.9099 20.0896 21.7622 22.7020 21.5233 010015............................ 0.9785 0.7495 18.8890 20.4732 22.1736 20.6719 010016............................ 1.3257 0.8979 21.7918 23.0414 25.1502 23.3217 010018............................ 1.3369 0.8979 19.2071 20.5888 22.2990 20.6865 010019............................ 1.2272 0.8305 18.9177 20.1336 22.0906 20.4039 010021 h.......................... 1.1869 0.7743 17.7596 20.7108 18.6785 19.0123 010022............................ 0.9401 0.9414 22.2267 25.8797 24.5670 24.2502 010023............................ 1.8430 0.8600 20.4901 23.7791 27.3303 23.6794 010024............................ 1.5884 0.8600 18.5942 20.0067 20.7265 19.7702 010025............................ 1.3235 0.8402 19.3649 19.8561 21.2674 20.1430 010027............................ 0.7634 0.7495 14.0975 14.9585 15.3704 14.7992 010029............................ 1.5415 0.8402 20.9868 21.6724 22.6976 21.8061 010031............................

***

* 21.0176 20.9463

* 20.9818 010032............................ 0.8730 0.7495 16.4713 18.5073 19.1555 18.1219 010033............................ 2.0553 0.8979 24.5088 25.5165 26.4666 25.5126 010034............................ 0.9588 0.8600 14.9333 17.1625 16.9686 16.3417 010035............................ 1.2540 0.8872 21.6182 23.1319 22.2870 22.3532 010036............................ 1.1183 0.7495 19.2501 20.5125 22.9747 20.9446 010038............................ 1.3277 0.7702 18.6578 20.3935 21.4509 20.2189

[[Page 23484]]

010039............................ 1.6315 0.9124 23.0339 23.4151 25.8594 24.1509 010040............................ 1.4605 0.7974 20.7779 21.6708 22.8851 21.7864 010043............................ 1.0587 0.8979 19.9012 19.5422 22.5945 20.7320 010044............................ 1.0475 0.8872 25.8560 23.0220 21.4036 23.2608 010045............................ 1.0959 0.8872 22.7713 20.5658 20.0357 20.9382 010046............................ 1.4626 0.7974 19.6754 20.8935 21.6965 20.8067 010047............................ 0.8793 0.7495 16.1695 19.5937 21.0604 18.8438 010049............................ 1.0828 0.7495 16.2973 17.7801 20.2413 18.1494 010050............................ 1.0401 0.8979 20.7398 21.5625 22.1584 21.5077 010051............................ 0.8969 0.8724 14.3006 14.7053 15.2208 14.7351 010052............................ 0.8624 0.7495 11.9019 21.3673 16.4959 15.4174 010053............................ 1.0098 0.7495 17.3238 17.4160 19.0108 17.9166 010054............................ 1.0570 0.8517 20.6382 23.1894 22.5554 22.1149 010055............................ 1.4983 0.7743 18.9664 19.1847 22.6828 20.2397 010056............................ 1.5206 0.8979 21.1104 22.7183 23.7144 22.5773 010058............................ 0.8800 0.8979 17.7800 20.3182 18.5537 18.9295 010059............................ 1.0562 0.8517 20.5534 23.6963 21.3237 21.8874 010061............................ 0.9666 0.7495 17.0447 20.5683 21.9374 19.8090 010062............................ 1.0674 0.7743 17.1786 18.1323 18.3435 17.8796 010064............................ 1.7183 0.8979 22.2280 25.4345 26.1110 24.2542 010065............................ 1.4288 0.8276 17.2698 20.0108 21.2363 19.5522 010066............................ 0.8327 0.7495 14.8696 17.0935 17.6152 16.5083 010068............................ 1.2192 0.8979 18.3308 17.5690 19.0789 18.3440 010069............................ 1.0478 0.7495 17.0957 19.6317 21.3608 19.4027 010072............................ 1.1391 0.7702 18.8807 21.5419 21.8169 20.7331 010073............................ 0.9330 0.7495 14.9826 16.4043 16.4168 15.9303 010078............................ 1.3809 0.7702 20.1447 21.0633 21.5616 20.9141 010079............................ 1.1647 0.9124 20.7401 20.4254 21.8199 21.0143 010083 h.......................... 1.2094 0.8089 19.8524 20.2166 22.3041 20.7945 010084............................ 1.5531 0.8979 21.6522 22.5219 24.7127 22.9810 010085............................ 1.2261 0.8517 22.5282 23.7007 24.4710 23.5499 010086............................ 1.0771 0.7495 18.0122 19.4332 18.6081 18.6721 010087............................ 1.9176 0.7902 19.7620 21.6226 22.5225 21.2536 010089............................ 1.2348 0.8979 19.5783 22.2508 22.7508 21.4924 010090............................ 1.6643 0.7902 20.0287 21.4322 23.6948 21.7237 010091............................ 0.9178 0.7495 17.4672 19.4222 18.6912 18.5367 010092............................ 1.5079 0.8724 19.9351 22.0709 24.6542 22.1991 010095............................ 0.8622 0.8724 12.5243 13.4426 13.9326 13.3037 010097............................ 0.7734 0.8600 15.1593 17.1735 16.7548 16.2912 010098............................ 1.1131 0.7495 15.1629 19.6717 14.3076 16.0844 010099............................ 0.9798 0.7495 16.3307 18.1849 18.7909 17.7973 010100 h.......................... 1.6637 0.8089 19.8146 20.0027 21.2915 20.4113 010101............................ 1.1105 0.7702 19.0718 21.0085 21.6593 20.5878 010102............................ 0.8953 0.7495 16.4637 19.9196 21.0903 19.1526 010103............................ 1.8475 0.8979 22.5709 24.2201 26.1163 24.2529 010104............................ 1.7281 0.8979 20.9391 24.1929 24.9226 23.2581 010108............................ 1.0770 0.8600 20.7787 23.7803 28.4624 24.2639 010109............................ 0.9471 0.7495 18.2235 21.7128 21.7997 20.5179 010110............................ 0.7216 0.7495 16.0015 19.2706 18.6633 18.1283 010112............................ 0.9699 0.7495 17.9243 17.2963 16.8902 17.3960 010113............................ 1.6431 0.7902 19.4106 20.4181 21.4209 20.4385 010114............................ 1.3235 0.8979 20.1763 21.5319 22.3431 21.3345 010115............................ 0.8225 0.7495 15.7872 17.5985 29.1465 19.5466 010118............................ 1.2436 0.8276 19.5302 18.8560 19.7673 19.4467 010119............................

***

* 20.5245 21.8215

* 21.1743 010120............................ 0.9483 0.7902 19.4368 20.5855 20.9450 20.3424 010121............................

***

* 17.1640 17.0329 24.0867 18.5589 010125............................ 1.0257 0.7495 16.8622 16.8419 18.4114 17.3762 010126............................ 1.1015 0.8276 19.9647 23.1856 23.1381 22.1149 010128............................ 0.8325 0.7495 14.7646 17.9354 21.4201 18.0579 010129 h.......................... 0.9813 0.7902 16.4905 18.7821 21.3555 19.1436 010130............................ 0.9433 0.8979 18.7190 18.4944 23.2488 20.0658 010131............................ 1.3281 0.9124 22.9969 24.2197 25.7837 24.4029 010134............................

*** 0.7495 17.7717

*

* 17.7717 010138............................ 0.6035 0.7495 14.2025 13.5082 13.8475 13.8713 010139............................ 1.5206 0.8979 22.8390 24.9410 25.3014 24.4108 010143............................ 1.1648 0.8872 20.5639 22.1312 22.0215 21.5734

[[Page 23485]]

010144............................ 1.5626 0.7902 19.1497 20.6425 20.7433 20.2040 010145............................ 1.2572 0.8724 22.1394 23.1976 25.1442 23.5267 010146............................ 1.0392 0.7702 21.3083 19.9944 20.8917 20.7213 010148............................ 0.8756 0.7495 17.6829 18.5309 20.5294 19.0227 010149............................ 1.3179 0.8600 21.0086 23.1593 26.5854 23.4663 010150............................ 1.0456 0.7495 21.2360 20.6738 21.6377 21.1783 010152............................ 1.1957 0.7902 21.6038 22.1626 22.6202 22.1446 010157............................ 1.1130 0.8305 19.6977 21.3574 24.3560 21.7462 010158............................ 1.0822 0.8517 18.5464 22.4440 24.3531 21.6528 010161............................

***

*

* 27.5119

* 27.5119 020001............................ 1.6973 1.2110 30.1452 31.6091 33.6407 31.9031 020004............................ 1.1807 1.1977 27.3516 29.9926 32.0966 29.8229 020005............................ 0.9509 1.1977 32.7936

*

* 32.7936 020008............................ 1.2368 1.1977 33.4543 34.5856 35.9236 34.6652 020010............................

*** 1.1977 20.7929

*

* 20.7929 020013............................

*** 1.1977 30.6423

*

* 30.6423 020017............................ 1.9426 1.2110 30.3017 32.9281 33.5852 32.3606 020024............................ 1.1382 1.1977 28.0930 27.9799 33.0644 29.9221 030001............................ 1.3278 1.0139 25.7513 27.7572 29.9840 27.8499 030002............................ 2.0596 1.0139 25.6038 27.9628 29.0519 27.5075 030003............................

***

* 22.1436

*

* 22.1436 030007............................ 1.3390 0.8991 26.1551 26.9442 29.6174 27.6578 030009............................ 0.8821 0.9007 19.9131 21.4065 22.3992 21.1294 030010............................ 1.3277 0.9007 20.7204 22.8647 24.8275 22.8055 030011............................ 1.4456 0.9007 21.0028 22.8422 25.1361 23.0075 030012............................ 1.2863 0.9884 24.2366 25.5205 26.3859 25.4550 030013............................ 1.3235 0.9102 21.9766 23.5229 25.7050 23.8047 030014............................ 1.4420 1.0139 23.3663 25.1189 25.6259 24.7232 030016............................ 1.2336 1.0139 24.3380 27.1583 26.7003 26.0910 030017............................ 1.9999 1.0139 21.8792 24.4055 26.2452 24.0378 030018............................ 1.2176 1.0139 24.9216 24.4308 28.9476 25.9371 030019............................ 1.3058 1.0139 23.2973 28.4917 27.3156 26.2053 030022............................ 1.5630 1.0139 24.9941 25.1461 26.4404 25.5437 030023............................ 1.6295 1.2094 28.6627 28.4112 33.8333 30.2808 030024............................ 1.9347 1.0139 26.7641 28.3470 31.6658 28.9293 030027............................ 0.9159 0.8991 19.4583 21.0527 20.4031 20.3074 030030............................ 1.6344 1.0139 25.2425 24.6005 30.2712 26.5838 030033............................ 1.1959 1.1713 26.3814 26.6009 26.6531 26.5511 030036............................ 1.3185 1.0139 24.9432 26.5708 30.3521 27.3868 030037............................ 2.1135 1.0139 23.0542 30.3907 28.6453 27.0409 030038............................ 1.5694 1.0139 25.2632 26.5178 29.5509 27.6724 030040............................ 0.9316 0.8991 21.2717 22.5130 24.8145 22.8703 030043............................ 1.3135 0.8991 23.5172 26.0825 24.7932 24.8113 030044............................ 0.8987 0.8991 21.9503 19.5714

* 20.6512 030055 h.......................... 1.3518 1.1416 22.8612 23.1837 24.5202 23.5684 030059............................

***

*

* 24.7676

* 24.7676 030060............................ 1.1006 0.8991 21.7685 22.3551 24.3523 22.7950 030061............................ 1.6076 1.0139 22.9706 23.4722 25.5529 24.0363 030062............................ 1.1689 0.8991 21.1639 21.9849 23.8068 22.3433 030064............................ 1.9175 0.9007 22.8009 24.6732 25.4922 24.2954 030065............................ 1.5581 1.0139 24.6064 25.6738 27.1646 25.8836 030067............................ 1.0095 0.8991 18.4003 19.1332 20.4376 19.2370 030068............................ 1.0906 0.8991 19.7097 19.7030 20.8846 20.1346 030069 h.......................... 1.3425 1.1416 24.5432 25.6243 26.3518 25.5167 030080............................ 1.5124 0.9007 22.8953 24.3573 25.2077 24.1500 030083............................ 1.2683 1.0139 24.3273 24.9269 27.5353 25.6343 030085............................ 1.5138 0.9007 21.8196 23.2070 24.5792 23.3008 030087............................ 1.5725 1.0139 25.6351 26.3878 26.6594 26.2197 030088............................ 1.3763 1.0139 23.5761 23.2478 26.6796 24.5472 030089............................ 1.5398 1.0139 24.5055 26.2166 27.1835 26.0965 030092............................ 1.3775 1.0139 24.0515 25.4127 27.3203 25.7452 030093............................ 1.2260 1.0139 23.2485 23.5623 25.8955 24.3686 030094............................ 1.3354 1.0139 24.5992 26.9985 29.5948 27.0516 030099............................ 0.8991 0.8991 20.3310 26.7996 26.3236 24.0344 030100............................ 1.9686 0.9007 27.6299

* 29.0691 28.4177 030101 h.......................... 1.3930 1.1416 23.7661 25.0077 26.1927 25.0150 030102............................ 2.4590 1.0139 27.9419

* 29.0942 28.5553

[[Page 23486]]

030103............................ 1.6379 1.0139 29.1105 28.2832 30.1994 29.2117 030104............................

***

* 34.6028

*

* 34.6028 030106............................ 1.5145 1.0139

* 30.4791 34.7222 32.1177 040001............................ 1.0582 0.8615 18.7141 23.1475 23.7718 21.8056 040002............................ 1.1265 0.7478 18.0776 19.3429 20.1384 19.2037 040003............................ 1.0545 0.7478 16.3918 18.5000

* 17.3854 040004............................ 1.5197 0.8615 21.2335 23.3504 25.0286 23.2843 040007............................ 1.6581 0.8768 23.3992 23.4565 25.7142 24.1728 040010............................ 1.3488 0.8615 20.7114 22.0984 23.0274 21.9856 040011............................ 1.0063 0.7478 18.8346 19.0319 17.9740 18.5849 040014............................ 1.3420 0.8552 22.4970 24.0846 25.3451 23.9535 040015............................ 1.0378 0.7478 18.8513 18.0793 19.2831 18.7435 040016............................ 1.6546 0.8768 21.2198 22.7219 22.1228 22.0244 040017............................ 1.0968 0.8251 17.7545 19.4365 21.9875 19.7066 040018............................ 0.9839 0.8231 22.0408 23.8515 23.6044 23.2404 040019............................ 1.1290 0.9108 21.1711 21.5316 23.7328 22.1722 040020............................ 1.5076 0.9108 18.6419 20.9136 21.6603 20.4199 040021............................ 1.2489 0.8768 23.5620 24.7771 25.6917 24.7363 040022............................ 1.6031 0.8615 21.4194 23.7462 25.3039 23.4686 040024............................ 1.0523 0.7478 17.5750 20.1101

* 18.8371 040026............................ 1.4887 0.9066 22.7699 24.3053 25.4072 24.2169 040027............................ 1.3418 0.8251 19.3388 19.9348 21.1412 20.1077 040029............................ 1.5379 0.8768 22.1882 22.8770 24.0704 23.0869 040032............................ 0.9581 0.7478 16.2781 18.5171

* 17.4291 040035............................ 0.9080 0.7478 11.8237 13.4265

* 12.6475 040036............................ 1.5682 0.8768 21.6742 24.2851 26.3226 24.0976 040039............................ 1.3369 0.7793 15.9673 17.7976 19.5998 17.8170 040041............................ 1.1827 0.8552 20.4646 22.0188 22.1531 21.5535 040042............................ 1.3549 0.9346 16.2285 18.9550 19.9627 18.3286 040045............................ 0.9321 0.7478 19.5572 18.7952 17.6742 18.6280 040047............................ 1.0748 0.7793 21.6323 21.5334 21.9163 21.6924 040050............................ 1.0797 0.7478 15.1428 15.4782 16.3930 15.6589 040051............................ 0.9177 0.7478 17.6964 18.8943 19.1401 18.6103 040053............................ 0.9720 0.7478 19.2586 20.8153 20.7824 20.2863 040054............................ 1.0287 0.7478 16.5573 16.7370 18.2684 17.1740 040055............................ 1.5474 0.8231 19.7336 22.2237 23.3156 21.7960 040062............................ 1.5855 0.8231 21.9336 21.6403 23.1543 22.2707 040066............................ 1.0396 0.7478 21.7766 23.4616

* 22.6592 040067............................ 1.0244 0.7478 16.0516 15.1441 16.8799 16.0038 040069............................ 1.0357 0.9108 20.5968 21.7607 24.4662 22.2668 040071............................ 1.5128 0.8552 19.4324 22.9350 24.3824 22.1870 040072............................ 1.0728 0.8552 19.3079 20.8269 19.9009 19.9951 040074............................ 1.1860 0.8768 22.0800 22.6147 25.2423 23.2187 040075............................ 0.9521 0.7478 15.7875 16.2583 18.3254 17.1733 040076............................ 1.0208 0.8552 23.5947 21.0442 20.6272 21.3785 040077............................ 0.9549 0.7478 16.7832 18.3261 17.1210 17.3842 040078............................ 1.5395 0.8552 21.4854 24.4589 24.5378 23.4806 040080............................ 0.9908 0.7793 18.4470 21.3483 22.3392 20.6867 040081............................ 0.8047 0.7478 13.2797 13.7148 15.1081 14.0348 040084............................ 1.0773 0.8768 20.1163 22.6441 24.7225 22.5619 040085............................ 0.9955 0.7478 15.5811 18.0756 29.8444 19.6100 040088............................ 1.3084 0.8767 20.0032 21.2974 22.6183 21.3215 040091............................ 1.1599 0.8293 20.6688 23.0252 23.0080 22.2365 040100............................ 1.3376 0.8552 17.8889 19.3560 20.0460 19.1639 040105............................ 1.0117 0.7478 15.4697 15.8171 18.2182 16.4079 040107............................ 0.7276 0.7478 17.6695

*

* 17.6695 040114............................ 1.7030 0.8768 21.6849 23.5628 24.8992 23.4046 040118............................ 1.4016 0.7968 21.7913 24.2547 24.7363 23.6447 040119............................ 1.4402 0.8552 19.9013 20.1631 21.0103 20.3637 040126............................ 0.8718 0.7478 13.3832 12.5944 14.0701 13.3074 040132............................

***

* 29.2343 36.5525 28.1390 31.3524 040134............................ 2.4142 0.8768 24.4646

* 27.3412 25.9794 040137............................ 1.1908 0.8768 24.7813 23.4672 25.2907 24.5263 040138............................ 1.2572 0.8615 22.3523 23.3615 25.7513 23.9295 040140............................

***

*

* 25.1224

* 25.1224 040141............................ 0.7691 0.8615

*

* 24.0901 24.0901 040142............................ 1.2882 0.9066

*

* 27.9695 27.9695

[[Page 23487]]

050002............................ 1.3621 1.5474 30.9729 31.9709 34.1948 32.4064 050006............................ 1.6269 1.1909 25.4604 27.6176 30.5373 27.9248 050007............................ 1.4885 1.4970 34.1406 37.5804 38.7033 36.8959 050008............................ 1.3528 1.4970 32.4067 36.9371 39.1539 36.3445 050009............................ 1.7971 1.3955 30.2740 35.5384 39.6393 35.2947 050013............................ 2.0269 1.3955 29.8401 31.7637 31.9837 31.2570 050014............................ 1.1326 1.2953 27.7646 29.5726 33.0373 30.2311 050015............................ 1.2904 1.0848 27.5652 30.1398 30.7940 29.4852 050016............................ 1.2223 1.1357 25.5508 25.5735 26.2162 25.7788 050017............................ 1.9454 1.2953 28.4911 30.5863 36.8978 31.9726 050018............................ 1.1521 1.1762 17.9621 20.3179 22.3472 20.1629 050022............................ 1.5867 1.1297 28.1312 28.2773 29.8632 28.8610 050024............................ 1.0894 1.1417 25.1425 26.9378 27.5587 26.6747 050025............................ 1.8083 1.1417 29.8262 31.7242 36.1622 32.6605 050026............................ 1.5241 1.1417 24.2564 26.6406 28.3027 26.5474 050028............................ 1.2262 1.0848 18.7866 21.5448 26.6160 21.9931 050029............................

***

* 30.2538 34.3934

* 31.9320 050030............................ 1.2312 1.0848 21.9251 22.9148 24.9707 23.2719 050032............................

***

* 28.8046

*

* 28.8046 050038............................ 1.5479 1.5114 36.1619 35.0441 38.7527 36.6692 050039............................ 1.6010 1.0848 26.8993 29.8179 31.6734 29.4369 050040............................ 1.2018 1.1762 30.7426 31.8983 32.7413 31.8084 050042............................ 1.3668 1.1909 27.6765 29.8062 33.9415 30.4516 050043............................ 1.6285 1.5474 37.3217 39.6054 43.1589 40.0134 050045............................ 1.2751 1.0848 22.1691 22.7051 23.8408 22.8906 050046............................ 1.2116 1.1660 25.5490 25.2786 25.6875 25.5104 050047............................ 1.7028 1.4970 34.4427 39.3993 40.9874 38.4201 050054............................ 1.1776 1.1297 21.3495 27.1437 24.1262 24.0051 050055............................ 1.2386 1.4970 36.1182 36.9386 37.5879 36.9364 050056............................ 1.3348 1.1762 27.1458 29.4829 27.9330 28.1647 050057............................ 1.6190 1.0848 24.2759 26.2099 29.4351 26.6650 050058............................ 1.5358 1.1762 25.9389 27.3584 33.8215 29.0264 050060............................ 1.4954 1.0848 22.9491 26.5515 27.3282 25.6824 050061............................ 0.8559 1.1525 25.3042

* 32.2172 28.5425 050063............................ 1.3227 1.1762 28.6093 32.0515 33.3039 31.3845 050065............................ 1.7399 1.1660 28.8369 33.8223 34.0280 32.3405 050067............................ 1.2228 1.1885 27.8867 29.6982 31.9597 29.7844 050068............................

***

* 21.9031

*

* 21.9031 050070............................ 1.2848 1.4970 39.5178 40.5645 45.3382 41.9509 050071............................ 1.3395 1.5474 40.1344 41.1036 45.3882 42.3609 050072............................ 1.3403 1.5474 39.2529 40.8108 44.2651 41.6223 050073............................ 1.3622 1.5474 38.6763 41.3430 45.9765 42.1975 050075............................ 1.2439 1.5474 40.2265 43.7101 47.2356 44.0053 050076............................ 2.0351 1.5474 40.8075 43.0845 46.4990 43.5903 050077............................ 1.6700 1.1417 27.1234 29.6264 32.0245 29.6181 050078............................ 1.2906 1.1762 24.1091 25.6814 27.9269 25.7615 050079............................ 1.4307 1.5474 38.8981 42.7385 47.8597 43.4884 050082............................ 1.6699 1.1660 27.5022 28.9139 37.7783 31.5037 050084............................ 1.5479 1.1333 26.0607 28.2664 33.0179 29.0525 050088............................

*** 1.1357 27.1103 26.4093 25.7385 26.4472 050089............................ 1.3648 1.1660 24.7857 29.4884 33.5323 29.3416 050090............................ 1.2969 1.4739 27.4193 31.1774 32.9584 30.4520 050091............................ 1.1034 1.1762 29.2522 30.1534 30.8560 30.1209 050093............................ 1.5128 1.0848 29.2642 31.1083 33.4119 31.3614 050096............................ 1.3036 1.1762 23.0525 24.2277 24.6680 23.9648 050097............................

***

* 24.6726 26.6788

* 25.5991 050099............................ 1.5210 1.1660 27.1282 28.7711 31.0437 29.0188 050100............................ 1.7200 1.1417 25.6798 28.0303 29.6949 27.8627 050101............................ 1.2944 1.4888 32.9866 35.4655 39.5330 36.1079 050102............................ 1.3036 1.1297 25.5763 24.9381 29.1364 26.2832 050103............................ 1.5463 1.1762 27.8079 28.7375 34.2529 30.2688 050104............................ 1.4057 1.1762 26.1592 29.1240 29.7326 28.3301 050107............................ 1.3890 1.1525 22.6900 27.6002 33.1358 27.7768 050108............................ 1.9703 1.2953 28.5244 31.4271 35.5711 32.0693 050110............................ 1.2602 1.1525 21.9297 20.0769 22.4428 21.4435 050111............................ 1.2835 1.1762 23.7715 26.6345 28.1588 26.1803 050112............................ 1.5361 1.1762 31.9797 34.0258 36.8026 34.4310

[[Page 23488]]

050113............................ 1.2729 1.4970 32.6932 34.2851 33.8064 33.6092 050114............................ 1.3830 1.1762 28.1938 29.2858 31.1294 29.5973 050115............................ 1.4364 1.1417 24.1481 27.5207 30.9288 27.6106 050116............................ 1.5151 1.1762 28.2924 28.8193 34.5110 30.5901 050117............................ 1.2630 1.1123 24.7555 28.2227 32.4414 28.3268 050118............................ 1.1710 1.1885 28.9358 33.0650 35.4044 32.6634 050121............................ 1.3350 1.0848 25.0858 25.5962 27.9537 26.3210 050122............................ 1.5372 1.1333 29.1534 29.7629 34.2416 31.1709 050124............................ 1.2385 1.1762 23.0843 26.7065 28.0288 25.9680 050125............................ 1.3685 1.5114 35.6573 40.9218 41.7020 39.5040 050126............................ 1.3912 1.1762 27.7126 29.6203 26.4194 27.8473 050127............................ 1.3401 1.2953 21.8719 23.6208 26.0500 23.7297 050128............................ 1.5403 1.1417 28.7668 28.3278 31.0662 29.4553 050129............................ 1.7571 1.1660 25.2780 27.8488 32.2680 28.7272 050131............................ 1.2972 1.4970 37.7845 38.6834 40.5321 39.0707 050132............................ 1.4262 1.1762 27.8805 29.4317 35.1544 30.7495 050133............................ 1.4967 1.0951 25.1948 27.6030 31.3530 28.2112 050135............................ 0.9765 1.1762

* 24.9415 24.3927 24.6796 050136............................ 1.2106 1.4739 31.6146 35.2834 37.4560 34.8123 050137............................ 1.2468 1.1762 35.0503 36.5409 38.4827 36.7225 050138............................ 1.9167 1.1762 43.0858 43.8671 46.9557 44.6742 050139............................ 1.2908 1.1762 33.8749 35.1013 37.6217 35.5604 050140............................ 1.4660 1.1660 36.1708 37.5473 39.6269 37.8550 050144............................ 1.4053 1.1762 30.3679 32.4042 33.5109 32.1636 050145............................ 1.3142 1.4140 37.5722 39.5676 42.3134 39.8846 050148............................ 1.1060 1.0848 17.3908 24.7063 27.3005 22.6027 050149............................ 1.4351 1.1762 28.0500 30.1596 33.2270 30.4737 050150............................ 1.1785 1.2953 26.7728 31.5333 31.7560 29.9321 050152............................ 1.4009 1.4970 34.5694 40.3464 43.6487 39.6060 050153............................ 1.5352 1.5114 34.5870 40.4446 43.3190 39.3912 050155............................ 0.9838 1.1762 21.2068 21.8829 21.8550 21.6128 050158............................ 1.2377 1.1762 30.6598 33.6400 35.1326 33.3121 050159............................ 1.3232 1.1660 27.4051 30.8069 31.3199 29.8120 050167............................ 1.3635 1.1333 23.2022 25.9850 28.5179 25.9911 050168............................ 1.6244 1.1660 27.5313 30.8036 33.2506 30.5684 050169............................ 1.4269 1.1762 25.6896 26.2864 27.4644 26.5104 050170............................

***

* 29.4075

*

* 29.4075 050173............................ 1.2514 1.1660 27.7070 27.6097 30.3582 28.5541 050174............................ 1.6425 1.4739 33.5204 36.3117 40.1747 36.7717 050175............................ 1.2918 1.1762 26.9627 31.5615 30.5733 29.6977 050177............................ 1.2491 1.1660 23.1575 24.7531 25.1442 24.3743 050179............................ 1.2005 1.1885 23.0583 25.8072 27.1155 25.4092 050180............................ 1.5845 1.5474 36.9905 40.8101 39.8123 39.2517 050186............................

***

* 27.6638

*

* 27.6638 050189............................ 0.9939 1.4140 32.3513 20.0709 29.1280 26.2226 050191............................ 1.4343 1.1762 28.1689

* 34.2091 31.2052 050192............................ 0.9731 1.0848 19.5327 21.2448 27.0424 22.7189 050193............................ 1.1968 1.1660 24.6307 30.7341 29.6421 28.4881 050194............................ 1.3119 1.5159 28.1413 38.6750 40.9096 35.6972 050195............................ 1.5170 1.5474 42.1735 43.9696 48.4358 44.9294 050196............................ 1.0762 1.0848 20.7257 25.2168 32.1933 25.8088 050197............................ 1.9645 1.4970

* 40.8832 48.9052 44.8389 050204............................ 1.4068 1.1762 24.9458 25.2512 28.6423 26.2829 050205............................ 1.2244 1.1762 25.2841 28.0504 27.8611 27.0700 050207............................ 1.2714 1.0951 25.1863 27.0216 29.5215 27.2272 050211............................ 1.2713 1.5474 34.3396 38.3319 41.2166 37.8840 050214............................

*** 1.1762 22.4773 24.4785 23.9972 23.6229 050215............................ 1.6351 1.5114 36.6063 41.6886 43.7985 40.7257 050217............................ 1.1451 1.0848 22.2055 23.6286 24.9606 23.6369 050219............................ 1.0993 1.1762 21.8649 22.9226 22.4065 22.4391 050222............................ 1.6663 1.1417 25.2922 26.3882 29.1094 27.0242 050224............................ 1.7203 1.1660 26.2108 26.7916 29.3143 27.4653 050225............................ 1.5203 1.0848 25.0219 29.5184 29.9656 28.1785 050226............................ 1.5875 1.1660 26.0826 29.2259 30.6541 28.6959 050228............................ 1.3521 1.5474 38.6751 40.1362 42.4226 40.4482 050230............................ 1.3593 1.1660 30.0380 34.1417 32.9555 32.4641 050231............................ 1.6236 1.1762 27.8896 30.1298 30.9607 29.7082

[[Page 23489]]

050232............................ 1.4386 1.1357 25.3439 24.4383 27.4099 25.6865 050234............................ 1.1726 1.1417 24.0754 29.2421 29.6560 27.4243 050235............................ 1.5578 1.1762 27.2838 27.8965 29.2979 28.1654 050236............................ 1.3813 1.1660 27.0687 28.1969 32.1647 29.0012 050238............................ 1.4440 1.1762 26.0312 29.1481 31.1764 28.8569 050239............................ 1.5765 1.1762 27.0866 28.2327 31.0963 28.8857 050240............................ 1.6442 1.1762 32.8542 35.2284 35.5735 34.6528 050242............................ 1.3378 1.5159 34.4412 39.7629 44.3130 39.6054 050243............................ 1.6214 1.1297 28.5626 31.8153 31.4883 30.6830 050245............................ 1.3020 1.1660 25.7585 27.0949 28.6527 27.2127 050248............................ 1.0286 1.4140 29.1192 31.6240 35.3864 32.0261 050251............................ 1.0004 1.0848 24.4552 26.5021 27.2675 26.0899 050253............................

*** 1.1564 23.9246 22.2450 24.0044 23.3808 050254............................ 1.2166 1.2953 23.3358 24.1512 26.3150 24.6804 050256............................ 1.5778 1.1762 26.8618 28.4728 29.8194 28.4077 050257............................ 0.9814 1.0848 17.4909 20.8367 21.3216 19.7770 050261............................ 1.3007 1.0848 21.4693 25.3005 27.3234 24.7145 050262............................ 2.1232 1.1762 33.0425 36.1162 44.0256 37.8981 050264............................ 1.3196 1.5474 37.4742 41.3478 41.1211 39.9496 050267............................

***

* 26.6558 26.7060

* 26.6806 050270............................ 1.3272 1.1417 27.9871 30.0540 32.4812 30.2697 050272............................ 1.3628 1.1660 24.0921 25.9103 27.1989 25.7666 050276............................ 1.1883 1.5474 34.7422 41.2251 39.3778 38.5361 050277............................ 1.0330 1.1762 35.6323 35.8246 32.5213 34.3014 050278............................ 1.5907 1.1762 26.0331 28.0351 29.9244 28.0988 050279............................ 1.2108 1.1660 23.5145 25.5299 27.6573 25.5685 050280............................ 1.6443 1.2207 28.5504 30.6723 35.2030 31.5494 050281............................ 1.4863 1.1762 25.7832 26.2623 27.3824 26.5030 050283............................ 1.5233 1.5474 35.1831 38.5600 42.8618 39.0003 050286............................

***

* 19.7352 19.4973

* 19.6057 050289............................ 1.5691 1.4970 34.9645 38.6875 41.1061 38.2220 050290............................ 1.6177 1.1762 31.9510 32.6388 34.5482 33.0758 050291............................ 1.8090 1.4739 28.3451 29.6162 35.3653 31.1027 050292............................ 0.9624 1.1297 27.6114 27.0775 26.8879 27.1685 050295............................ 1.5134 1.0848 25.4332 31.5960 36.1950 30.7774 050296............................ 1.1551 1.5114 33.5948 34.9952 39.0061 36.0343 050298............................ 1.1272 1.1660 26.1707 25.8232 27.7416 26.6026 050299............................ 1.2244 1.1762 26.9870 27.7535 31.5435 28.9060 050300............................ 1.5741 1.1660 26.3182 28.3862 30.7148 28.5022 050301............................ 1.2254 1.0848 25.7167 28.5769 31.9995 28.7858 050305............................ 1.4519 1.5474 38.7597 40.9978 44.8630 41.5654 050308............................ 1.4919 1.5114 31.6790 38.0564 43.0691 37.5162 050309............................ 1.3873 1.2953 25.5367 28.9181 34.4278 29.9079 050312............................ 1.4865 1.2207 28.2557 32.6846 33.9022 31.7615 050313............................ 1.2403 1.1333 25.3372 27.5321 31.4999 28.4222 050315............................ 1.2710 1.0848 23.6638 26.1224 27.6037 25.8181 050320............................ 1.2238 1.5474 31.4570 36.3252 40.2352 36.0082 050324............................ 1.9289 1.1417 28.4931 30.9958 32.9792 30.9355 050325............................ 1.1756 1.0848 26.6325 30.2280 30.6117 29.1581 050327............................ 1.6847 1.1660 33.0549 29.8327 33.0087 31.8986 050329............................ 1.2743 1.1297 26.6341 26.8021 26.2120 26.5339 050331............................ 1.1721 1.4739 21.5193 20.9847 20.2692 20.9637 050333............................ 1.0706 1.0848 15.6929 15.3119 23.4009 17.5306 050334............................ 1.6937 1.4140 37.2336 38.7635 40.7467 38.9455 050335............................ 1.4438 1.0848 24.9274 27.4046 26.2576 26.2253 050336............................ 1.1664 1.1333 23.2687 25.3062 28.5659 25.7519 050342............................ 1.2238 1.0848 23.0282 24.7654 26.8507 24.9581 050348............................ 1.6959 1.1660 28.9864 33.2676 37.7898 33.4975 050349............................ 0.9453 1.0848 15.6043 16.9251 17.4791 16.6299 050350............................ 1.3661 1.1762 27.2573 29.4262 31.1833 29.2715 050351............................ 1.5133 1.1762 27.4042 29.3082 30.8661 29.2314 050352............................ 1.2358 1.2953 32.6572 24.2931 33.9362 30.0053 050353............................ 1.5568 1.1762 25.4309 26.6332 29.1630 27.0686 050355............................

*** 1.0848

* 11.2498 5.0506 7.4928 050357............................ 1.4494 1.1525 25.2126 26.7265 32.3095 27.5322 050359............................ 1.1442 1.0848 22.9175 23.6030 24.7311 23.7960 050360............................ 1.4616 1.4970 35.9032 38.8658 37.0769 37.3332

[[Page 23490]]

050366............................ 1.2256 1.0848 23.4696 25.7692 31.1854 26.8679 050367............................ 1.4438 1.4888 32.6760 34.4959 38.7604 35.6778 050369............................ 1.3974 1.1762 28.0909 27.1327 29.5697 28.2751 050373............................ 1.4860 1.1762 30.7301 32.2315 32.2596 31.7447 050376............................ 1.4575 1.1762 30.3530 30.7562 32.5870 31.2266 050377............................

***

* 14.3892 20.2484

* 16.9896 050378............................ 0.9702 1.1762 30.4937 33.9087 34.2417 32.8674 050379............................

*** 1.0848 27.5151 31.7645 32.9575 30.5157 050380............................ 1.5471 1.5114 35.8014 39.1098 42.0782 38.9514 050382............................ 1.4204 1.1762 26.8950 26.0927 27.4131 26.8049 050385............................ 1.3521 1.4739

* 25.5735 34.5184 29.9098 050390............................ 1.1788 1.1297 25.7881 28.7761 26.0066 26.7871 050391............................ 1.3048 1.1762 20.2887 21.3012 18.1004 19.7304 050392............................ 1.0187 1.0848 21.8139 22.7209

* 22.2790 050393............................ 1.3163 1.1762 26.4918 28.2369 30.0661 28.2139 050394............................ 1.4938 1.1660 25.1869 26.0074 27.2543 26.2043 050396............................ 1.5902 1.1525 28.4161 30.5470 33.5699 30.9065 050397............................ 0.8283 1.0848 24.7279 27.4716 28.1640 26.7356 050407............................ 1.1949 1.4970 33.2894 35.6035 37.9066 35.6609 050410............................ 0.9616

* 19.8436 19.4995 21.3814 20.2094 050411............................ 1.4055 1.1762 35.5207 37.3817 37.8064 36.9551 050414............................ 1.3026 1.2953 28.2381 28.8561 34.6532 30.6007 050417............................ 1.2841 1.0848 24.5360 25.2930 29.5031 26.5285 050419............................ 1.3330 1.1909 26.4357 28.4471 33.3125 29.3954 050420............................ 1.1285 1.1762 26.7537 26.1838 24.9401 25.8686 050423............................ 0.9475 1.1297 26.5188 28.5944 30.6416 28.6936 050424............................ 1.9635 1.1417 27.5273 29.9133 31.0730 29.4697 050425............................ 1.3899 1.2953 37.7347 38.5317 42.4177 39.7789 050426............................ 1.3183 1.1660 30.9610 30.0077 30.6899 30.5313 050430............................ 0.9585 1.0848 31.5170 24.6684 25.0607 26.4412 050432............................ 1.5149 1.1762 28.1105 30.3547 30.8030 29.8170 050433............................ 0.9214 1.0848 14.3846 20.7565 23.0806 19.1896 050434............................ 1.1299 1.0848

* 25.9506 26.1621 26.0550 050435............................ 1.0952 1.1417 22.6618 32.2183 28.0306 27.3138 050438............................ 1.5305 1.1762 26.5535 26.4668 27.2662 26.7804 050441............................ 1.9649 1.5114 36.6680 38.2823 42.9765 39.2937 050444............................ 1.3319 1.1123 23.5299 27.6971 30.5504 27.3177 050447............................ 0.8880 1.1417 25.7274 21.8552 25.2573 24.1974 050448............................ 1.1326 1.0848 26.6967 25.0983 27.9759 26.6380 050454............................ 1.8679 1.4970 34.4813 36.8383 43.3278 38.3744 050455............................ 1.6861 1.0848 24.1694 24.5314 21.8846 23.4157 050456............................ 1.2166 1.1762 23.7594 22.1675 22.5630 22.8117 050457............................ 1.6122 1.4970 37.4570 40.2725 45.5829 41.0011 050464............................ 1.6731 1.1885 31.4768 37.1342 37.3692 35.4838 050468............................ 1.4533 1.1762 17.8128 29.4280 29.5448 24.3346 050469............................ 1.0831 1.0848 25.7995 27.3281 28.9079 27.4122 050470............................ 1.0907 1.0848 21.6981 18.4689 23.6649 21.2384 050471............................ 1.7659 1.1762 32.3570 34.5484 34.5211 33.8184 050476............................ 1.3587 1.0848 26.0482 30.9974 34.6585 30.3567 050477............................ 1.4963 1.1762 32.1676 34.6400 34.6995 33.8960 050478............................ 0.9760 1.1525 28.3894 30.9865 33.3998 30.9361 050481............................ 1.4169 1.1762 30.3890 31.9177 33.7446 32.0928 050485............................ 1.5976 1.1762 27.1437 28.8459 31.4233 29.1407 050488............................ 1.3096 1.5474 37.2438 40.5313 42.9904 40.3037 050491............................

*** 1.1564 29.2987 30.6461 32.1379 30.5664 050492............................ 1.4025 1.0848 23.7384 27.4933 27.1540 26.2639 050494............................ 1.3712 1.0848 30.8706 35.1457 34.8963 33.6068 050496............................ 1.7798 1.5474 35.7115 38.2871 42.2672 38.6931 050497............................

***

* 14.4481 15.9501

* 15.1581 050498............................ 1.2871 1.2953 28.2196 28.2667 32.7708 29.8260 050502............................ 1.7452 1.1762 28.0102 28.7200 29.5615 28.8118 050503............................ 1.4596 1.1417 26.7924 29.2001 31.6418 29.3049 050506............................ 1.7058 1.1357 30.4731 32.4509 36.0164 33.1455 050510............................ 1.2059 1.5474 39.6005 44.3883 47.5510 44.1129 050512............................ 1.4016 1.5474 39.0767 41.8921 46.9233 42.8915 050515............................ 1.3200 1.1417 36.3131 37.4251 38.9978 37.6365 050516............................ 1.4489 1.2953 30.0985 29.4936 36.2618 31.8675

[[Page 23491]]

050517............................ 1.0642 1.1660 23.4131 23.6034 23.9007 23.6377 050522............................

***

* 38.9157

*

* 38.9157 050526............................ 1.2090 1.1660 29.0004 29.9495 31.3744 30.1287 050528............................ 1.1389 1.0848 23.9177 28.6273 29.6838 27.7337 050531............................ 1.0915 1.1762 22.7311 25.0157 26.9420 24.9597 050534............................ 1.2648 1.1297 26.7941 29.7546 29.8603 28.8863 050535............................ 1.3449 1.1660 29.7904 32.3646 32.3723 31.6438 050537............................ 1.3781 1.2953 25.1291 27.4196 31.4527 28.1309 050539............................ 1.2398 1.0848 25.3328 28.0586 29.6856 27.7611 050541............................ 1.5362 1.5474 41.1980 43.7765 46.1121 43.8355 050542............................ 1.0327 1.0848 21.2846

*

* 21.2846 050545............................ 0.6959 1.1762 33.4322 42.9451 30.5554 35.4562 050546............................ 0.7147 1.0848 42.8052 52.7180 30.2329 41.5266 050547............................ 0.8260 1.4739 40.6483 45.1842 33.2205 39.9154 050548............................ 0.7101 1.1660 32.3944 37.1314

* 34.6019 050549............................ 1.5565 1.1604 31.8525 33.8288 34.9818 33.6342 050550............................ 1.3762 1.1660 29.0938 31.1918 30.2302 30.2108 050551............................ 1.2853 1.1660 28.6834 31.6782 31.6165 30.7425 050552............................ 1.1118 1.1762 24.9755 26.8274 27.1744 26.5471 050557............................ 1.5548 1.1885 25.8719 28.3111 31.1871 28.6462 050559............................

***

* 25.3299 26.9662

* 26.0948 050561............................ 1.2178 1.1762 35.9611 37.5863 38.8651 37.5449 050567............................ 1.5865 1.1660 27.8475 30.1167 32.9829 30.4114 050568............................ 1.2251 1.0848 20.8324 22.5008 24.4061 22.5795 050569............................ 1.3462 1.3480 27.7955 30.4874 33.0259 30.5066 050570............................ 1.5162 1.1660 29.9470 32.6896 34.0171 32.2949 050571............................ 1.2578 1.1762 29.1716 32.1656 33.6156 31.7338 050573............................ 1.7100 1.1297 27.2328 30.5249 33.3268 30.3962 050575............................ 1.2597 1.1762 23.1358 23.2447 25.2513 23.9658 050577............................ 1.2157 1.1762 26.4806 28.7060 30.8841 28.7176 050578............................ 1.7450 1.1762 30.4934 31.5953 33.8825 31.9512 050579............................ 1.4291 1.1762 34.9794 40.2740 39.4976 38.3190 050580............................ 1.2595 1.1660 27.2431 29.4337 31.6256 29.3950 050581............................ 1.4452 1.1762 28.9696 32.0823 32.1801 31.1581 050583............................ 1.5670 1.1417 30.0427 33.5209 33.3697 32.3610 050584............................ 1.2914 1.1660 24.5544 24.5757 24.8180 24.6565 050585............................ 1.1457 1.1660 26.0595 27.2982 22.7121 24.9986 050586............................ 1.1583 1.1660 25.7172 25.3551 27.4173 26.0841 050588............................ 1.3347 1.1762 30.5453 32.3603 32.8212 31.9715 050589............................ 1.2362 1.1660 27.9845 30.6273 30.9547 29.9199 050590............................ 1.2814 1.2953 27.0620 31.5987 32.1654 30.1866 050591............................ 1.1623 1.1762 28.6151 28.5915 28.8549 28.6959 050592............................ 1.1716 1.1660 25.9545 32.5000 24.4542 27.4073 050594............................ 1.9876 1.1660 30.8028 34.6747 34.7946 33.5328 050597............................ 1.2330 1.1762 24.5542 25.4868 27.5691 25.8776 050598............................

***

* 24.6875

*

* 24.6875 050601............................ 1.5414 1.1762 32.3033 35.0325 34.7409 34.0841 050603............................ 1.3839 1.1660 25.0996 28.6982 30.2464 28.0787 050604............................ 1.2162 1.5114 42.0018 45.4433 49.9429 45.9484 050608............................ 1.3821 1.0848 20.7955 22.1999 23.3630 22.1922 050609............................ 1.3707 1.1660 37.4563 38.4561 41.1797 39.1280 050615............................ 1.3061 1.1762 29.4323 32.8786 33.2909 31.8903 050616............................ 1.3796 1.1660 23.1748 28.5636 36.9017 29.6253 050618............................ 1.0245 1.0848 22.3481 25.4500 27.4539 25.0614 050623............................

*** 1.1762 29.9553 29.6550 32.0627 30.4768 050624............................ 1.2620 1.1762 23.3492 28.1941 32.2907 27.6796 050625............................ 1.7422 1.1762 30.8013 33.5137 36.3631 33.6260 050630............................

***

* 27.7051 28.0726 30.9410 28.9666 050633............................ 1.2315 1.1357 30.2883 33.4771 35.3734 33.1070 050636............................ 1.3084 1.1417 23.2573 27.2360 30.5156 27.0926 050641............................ 1.2243 1.1762 21.5030 20.4720 21.4612 21.1520 050644............................ 0.8876 1.1762 28.4054 25.6614 27.6547 27.1915 050662............................ 0.7678 1.5114 40.9242 47.5065 32.6362 40.4932 050663............................ 1.0263 1.1762 22.9161 25.1493 25.7747 24.4728 050667............................ 0.8884 1.3955 31.4906 25.9250 26.3937 27.9100 050668............................ 0.9981 1.5474 55.9594

* 31.8065 41.1707 050674............................ 1.2840 1.2953 36.8871 38.4454 42.6866 39.5960

[[Page 23492]]

050677............................ 1.4811 1.1762 36.2702 37.3389 38.7984 37.5511 050678............................ 1.2324 1.1660 27.1337 29.1159 30.7220 29.1295 050680............................ 1.2133 1.4888 32.7065 35.6614 38.3946 35.9028 050682............................ 0.8920 1.0848 23.0984 21.7264 21.7791 22.0865 050684............................ 1.1341 1.1297 23.7443 25.2575 26.4234 25.2119 050686............................ 1.2605 1.1297 37.3033 38.5595 40.9486 39.0574 050688............................ 1.2096 1.5114 36.5555 41.3305 41.9325 39.9230 050689............................ 1.5618 1.5474 37.5449 40.3815 42.2018 40.1932 050690............................ 1.2343 1.4739 41.1385 43.9228 47.2769 44.3743 050693............................ 1.2978 1.1660 32.6638 34.8040 35.0621 34.2547 050694............................ 1.1914 1.1297 25.8298 26.7041 28.9544 27.1978 050695............................ 1.1012 1.1333 27.8742 30.1226 35.6549 31.4872 050696............................ 2.0751 1.1762 29.9410 36.9314 35.9220 34.4812 050697............................ 1.0277 1.2207 18.6962 19.2603 25.1984 20.8006 050699............................

***

* 26.0909 25.6818 26.8210 26.1958 050701............................ 1.2779 1.1297 28.4650 29.6896 29.6253 29.3536 050704............................ 1.0120 1.1762 24.6072 24.6609 25.3488 24.8998 050707............................ 1.3813 1.4970 27.7366 32.4877 34.0550 31.4563 050708............................ 1.6591 1.0848 22.1606 21.2163 22.5034 21.9751 050709............................ 1.2193 1.1660 22.7897 21.9079 25.6119 23.3937 050710............................ 1.4396 1.0848 33.7204 34.8311 39.9858 36.4647 050713............................ 1.2543 1.1762 19.0071 20.7448 20.2803 19.9969 050714............................ 1.3580 1.5159 30.3263 32.4491 33.6676 32.2064 050717............................ 1.0612 1.1762 33.0719 34.5519 38.0796 35.2375 050718............................ 1.0152 1.1297 21.7835 15.4037 21.4996 18.9377 050719............................

***

* 22.0998

*

* 22.0998 050723............................ 1.2353 1.1762 33.0797 34.9814 35.0119 34.4384 050724............................ 2.1341 1.0848 23.7567

* 34.4267 28.5323 050725............................ 0.9684 1.1762 20.6592 22.0946 21.7816 21.6358 050726............................ 1.6664 1.1885 25.8742 27.0928 27.8433 27.0367 050727............................ 1.2727 1.1762

* 23.7179 23.9437 23.8301 050728............................ 1.3207 1.4739

* 31.4768 36.0820 33.6891 050729............................ 1.4238 1.1762

*

* 34.2580 34.2580 050730............................ 1.2649 1.1762

*

* 51.5425 51.5425 060001............................ 1.5772 1.0517 23.1548 24.9410 26.8470 25.0779 060003............................ 1.3962 1.0517 23.0807 24.7856 24.2224 24.0730 060004............................ 1.1960 1.0710 25.0037 28.0656 29.9649 27.8289 060006............................ 1.3423 0.9379 21.8609 22.7493 24.5704 23.0964 060007............................ 1.0128 0.9379 21.4244 21.4792

* 21.4535 060008............................ 1.1014 0.9379 19.8803 21.8037 23.3859 21.7601 060009............................ 1.4646 1.0710 24.7920 27.0511 28.7645 26.9116 060010............................ 1.7149 1.0146 25.8475 27.2290 28.9850 27.4402 060011............................ 1.4232 1.0710 25.8919 26.1958 27.2833 0126.4630 060012............................ 1.4557 0.9379 22.6374 24.1557 26.2469 24.3434 060013............................ 1.3659 0.9379 23.3954 24.9708 24.5994 24.0758 060014............................ 1.7846 1.0710 27.0326 29.6744 31.2588 29.2315 060015............................ 1.7206 1.0710 27.6338 30.1158 30.4533 29.4109 060016............................ 1.1655 0.9379 22.9300 23.9655 25.6527 24.2479 060018............................ 1.2136 0.9379 21.0581 23.6620 25.7628 23.4747 060020............................ 1.5388 0.9379 20.9025 22.2052 22.6748 21.9753 060022............................ 1.5930 0.9457 24.7928 25.7832 26.5238 25.7483 060023............................ 1.6438 0.9578 24.3749 26.7285 27.7644 26.3625 060024............................ 1.7403 1.0710 25.2409 28.7231 29.0130 27.7028 060027............................ 1.5666 1.0517 25.1480 26.6348 28.0909 26.7085 060028............................ 1.3838 1.0710 27.1303 27.9686 30.0448 28.4352 060029............................

*** 0.9379 19.7379

*

* 19.7379 060031............................ 1.5393 0.9457 23.8781 25.6207 26.3650 25.3306 060032............................ 1.5419 1.0710 27.1783 28.2234 30.4247 28.6396 060033............................ 0.9865 0.9379 16.7266

*

* 16.7266 060036............................ 1.1170 0.9379 19.4144 20.4635 20.7131 20.1878 060041............................ 0.9219 0.9379 20.8746 22.7123 23.4978 22.3670 060043............................ 0.9477 0.9379 19.1085 20.0939 18.7896 19.3418 060044............................ 1.1417 1.0517 25.6112 25.2471 25.0360 25.3737 060049............................ 1.2784 1.0146 25.3425 26.8089 29.0598 27.1748 060050............................ 1.1981 0.9379 20.4386 21.9108

* 21.1679 060054............................ 1.4335 0.9590 21.1281 23.5803 22.3490 22.3633 060057............................ 1.0788 0.9379 24.3982 26.9891

* 25.7472

[[Page 23493]]

060064............................ 1.4680 1.0710 29.1806 30.0963 31.3105 30.2470 060065............................ 1.2936 1.0710 29.2377 28.5282 31.1987 29.6323 060070............................

*** 0.9379 22.6894

*

* 22.6894 060075............................ 1.2070 0.9379 27.7835 30.7835 32.7563 30.4907 060076............................ 1.2848 0.9379 23.6266 25.5406 26.8236 25.4496 060096............................ 1.5124 1.0517 26.4167 27.4085 30.0602 27.9908 060100............................ 1.6735 1.0710 28.0561 29.7690 32.1537 30.0220 060103............................ 1.1833 1.0517 26.6863 28.8063 30.3002 28.6961 060104............................ 1.3558 1.0710 26.7683 30.8625 32.0889 29.9703 060107............................ 1.4178 1.0710

* 26.8267 26.1883 26.4984 060108............................

***

* 19.0011

*

* 19.0011 060111............................

***

*

* 31.2571

* 31.2571 070001............................ 1.6316 1.1790 29.9592 32.2718 34.0302 32.0467 070002............................ 1.8165 1.1790 28.1101 29.0663 31.1530 29.4722 070003............................ 1.0898 1.1790 29.8684 31.3716 32.7173 31.3528 070004............................ 1.1896 1.1790 25.7207 27.3004 29.2292 27.3764 070005............................ 1.3796 1.1790 29.8173 29.3265 32.1668 30.4848 070006 \2\........................ 1.3118 1.2607 33.3814 33.9310 36.8469 34.7695 070007............................ 1.2843 1.1790 29.0336 30.3648 31.7097 30.4054 070008............................ 1.2463 1.1790 24.3907 24.9176 26.4806 25.2986 070009............................ 1.1856 1.1790 25.6072 28.8649 30.2706 28.2076 070010............................ 1.8269 1.2607 30.4192 33.1535 32.5798 32.0648 070011............................ 1.3577 1.1790 24.9457 27.5391 29.9105 27.3901 070012............................ 1.1771 1.1790 34.9099 40.3337 44.1424 39.6372 070015............................ 1.4329 1.1790 30.0614 30.9728 33.4595 31.5141 070016............................ 1.3424 1.1790 29.7505 29.6662 31.0903 30.2000 070017............................ 1.3696 1.1790 29.2978 30.3951 31.7223 30.4949 070018 \2\........................ 1.3351 1.2607 33.8654 35.7189 37.6081 35.8796 070019............................ 1.2584 1.1790 27.9838 29.6290 31.8148 29.8448 070020............................ 1.3392 1.1790 28.4084 29.9507 31.0935 29.8423 070021............................ 1.2614 1.1790 30.3254 31.4397 33.2357 31.7179 070022............................ 1.7784 1.1790 29.7376 32.3625 33.9804 32.0199 070024............................ 1.3851 1.1790 28.3460 30.8308 32.0430 30.4352 070025............................ 1.8564 1.1790 28.3017 29.2540 30.9938 29.5451 070027............................ 1.2911 1.1790 36.9700 27.3487 31.8018 31.4568 070028............................ 1.5983 1.2607 28.2078 29.5653 31.5036 29.7843 070029............................ 1.2773 1.1790 25.8107 26.3871 27.7213 26.6692 070031............................ 1.2393 1.1790 25.5880 27.2359 28.9190 27.3126 070033............................ 1.2635 1.3191 34.3904 35.5355 37.1929 35.7524 070034 \2\........................ 1.3877 1.2607 32.8074 35.6831 36.2719 34.9418 070035............................ 1.2964 1.1790 26.1693 27.1816 27.5585 26.9760 070036............................ 1.6654 1.1790 35.0701 34.0555 36.1610 35.1155 070038............................ 1.1608

*

* 31.1133 25.7516 26.9407 070039............................ 0.9382 1.1790 32.6059 35.0164 31.2269 32.9340 080001............................ 1.6701 1.0652 28.0859 30.2463 30.0242 29.4815 080002............................

***

* 23.7309 26.4192 27.9670 26.0445 080003............................ 1.5462 1.0652 24.8199 27.1131 29.2266 26.9651 080004............................ 1.3741 1.0652 24.2251 26.0092 27.4735 25.9428 080006............................ 1.2769 0.9606 23.6838 24.4204 25.6160 24.5955 080007............................ 1.3900 1.0289 23.4964 24.6485 27.0074 25.0565 090001............................ 1.7108 1.0935 29.5432 31.3552 35.0413 32.0128 090002............................

***

* 23.5158 29.6780

* 25.5760 090003............................ 1.2607 1.0935 22.7014 27.0514 29.2660 26.1789 090004............................ 1.9783 1.0935 28.7417 29.9785 32.0186 30.3834 090005............................ 1.3818 1.0935 28.6142 30.2504 30.7728 29.9417 090006............................ 1.3806 1.0935 23.7241 25.9086 29.5590 26.3083 090007............................

***

* 25.8430 30.1419

* 27.7359 090008............................ 1.4284 1.0935 19.3212 29.6744 29.1059 25.7761 090011............................ 2.0113 1.0935 31.7710 32.4412 34.0693 32.7262 100001............................ 1.5628 0.9303 22.6150 25.2381 24.4060 24.0790 100002............................ 1.3511 1.0061 22.5982 22.1269 25.3389 23.3729 100004............................ 0.9314 0.8613 15.6306 16.2637 16.5974 16.2012 100006............................ 1.6100 0.9446 23.3745 26.2372 26.2258 25.3340 100007............................ 1.6285 0.9446 24.3305 25.4333 26.5612 25.5135 100008............................ 1.6365 0.9757 22.7706 25.7377 27.4314 25.4374 100009............................ 1.4157 0.9757 24.7811 24.4666 25.9381 25.0983 100010............................

***

* 25.5614 26.9486

* 26.2759

[[Page 23494]]

100012............................ 1.6376 0.9333 24.2602 24.5762 26.3798 25.1067 100014............................ 1.2930 0.9307 21.7566 22.3054 24.5862 22.8508 100015............................ 1.3050 0.9292 22.1272 22.5781 24.6038 23.0946 100017............................ 1.5188 0.9307 21.1905 22.9545 26.1580 23.5300 100018............................ 1.6120 1.0115 24.1885 27.8582 28.1191 26.7581 100019............................ 1.6412 0.9826 24.2888 25.5566 27.5435 25.8847 100020............................ 1.3242 0.9757 23.5303 23.6106 23.8785 23.6811 100022............................ 1.7131 1.0508 27.9072 29.0519 29.9345 29.0212 100023............................ 1.4290 0.9446 21.8111 21.4015 23.0074 22.0889 100024............................ 1.2486 0.9757 24.4070 27.6476 30.2395 27.3189 100025............................ 1.6929 0.8613 21.2568 21.1174 22.1580 21.5429 100026............................ 1.6114 0.8613 20.1602 21.3533 21.3651 20.9595 100027............................ 1.2106 0.8613 23.8982 12.0314 16.1223 16.3797 100028............................ 1.2795 0.9826 21.8879 23.7818 26.8661 24.1693 100029............................ 1.1347 0.9757 24.6814 26.9307 27.5844 26.4439 100030............................ 1.2887 0.9446 21.8567 22.4887 24.0943 22.9211 100032............................ 1.6962 0.9292 21.6415 23.0174 25.2033 23.3437 100034............................ 1.8227 0.9757 23.1111 24.4064 25.9415 24.5360 100035............................ 1.5678 0.9554 22.6349 25.3590 26.9407 24.9239 100038............................ 1.8717 1.0508 25.7948 27.4422 29.8583 27.7714 100039............................ 1.3916 1.0508 23.8060 26.6016 28.4627 26.3398 100040............................ 1.6805 0.9303 22.4679 23.5372 23.6443 23.2382 100043............................ 1.2649 0.9292 21.7738 22.8963 25.2273 23.3549 100044............................ 1.4156 1.0162 23.9952 26.3208 28.3596 26.2570 100045............................ 1.3130 0.9446 25.2285 23.0520 26.9641 25.0756 100046............................ 1.2283 0.9292 24.2746 26.6169 26.3673 25.8723 100047............................ 1.6670 0.9274 24.3522 24.4212 25.0404 24.6186 100048............................ 0.9388 0.8613 17.5533 18.3767 18.8771 18.2575 100049............................ 1.1939 0.8934 21.8679 22.9532 22.9810 22.6230 100050............................ 1.1699 0.9757 20.0405 20.6893 19.8713 20.2035 100051............................ 1.3249 0.9446 20.0231 22.3311 23.2764 22.0397 100052............................ 1.3546 0.8934 20.5916 20.9078 22.3920 21.3174 100053............................ 1.2271 0.9757 23.7837 27.3383 27.3224 26.2170 100054............................ 1.1950 0.8877 22.0352 25.7279 28.0512 25.3241 100055............................ 1.3505 0.9292 19.6350 22.1051 23.5332 21.7040 100056............................

***

* 25.9245 25.7945

* 25.8574 100057............................ 1.4813 0.9446 24.6417 22.6038 25.3897 24.1823 100061............................ 1.5361 0.9757 26.1273 26.7673 29.2565 27.4077 100062............................ 1.7092 0.8955 24.9807 24.1413 25.2340 24.7789 100063............................ 1.2093 0.9292 21.5620 21.5566 24.7026 22.5862 100067............................ 1.4142 0.9292 23.8892 23.9333 25.4597 24.4499 100068............................ 1.7170 0.9307 23.7840 24.9025 25.9202 25.2289 100069............................ 1.3251 0.9292 19.6037 22.4386 24.3111 22.1685 100070............................ 1.6333 0.9554 23.5524 23.7746 24.9751 24.0912 100071............................ 1.2241 0.9292 21.7675 23.4176 24.9682 23.4234 100072............................ 1.3679 0.9307 23.5362 24.2934 26.0379 24.6995 100073............................ 1.6820 1.0508 23.5843 25.3685 30.3358 26.4443 100075............................ 1.4565 0.9292 22.3890 23.3503 25.1691 23.6907 100076............................ 1.2340 0.9757 19.6444 21.0777 21.9483 20.8673 100077............................ 1.4278 0.9274 22.3755 24.3478 26.0347 24.2410 100080............................ 1.7259 1.0061 22.8704 26.3596 27.0126 25.4415 100081............................ 1.0413 0.8672 16.8087 16.9168 15.6662 16.4022 100084............................ 1.7911 0.9446 24.1122 25.4140 26.3475 25.2653 100086............................ 1.2082 1.0508 25.2375 26.4817 28.2641 26.6950 100087............................ 1.8721 0.9554 26.5915 25.9909 26.4999 26.3569 100088............................ 1.6620 0.9303 23.6270 24.8729 25.9182 24.8465 100090............................ 1.4618 0.9303 22.5894 24.0501 24.2422 23.6608 100092............................ 1.5036 0.9826 25.4630 26.0856 28.4789 26.7319 100093............................ 1.6987 0.8613 20.2949 21.1547 21.3524 20.9431 100098............................ 1.0859 0.8613 20.0639 21.2505

* 20.6613 100099............................ 1.0146 0.8934 18.5287 20.4328 21.3036 20.1035 100102............................ 1.0412 0.8613 21.6772 22.8850 23.8596 22.8413 100103............................ 0.9567 0.8613 20.3633 21.7494 22.9256 21.7001 100105............................ 1.3654 0.9458 24.5464 24.9503 26.8091 25.4381 100106............................ 0.9426 0.8613 20.3417 20.2882 24.0389 21.6406 100107............................ 1.1491 0.9333 23.3789 24.4484 26.1337 24.6951 100108............................ 0.7656 0.8613 14.8039 16.3757 22.0750 17.7359

[[Page 23495]]

100109............................ 1.2500 0.9446 23.0779 23.8836 24.9951 24.0208 100110............................ 1.5138 0.9446 24.4533 28.3699 29.1494 27.5406 100113............................ 1.9521 0.9461 24.3614 25.0067 26.6479 25.3817 100114............................ 1.3471 0.9757 25.3699 27.7413 29.2195 27.4364 100117............................ 1.1856 0.9303 23.9134 26.0451 26.4536 25.5634 100118............................ 1.3280 0.9303 24.1104 23.6669 28.0569 25.5448 100121............................ 1.0708 0.8934 23.1100 24.0937 24.8579 24.0497 100122............................ 1.2187 0.8877 24.1820 21.2597 23.4751 22.8811 100124............................ 1.1623 0.8613 24.3048 21.6483 22.7023 22.7933 100125............................ 1.1807 0.9757 22.4185 25.3532 26.7452 24.9756 100126............................ 1.4012 0.9292 21.7977 23.2996 24.0192 23.0655 100127............................ 1.6390 0.9292 21.0153 21.3223 23.8920 22.0931 100128............................ 2.1468 0.9292 24.4104 25.6763 29.4979 26.6451 100130............................ 1.1903 1.0061 20.2478 22.8324 24.2046 22.4252 100131............................ 1.2656 0.9757 25.4811 25.8316 29.2462 26.9103 100132............................ 1.2174 0.9292 21.1538 23.0428 24.3293 22.8670 100134............................ 0.9426 0.8613 18.3391 19.5337 20.9244 19.6271 100135............................ 1.5934 0.8712 20.4915 22.3071 24.0024 22.2526 100137............................ 1.1612 0.8934 20.4007 23.3692 25.1974 23.1447 100139............................ 0.8526 0.9461 18.2204 14.5046 17.5489 16.8211 100140............................ 1.1665 0.9303 22.5124 24.8165 26.4720 24.7189 100142............................ 1.2175 0.8613 20.0689 20.7219 22.9577 21.2432 100147............................

*** 0.8613 17.1045

*

* 17.1045 100151............................ 1.7655 0.9303 26.6470 26.1848 28.1322 27.0891 100154............................ 1.5497 0.9757 23.0820 26.3703 27.6127 25.8181 100156............................ 1.1022 0.8613 20.6928 22.2757 26.7092 23.2451 100157............................ 1.5782 0.9292 23.1045 25.9133 27.3851 25.4671 100160............................ 1.1887 0.8613 23.4877 27.2019 26.9851 25.9544 100161............................ 1.5792 0.9446 24.6268 28.3607 28.8077 27.4143 100162............................

***

* 23.8001

*

* 23.8001 100167............................ 1.2864 1.0508 26.4517 26.8584 30.3694 27.8827 100168............................ 1.3732 1.0061 24.6276 26.0864 27.1292 25.9577 100169............................

***

* 23.4575

*

* 23.4575 100173............................ 1.7343 0.9292 19.7190 22.4866 24.5390 22.2987 100175............................ 0.9876 0.8613 21.0474 22.0666 23.5455 22.2224 100176............................ 1.8792 1.0162 26.8740 29.8326 31.2694 29.3692 100177............................ 1.3177 0.9826 24.5078 25.3973 26.6781 25.6089 100179............................ 1.7603 0.9303 24.1801 26.6537 29.5619 26.9037 100180............................ 1.3719 0.9292 24.9433 26.3299 27.1804 26.1924 100181............................ 1.0880 0.9757 18.1320 19.5022 21.8540 19.8108 100183............................ 1.1753 0.9757 24.4575 26.7893 27.4951 26.3276 100187............................ 1.2686 0.9757 23.4760 26.1394 27.3653 25.7401 100189............................ 1.3096 1.0508 26.6846 26.5763 28.4136 27.3048 100191............................ 1.3075 0.9292 24.1911 24.3553 26.6340 25.0785 100200............................ 1.3785 1.0508 24.8120 28.0926 29.8963 27.6635 100204............................ 1.5254 0.9461 22.2613 24.4697 25.7537 24.2423 100206............................ 1.2968 0.9292 22.8782 23.0340 25.2196 23.7228 100208............................

***

* 24.1482 24.9854

* 24.5807 100209............................ 1.3575 0.9757 23.8502 25.0778 26.6246 25.2683 100210............................ 1.5359 1.0508 26.0933 28.6449 28.9486 27.9114 100211............................ 1.1787 0.9292 24.3243

* 24.7095 24.5352 100212............................ 1.4636 0.8955 22.6584 24.2669 24.7566 23.9351 100213............................ 1.5843 0.9554 24.4467 25.1893 27.1983 25.6153 100217............................ 1.1771 1.0162 24.0291 25.2635 25.2907 24.8791 100220............................ 1.6524 0.9333 24.9733 25.0154 26.0905 25.3692 100223............................ 1.5843 0.8877 21.2434 23.4556 24.7015 23.2004 100224............................ 1.2340 1.0508 23.0804 23.3593 24.8077 23.7932 100225............................ 1.2707 1.0508 23.9971 27.9473 28.4316 26.8326 100226............................ 1.2697 0.9303 23.8701 27.8003 29.3317 27.1288 100228............................ 1.3187 1.0508 26.2593 27.2873 29.8952 28.0013 100229............................

***

* 21.0038

*

* 21.0038 100231............................ 1.6878 0.8613 23.5418 24.6994 25.5175 24.6455 100232 h.......................... 1.2214 0.9303 21.8105 23.9405 24.9322 23.5285 100234............................ 1.3110 1.0061 24.9141 25.2574 26.3601 25.5144 100236............................ 1.3623 0.9274 23.9781 25.9282 26.6585 25.5663 100237............................ 1.9568 1.0508 26.7664 25.6112 31.3543 27.7849 100238............................ 1.5077 0.9292 24.6513 27.1748 28.4302 26.8154

[[Page 23496]]

100239............................ 1.2789 0.9554 25.0509 26.9668 27.7592 26.6605 100240............................ 0.9534 0.9757 23.0650 23.4830 25.3265 24.0024 100242............................ 1.3586 0.8613 20.4681 21.5130 24.0990 22.0856 100243............................ 1.5324 0.9292 23.2812 25.2987 26.1131 24.9766 100244............................ 1.3330 0.9333 23.4876 24.1515 25.2584 24.3502 100246............................ 1.6049 1.0162 26.7630 27.6382 28.9894 27.8151 100248............................ 1.4986 0.9292 23.8742 25.9170 27.7797 25.9263 100249............................ 1.2539 0.8955 21.3942 23.4021 23.2084 22.6697 100252............................ 1.1974 1.0162 22.6475 24.9860 25.8540 24.5257 100253............................ 1.3797 1.0061 23.6939 24.4051 25.7121 24.6472 100254............................ 1.5814 0.8712 23.2794 25.0192 25.7338 24.6995 100255............................ 1.1947 0.9292 22.9793 22.2341 24.1169 23.1055 100256............................ 1.9673 0.9292 24.1969 26.0629 28.8856 26.4333 100258............................ 1.4847 1.0061 24.5699 31.8772 31.2482 29.0443 100259............................ 1.2244 0.9292 24.1148 24.9404 26.0175 25.0705 100260............................ 1.3413 1.0162 23.5164 25.2630 27.5188 25.5518 100262............................

***

* 23.8006 26.3954

* 25.1412 100264............................ 1.2531 0.9292 22.4800 25.0250 25.5489 24.4115 100265............................ 1.2774 0.9292 21.0688 23.4758 23.6151 22.8276 100266............................ 1.4031 0.8613 21.5258 22.6614 23.2340 22.5196 100267............................ 1.2776 0.9554 23.3760 26.5059 27.3768 25.7444 100268............................ 1.1529 1.0061 26.0297 29.8289 29.2898 28.4053 100269............................ 1.3034 1.0061 24.9002 25.3228 26.7450 25.7303 100275............................ 1.2616 1.0061 23.1419 24.3059 26.0361 24.5544 100276............................ 1.2369 1.0508 25.4557 27.2589 30.0576 27.6322 100277............................ 1.3339 0.9757 25.2985 47.3905 16.5427 24.0477 100279............................ 1.2334 0.9333 24.8484 25.4909 26.8606 25.7747 100281............................ 1.2641 1.0508 25.3382 27.0864 28.6660 27.1929 100284............................ 1.0813 0.9757 22.3046 22.5927 23.8170 22.9628 100286............................ 1.5579 1.0115

* 27.1051 29.4284 28.3288 100287............................ 1.3676 1.0061

* 28.2229 28.3427 28.2858 100288............................ 1.5140 1.0061

* 37.4785 33.8141 35.4781 100289............................ 1.7415 1.0508

* 28.4504 29.2915 28.8970 100290............................ 1.1280 0.8613

*

* 23.5080 23.5080 100292............................ 1.2103 0.8672

*

* 25.9093 25.9093 110001............................ 1.2172 0.9637 24.0561 25.1164 25.2695 24.8146 110002............................ 1.2471 0.9637 20.4502 21.8616 25.3897 22.5380 110003............................ 1.2762 0.9303 19.7061 20.0968 21.4002 20.4029 110004............................ 1.2242 0.9099 21.8791 22.7929 23.9911 22.8563 110005............................ 1.1543 0.9637 23.6146 22.3645 22.8082 22.9077 110006............................ 1.4983 0.9813 23.8762 25.0719 28.6090 25.8225 110007............................ 1.5952 0.8645 28.2025 30.7430 23.8785 27.0990 110008............................ 1.3541 0.9637 22.6308 23.4662 27.0198 24.4256 110010............................ 2.1112 0.9637 27.2029 28.7690 29.7142 28.5850 110011............................ 1.1841 0.9637 23.2149 25.4620 26.0899 24.9213 110015............................ 1.1253 0.9637 23.2280 25.5661 26.6610 25.2080 110016............................ 1.1938 0.7684 18.8228 18.8376 21.7610 19.7802 110018............................ 1.1764 0.9637 24.7007 25.6485 28.2431 26.2640 110020............................ 1.2808 0.9637 23.3004 24.8735 26.8501 25.0177 110023............................ 1.3725 0.9637 23.5673 25.3746 27.3029 25.5307 110024............................ 1.3712 0.9483 22.1471 23.8091 25.7205 23.8901 110025............................ 1.4319 0.9303 29.0965 31.5253 26.1311 28.6493 110026............................ 1.1005 0.7684 19.3201 20.5740 21.2826 20.4005 110027............................ 1.0627 0.7684 19.8351 19.2323 20.2175 19.7328 110028............................ 1.7504 0.9567 25.9474 25.1836 27.9184 26.3393 110029............................ 1.6515 0.9637 22.7981 25.2335 24.8893 24.3542 110030............................ 1.1953 0.9637 22.2341 25.0842 26.4770 24.7162 110031............................ 1.2600 0.9637 22.8695 24.1711 26.0384 24.4325 110032............................ 1.1631 0.7684 18.0744 20.7211 21.9407 20.2437 110033............................ 1.3973 0.9637 24.1447 25.2326 28.3210 25.8930 110034............................ 1.6993 0.9567 24.0791 24.4141 27.0099 25.1876 110035............................ 1.4949 0.9637 24.2581 25.7562 27.5532 25.9518 110036............................ 1.7799 0.9483 24.4788 25.4854 26.8789 25.6507 110038............................ 1.5400 0.8420 20.1710 20.5880 21.2138 20.6802 110039............................ 1.4119 0.9567 17.0608 19.4032 19.7892 18.7582 110040............................ 1.1097 0.9637 17.3095 18.8744 19.7509 18.6568 110041............................ 1.2580 0.9684 20.8080 21.5402 23.4074 21.9417

[[Page 23497]]

110042............................ 1.0979 0.9637 25.5588 26.8321 23.4645 25.2397 110043............................ 1.7289 0.9483 22.7589 25.2788 26.7522 24.9357 110044............................ 1.1609 0.7684 19.2562 19.6940 20.9654 19.9819 110045............................ 1.1384 0.9637 19.7746 21.3922 24.9821 22.1119 110046............................ 1.1501 0.9637 21.6201 24.0022 23.8292 23.2190 110049............................ 0.9635 0.7684 18.9096 19.8706

* 19.4074 110050............................ 1.0937 0.9033

* 25.6020

* 25.6020 110051............................ 1.1347 0.7684 17.6816 19.0995 19.4276 18.7634 110054............................ 1.4875 0.9637 20.5387 22.2250 25.7085 22.7254 110056............................ 0.9430 0.7684 21.7608 23.0080

* 22.3710 110059............................ 1.0697 0.7684 19.9802 18.7097 20.5565 19.6943 110061............................

*** 0.8873 18.6696

*

* 18.6696 110064............................ 1.4700 0.8570 21.7636 23.8739 24.2739 23.3486 110069............................ 1.2734 0.9087 21.0518 22.3006 24.1669 22.5324 110071............................ 0.9739 0.7684 15.2336 13.3731 18.0224 15.4555 110073............................ 1.0759 0.7684 15.2711 16.3610 18.6336 16.6863 110074............................ 1.4999 0.9813 24.4094 27.5836 27.0337 26.3402 110075............................ 1.2670 0.9316 20.4634 20.9973 22.0935 21.2149 110076............................ 1.4563 0.9637 23.8211 25.2424 26.3506 25.1774 110078............................ 2.0424 0.9637 28.2149 27.8627 24.8746 26.9445 110079............................ 1.3966 0.9637 22.8017 24.5255 23.1024 23.4646 110080............................ 1.2439 0.9637 24.1958 21.5482 22.3213 22.5788 110082............................ 1.9154 0.9637 27.2931 28.9731 29.8366 28.7072 110083............................ 1.9070 0.9637 24.6460 26.2604 27.8245 26.3029 110086............................ 1.3847 0.7684 18.8751 20.8557 21.1509 20.2673 110087............................ 1.4065 0.9637 25.7908 26.2872 28.0471 26.7332 110089............................ 1.1502 0.7684 20.6757 21.2013 21.9509 21.2887 110091............................ 1.2996 0.9637 24.3354 26.3857 26.5523 25.8218 110092............................ 1.0125 0.7684 16.9116 18.7397 18.5527 18.0853 110095............................ 1.3953 0.8710 20.1024 21.8709 23.4846 21.8636 110096............................ 0.9779 0.7684 18.5513 19.4498

* 19.0000 110100............................ 0.9643 0.7684 15.1316 16.5833 16.5600 16.0845 110101............................ 1.0706 0.7684 13.3943 14.4630 16.4270 14.7428 110104............................ 1.0494 0.7684 17.9805 19.5575 18.7951 18.8040 110105............................ 1.3229 0.7684 19.2156 20.6270 21.1077 20.3365 110107............................ 1.8630 0.9485 21.8167 26.0763 26.2526 24.6977 110109............................ 1.0104 0.7684 18.7397 20.4726 21.4280 20.2690 110111............................ 1.1313 0.9567 20.9535 20.5577 29.2190 22.9282 110112............................ 0.9374 0.7684 20.4565 21.0612 24.2463 21.7104 110113............................ 1.0686 0.9567 18.0770 16.7641 19.1753 18.0155 110115............................ 1.6816 0.9637 26.3274 29.8699 32.0197 29.3454 110118............................

*** 0.7684 17.7344

*

* 17.7344 110121............................ 1.0384 0.7684 19.5230 21.2534 21.6637 20.8173 110122............................ 1.5295 0.8420 20.4184 22.0210 23.7589 22.1314 110124............................ 1.0742 0.7684 19.7004 20.9334 22.7058 21.1178 110125............................ 1.2373 0.9087 19.8695 22.1458 22.4238 21.5044 110128............................ 1.2076 0.9316 28.4943 23.2576 24.4596 24.9779 110129............................ 1.5230 0.8570 21.8204 22.4202 23.3631 22.5595 110130............................ 0.9412 0.7684 17.5272 17.6529 18.7549 18.0115 110132............................ 1.0349 0.7684 17.2924 18.9927 19.2307 18.5224 110135............................ 1.2847 0.7684 18.5125 20.0057 20.4411 19.6750 110136............................ 1.0675 0.7684 21.1235 22.7715 15.3030 19.7964 110142............................ 0.9587 0.7684 16.3359 17.3328 18.1980 17.2921 110143............................ 1.3701 0.9637 24.3898 25.4932 24.2240 24.6996 110146............................ 1.0472 0.7684 17.2250 19.9221 23.9067 20.1122 110149............................ 1.3335 0.9637 25.3619 24.7686 27.1477 25.8232 110150............................ 1.2656 0.9087 22.7366 23.8157 22.6624 23.0726 110153............................ 1.1467 0.9087 21.5300 22.8660 24.5368 22.9872 110155............................

***

* 16.1785

*

* 16.1785 110163............................ 1.4114 0.8645 21.9411 25.5461 26.0764 24.4314 110164............................ 1.5149 0.9485 23.7801 26.4450 27.0600 25.7931 110165............................ 1.3808 0.9637 23.4071 24.3897 26.8378 24.9170 110166............................

*** 0.9485 23.6665 25.2264 26.8070 25.1758 110168............................ 1.8280 0.9637 23.3426 24.6321 27.0022 25.0628 110169............................

***

* 24.7083

*

* 24.7083 110172............................ 1.1832 0.9637 25.2396 27.0240 29.1703 27.1002 110177............................ 1.6699 0.9567 24.0700 25.0129 26.7504 25.3590

[[Page 23498]]

110179............................

***

* 26.0365 26.1173 26.0759 26.0760 110183............................ 1.2345 0.9637 26.4248 27.6020 26.8591 26.9602 110184............................ 1.2007 0.9637 24.3379 25.5420 23.3803 24.3763 110186............................ 1.3771 0.8570 21.1176 23.2348 25.0299 23.1796 110187............................ 1.2237 0.9637 23.2571 22.5730 24.2933 23.3967 110188............................

***

* 24.4785

*

* 24.4785 110190............................ 1.0046 0.7684 21.9008 19.1054 14.2517 17.7557 110191............................ 1.2930 0.9637 24.0572 25.8409 26.8277 25.5872 110192............................ 1.3222 0.9637 24.3823 25.7406 26.7852 25.7103 110193............................ 1.4229 0.9637 25.1779 27.8223 27.3341 26.8213 110194............................ 0.9346 0.7684 16.8075 16.3148 18.4776 17.2529 110198............................ 1.3834 0.9637 28.0634 30.8014 31.7748 30.3084 110200............................ 1.8830 0.8570 20.1816 21.2177 22.3249 21.2486 110201............................ 1.3894 0.9485 24.1171 27.0388 28.2232 26.3653 110203............................ 0.9912 0.9637 30.2609 25.8951 26.8768 27.4232 110205............................ 1.0674 0.9637 23.1969 20.6150 19.7409 21.0203 110209............................ 0.5352 0.7684 17.4145 19.1000 19.0450 18.5793 110212............................ 1.0406 0.8873 18.7651 20.9365 40.5120 27.9394 110215............................ 1.2618 0.9637 22.5679 23.9657 25.7886 24.2458 110218............................

***

*

* 26.1073

* 26.1073 110219............................ 1.3845 0.9637

* 27.1880 27.0362 27.1115 120001............................ 1.7853 1.1206 30.0871 31.7108 34.6602 32.1463 120002............................ 1.2134 1.0598 24.2715 26.9900 29.9913 27.2572 120004............................ 1.2673 1.1206 26.8010 28.3569 28.6527 27.9367 120005............................ 1.2757 1.0598 23.0113 26.9053 29.3405 26.3828 120006............................ 1.2232 1.1206 28.1562 29.6751 31.1372 29.6846 120007............................ 1.6776 1.1206 27.8497 28.7964 30.4247 29.0434 120010............................ 1.6785 1.1206 25.4050 27.1265 30.1659 27.2823 120011............................ 1.4508 1.1206 30.9308 31.7447 34.1643 32.3199 120014............................ 1.2099 1.0598 25.3682 28.0786 28.6416 27.3772 120016............................ 1.6705

* 39.1173 52.1034 19.6034 33.6763 120019............................ 1.2043 1.0598 24.4036 28.9661 30.3809 27.8836 120022............................ 1.8525 1.1206 22.4951 24.7875 26.6100 24.7024 120025............................

*** 1.0598 40.2473 48.7148 30.2358 39.7283 120026............................ 1.2887 1.1206 26.3653 28.5048 30.3293 28.4200 120027............................ 1.2295 1.1206 24.9464 26.4630 28.4378 26.4965 120028............................ 1.2577 1.1206 29.5070 31.3195 30.3794 30.4272 130002............................ 1.3569 0.9048 20.1143 21.6626 23.6078 21.8876 130003............................ 1.3696 1.0061 23.9403 25.4904 27.6345 25.7287 130005............................

***

* 24.4844 25.2550 25.7523 25.1326 130006............................ 1.7884 0.9048 22.8567 24.3982 25.3221 24.2894 130007............................ 1.7321 0.9048 22.8475 24.8764 24.9562 24.2827 130011............................ 1.2145 0.8810 23.1120 22.9336

* 23.0196 130013............................ 1.2894 0.9048 23.5316 26.3118 27.9209 25.9669 130014............................ 1.1794 0.9048 21.6495 23.4789 24.3884 23.2115 130018............................ 1.5937 0.8810 22.2249 23.9798 26.4125 24.2860 130021............................

*** 0.8810 18.0006 18.9400 16.1658 17.7607 130022............................ 1.1803 0.8810 21.5602

*

* 21.5602 130025............................ 1.1842 0.8810 18.7814 19.7066 20.1452 19.5513 130026............................ 1.1103 0.8810 24.4976 25.4020

* 24.9502 130028............................ 1.3641 0.9348 21.1492 25.2938 26.3443 24.2492 130036............................

***

* 18.5921 16.7907

* 17.6689 130045............................

*** 0.9183 19.0270

*

* 19.0270 130060............................

***

* 24.6773 26.7516

* 25.7861 130062............................

*** 0.9409 24.0494 16.7951 20.6642 20.3051 130063............................ 1.4243 0.9048 18.8782 20.9502 22.5904 20.7967 140001............................ 1.0825 0.8285 20.0247 21.4779 22.3170 21.3141 140002............................ 1.2711 0.8953 23.0207 24.4908 24.6954 24.0687 140003............................ 1.0209 0.8285 19.2097 22.6230

* 20.9305 140005............................

*** 0.8285 13.2365

*

* 13.2365 140008............................ 1.4951 1.0846 26.3287 27.2211 28.5297 27.3790 140010............................ 1.4434 1.0846 29.0224 31.5774 36.6365 32.6197 140011............................ 1.1508 0.8285 19.0903 20.6338 22.4091 20.7429 140012............................ 1.2283 1.0698 24.4070 24.3675 28.6564 25.7920 140013............................ 1.4165 0.8844 19.9800 22.6022 23.3065 21.9604 140015............................ 1.3843 0.8953 21.4328 22.2266 23.0600 22.2778 140016............................ 1.0074 0.8285 16.3417 17.1372 18.1242 17.2195

[[Page 23499]]

140018............................ 1.4161 1.0846 24.3285 27.3334 27.7548 26.4350 140019............................ 0.9635 0.8285 17.4206 18.4554 18.9228 18.2432 140024............................ 0.9981 0.8285 15.6616 16.9672 17.5249 16.7192 140026............................ 1.1611 0.8285 20.4084 21.6847 23.0470 21.6994 140027............................ 1.1589 0.8285 20.9855 22.6208

* 21.8225 140029............................ 1.5505 1.0846 25.0485 27.7304 28.9717 27.3787 140030............................ 1.6859 1.0846 26.5733 28.7623 29.3100 28.2629 140032............................ 1.1817 0.8953 20.6273 22.8157 24.0574 22.5257 140033............................ 1.2115 1.0444 23.4279 26.1553 25.6068 25.0497 140034............................ 1.2308 0.8953 20.9635 22.1003 23.0034 21.9987 140037............................ 0.8583 0.8285 15.5578

*

* 15.5578 140043............................ 1.2327 0.9667 23.3751 26.0330 26.7996 25.3939 140045............................ 1.0328 0.8285 18.9587 21.0042 20.6548 20.2345 140046............................ 1.4582 0.8953 21.7969 22.5022 23.2127 22.5567 140048............................ 1.2496 1.0846 25.9122 27.0874 28.2222 27.0819 140049............................ 1.5568 1.0846 21.9546 26.6533 27.4009 25.3465 140051............................ 1.5044 1.0846 24.2472 27.9935 27.7901 26.6740 140052............................ 1.1992 0.8953 21.8161 22.2588 23.5662 22.5560 140053............................ 1.8567 0.8879 22.6099 23.5477 24.8455 23.6468 140054............................ 1.4302 1.0846 35.5659 31.7265 31.8564 32.8769 140058............................ 1.2547 0.8953 20.5089 22.1269 22.8423 21.8133 140059............................ 1.0783 0.8953 19.9777 22.7121 22.4651 21.7552 140061............................ 0.9751 0.8953 22.7515 30.9925 20.8063 24.6734 140062............................ 1.2085 1.0846 30.7005 31.2359 34.7113 32.2167 140063............................ 1.3649 1.0846 30.5430 26.5584 27.8306 28.2367 140064............................ 1.1568 0.8844 20.6505 21.7470 22.0407 21.4911 140065............................ 1.3774 1.0846 26.3521 26.1904 34.6406 28.8914 140066............................ 1.1153 0.8953 18.0915 20.4353 19.4775 19.2927 140067............................ 1.8344 0.8844 21.9579 23.5906 25.3986 23.6801 140068............................ 1.1769 1.0846 24.1316 25.8963 27.3956 25.8156 140070............................

***

* 25.2960

*

* 25.2960 140077............................ 0.9555 0.8953 18.0487 19.0922 19.1363 18.7657 140079............................

***

* 25.7090 29.3040

* 27.5634 140080............................ 1.4264 1.0846 24.4056 26.0109 23.2575 24.4826 140082............................ 1.3940 1.0846 25.0474 26.8077 25.6645 25.8332 140083............................ 1.0155 1.0846 23.2822 24.6491 26.5562 24.8886 140084............................ 1.1998 1.0444 25.4818 27.6819 29.2515 27.5306 140088............................ 1.8091 1.0846 28.4219 31.0364 32.4978 30.6729 140089............................ 1.1918 0.8285 20.7632 22.1227 23.3401 22.0452 140090............................

***

* 35.0300

*

* 35.0300 140093............................ 1.1539 0.9048 21.5376 22.1540 25.3127 22.9099 140094............................ 1.0354 1.0846 24.2166 25.3678 27.0578 25.5410 140095............................ 1.2149 1.0846 24.7706 29.9746 27.6799 27.5947 140100............................ 1.2204 1.0444 27.1868 32.8743 37.0819 32.5610 140101............................ 1.1371 1.0846 24.6106 25.4784 28.5365 26.3107 140102............................ 1.0407 0.8285 19.8678 21.2278

* 20.5493 140103............................ 1.2439 1.0846 21.2404 21.7512 23.3258 22.1297 140105............................ 1.2336 1.0846 27.3323 26.3054 27.4531 27.0018 140109............................ 1.1423 0.8285 16.4261 17.8103 19.5675 17.9602 140110............................ 1.0533 1.0698 21.9880 25.6561 27.9844 25.2166 140113............................ 1.5519 0.9591 25.6621 23.5337 26.7969 25.2477 140114............................ 1.4645 1.0846 24.1926 25.7968 28.3014 26.1695 140115............................ 1.1252 1.0846 25.3410 26.3677 25.1498 25.6313 140116............................ 1.2744 1.0846 26.8924 30.5166 31.9902 29.9696 140117............................ 1.5049 1.0846 23.3531 25.6314 26.8973 25.3122 140118............................ 1.6963 1.0846 26.7350 27.7392 29.7570 28.1023 140119............................ 1.7432 1.0846 31.3486 33.6302 36.1419 33.6518 140120............................ 1.2478 0.8844 20.3237 22.5795 22.7375 21.8812 140121............................ 1.6002 0.8844 17.6019

*

* 17.6019 140124............................ 1.2606 1.0846 30.9648 35.2798 36.1327 34.0784 140125............................ 1.2180 0.8953 19.5359 20.7189 20.4014 20.2151 140127............................ 1.5733 0.9083 21.3102 22.8172 24.1658 22.7988 140129............................

*** 0.8285 21.6495

*

* 21.6495 140132............................

***

* 23.0595

*

* 23.0595 140135............................ 1.3954 0.8285 19.7919 21.2104 22.3264 21.1811 140137............................ 1.0383 0.8953 21.6017 20.5053 21.4700 21.1955 140140............................ 1.0049 0.8285 19.1636 21.4710

* 20.3063

[[Page 23500]]

140141............................ 1.0111 0.8953 20.3706 23.0515 21.7871 21.7302 140143............................ 1.1472 0.8844 22.0009 23.8255 26.2954 24.0154 140144............................ 0.9464 1.0846 26.9258 27.8046

* 27.3474 140145............................ 1.1245 0.8953 19.6429 21.6168 23.4608 21.6090 140147............................ 1.1208 0.8285 18.2692 19.5896 19.8541 19.2467 140148............................ 1.7042 0.8879 21.5777 23.0022 25.2030 23.2104 140150............................ 1.5763 1.0846 32.9291 33.9013 35.2711 34.0702 140151............................ 0.8471 1.0846 21.5167 22.4842 23.4879 22.5018 140152............................ 1.1463 1.0846 28.5468 29.6882 27.6086 28.6011 140155 \2\........................ 1.2537 1.0991 25.2034 27.6610 28.9724 27.2937 140158............................ 1.3922 1.0846 22.5638 23.8542 28.6818 24.8001 140160............................ 1.2262 0.9667 20.9986 22.7002 24.5373 22.7502 140161............................ 1.1181 1.0698 22.2191 24.1071 23.1647 23.1691 140162............................ 1.5842 0.9083 22.6426 26.0312 27.4472 25.4182 140164............................ 1.7335 0.8953 19.7774 22.0424 23.7457 21.8696 140165............................ 1.0648 0.8285 17.0666 15.9312 16.6304 16.5175 140166............................ 1.1685 0.8285 20.7849 21.7776 23.1005 21.8859 140167............................ 1.0308 0.8285 19.5959 19.7610 22.8911 20.7477 140168............................ 1.1558 0.8953 18.7504 20.0225

* 19.4021 140170............................ 0.9276 0.8285 17.0665 17.1608

* 17.1147 140171............................

*** 0.8285 17.3214

*

* 17.3214 140174............................ 1.4550 1.0846 23.6893 24.7011 27.8131 25.3970 140176............................ 1.2096 1.0846 25.6824 28.9378 31.3490 28.8390 140177............................ 0.8782 1.0846 20.8526 19.3328 22.5610 20.9656 140179............................ 1.3651 1.0846 24.1539 26.3200 27.6376 26.0525 140180............................ 1.2658 1.0846 25.4022 27.4366 28.3649 27.0717 140181............................ 1.1677 1.0846 23.7308 23.6034 25.0100 24.1182 140182............................ 1.4864 1.0846 32.1969 28.0337 28.2211 28.8901 140184............................ 1.2150 0.8285 20.6499 20.1279 21.1802 20.6885 140185............................ 1.4160 0.8953 20.0903 22.0222 23.8531 22.0093 140186 \2\........................ 1.4842 1.0991 26.0970 28.1977 31.7593 28.8521 140187............................ 1.4808 0.8953 20.5829 22.0674 23.2892 21.9710 140189............................ 1.1406 0.9335 22.5875 25.6954 23.7198 24.0159 140190............................ 1.0678 0.8285 17.9193 18.8530 19.8297 18.8585 140191............................ 1.3038 1.0846 24.5446 25.2817 25.8813 25.2456 140193............................ 0.9615 0.8285 20.5958 22.9443

* 21.7731 140197............................ 1.2361 1.0846 19.2980 21.8060 23.0684 21.2577 140199............................ 1.0379 0.8285 19.7888 21.3464 22.0315 21.0597 140200............................ 1.4887 1.0846 24.1358 24.9217 26.6881 25.2459 140202............................ 1.5458 1.0444 26.2460 27.4336 29.7870 27.9702 140203............................ 1.0810 1.0846 26.5789 28.2212

* 27.4338 140205............................ 0.5846 0.9975 25.1010

*

* 25.1010 140207............................ 1.3693 1.0846 23.3197 25.7331 24.1048 24.4812 140208............................ 1.6342 1.0846 27.4671 27.6586 29.4708 28.2131 140209............................ 1.5435 0.8844 22.0813 23.3886 24.4266 23.3169 140210............................ 1.0967 0.8285 15.5339 16.6729 19.2639 17.1406 140211............................ 1.3023 1.0846 25.8556 29.5114 29.7054 28.4947 140213............................ 1.1645 1.0846 27.4607 29.1649 30.2945 29.0178 140215............................

***

* 18.6962 22.3097

* 20.4262 140217............................ 1.4239 1.0846 24.7146 29.3711 31.5324 28.5274 140223............................ 1.4296 1.0846 27.4355 29.2540 30.4923 29.0769 140224............................ 1.3921 1.0846 27.1725 29.0350 28.2177 28.1560 140228............................ 1.5304 0.9975 22.9899 25.0074 25.6419 24.5738 140231............................ 1.4741 1.0846 25.5536 28.3545 30.6410 28.2754 140233............................ 1.5549 1.0698 24.7103 27.3379 28.6305 26.9841 140234............................ 1.0501 0.8844 20.8676 23.2604 23.6928 22.6766 140239............................ 1.5495 0.9975 23.9205 24.2112 29.0092 25.6976 140240............................ 1.3929 1.0846 25.0325 27.2654 31.8945 27.8715 140242............................ 1.4842 1.0846 28.8686 30.4005 32.0522 30.5576 140245............................ 0.9866 0.8285 15.2537 16.0772

* 15.6642 140246............................

*** 0.8285 16.1305

*

* 16.1305 140251............................ 1.2806 1.0846 24.8256 26.7266 27.1870 26.2433 140252............................ 1.3977 1.0846 28.3479 30.2656 33.3885 30.8286 140258............................ 1.5252 1.0846 27.5741 27.9478 30.2639 28.6430 140271............................ 0.8733 0.8285 17.5174 18.8535

* 18.2163 140275............................ 1.2740 0.8716 23.1871 25.2824 26.1473 24.8583 140276............................ 1.7772 1.0846 25.3222 27.5936 29.1983 27.3299

[[Page 23501]]

140280............................ 1.4521 0.8716 21.7004 21.9302 23.4343 22.3632 140281............................ 1.6920 1.0846 27.9115 29.2602 30.4849 29.2420 140285............................

*** 0.8879

* 17.7824 20.7576 19.1679 140286............................ 1.1088 1.0846 25.5805 28.4378 29.1543 27.7906 140288............................ 1.5237 1.0846 26.3572 26.9581 29.3988 27.5648 140289............................ 1.3248 0.8953 20.7506 22.3274 22.6211 21.9308 140290............................ 1.3237 1.0846 29.9098 28.6926 31.7341 30.1371 140291............................ 1.2597 1.0698 27.6675 28.2338 29.8958 28.6610 140292............................ 1.1534 1.0846 26.4077 26.1781 27.6230 26.7673 140294............................ 1.1263 0.8285 21.7473 22.6123 23.4504 22.6034 140300............................ 1.1599 1.0846 30.5172 33.3983 34.8568 32.8808 140301............................ 1.1555 1.0846

*

* 31.7073 31.7073 150001............................ 1.1532 0.9922 25.4897 27.1021 29.6844 27.4774 150002............................ 1.3813 1.0698 22.3327 23.3804 25.0063 23.5866 150003............................ 1.6528 0.8730 21.0944 23.3196 25.3458 23.2610 150004............................ 1.5181 1.0698 23.6169 24.8884 26.8458 25.1066 150005............................ 1.1975 0.9922 23.8818 25.4443 27.2369 25.6152 150006............................ 1.2943 0.9785 23.1779 24.8976 26.4061 24.8616 150007............................ 1.2960 0.9555 22.1098 23.5841 26.6073 24.2353 150008............................ 1.4015 1.0698 23.8916 23.6953 26.6928 24.7814 150009............................ 1.3653 0.9264 19.4763 20.4993 22.2147 20.7473 150010............................ 1.3255 0.9555 22.5445 23.9740 26.8524 24.4792 150011............................ 1.1602 0.9776 22.1559 23.2249 24.3490 23.2593 150012............................ 1.5342 0.9785 23.1644 22.9314 27.3031 24.2924 150013............................ 0.9799 0.8632 19.8564 19.7689 21.8465 20.4949 150014............................ 1.2880 0.9922 24.3754 26.5785

* 25.4309 150015............................ 1.3161 1.0698 23.1616 24.3015 26.2434 24.6064 150017............................ 1.8224 0.9797 22.7979 23.7180 25.2342 23.9446 150018............................ 1.6280 0.9616 24.6138 24.7048 26.3289 25.2344 150019............................ 1.0534 0.8632 17.3170

*

* 17.3170 150021............................ 1.7262 0.9797 24.3658 27.8168 29.6967 27.2581 150022............................ 1.0471 0.8632 22.2973 22.8035 22.6773 22.6089 150023............................ 1.5248 0.8632 20.6926 23.1253 23.7159 22.4697 150024............................ 1.3936 0.9922 21.7593 24.7879 27.1589 24.7582 150026............................ 1.2781 0.9616 23.2169 23.7185 28.1127 25.1166 150027............................ 0.9951 0.9922 21.5766 21.2855 17.4862 19.9164 150029............................ 1.4269 0.9785 25.2067 23.4103 26.9680 25.0754 150030............................ 1.2034 0.9776 23.0196 24.4361 26.9533 24.8565 150031............................ 1.0678 0.8632 18.9180

*

* 18.9180 150034............................ 1.4639 0.9366 22.8812 23.9388 26.0465 24.3610 150035............................ 1.4585 0.9366 23.5468 26.0952 26.6620 25.4702 150037............................ 1.2877 0.9922 24.4997 27.7009 28.5451 26.8949 150038............................ 1.0995 0.9922 21.6608 24.4188 28.8054 24.9650 150042............................ 1.3907 0.8632 23.7838 21.9917 23.0102 22.8781 150044............................ 1.3121 0.9264 20.5156 23.1200 23.7065 22.4683 150045 h.......................... 1.0499 0.9797 23.0361 24.2899 25.2225 24.2205 150046............................ 1.4135 0.8632 20.3453 21.0417 21.9369 21.1254 150047............................ 1.7002 0.9797 24.8786 24.5455 25.8349 25.1035 150048............................ 1.3259 0.9604 22.5181 24.5864 27.1817 24.7509 150049............................ 1.1169 0.8632 18.4942 20.2178 22.3370 20.2342 150051............................ 1.5540 0.8632 21.4009 22.6866 23.7061 22.5941 150052 h.......................... 1.0320 0.9264 19.1070 19.6073 20.6339 19.7871 150056............................ 1.8253 0.9922 24.7841 27.6754 28.2842 26.9368 150057............................ 2.0135 0.9922 28.0884 22.7804 24.8605 24.9551 150058............................ 1.5550 0.9785 24.9479 26.9753 27.5341 26.5322 150059............................ 1.5671 0.9922 25.6738 27.0792 28.5715 27.1975 150060............................ 1.0728 0.8632 19.8990 23.2409 24.8544 22.6276 150061............................ 1.1040 0.8632 19.2826 21.3640 22.2822 20.9919 150062............................ 1.1136 0.8632 22.9214 23.5550 24.6088 23.7293 150063............................

***

* 24.4091 19.0377

* 21.8339 150064............................ 1.1597 0.8632 21.2512 21.6370 23.7707 22.2400 150065............................ 1.2439 0.9776 23.0636 24.4451 25.9461 24.5094 150067............................ 1.0162 0.8632 21.4374

*

* 21.4374 150070............................ 0.9415 0.8632 20.7413 22.6260

* 21.7117 150072............................ 1.1999 0.8632 18.5447 20.3191 20.5111 19.8274 150073............................

***

* 14.8287

*

* 14.8287 150075............................ 1.0759 0.9797 20.1119 24.2085 24.0745 22.8038

[[Page 23502]]

150076............................ 1.2278 0.9785 25.4519 24.1434 28.1874 25.9085 150078............................ 0.9426 0.8632 20.1259 21.2476 21.9771 21.1303 150079............................ 1.0871 0.9264 19.3860 20.6486 21.4067 20.5165 150082............................ 1.7137 0.8735 21.0651 22.2054 25.5860 22.9776 150084............................ 1.7636 0.9922 27.8354 28.7722 29.3905 28.6939 150086............................ 1.2074 0.9604 21.5815 22.4471 23.9404 22.7151 150088............................ 1.2662 0.9776 22.2627 23.0998 23.6253 23.0168 150089............................ 1.4706 0.8952 21.6806 22.6545 25.0449 23.0977 150090............................ 1.4690 1.0698 24.9021 24.6758 26.2899 25.3163 150091 h.......................... 1.0853 0.9797 26.4248 27.8087 30.6209 28.2762 150096............................ 0.9741 0.8632 19.7975 21.9091 23.8092 21.8206 150097............................ 1.0577 0.9922 22.4564 24.4179 25.0367 24.0346 150100............................ 1.6892 0.8735 21.2980 22.2687 24.3530 22.6387 150101............................ 1.0267 0.9797 26.1271 27.9745 29.1657 27.6430 150102............................ 1.0711 0.9366 21.3313 22.6870 24.5923 22.8112 150104............................ 1.0414 0.9922 21.0799 21.8172 25.5871 22.8454 150106 h.......................... 1.0517 0.9797 19.1976 20.9955 20.9387 20.4063 150109............................ 1.3698 0.8730 23.4642 24.3786 23.5865 23.8124 150112............................ 1.4147 0.9776 23.5151 24.7455 26.5643 24.9478 150113............................ 1.1907 0.9776 21.2412 23.0450 24.8760 23.1460 150115............................ 1.3246 0.8632 20.3863 20.5215 19.3411 20.0486 150122............................ 1.1182 0.8632 22.2752 24.2471 26.0173 24.2508 150123............................

*** 0.8735 15.5997 15.3050

* 15.4580 150124............................ 1.1187 0.8632 17.9063 18.8218 21.3933 19.4269 150125............................ 1.4937 1.0698 23.1464 24.3872 26.7666 24.8140 150126............................ 1.4161 1.0698 24.1917 25.5585 26.9887 25.6255 150128............................ 1.3711 0.9922 20.9869 23.1660 26.4976 23.5710 150129............................ 1.1881 0.9922 34.3166 35.4311 29.9099 32.9368 150130............................ 1.0196 0.8735 18.5578 21.5678 21.7399 20.5294 150132............................ 1.3880 1.0698 22.2707 24.2559 25.6257 24.1021 150133............................ 1.2457 0.9797 21.8807 21.8839 22.7293 22.1682 150134............................ 1.0951 0.9264 20.7680 22.1085 23.8526 22.2228 150136............................

*** 0.9922 25.8467 25.7004 26.2703 25.9403 150146............................ 1.0119 0.9797 25.1827 26.1168 29.3383 26.7878 150147............................ 1.1985 1.0698

* 32.3336 22.8456 26.0420 150148............................

***

* 26.2188 27.2081

* 26.7661 150149............................ 0.9756 0.8735

* 23.8554 23.6361 23.7419 150150............................ 1.2639 0.9797

* 26.5138 25.5331 26.0172 150151............................

***

*

*

* 38.1446 38.1446 150152............................

*** 0.9922

*

* 44.7143 44.7143 160001............................ 1.1965 0.9231 22.8426 23.8657 25.1220 23.9155 160002............................

*** 0.8563 19.9607

*

* 19.9607 160005............................ 1.1819 0.8563 20.3313 21.1745 21.8950 21.1337 160008............................ 1.0624 0.8563 17.9463 19.8066 20.7200 19.4883 160013............................ 1.2044 0.8563 21.0541 23.0163 23.7163 22.5118 160014............................ 0.9866 0.8563 18.3097 19.2447 20.9256 19.5050 160016............................ 1.5746 0.9413 21.8400 21.2785 23.3031 22.1576 160020............................ 1.0649 0.8563 16.6092 19.0043 19.5752 18.4226 160024............................ 1.5772 0.9650 22.4256 24.2385 26.2392 24.3248 160026............................ 0.9843 0.9231 22.8967 24.2045 24.7424 23.9779 160028............................ 1.3058 0.9555 25.1998 26.0052 26.2948 25.8671 160029............................ 1.6068 0.9751 23.7268 24.9493 27.9277 25.5651 160030............................ 1.2629 0.9546 23.3687 24.9920 26.7068 25.0247 160031............................ 0.9566 0.8563 17.8994 18.5281 19.7585 18.7487 160032............................ 1.0533 0.8563 20.5024 22.3837 23.4727 22.1329 160033............................ 1.7259 0.8716 22.2660 23.4148 24.6768 23.4865 160034............................ 0.9398 0.8563 19.0684 19.4837 19.3503 19.3060 160039............................ 0.9260 0.8563 19.8851 20.9623 22.1629 21.0029 160040............................ 1.2162 0.8564 20.0567 21.8187 23.9053 21.9454 160043............................

*** 0.8563 15.5765

*

* 15.5765 160045............................ 1.6924 0.8605 22.1285 24.4957 25.4153 24.0445 160047............................ 1.3599 0.9555 22.1550 24.5000 25.2072 23.9813 160048............................ 1.0546 0.8563 18.1174 19.5701 19.6431 19.1317 160050............................ 1.1022 0.8563 21.6247 23.8830 24.5403 23.3364 160057............................ 1.2499 0.9574 20.8345 22.0472 23.2913 22.0638 160058............................ 1.8388 0.9751 23.5663 25.5244 27.1646 25.4595 160064............................ 1.5830 0.8563 23.8367 27.6301 28.6139 26.8350

[[Page 23503]]

160066............................ 1.0921 0.8563 20.4609 21.4631 22.7453 21.6034 160067............................ 1.3469 0.8564 19.9422 21.9418 23.4060 21.8952 160069............................ 1.4317 0.9116 21.7197 22.7514 25.8067 23.4426 160072............................

*** 0.8563 15.8236

*

* 15.8236 160076............................ 0.9917 0.8563 20.1603 20.9749

* 20.5825 160079............................ 1.4983 0.8605 21.6562 22.5299 22.4291 22.2178 160080............................ 1.3105 0.9667 21.1713 23.5721 23.0138 22.5698 160081............................ 1.1704 0.8563 20.4415 21.3614 23.1930 21.6437 160082............................ 1.7449 0.9650 21.6230 23.8181 26.2453 23.8567 160083............................ 1.6465 0.9650 23.4670 25.0617 28.2193 25.6738 160089............................ 1.2795 0.9413 19.9688 21.5693 22.6551 21.4092 160090............................ 0.9949 0.8563 19.6767 21.2753

* 20.4851 160091............................ 0.9514 0.8563 16.1660 18.0630 17.9255 17.3725 160092............................ 0.9582 0.8563 20.4731 22.0841

* 21.2805 160093............................

*** 0.8605 22.8553

*

* 22.8553 160104............................ 1.3676 0.8716 23.2832 24.0075 24.9134 24.0516 160106............................ 1.1242 0.8563 19.8905 21.4912

* 20.6919 160107............................ 1.0394 0.8563 19.5111 21.3754

* 20.4402 160110............................ 1.6369 0.8564 21.9299 24.1762 24.9434 23.7256 160112............................ 1.2659 0.8563 20.4038 21.8901 23.0673 21.8008 160113............................ 0.9601 0.8563 16.7574 18.6599

* 17.7162 160114............................ 0.9804 0.8563 19.1743

*

* 19.1743 160116............................ 1.0412 0.8563 19.6923 22.2019

* 20.9445 160117............................ 1.2747 0.9116 22.3228 23.4250 25.0278 23.6002 160118............................ 1.0219 0.8563 16.9466 18.3322 19.7764 18.4025 160122............................ 1.0854 0.8563 21.2843 22.9565 22.5810 22.2832 160124............................ 1.1255 0.8563 21.2279 22.7223 23.1690 22.3848 160126............................ 1.0455 0.8563 20.0149 20.3748 19.6296 20.0068 160131............................ 0.9332 0.8563 18.0486

*

* 18.0486 160143............................ 1.0569 0.8563 19.0623

*

* 19.0623 160147............................ 1.2103 0.9231 22.7993 26.6577 25.1228 24.8830 160153............................ 1.5766 0.9360 23.5212 26.3671 28.9881 26.3386 170001............................ 1.1572 0.8032 19.8149 20.9837 21.9131 20.9143 170006............................ 1.2459 0.8458 19.4488 20.6460 21.9019 20.7240 170008............................

*** 0.8032 18.2352

*

* 18.2352 170010............................ 1.2414 0.8313 20.6294 21.2131 24.0008 21.9435 170012............................ 1.6156 0.8946 21.8587 22.6869 24.7392 23.0750 170013............................ 1.5825 0.8946 21.4954 23.1159 24.9709 23.1630 170014............................ 0.9823 0.9454 21.3416 22.9772 23.5960 22.6522 170015............................ 1.0532 0.8032 18.0485 19.1902 20.2367 19.1620 170016............................ 1.6153 0.8921 22.9479 24.2336 25.9482 24.4090 170017............................ 1.1022 0.9156 21.6323 23.3030 24.7771 23.3226 170018............................ 0.8898 0.8032 16.9169 17.9497 17.2199 17.3753 170019............................ 1.2134 0.8032 18.7916 20.3243 22.0251 20.4068 170020............................ 1.5747 0.8946 20.6658 22.2571 23.1800 22.0586 170022............................ 1.0924 0.9454 21.1947 22.9313 22.2878 22.1486 170023............................ 1.4742 0.8946 21.6273 23.2690 22.5551 22.4908 170024............................

*** 0.8032 16.1196

*

* 16.1196 170026............................

*** 0.8032 17.0836

*

* 17.0836 170033............................ 1.3844 0.8946 20.0627 20.0801 20.5954 20.2325 170034............................ 0.8698 0.8032 18.1074

*

* 18.1074 170040............................ 1.8787 0.9454 24.5234 27.1771 28.2856 26.8014 170041............................

*** 0.8032 13.9709

*

* 13.9709 170052............................ 1.1985 0.8032 15.8809 17.3794 18.5291 17.3370 170054............................ 0.9966 0.8032 18.5239 17.5500

* 18.0250 170056............................

*** 0.8032 17.1872

*

* 17.1872 170068............................ 1.1985 0.9165 20.5512 20.8771 22.6087 21.3531 170070............................ 1.0679 0.8032 15.0539 16.4767 16.0162 15.8428 170074............................ 1.1969 0.8032 18.5446 20.4936 21.0565 20.0516 170075............................ 0.8302 0.8032 15.6809 16.2047 16.5444 16.1586 170077............................

*** 0.8032 14.6377

*

* 14.6377 170082............................

*** 0.8032 15.9973

*

* 15.9973 170086............................ 1.5458 0.8921 22.1067 22.7737 24.0812 23.0117 170090............................ 0.9249 0.8032 16.3550 15.9807

* 16.1812 170093............................ 0.8184 0.8032 15.0307 16.8710 16.5553 16.1514 170094............................ 0.9938 0.8032 20.1253 20.3678 21.3887 20.6420 170097............................ 0.8884 0.8032 18.9865 20.3391

* 19.6594

[[Page 23504]]

170098............................ 1.0009 0.8032 18.6676 20.0078 19.8881 19.5154 170099............................ 0.8971 0.8032 15.8117

*

* 15.8117 170103............................ 1.2452 0.9156 20.1263 21.4985 22.8707 21.5590 170104............................ 1.5039 0.9454 23.6589 26.1866 26.6100 25.5135 170105............................ 1.0723 0.8032 18.3824 19.6687 21.4422 19.8723 170109............................ 0.9921 0.9454 20.7580 22.7166 23.2626 22.2703 170110............................ 0.9659 0.8032 16.5883 21.8904 22.2650 20.1717 170113............................ 1.0330 0.8032 19.9957

*

* 19.9957 170116............................ 0.9958 0.8032 20.8800 23.1127

* 21.9980 170120............................ 1.2748 0.8458 18.5895 19.8723 21.0499 19.8632 170122............................ 1.6149 0.9156 22.2681 24.5826 25.3981 24.1100 170123............................ 1.6579 0.9156 25.0073 26.4676 27.2239 26.2255 170133............................ 1.0482 0.9454 20.0593 21.7748 22.9309 21.5574 170137............................ 1.2299 0.8032 21.4394 22.7676 23.8863 22.7099 170142............................ 1.3359 0.8785 19.8269 22.4095 22.5778 21.6027 170143............................ 1.1294 0.8032 18.0308 19.7643 20.4459 19.4072 170144............................

***

* 23.9180 24.4259 24.6260 24.3634 170145............................ 1.0646 0.8032 20.5143 21.4472 21.2071 21.0600 170146............................ 1.5346 0.9454 27.0312 28.1965 28.8062 28.0903 170147............................ 1.2185 0.9156 18.2480 23.1610 20.7436 20.6771 170148............................

***

* 26.3491

*

* 26.3491 170151............................ 1.0014 0.8032 15.7242

*

* 15.7242 170171............................

***

* 14.7251

*

* 14.7251 170176............................ 1.2996 0.9454 25.5404 24.2283 26.2366 25.2863 170180............................

***

* 25.0935

* 25.1366 25.1166 170182............................ 1.4072 0.9454 23.2115 24.3820 25.7443 24.4497 170183............................ 1.9491 0.9156 19.6919 22.8633 24.5539 22.4468 170185............................ 1.2969 0.9454 26.8307 24.8478 26.7797 26.1506 170186............................ 2.9412 0.9156 28.5602 30.5157 31.7896 30.4381 170187............................ 1.1355 0.8032 20.8289 21.0780 23.3702 21.8354 170188............................ 2.0008 0.9454 25.2504 27.2225 29.9751 27.6756 170189............................

***

* 28.1996

*

* 28.1996 170191............................ 1.1514 0.8032

* 24.9599 21.3069 23.1771 170192............................ 2.0555 0.9156

*

* 27.0380 27.0380 170193............................ 1.2126 0.8032

*

* 24.7430 24.7430 170194............................ 1.6735 0.9454

*

* 27.9904 27.9904 180001............................ 1.2733 0.9604 22.2674 24.7647 25.4217 24.1342 180002............................ 1.0456 0.7788 20.5135 21.6843 22.9727 21.7424 180004............................ 1.0968 0.7788 19.8552 19.0834 19.5437 19.4871 180005............................ 1.1514 0.9119 22.6704 22.8871 24.5561 23.3888 180006............................ 0.8988 0.7788 14.4066 15.7136 14.8011 14.9439 180007............................ 1.4096 0.9060 21.3545 21.8724 22.7606 21.9873 180009............................ 1.6162 0.9482 22.4450 24.0971 25.3837 24.0052 180010............................ 1.9470 0.9060 22.6846 16.6893 24.7256 20.7808 180011............................ 1.3310 0.8830 18.8056 22.3183 22.7364 21.2726 180012............................ 1.4989 0.9264 20.2758 22.9096 24.6642 22.6125 180013............................ 1.4422 0.9492 21.0512 21.4728 22.9512 21.8902 180016............................ 1.3138 0.9264 20.5203 22.2148 23.1832 22.0005 180017............................ 1.2408 0.8286 18.0329 19.0694 20.8630 19.3296 180018............................ 1.3264 0.8830 17.5670 18.3314 19.0992 18.3166 180019............................ 1.1667 0.9604 20.8416 22.0379 24.1342 22.3292 180020............................ 1.0301 0.7788 20.9964 22.3477 21.9494 21.7537 180021............................ 1.0255 0.7788 17.6331 17.9346 18.5966 18.0522 180024............................ 1.1362 0.9264 22.3922 23.6826 32.1824 25.9352 180025............................ 1.0433 0.9264 18.3306 17.4781 19.1543 18.3232 180026............................ 1.1055 0.7788 15.5354 15.8431 18.2120 16.5328 180027............................ 1.2138 0.8092 20.5017 22.1072 23.8763 22.1722 180028............................ 0.8828 0.9119 20.6324 21.4766 24.7968 22.1418 180029............................ 1.2700 0.8095 20.4262 21.2110 23.0536 21.5776 180035............................ 1.5412 0.9604 24.3874 26.7702 29.8438 27.1206 180036............................ 1.1727 0.9482 22.2389 23.1636 25.1154 23.5250 180037............................ 1.2780 0.9264 22.7893 24.4451 25.7361 24.4985 180038............................ 1.3465 0.8806 20.6888 22.2750 24.6348 22.4970 180040............................ 2.0835 0.9264 23.2341 24.5590 26.2125 24.7248 180041............................ 1.0740 0.7788 19.1325 18.5483

* 18.8494 180043............................ 1.1986 0.7788 20.6498 18.8436 19.0617 19.4791 180044............................ 1.5046 0.9119 21.8163 21.6837 23.0971 22.1791

[[Continued on page 23505]]

From the Federal Register Online via GPO Access [wais.access.gpo.gov] ]

[[pp. 23505-23554]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2006 Rates

[[Continued from page 23504]]

[[Page 23505]]

180045............................ 1.3290 0.9604 22.1027 24.5856 25.8349 24.1325 180046............................ 1.0500 0.9060 23.1139 24.7562 27.2244 25.0514 180047............................ 0.8429 0.7788 17.8574 20.4768 21.8037 20.0588 180048............................ 1.2624 0.9264 20.0114 22.3601 21.6571 21.3621 180049 h.......................... 1.3812 0.9060 18.5188 19.4488 23.3407 20.4067 180050............................ 1.1118 0.7788 19.9082 21.7150 22.6473 21.3727 180051............................ 1.3901 0.8272 18.8186 19.2100 21.3312 19.7863 180053............................ 1.0384 0.7788 17.6239 18.6610 19.1578 18.5083 180054............................ 0.9619 0.7788 19.1340 19.0657

* 19.0979 180055 h.......................... 1.0038 0.9060 17.8704 21.1989 20.7237 19.9661 180056............................ 1.0631 0.8735 19.4072 21.4695 22.8910 21.2490 180063............................ 1.1680 0.7788 15.5078 15.9185 17.9741 16.5674 180064............................ 1.2463 0.7788 21.1067 15.3819 16.2638 17.3349 180066............................ 1.0468 0.9492 21.1884 24.6359 24.9543 23.6588 180067............................ 1.9180 0.9060 22.0056 24.0551 25.4080 23.7960 180069............................ 1.0456 0.9119 20.3982 20.8797 22.3674 21.2166 180070............................ 1.1131 0.7788 16.9892 17.4266 20.1308 18.1917 180072............................

***

* 17.5411

*

* 17.5411 180079............................ 1.1252 0.7788 18.0472 19.5783 19.7791 19.1405 180080............................ 1.3087 0.8470 18.9582 20.1651 21.7380 20.2813 180087............................ 1.1742 0.7788 16.4726 17.7758 18.4331 17.6017 180088............................ 1.5651 0.9264 23.7217 24.6053 27.5767 25.3642 180092............................ 1.1282 0.9060 19.6790 22.4864 22.5679 21.6047 180093............................ 1.4227 0.8508 18.8469 19.2748 20.5422 19.5520 180094............................ 0.9602 0.7788 15.7640

*

* 15.7640 180099............................

*** 0.7788 14.0115

*

* 14.0115 180102............................ 1.5476 0.8092 20.1885 19.1136 18.4388 19.1595 180103............................ 2.2069 0.9060 21.3867 25.1577 26.9407 24.4722 180104............................ 1.6243 0.8092 21.3866 22.8911 24.9441 23.1113 180105............................ 0.8484 0.7788 18.3521 19.5364 19.7615 19.2381 180106............................ 0.9458 0.7788 15.4937 15.7851 17.8020 16.4485 180108............................

*** 0.7788 16.7327

*

* 16.7327 180116............................ 1.2066 0.8285 20.5453 21.8698 22.7353 21.7465 180117............................ 0.9835 0.7788 17.7885 20.5952 21.1854 19.7909 180120............................ 0.7761 0.7788 20.4507

*

* 20.4507 180124............................ 1.3086 0.9492 20.5369 21.4270 23.1917 21.6877 180126............................ 1.0372 0.7788 14.5644 15.1776

* 14.8844 180127............................ 1.2754 0.9264 20.0059 21.4633 23.4765 21.6735 180128............................ 0.9399 0.7788 19.8502 20.5575 20.8406 20.4307 180129............................

*** 0.7788 14.1861

*

* 14.1861 180132............................ 1.3264 0.8830 19.9358 22.2101 23.7652 21.9796 180134............................ 1.0635 0.7788

* 17.3449 18.6779 18.0324 180138............................ 1.2100 0.9264 23.0996 25.1789 27.3400 25.1767 180139............................ 1.0372 0.8830 20.6287 21.3797 23.5363 21.8425 180141............................ 1.7146 0.9264 22.6722 24.3140 25.3042 24.1450 180143............................ 1.4820 0.9060 20.1309 14.2734 25.1613 19.0124 190001............................ 1.0754 0.9003 20.4946 19.5680 19.7516 19.8963 190002............................ 1.7155 0.8429 20.7172 21.7000 22.0056 21.4744 190003............................ 1.4560 0.8429 20.7505 21.8156 23.4977 22.0368 190004............................ 1.2890 0.7903 20.5272 22.1835 23.3290 21.9727 190005............................ 1.4326 0.9003 20.0551 20.7987 22.3208 21.0635 190006............................ 1.2504 0.8429 18.8115 19.4573 22.2467 20.1618 190007............................ 1.1174 0.7445 17.9392 18.7854 19.7528 18.8587 190008............................ 1.6429 0.7903 20.3278 21.4137 24.0111 21.9572 190009............................ 1.2155 0.8048 17.5144 18.8295 19.8404 18.6932 190010............................ 1.1212 0.7445 18.1797 19.9788 21.6889 19.9508 190011............................ 1.0256 0.8044 15.4699 18.1525 19.7319 17.7235 190013............................ 1.3334 0.7847 18.7538 19.6346 20.8626 19.7509 190014............................ 1.1677 0.7445 17.0630 17.4740 22.4596 18.7727 190015............................ 1.3076 0.9003 20.6167 22.1046 22.8875 21.9289 190017 h.......................... 1.3418 0.8429 18.3528 18.6962 21.5033 19.4006 190018............................

*** 0.7445 19.2055

*

* 19.2055 190020............................ 1.1401 0.8605 18.5659 19.8505 21.6136 19.9828 190025............................ 1.2473 0.7445 19.9969 20.4651 20.8950 20.4776 190026............................ 1.5166 0.8048 19.9229 21.3386 22.5087 0121.3125 190027............................ 1.6352 0.7847 19.4057 21.2449 21.2526 20.6470 190034............................ 1.1567 0.7445 16.8439 17.5002 19.6943 18.0127

[[Page 23506]]

190036............................ 1.6456 0.9003 23.3903 23.7356 24.8359 24.0024 190037............................ 0.9457 0.7847 15.6062 16.7629 18.6393 17.0499 190039............................ 1.4625 0.9003 20.4900 23.3105 25.6665 23.2338 190040............................ 1.3133 0.9003 22.9262 23.8076 26.7428 24.3506 190041............................ 1.4459 0.8767 21.9983 23.9082 24.6734 23.4433 190043............................ 1.0017 0.7445 15.7333 16.8944 17.3477 16.6784 190044 h.......................... 1.2058 0.8429 17.7460 19.5304 19.5567 18.9595 190045............................ 1.5902 0.9003 22.8709 24.0490 25.3854 24.1220 190046............................ 1.4233 0.9003 21.1019 22.2884 24.2128 22.4847 190048............................ 1.0523 0.7445 18.1698 18.6148 19.6288 18.7855 190049............................ 1.0149 0.7445 19.3768 20.1229

* 19.7625 190050............................ 1.0741 0.7445 18.6663 18.5287 19.1076 18.7685 190053............................ 1.1232 0.7445 13.8037 15.7258 16.4968 15.3819 190054............................ 1.3671 0.7445 19.9370 20.3525 20.1108 20.1339 190059............................ 0.8367 0.8605 18.3334 19.2396

* 18.7888 190060............................ 1.5006 0.7847 20.2207 22.1499 23.6278 21.9859 190064............................ 1.5577 0.8605 21.1262 21.5514 23.3617 22.0132 190065............................ 1.4890 0.8605 20.3583 23.0523 23.7450 22.3992 190077............................ 0.8526 0.8044 17.0480 18.4043 18.8409 18.0986 190078 h.......................... 1.0049 0.8429 19.8607 21.5782 21.3786 20.9721 190079............................ 1.2488 0.9003 20.5000 21.8158 21.2546 21.1972 190081............................ 0.8882 0.7445 11.4756 14.9141 15.6146 13.9838 190083............................ 0.8728 0.7445 18.4954 19.2683

* 18.9013 190086............................ 1.2357 0.8767 18.2005 18.8306 19.8823 18.9783 190088 h.......................... 1.0702 0.8767 18.6738 22.5045 22.3480 20.9939 190089............................ 0.9609 0.7445 15.5151 16.2961

* 15.9103 190090............................ 1.0843 0.7445 19.0519 20.0745 20.2045 19.8076 190095............................

***

* 16.9519 18.7302 18.0174 17.8930 190098............................ 1.5840 0.8767 20.7537 23.0802 24.6353 22.7792 190099............................ 1.0296 0.8470 23.1606 21.1657 20.4597 21.4552 190102............................ 1.6258 0.8429 22.0190 23.4618 25.2267 23.6255 190106............................ 1.2114 0.8048 20.3114 21.5643 21.7228 21.2163 190109............................ 1.1376 0.7903 16.6515 17.4842 18.6524 17.5941 190110 h.......................... 0.8513 0.8429 16.5007 19.0611

* 17.8105 190111............................ 1.5580 0.8767 24.4380 25.2370 24.4998 24.7275 190114............................ 1.0513 0.7445 13.6101 14.6258 15.8031 14.6821 190115............................ 1.1772 0.8767 25.4984 26.0272 26.6295 26.0395 190116............................ 1.2394 0.7445 17.8297 18.6074 20.3844 18.9443 190118............................ 0.9389 0.8767 17.5060 19.0200 19.7025 18.7558 190122............................ 1.1878 0.8605 17.7811 19.3131 23.7082 20.0706 190124............................ 1.5270 0.9003 23.3859 23.4862 24.6675 23.8477 190125............................ 1.6350 0.8044 21.5692 22.3976 23.9649 22.6514 190128............................ 1.0700 0.8605 23.8786 24.7842 27.9136 25.5637 190130............................ 0.9482 0.7445 15.2678 16.6910

* 15.9880 190131............................ 1.1718 0.9003 21.3154 22.5032 25.1917 22.9740 190133............................ 0.8895 0.7445 13.4062 14.3089 13.6266 13.7628 190135............................ 1.4454 0.9003 24.4908 26.9920 26.8238 26.1247 190140............................ 0.9845 0.7445 15.4030 17.0371 17.6936 16.7104 190144 h.......................... 1.1367 0.8767 21.3838 21.1658 21.7547 21.4426 190145............................ 0.9459 0.7445 17.4407 17.3361 18.9678 17.9319 190146............................ 1.5445 0.9003 22.1502 23.7721 26.1792 24.0255 190147............................

*** 0.7445 16.3596

*

* 16.3596 190149............................ 0.9266 0.7445 18.4197 17.1671 18.8819 18.1219 190151............................ 1.0072 0.7445 17.3402 17.8741 18.6293 17.9597 190152............................ 1.3530 0.9003 25.1136 27.4708 27.6099 26.7879 190156............................ 0.8717 0.7445 18.0528 18.3702

* 18.2089 190158............................ 1.3600 0.9003 23.2361 26.2352 26.3042 25.4140 190160............................ 1.4780 0.8044 19.8428 20.0025 21.6740 20.5204 190161............................ 1.1157 0.7847 16.5322 17.8794 19.1022 17.8227 190162............................

*** 0.9003 20.7350 22.1781 25.0328 22.6102 190164............................ 1.1345 0.8048 20.2791 21.4247 22.8599 21.6241 190167............................ 1.2264 0.7445 17.2643 17.8604 24.3185 19.7786 190175............................ 1.3314 0.9003 22.7574 24.6790 27.1531 25.0038 190176............................ 1.7308 0.9003 25.2536 25.8482 25.6997 25.6097 190177............................ 1.5627 0.9003 22.3318 25.4769 27.4621 25.2171 190182............................ 0.9036 0.9003 23.6016 25.0837 28.4799 25.6314 190183............................ 1.1870 0.7903 17.1805 18.3151 19.8084 18.4205

[[Page 23507]]

190184............................ 1.0174 0.7445 20.6096 21.3191 23.9609 21.8425 190185............................ 1.3314 0.9003 29.7870 24.4176 24.7912 25.8807 190190............................ 0.8693 0.7445 16.2819 14.0052 16.1195 15.4593 190191 h.......................... 1.3627 0.8470 21.9141 22.3755 23.5734 22.6642 190196............................ 0.8706 0.8429 20.7601 21.9355 24.7135 22.5497 190197............................ 1.3476 0.8044 21.6908 22.9631 24.3735 23.0241 190199............................ 1.1533 0.8605 19.7776 18.5317 14.1410 17.3575 190200............................ 1.5526 0.9003 24.1667 26.4258 27.5681 25.9873 190201............................ 1.2736 0.7847 21.4335 22.5588 24.5877 22.9165 190202............................ 1.2371 0.8605 22.4062 21.8900 24.7944 23.0825 190203............................ 1.5000 0.9003 24.9518 26.9099 26.8795 26.2979 190204............................ 1.4751 0.9003 26.1231 28.8777 28.3684 27.8932 190205............................ 1.7106 0.8429 20.2374 21.7696 24.4540 22.1979 190206............................ 1.6684 0.9003 24.2892 26.9117 26.0139 25.7960 190207............................

***

* 21.5325

*

* 21.5325 190218............................ 1.1570 0.7445 21.6206 23.9182 25.0356 23.6192 190236............................ 1.4154 0.8767 24.4661 23.8233 23.6824 23.9582 190240............................ 0.9780 0.7445 15.4026 13.9888

* 14.7116 190241............................ 1.2944 0.7903 24.2462 28.9620 23.9700 25.7012 190242............................ 1.1208 0.8605 18.6672 20.5937 23.0072 20.7608 190243............................

***

*

* 30.6060

* 30.6060 190245............................ 2.1960 0.8044

*

* 27.1786 27.1786 200001............................ 1.2980 0.9985 21.6050 23.2210 25.1145 23.3710 200002............................ 1.1625 0.9884 22.0700 24.1446 25.7478 23.9468 200007............................ 1.0638 1.0382 21.0603 22.3920

* 21.7470 200008............................ 1.2535 1.0382 25.1115 25.1741 27.4412 25.9041 200009............................ 1.9724 1.0382 24.9041 28.1409 31.1056 28.0391 200012............................ 1.1372 0.8840 21.8529 24.1243 25.7623 23.9787 200013............................ 1.1001 0.8840 22.8909 23.9048 24.4131 23.7685 200018............................ 1.1627 0.8840 21.1330 24.3294 23.6337 23.0851 200019............................ 1.2839 1.0382 23.1114 24.0926 25.1367 24.1296 200020............................ 1.2562 1.0503 27.0798 28.7351 31.7083 29.2990 200021............................ 1.1892 1.0382 24.9925 25.1027 24.5519 24.8792 200024............................ 1.5272 0.9884 22.9698 24.6484 26.0080 24.6372 200025............................ 1.0696 1.0382 22.9023 24.3646 26.0573 24.4151 200026............................ 1.0384 0.8840 19.7172 21.9997

* 20.8927 200027............................ 1.2155 0.8840 21.0156 23.2912 26.3118 23.4478 200028............................ 1.0270 0.8840 21.2180 24.3061 24.3271 23.3297 200031............................ 1.3580 0.8840 18.8262 20.6202 21.9489 20.4626 200032............................ 1.2155 0.8840 23.0487 24.2221 25.5227 24.3050 200033............................ 1.8521 0.9985 25.1723 26.8727 28.6479 26.9328 200034............................ 1.3802 0.9884 23.5415 26.1150 26.2926 25.3574 200037............................ 1.1932 0.8840 22.6534 23.3490 23.2333 23.0870 200039............................ 1.2758 0.9884 22.1333 24.0474 25.1196 23.8217 200040............................ 1.2240 1.0382 21.8528 23.6791 25.5405 23.6763 200041............................ 1.1389 0.8840 21.3816 23.6797 24.5532 23.3316 200050............................ 1.2560 0.9985 23.4391 25.5233 26.4992 25.2144 200052............................ 1.0527 0.8840 19.0535 22.7763 21.8726 21.2769 200063............................ 1.1744 0.9884 23.0135 24.7235 25.0167 24.2686 200066............................ 1.2279 0.8840 19.5890 21.6354

* 20.6005 210001............................ 1.4095 0.9528 22.6614 26.3144 27.7561 25.5750 210002............................ 1.9808 0.9892 25.6975 25.2859 26.4992 25.8584 210003............................ 1.6574 1.0935 23.0790 32.3042 29.8684 28.0698 210004............................ 1.4432 1.1471 29.4841 29.4300 34.2392 31.0347 210005............................ 1.2836 1.1471 24.7185 27.1276 28.7557 26.8963 210006............................ 1.0893 0.9892 24.7327 25.6396 25.4081 25.2468 210007............................ 1.8793 0.9892 27.5104 28.4496 30.2548 28.7829 210008............................ 1.3153 0.9892 24.6569 26.3008 25.2833 25.4086 210009............................ 1.8013 0.9892 23.4889 24.6332 26.2360 24.8136 210010............................

*** 0.9099 23.7761 24.5071 25.7850 24.6945 210011............................ 1.4100 0.9892 22.3262 24.8373 27.5031 24.9589 210012............................ 1.5973 0.9892 25.2892 25.7934 27.4103 26.2116 210013............................ 1.2668 0.9892 23.0151 23.9875 25.1348 24.0450 210015............................ 1.3230 0.9892 23.8419 25.8532 28.2029 25.9683 210016............................ 1.8143 1.1471 27.2632 28.6992 32.2081 29.4293 210017............................ 1.1663 0.9099 19.0248 21.3983 23.2168 21.2523 210018............................ 1.2267 1.1471 25.3112 27.5431 29.2153 27.3955

[[Page 23508]]

210019............................ 1.7403 0.9099 23.5259 24.9252 26.1824 24.9054 210022............................ 1.4002 1.1471 27.6680 30.1470 33.8015 30.5481 210023............................ 1.4502 0.9892 26.7837 29.0844 30.4656 28.8005 210024............................ 1.6742 0.9892 24.8939 27.1756 29.5579 27.2560 210025............................ 1.2278 0.9310 22.8882 23.8943 26.0771 24.3114 210027............................ 1.4821 0.9310 19.3517 23.9255 26.0111 22.9283 210028............................ 1.0800 0.9099 22.4054 24.1265 25.9221 24.1901 210029............................ 1.2469 0.9892 26.2082 31.2888 27.9741 28.3176 210030............................ 1.2604 0.9099 20.7802 27.5507 29.5702 25.7230 210032............................ 1.1336 1.0652 20.3407 25.7138 26.1829 23.9925 210033............................ 1.1618 0.9892 25.0301 26.6113 29.0420 26.9838 210034............................ 1.2910 0.9892 22.8827 26.3896 28.4308 25.7800 210035............................ 1.3279 1.0935 21.6973 24.5198 26.1082 24.1712 210037............................ 1.1827 0.9099 23.5536 24.1913 24.8719 24.2175 210038............................ 1.2100 0.9892 26.5696 28.3414 29.5979 28.1851 210039............................ 1.1063 1.0935 24.0987 25.8415 27.6940 25.8514 210040............................ 1.2556 0.9892 25.4729 28.3723 29.3514 27.8674 210043............................ 1.3070 0.9892 22.2177 24.3070 27.5657 24.7038 210044............................ 1.3455 0.9892 23.8101 24.8083 28.8700 25.7966 210045............................ 1.0505 0.9099 11.8350 15.0867 15.6380 14.3653 210048............................ 1.3334 0.9892 24.4328 25.0617 28.4638 26.0370 210049............................ 1.2251 0.9892 24.7148 25.9342 26.9656 25.9278 210051............................ 1.3202 1.0935 25.7103 27.3692 29.2998 27.5052 210054............................ 1.3345 1.0935 27.3551 24.6658 26.2295 26.0806 210055............................ 1.1840 1.0935 27.4218 28.0014 29.9708 28.5097 210056............................ 1.3191 0.9892 23.5881 26.6884 28.6091 26.3638 210057............................ 1.4185 1.1471 27.3520 29.2233 32.2883 29.7939 210058............................ 1.0819 0.9892 22.0351 24.8576 29.7841 25.5191 210060............................ 1.1664 1.0935 25.8377 28.7531 28.5087 27.8143 210061............................ 1.2457 0.9099 22.5455 24.1369 23.6662 23.5086 220001............................ 1.2068 1.1233 25.8030 27.3238 28.9854 27.3824 220002............................ 1.3775 1.1233 26.3348 28.9722 30.3598 28.5921 220003............................ 1.1465 1.1233 18.8150 20.5790 22.0549 20.5049 220006............................ 1.5005 1.0525 27.1576 29.5946 30.7583 29.2881 220008............................ 1.2473 1.0952 25.6647 27.1675 30.1043 27.7253 220010............................ 1.2849 1.1233 24.5020 27.4161 29.7998 27.3015 220011............................ 1.1320 1.1233 32.2266 32.6624 33.6258 32.9286 220012............................ 1.4769 1.2518 32.0521 32.9791 36.2075 33.8319 220015............................ 1.1789 1.0259 25.0272 25.5449 28.3397 26.3904 220016............................ 1.1162 1.0259 25.7740 26.8798 28.0609 26.8986 220017............................ 1.3302 1.1537 28.9024 28.8264 29.7108 29.1461 220019............................ 1.1847 1.1233 21.6620 22.2294 23.2544 22.3943 220020............................ 1.2561 1.0952 23.5737 24.2279 26.3475 24.7620 220024............................ 1.2397 1.0259 24.1071 25.5837 27.3488 25.6784 220025............................ 1.1085 1.1233 23.2374 24.5186 23.0637 23.5753 220028............................ 1.4399 1.1233 31.4858 31.3592 32.0980 31.6438 220029............................ 1.1188 1.1233 27.4792 28.1432 28.6970 28.1288 220030............................ 1.1096 1.0259 20.0816 23.6257 24.4289 22.7602 220031............................ 1.5358 1.1537 30.8324 32.2660 34.7388 32.5988 220033............................ 1.1835 1.1233 25.4500 26.8049 28.1859 26.8967 220035............................ 1.3734 1.1233 26.8486 27.5533 28.6238 27.6997 220036............................ 1.4886 1.1537 28.2182 29.6296 31.5184 29.8330 220041............................

***

* 28.8184 29.7464

* 29.2230 220046............................ 1.3512 1.0183 26.1955 27.7726 28.1396 27.3951 220049............................ 1.1526 1.1233 26.7688 27.0464 27.7517 27.2011 220050............................ 1.1149 1.0259 23.7326 24.9945 26.3768 25.0718 220051............................ 1.2065 1.0183 22.2965 26.5575 29.8380 26.3369 220052............................ 1.1597 1.1537 26.3043 28.0925 29.8577 28.1429 220058............................ 1.0018 1.1233 22.4885 25.0598 24.9642 24.1665 220060............................ 1.1851 1.2254 29.6960 30.8242 32.3362 31.0565 220062............................ 0.5670 1.1233 22.6598 21.9489 24.2779 22.9699 220063............................ 1.1890 1.1233 23.3704 25.5840 27.3967 25.3936 220065............................ 1.2103 1.0259 22.4143 24.8737 26.5513 24.6535 220066............................ 1.2809 1.0259 27.5575 26.2561 27.1317 26.9786 220067............................ 1.1716 1.1537 22.4968 28.5220 29.8911 26.7470 220070............................ 1.1474 1.1233 26.2697 28.9100 31.9283 28.7436 220071............................ 1.8635 1.1537 27.7773 31.8322 32.2591 30.6680

[[Page 23509]]

220073............................ 1.2181 1.0952 27.9309 29.2399 31.2591 29.4595 220074............................ 1.2979 1.1537 25.7840 27.5763 28.4930 27.3187 220075............................ 1.3687 1.1537 26.0527 27.9503 29.1588 27.7387 220076............................

*** 1.1078 24.8040 27.2534 29.7507 27.1315 220077............................ 1.7008 1.1085 27.0946 28.0935 30.2684 28.5352 220080............................ 1.2093 1.1233 24.7399 27.1578 28.9101 27.0523 220082............................ 1.2445 1.1233 23.9542 24.8060 26.9841 25.2609 220083............................ 1.1182 1.1537 28.3533 29.9001 32.9143 30.3719 220084............................ 1.2198 1.1233 26.8596 29.0505 32.5711 29.5958 220086............................ 1.7240 1.1537 29.4911 31.7482 34.1236 31.7544 220088............................ 1.8430 1.1537 26.5849 28.5711 28.5462 27.9606 220089............................ 1.2383 1.1233 28.9252 32.4409 31.1708 30.8836 220090............................ 1.2019 1.1233 26.5552 29.7945 30.8685 29.1558 220095............................ 1.0909 1.1233 23.7629 24.9871 27.4273 25.3894 220098............................ 1.1705 1.1233 26.2287 26.8538 28.8314 27.2888 220100............................ 1.2709 1.1537 27.0265 28.4848 29.6912 28.4369 220101............................ 1.3268 1.1233 26.9992 31.0834 33.1690 30.4912 220105............................ 1.2174 1.1233 26.7570 30.0892 31.9421 29.7099 220108............................ 1.2235 1.1537 26.0166 29.0804 30.6252 28.5516 220110............................ 2.0895 1.1537 33.0445 35.4242 36.6043 35.0919 220111............................ 1.1852 1.1537 27.7395 28.9092 31.1850 29.2950 220116............................ 2.0126 1.1537 30.9871 32.2337 32.9988 32.0845 220119............................ 1.1414 1.1537 25.9789 27.8372 28.2844 27.4417 220126............................ 1.1438 1.1537 26.9853 26.7660 28.7805 27.5408 220133............................

***

* 33.0819 31.2981 33.6003 32.6683 220135............................ 1.3023 1.2518 31.9159 31.3246 32.1205 31.7903 220153............................ 1.0112 1.0259

* 18.9267

* 18.9267 220154............................ 1.0325 1.1537 25.6069 30.9009 28.6462 28.0721 220163............................ 1.6217 1.1233 29.9312 30.5056 33.6484 31.2574 220171............................ 1.7280 1.1233 27.2647 28.9733 29.5666 28.6148 220174............................ 1.1830 1.1233

* 30.3356 31.7572 31.0464 230001............................ 1.1145 0.8923 22.0875 24.3660

* 23.2049 230002............................ 1.2858 1.0453 23.7972 27.0305 28.7861 26.5792 230003............................ 1.1978 0.9133 22.4322 25.2596 26.1278 24.6604 230004............................ 1.6865 0.9677 23.0827 25.5573 26.7206 25.1973 230005 h.......................... 1.2420 1.0885 20.3750 22.1018 24.1902 22.4061 230006............................ 1.1260 0.9786 22.0733 22.7656 23.8835 22.9495 230013............................ 1.3537 0.9858 20.4633 22.7014 23.7822 22.3686 230015............................ 1.0330 0.8923 21.7640 23.4512 24.6570 23.3267 230017............................ 1.6186 1.0403 26.1609 27.3259 29.5178 27.7392 230019............................ 1.5499 0.9858 24.7472 27.6563 28.4575 26.9496 230020............................ 1.6718 1.0453 25.8267 26.8516 29.2869 27.3788 230021............................ 1.5066 0.8923 22.0757 23.4663 24.9551 23.5352 230022............................ 1.1968 1.0628 22.2179 22.2528 23.3000 22.6032 230024............................ 1.5303 1.0453 24.7364 27.6555 30.0866 27.3402 230027............................ 1.0785 0.9398 21.2223 22.5736 23.5511 22.4431 230029............................ 1.6353 0.9858 26.7646 27.9012 29.0935 27.9121 230030............................ 1.2551 0.9090 19.9853 20.9867 22.3174 21.1301 230031............................ 1.3778 0.9858 22.1874 23.2910 25.4678 23.7275 230032............................

***

* 23.8366

*

* 23.8366 230035............................ 1.2892 0.9398 18.0735 20.9197 21.2317 19.9973 230036............................ 1.3478 0.8923 25.9801 26.5854 28.3622 26.9984 230037............................ 1.1932 1.0628 24.4115 24.7875 26.0167 25.1030 230038............................ 1.6544 0.9398 23.4685 25.2499 26.3480 25.2371 230040............................ 1.1923 0.9398 21.8062 21.9813 24.2349 22.7262 230041............................ 1.4739 0.9535 24.2297 25.2518 26.1760 25.1852 230042............................ 1.1899 0.9133 21.8241 24.3640 26.2037 24.1687 230046............................ 1.8546 1.0885 28.2320 29.2683 30.3591 29.3515 230047............................ 1.3775 1.0453 24.3622 26.2447 28.1351 26.3210 230053............................ 1.5876 1.0453 26.1415 28.3030 29.9871 28.0856 230054............................ 2.0368 0.9439 23.0818 24.0137 24.9905 24.0601 230055............................ 1.2813 0.8923 20.9350 23.7671 25.4143 23.4450 230058............................ 1.1454 0.8923 22.4516 21.9308 24.0657 22.7966 230059............................ 1.4370 0.9398 21.2743 23.1451 25.5350 23.3695 230060............................ 1.2849 0.8923 22.3512 24.5073 25.5015 24.1280 230065............................

*** 1.0453 26.3217 27.9179 28.4631 27.5421 230066............................ 1.3075 0.9677 23.9696 25.8517 27.4928 25.8295

[[Page 23510]]

230069............................ 1.1753 1.0654 26.0438 27.6815 29.5556 27.8051 230070............................ 1.5701 0.9474 22.8588 25.1587 24.2342 24.0769 230071............................ 0.8485 0.9858 23.6674 24.7707 26.3907 24.9681 230072............................ 1.3590 0.9133 22.9626 24.1560 24.4933 23.9114 230075............................ 1.3133 0.9492 22.6799 24.1482 27.6193 24.8869 230077............................ 1.9292 1.0654 29.2041 27.3117 30.3431 28.9610 230078............................ 1.0254 0.8923 20.5427 21.9200 23.9901 22.2077 230080............................ 1.2619 0.9090 20.2405 21.2840 21.2314 20.9185 230081............................ 1.1862 0.8923 20.4289 20.6777 23.0788 21.3975 230082............................ 1.0168 0.8923 21.3100 23.1240 22.2165 22.1964 230085............................ 1.2173 1.0403 24.2802 22.2569 22.7314 23.1872 230086............................ 1.1453 0.8923 27.8923 20.8759 22.2965 23.4562 230087............................

***

* 22.2688

* 16.9168 19.0752 230089............................ 1.3414 1.0453 23.3847 23.9486 28.7015 25.3973 230092............................ 1.2758 0.9300 22.3122 24.3768 26.3584 24.3257 230093............................ 1.1471 0.9398 25.1213 24.5055 26.4967 25.3702 230095............................ 1.2485 0.8923 19.1810 19.2244 21.3915 19.9401 230096............................ 1.1644 1.0403 26.7156 26.7578 28.7681 27.4077 230097............................ 1.7922 0.8923 22.9902 25.2104 26.5773 24.9608 230099............................ 1.2029 1.0628 23.5490 25.0390 26.4882 25.0486 230100............................ 1.0901 0.8923 19.8016 20.4565 21.8895 20.6965 230101............................ 1.0867 0.8923 22.3310 23.1349 24.3772 23.3147 230103............................ 0.9926 0.9786 19.4434 18.4304 21.6609 19.7646 230104............................ 1.5316 1.0453 27.4119 27.8864 30.5570 28.5801 230105............................ 1.9274 0.9535 23.9851 24.6853 27.2705 25.3146 230106............................ 1.1151 0.9398 23.1962 24.1128 24.3980 23.9236 230108............................ 1.1539 0.8923 19.9842 22.4966 18.4063 20.1757 230110............................ 1.2559 0.8923 21.5523 22.7621 28.7704 24.4693 230117............................ 1.8428 1.0403 28.1220 29.6361 29.4775 29.0873 230118............................ 1.0609 0.8923 22.2208 21.4886 22.3636 22.0278 230119............................ 1.2750 1.0453 25.3562 29.2509 30.4910 28.0624 230120 h.......................... 1.1085 1.0885 22.7243 21.7894 24.1485 22.9095 230121............................ 1.2547 0.9786 22.3708 23.4394 24.5220 23.4095 230124............................ 1.3011 0.8923 22.0097 23.0508

* 22.5308 230130............................ 1.7348 0.9858 23.7854 26.9907 26.6076 25.8001 230132............................ 1.3708 1.0654 29.0292 29.9106 30.5074 29.8111 230133............................ 1.4219 0.8923 20.4801 21.2273 22.7380 21.5235 230135............................ 1.1067 1.0453 19.8290 23.9000 25.8406 23.1673 230141............................ 1.6290 1.0654 23.9885 30.4643 28.6326 27.6090 230142............................ 1.2390 1.0453 22.9036 25.6044 26.9433 25.2019 230143............................ 1.2372 0.8923 19.5446 19.5387 21.4083 20.1494 230144............................

*** 1.0885 23.6959

*

* 23.6959 230146............................ 1.2340 1.0453 21.3539 24.3891 26.3432 24.1395 230149............................ 0.9394 0.8923 20.8933 21.4753

* 21.1778 230151............................ 1.3038 0.9858 23.8527 26.4669 27.1965 25.8699 230153............................ 1.0978 0.9786 22.8584 22.3404 22.8644 22.6896 230155............................ 1.0445 0.8923 18.0743 24.0404

* 20.6336 230156............................ 1.5897 1.0885 27.7164 29.4855 31.1909 29.5181 230165............................ 1.6979 1.0453 25.9534 27.3164 28.9636 27.4184 230167............................ 1.6158 0.9786 24.7935 26.6828 27.3362 26.2749 230169............................

*** 1.0453 24.9265 27.1172 31.8442 27.6798 230171............................ 1.0700 0.8923 19.9097 22.0635

* 20.9931 230172............................ 1.2263 1.0403 23.0023 24.0236 25.7402 24.2756 230174............................ 1.3089 0.9133 24.4671 26.2770 27.6920 26.1839 230175............................

***

* 22.5964

*

* 22.5964 230180............................ 1.0957 0.8923 20.9832 22.5454 24.7358 22.8206 230184............................ 1.2135 0.9300 21.4031 21.9346 23.6707 22.3438 230186............................

***

* 21.6147 27.1126 26.2282 24.5338 230188............................ 0.9259 0.8923 18.8076

*

* 18.8076 230190............................ 1.0114 1.0403 27.3430 28.7365 29.9604 28.6717 230193............................ 1.2672 0.9858 22.8916 24.3181 23.3565 23.5189 230195............................ 1.4253 1.0453 25.3285 27.1266 28.2892 26.9865 230197............................ 1.5717 1.0654 26.9840 28.3439 30.0367 28.4836 230204............................ 1.2871 1.0453 24.4095 25.9871 29.1466 26.3875 230207............................ 1.3574 0.9858 22.2848 22.2854 24.4641 22.9909 230208............................ 1.1926 0.9398 20.3171 20.9420 21.9651 21.0908 230212............................ 1.0168 1.0885 26.0656 27.3686 29.7980 27.6833

[[Page 23511]]

230216............................ 1.5428 0.9858 23.4262 26.1468 27.5230 25.7787 230217............................ 1.2812 0.9786 24.3650 26.7929 28.5002 26.7214 230222 h.......................... 1.3221 0.9474 24.6101 24.8925 26.3990 25.3118 230223............................ 1.2599 0.9858 28.5549 27.1503 29.2853 28.3304 230227............................ 1.5008 1.0453 27.7510 28.1105 29.6068 28.4994 230230............................ 1.4934 0.9786 23.9568 25.4471 27.9607 25.8281 230235............................ 1.0134 0.9090 19.9118 19.6046 21.8777 20.4653 230236............................ 1.4098 0.9398 25.7463 26.3988 28.4754 26.9289 230239............................ 1.2173 0.8923 19.8370 21.1643 22.1040 21.0930 230241............................ 1.1712 0.9858 24.2063 25.8671 27.4890 25.8668 230244............................ 1.3245 1.0453 23.9004 25.3817 26.4326 25.2154 230254............................ 1.3405 0.9858 24.2594 26.4431 28.1216 26.2901 230257............................ 1.0228 1.0453 24.8069 25.4086 27.8197 25.8794 230259............................ 1.2092 1.0885 24.8598 24.3067 26.8677 25.3750 230264............................ 2.1560 1.0453 17.4847 19.9992 19.2398 19.0176 230269............................ 1.3453 0.9858 25.3367 27.4732 28.8187 27.2692 230270............................ 1.2537 1.0453 22.8842 26.1113 27.8488 25.6802 230273............................ 1.4149 1.0453 25.8466 30.2209 29.9307 28.6762 230275............................ 0.4478 0.9474 29.4180 30.2244 23.1095 27.7059 230276............................

***

* 23.4928

*

* 23.4928 230279............................ 0.5281 1.0654 21.2467 23.1636 24.7673 22.9663 230283............................ 0.8624 1.0453 25.0038 24.9272 26.2622 25.3910 230288............................

***

* 30.3422

*

* 30.3422 230290............................

***

*

* 29.4792

* 29.4792 230291............................

***

*

*

* 30.9655 30.9655 230292............................

*** 0.9474

*

* 31.8943 31.8943 240001............................ 1.5054 1.1055 28.2239 29.9123 31.5753 29.9731 240002............................ 1.8195 1.0224 24.7674 26.9608 28.9860 26.9851 240004............................ 1.5291 1.1055 26.8197 27.8796 30.8072 28.5006 240006............................ 1.0536 1.1128 29.5789 30.2330 30.1950 30.0237 240007............................ 1.1446 0.9183 21.4367 23.7588 24.7344 23.3456 240010............................ 2.0425 1.1128 29.0955 30.4139 31.3733 30.3196 240011............................ 1.0425 0.9183 24.0364 22.9561

* 23.3835 240013............................ 1.2687 1.0905 27.3855 28.7202 28.3860 28.1704 240014............................ 1.0309 0.9183 26.5144 28.3788 29.8623 28.2985 240016............................ 1.2584 0.9183 25.2629 24.9211 26.7814 25.7376 240017............................ 1.2467 0.9183 21.6243 23.3314 24.4417 23.1535 240018............................ 1.2293 1.0905 27.3634 27.9218 25.6484 26.6329 240019............................ 1.1105 1.0224 25.1331 27.5441 28.6723 27.1439 240020............................ 1.0806 1.1055 24.7516 28.1568 31.2443 28.0203 240021............................ 0.8545 0.9183 23.9568 23.7096 27.1235 24.8433 240022............................ 1.1064 0.9183 23.4702 23.7368 25.2066 24.1392 240025............................ 1.0776 0.9183 21.2597 27.8656

* 24.3444 240027............................ 0.9440 0.9183 18.3340 20.2531 18.2481 18.8765 240029............................ 1.0819 0.9183 21.2342 24.3017 25.3568 23.3870 240030............................ 1.3564 0.9785 22.0200 23.3753 24.7154 23.4178 240031............................ 0.9494 1.0905 23.4389 26.7242 26.7778 25.6303 240036............................ 1.6880 1.0905 23.4857 27.0821 28.0812 26.3323 240037............................ 1.0359 0.9183 21.8392 24.3986

* 23.1115 240038............................ 1.5291 1.1055 28.9676 29.8465 31.0779 30.0073 240040............................ 1.0854 1.0224 21.3870 26.3177 27.4895 24.8843 240043............................ 1.1301 0.9183 19.5532 20.7155 21.8685 20.7481 240044............................ 1.1203 0.9183 22.7482 24.3009 22.5843 23.1864 240045............................ 1.1212 1.0224 25.9223 26.1743 27.5013 26.5626 240047............................ 1.5649 1.0224 29.6184 29.1211 28.8288 29.1562 240050............................ 1.0196 1.1055 24.7589 26.6687 26.4854 26.0710 240052............................ 1.1991 0.9183 23.5898 24.9870 26.4256 25.0236 240053............................ 1.4186 1.1055 26.7122 28.4733 29.5315 28.3118 240056............................ 1.2420 1.1055 28.5169 30.8619 31.6623 30.4153 240057............................ 1.8473 1.1055 27.7600 29.4870 30.6258 29.3431 240059............................ 1.0902 1.1055 27.0517 28.6340 29.7916 28.5358 240061............................ 1.7485 1.1128 28.7372 30.0031 30.6383 29.8381 240063............................ 1.5546 1.1055 26.7960 29.9603 32.3487 29.6692 240064............................ 1.2568 1.0224 24.9928 26.6996 29.9662 27.5790 240066............................ 1.3913 1.1055 27.4066 30.2716 33.4532 30.4657 240069............................ 1.1378 1.1128 25.6943 27.4990 28.9496 27.4534 240071............................ 1.1486 1.1128 24.8036 26.4780 28.0585 26.4808

[[Page 23512]]

240075............................ 1.1988 0.9785 24.4084 26.6607 26.1956 25.7681 240076............................ 1.1046 1.1055 26.7112 28.4519 29.8562 28.4067 240077............................

*** 0.9183 18.9735

*

* 18.9735 240079............................ 0.9411 1.1521 20.6644 20.9220

* 20.8010 240080............................ 1.6892 1.1055 27.8807 29.6274 31.6484 29.7472 240083............................ 1.2481 0.9183 24.4352 25.0214 26.6582 25.4096 240084............................ 1.1252 1.0224 23.9942 24.7856 26.8142 25.2047 240087............................ 1.0235 0.9183 20.1002 24.8479 24.9419 23.3753 240088............................ 1.2698 0.9785 25.5587 27.6323 28.0825 27.1245 240089............................

*** 0.9183 23.4028

*

* 23.4028 240094............................ 1.0759 1.1055 24.4166 27.3974 28.3973 26.8076 240097............................

***

* 34.2810

*

* 34.2810 240101............................ 1.1412 0.9183 24.3455 26.6078 25.5355 25.5132 240103............................ 1.0495 0.9183 20.2324 22.5416 22.7078 21.8542 240104............................ 1.1424 1.1055 27.4946 30.1392 31.4306 29.9577 240106............................ 1.4870 1.1055 25.5890 27.5171 29.3455 27.5527 240107............................ 0.9093 0.9183 24.5583 25.5199 26.1078 25.4514 240109............................ 0.9472 0.9183 14.5892 15.2076 16.5051 15.4279 240115............................ 1.6156 1.1055 27.0312 29.0261 31.3869 29.1786 240117............................ 1.1377 0.9183 20.1436 22.0463 23.8076 22.0056 240121............................ 0.9139 1.0224 24.5455

*

* 24.5455 240123............................ 1.0528 0.9183 20.0721 20.5755 21.7500 20.8397 240124............................ 0.9638 0.9183 23.5139 23.9297

* 23.7277 240127............................

***

* 19.3857 24.4824

* 21.5460 240128............................ 1.0138 0.9183 20.1960 21.2638 21.5791 21.0226 240132............................ 1.2654 1.1055 26.7063 29.5310 31.7139 29.3306 240133............................ 1.1406 0.9183 23.6068 26.1836 27.7658 25.8348 240135............................

***

* 17.8573 16.1837

* 16.9824 240137............................ 1.1919 0.9183 23.1752 23.8666

* 23.5315 240139............................ 1.0798 0.9183 22.4473 23.7898

* 23.1612 240141............................ 1.0222 1.1055 25.1597 26.7173 26.4016 26.1666 240143............................ 0.8521 0.9183 18.9442 21.1180 21.7416 20.6376 240145............................

*** 0.9183 22.6063

*

* 22.6063 240154............................ 1.0199 0.9183 21.3809 23.9643

* 22.6453 240162............................ 1.1601 0.9183 20.4807 22.3136 22.2721 21.7043 240166............................ 1.1135 0.9183 21.5002 23.4265 25.7509 23.5628 240179............................ 0.8255 0.9183 19.8249 20.8449

* 20.3419 240187............................ 1.2137 1.0905 24.8879 26.5129 27.8811 26.4667 240196............................ 0.8421 1.1055 27.2901 28.9380 30.7719 29.0287 240207............................ 1.2007 1.1055 27.4330 29.2395 31.7414 29.5819 240210............................ 1.2500 1.1055 26.6545 29.7227 32.1564 29.5372 240211............................ 0.9023 1.0905 32.8801 44.4214 18.8503 27.6876 240213............................ 1.3095 1.1055 27.5104 31.3974 32.7532 30.8794 250001............................ 1.8170 0.8313 20.9338 21.9176 22.7827 21.9287 250002............................ 0.8813 0.7685 21.6643 20.1310 23.3845 21.6434 250004............................ 1.8313 0.9108 20.9295 20.6828 24.1065 21.8737 250006............................ 1.0428 0.9108 20.3061 21.4038 24.0191 21.9290 250007............................ 1.2343 0.8922 21.2226 23.6933 25.8710 23.5817 250009............................ 1.2453 0.8799 19.7610 20.4329 22.2323 20.8522 250010............................ 0.9833 0.7685 17.6204 19.4130 19.4403 18.8097 250012............................ 0.9469 0.9346 15.6117 20.0493 20.2921 18.4571 250015............................ 1.0268 0.7685 19.3794 20.6931 20.7555 20.2702 250017............................ 1.0970 0.7685 19.0436 18.1013 21.3950 19.5260 250018............................ 0.9215 0.7685 16.8783 17.0689 16.6294 16.8678 250019............................ 1.5528 0.8922 22.9085 22.8358 23.9741 23.2493 250020............................ 0.9918 0.7685 19.1877 19.3390 21.4019 19.9847 250021............................

***

* 15.8485 15.1242 20.3559 16.0142 250023............................ 0.8443 0.8612 14.7355 16.1820 16.2418 15.7024 250025............................ 1.0405 0.7685 21.2651 20.6892 20.5258 20.8816 250027............................ 0.9794 0.7685 17.5937 17.3313 17.3481 17.4314 250030............................

*** 0.7685 27.2140

*

* 27.2140 250034............................ 1.5307 0.9108 20.3681 20.6752 24.3189 21.8100 250035............................ 0.8545 0.7685 17.1071 14.6149 17.2045 16.2933 250036............................ 1.0038 0.8164 17.0469 17.8313 19.1975 18.0476 250037............................ 0.8638 0.7685 16.6347 17.4463 17.4012 17.1789 250038............................ 0.9832 0.8313 16.8610 18.0209 18.9050 17.9032 250039............................ 0.9125 0.8313 16.8729 15.2939 17.3155 16.4505

[[Page 23513]]

250040............................ 1.4718 0.8612 20.8178 21.3451 23.2285 21.8161 250042............................ 1.2038 0.9108 19.4367 21.4117 23.4135 21.3957 250043............................ 1.0429 0.7685 17.7554 18.3322 19.8098 18.6971 250044............................ 1.0199 0.7685 20.3711 21.1198 23.3862 21.6199 250045............................ 1.0872 0.8922 25.3236 25.0863 26.3831 25.6144 250048............................ 1.5843 0.8313 19.3635 21.6547 22.9765 21.3756 250049............................ 0.8410 0.7685 13.4396 17.8154 17.7005 16.2411 250050............................ 1.1957 0.7685 16.6723 18.3170 19.1467 18.0183 250051............................ 0.8358 0.7685 10.5027 10.6908 10.6095 10.6008 250057............................ 1.1292 0.7685 19.0571 19.6789 20.1900 19.6573 250058............................ 1.2515 0.7685 16.5565 17.5160 18.1704 17.4280 250059............................ 0.9814 0.7685 19.0733 17.7270 19.2977 18.6884 250060............................ 0.7926 0.7685 14.0155 20.8115 16.8247 17.2475 250061............................ 0.8412 0.7685 11.4573 15.2515 12.8174 12.9127 250065............................ 0.8170 0.8313 16.2010 16.1984

* 16.1997 250066............................ 0.7831 0.7685 16.1044

*

* 16.1044 250068............................ 0.7547 0.7685 16.3759 16.9585

* 16.6506 250069............................ 1.4860 0.8614 21.2224 21.6617 22.8162 21.9460 250071............................ 0.8305 0.7685 13.7056 17.7149

* 15.4400 250072............................ 1.4976 0.8313 20.7827 22.9316 24.6587 22.7773 250077............................ 0.9403 0.7685 14.0318 14.2271 14.7632 14.3259 250078 \2\........................ 1.5963 0.7685 17.5186 18.6563 20.9354 19.1036 250079............................ 0.8383 0.8182 21.3506 27.2549 38.0031 29.5848 250081............................ 1.2295 0.8182 20.4513 21.3830 24.7031 21.9463 250082............................ 1.2744 0.8099 19.5962 20.5212 19.6966 19.9404 250083............................ 0.9072 0.7685 19.5217 19.9484

* 19.7505 250084............................ 1.1575 0.7685 22.4632 21.8001 18.5775 20.7280 250085............................ 0.9532 0.7685 18.0473 18.7367 19.7007 18.8283 250089............................ 1.0502 0.7685 16.0203

*

* 16.0203 250094............................ 1.5886 0.8612 19.9619 22.3312 22.7312 21.7001 250095............................ 0.9965 0.7685 18.6616 19.9553 21.3511 19.9748 250096............................ 1.0784 0.8313 20.7246 22.7458 22.6298 22.0767 250097............................ 1.3963 0.8470 18.8399 19.4534 20.1687 19.4858 250098............................

*** 0.7685 17.9561

*

* 17.9561 250100............................ 1.4464 0.8614 18.8877 22.0328 24.2209 21.7570 250101............................

***

*

* 21.2234

* 9.7147 250102............................ 1.5446 0.8313 21.3213 22.5518 24.2868 22.7655 250104............................ 1.4244 0.8182 20.5035 21.4431 22.6591 21.5782 250105............................ 0.8995 0.7685 17.0136 17.9468 18.1196 17.6992 250107............................ 0.9071 0.7685 16.7104 16.5369 17.8999 17.0742 250112............................ 0.9521 0.7685 16.8696 19.6172 21.2824 19.4217 250117............................ 1.0298 0.8612 18.8863 19.9774 23.3673 20.6608 250119............................

*** 0.7685 17.1373

*

* 17.1373 250122............................ 1.0617 0.7685 19.7966 23.7230 24.5854 22.7156 250123............................ 1.2675 0.8922 22.2184 22.0486 24.5115 22.9495 250124............................ 0.8390 0.8313 15.6866 15.4343 17.2181 16.1302 250125............................ 1.2819 0.8922 25.3415 26.8379 27.7077 26.6997 250126............................ 0.9380 0.9346 20.1118 20.4085 21.7111 20.7174 250128............................ 0.8826 0.7685 15.8352 15.9344 17.6269 16.4363 250131............................ 0.8879 0.7685 11.5396

*

* 11.5396 250136............................ 0.9767 0.8313 21.9977 22.5832 23.0637 22.5479 250138............................ 1.2637 0.8313 21.2490 22.7902 23.8861 22.6997 250141............................ 1.5358 0.9346 22.5187 24.5772 27.6158 25.2301 250146............................ 0.8784 0.7685 16.9341 17.2328 18.6486 17.5743 250149............................ 0.8979 0.7685 16.4228 15.0367 15.0641 15.5315 250151............................ 0.7214 0.7685 20.4581 21.8697 17.2205 18.4362 250152............................ 1.6630 0.8313

*

* 25.7837 25.7837 250153............................

*** 0.8313

*

* 29.0461 29.0461 260001............................ 1.6129 0.8594 22.6646 25.3084 25.9250 24.6413 260002............................

*** 0.8953 24.6812 27.2329 26.4879 26.0819 260003............................ 1.0250 0.7927 16.5931 17.6339

* 17.1135 260004............................ 0.9578 0.7927 16.4423 16.7742 16.9421 16.7356 260005............................ 1.4759 0.8953 25.5927 24.6142 26.5773 25.6220 260006............................ 1.4271 0.7927 24.1078 26.4948 26.7587 25.8174 260008............................

***

* 21.6256 17.6040 18.9522 19.2926 260009............................ 1.1793 0.9454 20.1679 21.2729 22.1816 21.2122 260011............................ 1.3859 0.8346 21.1625 21.4409 22.7061 21.7937

[[Page 23514]]

260012............................ 1.0499 0.7927 17.7854 19.3389 20.3061 19.2632 260013............................ 1.0044 0.8594 18.4857 19.2065 20.5007 19.3903 260015............................ 1.0786 0.7927 21.7581 22.4450 22.5409 22.2644 260017............................ 1.3014 0.8953 20.7837 21.1359 22.7022 21.5787 260018............................ 1.0599 0.7927 14.3278 14.8425 17.0434 15.4340 260020............................ 1.7361 0.8953 22.4709 25.7898 26.0407 24.8648 260021............................ 1.3546 0.8953 27.2478 27.8332 27.6330 27.5756 260022............................ 1.2242 0.8563 20.5417 21.7707 22.8085 21.6784 260023............................ 1.2675 0.8953 19.6324 21.2519 21.2077 20.7002 260024............................ 1.1370 0.7927 16.9968 17.5351 18.4829 17.6819 260025............................ 1.2646 0.8953 19.3535 20.0901 22.4645 20.6596 260027............................ 1.5961 0.9454 22.9973 24.7605 25.3348 24.3810 260029............................ 1.0866 0.9454 22.0390 22.2892 23.1185 22.4857 260031............................

***

* 24.3626 24.2877

* 24.3260 260032............................ 1.7985 0.8953 21.8830 23.1125 23.8459 22.9657 260034............................ 0.9517 0.9454 21.6108 23.3034 24.1143 23.0518 260035............................ 0.9459 0.7927 15.0468 16.8502 17.8741 16.5641 260036............................ 0.9500 0.9454 19.4559 20.1324 22.1912 20.4830 260040............................ 1.6194 0.8251 20.0422 21.9452 23.3566 21.8297 260044............................ 0.9352 0.7927 18.2413 20.0686 22.4498 20.3210 260047............................ 1.5009 0.8346 22.4585 22.6169 24.4185 23.1892 260048............................ 1.2518 0.9454 26.6363 25.8089 24.3906 25.5119 260050............................ 1.1354 0.7927 20.8510 20.6364 23.6849 21.9007 260052............................ 1.3148 0.8953 21.1297 22.5809 24.5165 22.8077 260053............................ 1.0393 0.8594 18.9606 20.0051 21.6607 20.2038 260057............................ 1.0346 0.9454 15.8404 16.4875 19.3335 17.1879 260059............................ 1.1931 0.7927 17.2807 18.6379 19.7243 18.6135 260061............................ 1.0883 0.7927 18.7280 19.6674 21.5264 19.9180 260062............................ 1.1811 0.9454 25.2958 26.0439 26.4539 25.9705 260063............................ 0.9686 0.9454 21.1284 22.0826

* 21.6180 260064............................ 1.3672 0.8346 17.5188 19.1587 19.0543 18.5908 260065............................ 1.7230 0.8251 22.0058 23.6969 23.0015 22.9155 260067............................ 0.8937 0.7927 14.9792 16.5364 17.6256 16.4270 260068............................ 1.7577 0.8346 22.0951 23.9340 24.9504 23.7077 260070............................ 0.9581 0.7927 11.2251 14.3881 18.4779 14.0836 260073............................ 1.0189 0.7927 17.8185 19.2744 21.6214 19.6354 260074............................ 1.1674 0.8346 18.7639 23.9301 24.8654 22.4254 260077............................ 1.6385 0.8953 21.9947 23.5466 25.5782 23.7347 260078............................ 1.1970 0.7927 16.9217 18.4017 19.0802 18.1811 260080............................ 0.8933 0.7927 13.6815 11.2817 14.7774 13.2210 260081............................ 1.4823 0.8953 22.6627 23.7447 26.3969 24.2793 260085............................ 1.5874 0.9454 22.7394 24.6046 25.6302 24.3659 260086............................ 0.8704 0.7927 17.2048 17.1202 19.1702 17.8711 260091............................ 1.5058 0.8953 23.9975 26.1149 27.2407 25.8446 260094............................ 1.6399 0.8251 20.1043 20.6805 23.2544 21.4540 260095............................ 1.3081 0.9454 22.8156 23.8671 25.5668 24.0702 260096............................ 1.4315 0.9454 23.5009 25.9932 27.5592 25.8492 260097............................ 1.1515 0.7927 19.6203 21.5077 21.3957 20.9049 260102............................ 0.8325 0.9454 24.1041 22.9283 24.2368 23.7509 260103............................

***

* 21.6192 23.3175

* 22.4894 260104............................ 1.4636 0.8953 22.4769 24.0038 26.2867 24.3941 260105............................ 1.7197 0.8953 24.6572 28.4652 28.8849 27.3498 260107............................ 1.3072 0.9454 23.1564 24.2001 26.7782 24.6444 260108............................ 1.8305 0.8953 22.7975 24.0936 25.0171 23.9907 260110............................ 1.6192 0.8953 22.0026 22.2730 3.7978 22.7167 260113............................ 1.0827 0.8285 16.3440 19.2467 20.9644 18.7740 260115............................ 1.1542 0.8953 20.4880 21.7450 21.9859 21.4408 260116............................ 1.1207 0.8285 16.9807 17.2698 18.5076 17.6168 260119............................ 1.3355 0.7927 18.7959 22.1588 24.9937 22.8442 260120............................

***

* 18.7651

*

* 18.7651 260123............................ 0.9970 0.7927 17.7996 16.1169

* 17.0002 260127............................ 0.9648 0.7927 19.7946 22.5328 21.8534 21.3553 260134............................ 1.1483 0.8953 18.4511 18.1531

* 18.2845 260137............................ 1.6384 0.8594 20.7638 21.3426 22.7431 21.6630 260138............................ 1.9066 0.9454 25.6579 27.8229 28.5610 27.3740 260141............................ 1.9089 0.8346 21.0771 21.1511 22.4886 21.5378 260142............................ 1.0487 0.7927 18.6412 19.6582 20.3993 19.6104

[[Page 23515]]

260147............................ 0.9384 0.7927 16.1171 17.2291 18.5153 17.2858 260159............................

*** 0.8953 23.1093 26.8924 23.7427 24.4817 260160............................ 1.0773 0.7927 18.8723 19.4997 21.0544 19.7923 260162............................ 1.3864 0.8953 22.5705 24.1246 25.1423 23.9984 260163............................ 1.1422 0.7927 18.1310 19.2885 20.1949 19.2038 260164............................ 1.0696 0.7927 16.9403 19.5539 19.7068 18.6878 260166............................ 1.1854 0.9454 22.8409 25.5151 27.0237 25.1725 260172............................ 0.9089 0.7927 17.1504 18.1438

* 17.6539 260175............................ 1.1001 0.7927 19.7939 21.1257 22.6171 21.1462 260176............................ 1.5811 0.8953 25.7802 29.2184 27.4244 27.5317 260177............................ 1.2174 0.9454 24.0550 25.0724 26.1178 25.1274 260178............................ 1.8186 0.8346 21.7704 21.4781 22.2251 21.8190 260179............................ 1.5692 0.8953 23.2824 24.8541 26.1419 24.7933 260180............................ 1.5399 0.8953 21.8585 21.9679 26.7461 23.4659 260183............................ 1.6506 0.8953 24.2330 23.3924 26.0418 24.6030 260186............................ 1.6276 0.8346 21.6620 23.4317 25.3148 23.5713 260190............................ 1.1384 0.9454 24.5014 25.1653 26.4505 25.4095 260191............................ 1.3158 0.8953 21.1331 22.4369 23.3856 22.3648 260193............................ 1.2140 0.9454 22.9556 24.4705 26.2979 24.7042 260195............................ 1.2803 0.8251 20.0889 20.1327 22.3958 20.9711 260198............................ 1.1855 0.8953 25.3390 27.6116 27.5996 26.8633 260200............................ 1.2198 0.8953 22.3913 25.1134 24.8624 24.2536 260207............................ 1.0594 0.8251 18.5247 19.2467 19.7294 19.2332 260208............................

***

* 28.3158

*

* 28.3158 260210............................ 1.2045 0.8953

*

* 25.3782 25.3782 260211............................ 1.5796 0.9454

*

* 33.9109 33.9109 270002 \2\........................ 1.2881 0.8822 19.7588 20.7620 22.7322 21.1317 270003............................ 1.2770 0.9074 23.0396 24.2823 26.4843 24.5714 270004............................ 1.6910 0.8855 21.5577 22.9081 23.5454 22.7035 270009............................ 1.2674 0.8822 21.5655

*

* 21.5655 270012 \2\........................ 1.4482 0.9074 21.7634 23.1697 25.2873 23.4084 270014............................ 1.8188 0.9535 20.3456 25.0650 26.2025 23.6425 270017............................ 1.2612 0.9535 23.2320 24.6186 27.5483 25.1665 270021............................ 1.0085 0.8822 21.1624 21.6758 21.7056 21.5330 270023............................ 1.5160 0.9535 23.7486 25.5525 26.7576 25.3555 270032............................ 1.0500 0.8822 20.1801 18.2377 19.6212 19.3552 270036............................ 0.7848 0.8822 18.8785 21.8255 20.4242 20.3944 270040............................ 1.1798 0.8822 20.7240

*

* 20.7240 270050............................ 1.0303 0.8822 21.0901 22.4195

* 21.7451 270051............................ 1.5685 0.9535 22.2580 26.4457 26.6619 25.1119 270057............................ 1.2222 0.8822 21.9997 22.6251 24.2980 23.0119 270060............................ 0.8776 0.8822

* 16.6592

* 16.6592 270079............................ 0.8473 0.8822

* 21.6382

* 21.6382 270081............................ 1.0052 0.8822 15.6833 17.3174 17.4862 16.8348 270082............................ 1.0621 0.8822 21.0150 19.6173

* 20.3610 270084 \2\........................ 0.9843 0.8822 19.6104 22.2340

* 21.0235 280003............................ 1.8332 1.0197 26.0937 27.2844 29.3921 27.8614 280005............................

***

* 23.9753

*

* 23.9753 280010............................

***

* 23.8325 22.6516

* 23.2571 280013............................ 1.8041 0.9555 23.4920 24.5214 26.1908 24.7334 280020............................ 1.7943 1.0197 23.4577 25.7522 26.5068 25.3300 280021............................ 1.1390 0.8666 21.5215 22.2864 22.0489 21.9595 280023............................ 1.4073 0.9666 19.6265 22.7207 22.3230 21.6126 280030............................ 1.9343 0.9555 29.2221 32.5601 30.7481 30.8807 280032............................ 1.3356 0.9666 21.5150 22.6510 23.6462 22.6240 280040............................ 1.6685 0.9555 23.6597 25.2965 26.9827 25.3499 280047............................ 0.7767 0.9555 19.5815

*

* 19.5815 280057............................ 0.8190 0.9666 22.5481 23.6793 20.4830 22.0597 280060............................ 1.6115 0.9555 23.1128 25.2288 26.2139 24.9273 280061............................ 1.3565 0.9207 21.2901 23.9110 24.9482 23.4090 280065............................ 1.2692 0.9597 23.8128 27.9937 26.0135 25.9591 280077............................ 1.3308 0.9555 22.7244 24.0516 25.5624 24.1150 280081............................ 1.6019 0.9555 24.3199 25.1973 26.0541 25.2026 280085............................

***

* 21.8473

*

* 21.8473 280108............................ 1.0415 0.8666 20.9016 22.5584 23.2502 22.2006 280111............................ 1.2083 0.8666 20.7398 22.1424 23.4770 22.1827 280117............................ 1.0762 0.8666 20.5464 22.0611 24.1521 22.2744

[[Page 23516]]

280118............................ 0.9146 0.8666 19.3466

*

* 19.3466 280125............................ 1.5050 0.8666 20.0643 21.8385 21.7658 21.2295 280126............................

***

* 33.8918

*

* 33.8918 290002............................ 0.8621 0.9786 16.8363 16.8433 18.3469 17.3909 290003............................ 1.7448 1.1416 27.4732 27.1099 28.1625 27.5886 290005............................ 1.3375 1.1416 24.6877 27.1531 27.6697 26.5417 290006............................ 1.2159 1.0805 24.2211 26.3617 27.9502 26.1547 290007............................ 1.5966 1.1416 35.1020 35.4193 37.5559 36.0546 290008............................ 1.1726 1.1249 27.0115 26.4086 27.9714 27.1141 290009............................ 1.8521 1.0984 26.9020 27.6011 29.8019 28.1837 290010............................ 1.0895 1.1416 25.4598 23.8733 23.9654 24.4204 290012............................ 1.3288 1.1416 25.8036 27.2675 31.0843 28.0502 290016............................ 1.1453 0.9079 22.5111 25.1726 26.1925 24.6281 290019............................ 1.3967 1.0805 25.1684 27.2484 28.6158 27.0192 290020 h.......................... 0.9611 1.1416 24.2373 21.3094 21.6993 22.1469 290021............................ 1.7247 1.1416 26.2510 28.3837 33.2116 29.2014 290022............................ 1.5056 1.1416 27.5364 29.8144 29.4422 28.9634 290027............................ 0.9165 0.9079 13.5031 17.8850 15.1448 15.3083 290032............................ 1.3609 1.0984 27.5425 29.4164 31.7105 29.6070 290039............................ 1.5069 1.1416 28.7599 29.6801 31.2941 30.0435 290041............................ 1.3172 1.1416 28.6294 30.1346 33.9878 31.0661 290045............................ 1.5063 1.1416 26.5644 26.9319 30.9612 28.4883 300001............................ 1.5520 1.0668 27.1312 29.4130 27.5032 28.0073 300003............................ 2.0702 1.0668 26.7859 27.8059 33.3560 29.3633 300005............................ 1.4218 1.0668 22.8163 25.1869 25.5583 24.5574 300006............................ 1.1092 1.0668 22.0187 20.6787 23.3200 21.9532 300007............................ 1.2560 1.0903 23.6919 25.3125 26.8347 25.3232 300010............................ 1.2942 1.0668 24.6295 26.9346 27.5028 26.4641 300011............................ 1.3026 1.0903 25.0979 27.3325 28.4044 26.9920 300012............................ 1.3884 1.0903 26.3914 28.4234 30.5198 28.4955 300013............................ 1.0657 1.0668 21.3397 23.1529

* 22.1888 300014............................ 1.2155 1.0668 23.7144 25.5059 27.5151 25.6846 300015............................ 1.0860 1.0668 24.4869 24.0620

* 24.2732 300016............................

*** 1.0668 18.9756 24.5498

* 21.6922 300017............................ 1.2121 1.0668 26.1104 28.3959 29.6957 28.0967 300018............................ 1.3882 1.0668 25.7851 28.0308 29.7209 27.9654 300019............................ 1.2223 1.0903 23.8076 25.3845 25.9656 25.1005 300020............................ 1.1875 1.0903 24.8189 26.8402 28.6723 26.8622 300022............................ 1.1118 1.0668 22.3918 23.5948 24.4048 23.4922 300023............................ 1.4230 1.0668 24.9992 25.4873 28.6309 26.4774 300024............................ 1.2139 1.0668 22.4883 23.9205

* 23.2005 300029............................ 1.7645 1.0668 24.5772 26.9484 29.0806 26.9920 300034............................ 2.0805 1.0903 26.9093 28.5375 29.7484 28.4471 310001............................ 1.7701 1.3191 30.1786 33.9360 35.3612 33.2483 310002............................ 1.8371 1.3191 33.9058 35.4567 37.3461 35.5944 310003............................ 1.2057 1.3191 30.4234 31.1040 32.8935 31.5180 310005............................ 1.3245 1.2192 26.0227 27.5690 29.0084 27.5943 310006............................ 1.2346 1.3191 25.9000 27.0436 27.4545 26.7958 310008............................ 1.3149 1.3191 28.0970 29.5857 31.2579 29.6725 310009............................ 1.2458 1.3191 24.6353 29.7760 32.7384 29.0885 310010............................ 1.2847 1.0837 26.7889 25.3139 28.5852 26.9172 310011............................ 1.2662 1.1031 26.1586 28.5241 30.8612 28.5543 310012............................ 1.6801 1.3191 31.1705 33.1622 34.6882 33.0545 310013............................ 1.3585 1.3191 25.0951 28.5016 30.6248 28.1586 310014............................ 1.8139 1.0607 29.1931 32.7222 29.7204 30.4762 310015............................ 1.8694 1.3191 30.1767 32.4980 36.4776 33.0707 310016............................ 1.3353 1.3191 25.7368 28.9788 33.9862 29.9150 310017............................ 1.3378 1.2192 25.2636 28.0930 30.9233 28.1646 310018............................ 1.1407 1.3191 25.9108 26.9399 30.3381 27.8107 310019............................ 1.6282 1.3191 26.8663 31.0524 29.6592 29.1388 310020............................ 1.5855 1.3191 25.0147 29.3392 30.6722 28.2107 310021............................ 1.6207 1.0837 29.4003 29.6308 31.3410 30.1313 310022............................ 1.2275 1.0607 26.7487 26.1914 28.2024 27.0808 310024............................ 1.3520 1.2192 26.9499 27.5278 30.9171 28.3714 310025............................ 1.2683 1.3191 26.8719 27.7960 31.1274 28.7415 310026............................ 1.2192 1.3191 24.6697 25.3970 27.5171 25.9064 310027............................ 1.2914 1.2192 22.1935 27.0982 53.3590 32.8604

[[Page 23517]]

310028............................ 1.2218 1.2192 25.7246 29.1101 31.3849 28.7946 310029............................ 1.8622 1.0607 25.9606 29.1439 30.7707 28.6905 310031............................ 2.9677 1.1301 29.5581 30.2345 33.9685 31.2972 310032............................ 1.2894 1.0652 25.7088 27.8754 27.5232 27.0476 310034............................ 1.3320 1.1301 26.5224 27.8517 29.9162 28.1036 310037............................ 1.3242 1.3191 30.1264 32.1471 35.0329 32.5209 310038............................ 1.9813 1.3191 32.3865 32.1977 33.4822 32.7188 310039............................ 1.2457 1.1301 24.6045 27.1054 28.8292 26.9337 310040............................ 1.3638 1.3191 27.4041 28.0068 34.1113 29.8744 310041............................ 1.2679 1.1301 26.8145 29.7335 32.8085 29.8863 310042............................ 1.1514 1.3191 26.9695 29.0207 30.7358 28.9101 310044............................ 1.3163 1.0837 25.1618 27.7752 31.3206 28.1678 310045............................ 1.5833 1.3191 31.7376 32.6359 34.0151 32.8526 310047............................ 1.3107 1.1618 26.1353 28.3415 32.8380 29.2921 310048............................ 1.3562 1.2192 27.4050 28.4715 30.2025 28.7345 310049............................

***

* 26.5332 32.7666 27.8564 27.2897 310050............................ 1.2751 1.2192 25.3772 27.2276 27.3033 26.7397 310051............................ 1.3708 1.2192 29.2386 32.0113 33.7168 31.6981 310052............................ 1.3032 1.1301 27.0324 28.1498 30.8036 28.6341 310054............................ 1.2802 1.3191 28.1880 30.6905 34.1860 31.0476 310057............................ 1.3058 1.0607 26.3903 26.4606 29.5221 27.5782 310058............................ 1.0940 1.3191 28.1753 26.4816 28.0815 27.5746 310060............................ 1.2669 1.0607 22.1914 23.2146 25.1575 23.5782 310061............................ 1.2605 1.0607 24.9678 27.5400 28.2129 26.9521 310063............................ 1.3317 1.2192 25.9868 28.3457 31.4884 28.5345 310064............................ 1.5192 1.1618 27.8388 29.5979 33.4440 30.4173 310067............................

*** 1.2192 26.3624 26.8068

* 26.5479 310069............................ 1.2630 1.0652 25.7690 27.9656 28.1681 27.3281 310070............................ 1.3475 1.3191 30.1917 32.1806 33.2310 31.9325 310072............................

***

* 25.3145 26.3520

* 25.8709 310073............................ 1.7716 1.1301 28.8791 29.6611 32.0329 30.2191 310074............................ 1.2859 1.3191 27.6789 28.4361 29.4834 28.5348 310075............................ 1.2656 1.1301 25.7726 26.2479 31.6870 27.8786 310076............................ 1.5940 1.3191 32.4533 34.9428 36.4280 34.6292 310077............................ 1.6607 1.3191 28.7352 30.7465 32.6644 30.7450 310078............................ 1.2963 1.3191 24.7753 26.9589 29.8014 27.2209 310081............................ 1.2485 1.0607 24.6083 26.4259 26.6136 25.9041 310083............................ 1.2961 1.3191 25.2465 24.6563 28.2392 25.9836 310084............................ 1.2192 1.1301 27.3680 29.9437 32.9001 30.0920 310086............................ 1.2110 1.0607 25.2751 27.3601 29.3058 27.3522 310088............................ 1.1766 1.1618 23.7846 25.5274 26.4966 25.2810 310090............................ 1.2599 1.2192 25.3640 27.1661 30.8941 27.8574 310091............................ 1.1909 1.0652 25.6405 27.1115 27.7204 26.8559 310092............................ 1.3547 1.0837 23.2226 25.7071 29.4999 26.1525 310093............................ 1.1809 1.3191 24.6942 25.8727 28.0401 26.2654 310096............................ 2.0766 1.3191 28.4705 30.3675 34.4275 31.1262 310105............................ 1.2212 1.3191 28.7333 30.9968 31.9769 30.6308 310108............................ 1.3809 1.1301 24.9090 29.1548 30.1002 28.0512 310110............................ 1.2871 1.0837 26.4175 27.8707 31.2164 28.8347 310111............................ 1.1936 1.1301 26.2496 28.8692 30.7475 28.7020 310112............................ 1.2335 1.1301 27.8796 28.9928 30.4192 29.1502 310113............................ 1.2365 1.1301 25.9143 27.5203 29.6079 27.7501 310115............................ 1.2658 1.0607 24.5413 26.2803 29.6020 26.9083 310116............................ 1.2404 1.3191 25.1189 26.6287 25.6976 25.7970 310118............................ 1.2786 1.3191 28.0517 28.1238 28.8797 28.3510 310119............................ 1.7690 1.3191 34.7468 35.6786 37.7876 36.1340 310120............................ 1.1565 1.2192 24.7078 27.2010 31.4110 27.6263 320001............................ 1.4765 0.9696 23.0290 26.1962 26.9434 25.3673 320002............................ 1.3821 1.0908 26.7332 28.6963 30.5158 28.6521 320003............................ 1.1105 0.8649 20.7939 22.3911 28.1402 23.4549 320004............................ 1.2830 0.8649 19.4799 24.0362 24.9481 23.1709 320005............................ 1.4230 0.9558 22.1677 21.2164 23.8264 22.4376 320006............................ 1.3163 1.0163 21.1222 22.5615 24.2812 22.6734 320009............................ 1.5090 0.9696 21.5870 24.4237 22.8293 22.9608 320011............................ 1.1653 0.8649 20.7714 23.1539 24.2279 22.7686 320013............................ 1.1462 1.0163 19.4487 27.8671 28.9276 24.8284 320014............................ 1.1040 0.8649 19.7656 26.7112 24.5310 23.5594

[[Page 23518]]

320016............................ 1.1520 0.8649 19.9326 21.7001 23.5040 21.7285 320017............................ 1.2523 0.9696 22.5460 23.6861 25.0286 23.7296 320018............................ 1.4565 0.8649 21.4650 23.0915 23.2360 22.6002 320019............................ 1.5397 0.9696 26.6900 31.2250 31.5192 29.7045 320021............................ 1.6254 0.9696 21.0913 28.5620 27.2357 25.1851 320022............................ 1.0969 0.8649 20.7919 22.1492 23.7160 22.2284 320030............................ 1.0284 0.8649 16.8696 18.0990 22.1971 18.9458 320033............................ 1.1545 1.0163 24.2703 24.1185 27.6393 25.3263 320037............................ 1.1552 0.9696 19.6466 21.6080 23.3999 21.6108 320038............................ 1.1959 0.8649 19.2962 21.2181 20.1533 20.2270 320046............................ 1.1718 0.8649 21.5915 22.9114 24.3534 22.9610 320063............................ 1.2785 0.9593 20.7804 24.9141 24.4696 23.4155 320065............................ 1.0973 0.9593 19.9012 21.6189 26.6603 22.8070 320067............................ 0.8271 0.8649 13.9459 20.4431 23.7745 19.8406 320069............................ 1.0924 0.8649 18.5375 19.7296 20.9167 19.7352 320074............................ 1.1664 0.9696 28.3086 35.5980 22.2175 28.2084 320079............................ 1.1142 0.9696 21.9090 23.8092 25.2105 23.6814 320083............................ 2.5985 0.9696 20.6771

* 28.2114 23.7546 320084............................ 1.0974 0.8649

*

* 17.2511 17.2511 320085............................ 1.6090 0.8649

*

* 24.8752 24.8752 330001............................

*** 1.3191 30.8509 31.3735 33.4718 31.9148 330002............................ 1.4447 1.3191 28.0882 29.3459 31.1924 29.5603 330003............................ 1.2641 0.8565 20.2744 21.6506 22.9945 21.6443 330004............................ 1.2725 1.0576 24.3703 23.9959 26.0445 24.8414 330005............................ 1.5973 0.8888 24.3578 25.9287

* 25.1198 330006............................ 1.2917 1.3191 28.3904 29.7509 31.5370 29.8730 330008............................ 1.1113 0.8888 20.6816 21.3269 21.8198 21.2850 330009............................ 1.2845 1.3191 33.3605 35.8367 35.4986 34.8796 330010............................

***

* 19.8211 17.9178 19.6920 19.0804 330011............................ 1.2998 0.8588 19.8035 20.3641 21.8008 20.6687 330013............................ 2.1105 0.8565 21.2063 23.9070 24.3512 23.1632 330014............................ 1.3351 1.3191 32.0824 35.4053 38.8123 35.4565 330016............................ 0.9933 0.8220 18.1603 18.9388 28.4392 20.9735 330019............................ 1.2932 1.3191 31.9042 32.3413 34.7814 33.0323 330023 \2\........................ 1.5678 1.0767 29.4538 29.2669 29.8943 29.5534 330024............................ 1.7206 1.3191 35.3598 36.5648 38.8643 36.8845 330025............................ 1.0421 0.8888 18.7663 19.7561 20.2775 19.6152 330027............................ 1.4553 1.3191 34.1281 35.1325 39.0717 36.0189 330028............................ 1.3838 1.3191 31.8452 33.5312 34.2709 33.2330 330029............................ 0.4208 0.8888 18.4354 18.6623 19.1589 18.7332 330030............................ 1.2550 0.9117 22.0574 22.4368 22.9937 22.4866 330033............................ 1.2667 0.8220 18.6316 21.3762 22.5681 20.8260 330036............................ 1.1360 1.3191 27.0970 27.6813 28.9409 27.8674 330037............................ 1.0926 0.9117 18.3557 19.6385 20.6904 19.5992 330041............................ 1.1922 1.3191 34.5461 36.2481 36.0286 35.6239 330043............................ 1.2957 1.2781 31.7873 34.1039 34.7480 33.5850 330044............................ 1.2690 0.8313 22.0465 23.1450 23.8719 23.0325 330045............................ 1.3308 1.2781 30.9046 34.4956 36.1749 33.9185 330046............................ 1.4018 1.3191 41.6759 42.0900 44.8494 42.8629 330047 h.......................... 1.1968 0.8565 20.1646 21.1244 24.0678 21.8925 330049............................ 1.3533 1.0767 24.7766 25.7022 29.2904 26.5366 330053............................ 1.0847 0.9117 18.1728 19.6807 18.5290 18.7942 330055............................ 1.6314 1.3191 34.9709 35.1393 38.4839 36.2207 330056............................ 1.4539 1.3191 32.0982 32.9295 37.8444 34.2883 330057............................ 1.6969 0.8565 20.9282 22.6519 24.4680 22.6890 330058............................ 1.3165 0.9117 19.2916 19.5520 20.8234 19.9138 330059............................ 1.5179 1.3191 36.4176 38.1019 39.7386 38.0767 330061............................ 1.2264 1.3191 28.6725 32.7427 33.2848 31.6301 330062............................ 1.1819 0.9204 20.0222 21.4270 21.0464 20.8258 330064............................ 1.1415 1.3191 36.0976 38.5719 36.6153 37.0956 330065............................ 1.0281 0.8888 20.5958 21.9192 23.9128 22.1517 330066............................ 1.3120 0.8565 20.9990 23.0916 24.7941 23.0025 330067 \2\........................ 1.4150 1.0767 24.8927 34.8416 26.4243 28.0084 330072............................ 1.3818 1.3191 32.9665 32.7905 36.4336 34.0607 330073............................ 1.1228 0.9117 18.4162 19.0781 20.1490 19.1772 330074............................ 1.3126 0.9117 21.7299 20.2874 21.4274 21.1093 330075............................ 1.1656 0.9595 19.9781 22.0240 22.4188 21.4854

[[Page 23519]]

330078............................ 1.4256 0.8888 20.8379 22.7762 23.3786 22.3586 330079............................ 1.3180 0.8220 21.1153 22.1064 22.5237 21.9214 330080............................ 1.1477 1.3191 33.5537 36.1171 39.1724 36.3260 330084............................ 1.0829 0.8220 19.2135 22.6365 21.5455 21.1058 330085............................ 1.1913 0.9315 21.8271 23.2927 23.9568 23.0352 330086............................ 1.3193 1.3191 27.1585 28.8425 29.1784 28.3884 330088............................ 1.0442 1.2781 29.5181 31.2631

* 39.0244 330090............................ 1.4373 0.8276 20.9327 22.7721 23.6174 22.4292 330091............................ 1.3675 0.8888 22.9396 22.5796 23.1637 22.8973 330094............................ 1.2532 0.8904 21.3659 22.1495 23.0001 22.1769 330095............................

***

* 28.9794 28.9914 31.9872 29.7944 330096............................ 1.0690 0.8220 21.1648 22.4895 22.0337 21.9119 330097............................ 1.1327 0.8220 18.6291 19.2233 20.2158 19.3250 330100............................ 1.0066 1.3191 31.5775 32.8406 34.4621 32.9762 330101............................ 1.8242 1.3191 38.4810 39.2601 38.7468 38.8311 330102............................ 1.3460 0.8888 23.5254 23.6141 24.8184 23.9846 330103............................ 1.0963 0.8220 17.9017 18.8763 21.1452 19.3116 330104............................ 1.3563 1.3191 36.8451 33.7556 32.8818 34.4566 330106............................ 1.7244 1.2781 38.7822 39.8558 41.2202 39.9816 330107............................ 1.2325 1.2781 29.1958 31.8528 31.3888 30.7790 330108............................ 1.1108 0.8276 20.2536 21.4680 22.2607 21.3131 330111............................ 1.0397 0.8888 17.7020 17.6185 20.9387 18.7250 330114............................

***

* 19.2566

*

* 19.2566 330119............................ 1.7468 1.3191 34.6591 36.5873 39.1114 36.7610 330121............................ 0.9116 0.8220 17.9757 19.7388 23.9397 20.5934 330122............................

***

* 25.6500 26.3849

* 26.0090 330125............................ 1.7658 0.9117 22.8078 24.6945 26.6379 24.8334 330126............................ 1.2826 1.0767 27.7155 28.8299 31.6370 29.4715 330127............................ 1.2655 1.3191 42.2836 43.7479 44.4667 43.5141 330128............................ 1.1790 1.3191 32.7050 34.5289

* 33.6278 330132............................ 1.0730 0.8220 16.0311 16.3088 17.4946 16.8474 330133............................ 1.3118 1.3191 35.3136 44.0704 36.6962 38.2248 330135............................ 1.2237 1.0767 25.6504 26.9969 29.0837 27.3649 330136............................ 1.4654 0.9315 21.4225 22.5447 24.2010 22.7506 330140............................ 1.7896 0.9595 21.1787 23.5774 25.7573 23.5011 330141............................ 1.3034 1.2781 29.3283 30.6616 34.8902 31.6934 330144............................ 1.0332 0.8220 17.3920 20.1805 20.9935 19.3948 330148............................ 1.0266 0.8313 17.6560 18.5443

* 18.0744 330151............................ 1.1030 0.8220 16.4028 17.6782 19.1841 17.7056 330152............................ 1.3177 1.3191 32.3332 32.0616 36.5136 33.6447 330153............................ 1.7022 0.8565 21.2843 21.9935 23.7172 22.3124 330157............................ 1.3678 0.9315 23.5522 23.6939 24.9042 24.0644 330158............................ 1.5489 1.3191 32.7159 33.0067 32.2990 32.6514 330159............................ 1.3811 0.9595 22.5580 24.1916 28.8391 25.0788 330160............................ 1.5392 1.3191 32.1266 34.0373 34.1960 33.4347 330162............................ 1.2612 1.3191 29.6042 31.3812 32.1783 31.0913 330163............................ 1.2015 0.8888 21.1517 22.4644 24.0200 22.5391 330164............................ 1.4792 0.9117 23.5427 24.4306 28.8481 25.6753 330166 h.......................... 1.0593 0.8220 18.4262 18.8777 19.4360 18.9008 330167............................ 1.7665 1.2781 30.9667 33.7365 34.4405 33.1152 330169............................ 1.4095 1.3191 36.2725 38.3498 39.3361 37.9349 330171............................ 1.1728 1.3191 25.9946 27.7810 30.0122 27.7871 330175............................ 1.1137 0.8220 20.4628 21.1944 22.2067 21.3007 330177............................ 0.9453 0.8220 19.0005 20.1850 19.6100 19.6031 330180............................ 1.2265 0.8565 19.8951 21.9641 22.1920 21.3178 330181............................ 1.3091 1.3191 37.1218 35.8846 38.5351 37.1836 330182............................ 2.3204 1.3191 35.2416 36.3831 39.6038 37.1311 330184............................ 1.4141 1.3191 30.7479 33.2843 34.4044 32.7893 330185............................ 1.2671 1.2781 28.9787 31.0179 32.3466 30.8714 330188............................ 1.2490 0.8888 21.1196 22.6803 23.9210 22.6030 330189............................ 0.9765 0.8565 19.0726 19.2538 21.6229 19.9266 330191............................ 1.2880 0.8565 20.9392 22.3719 24.0232 22.4577 330193............................ 1.2567 1.3191 36.2427 36.9866 37.1807 36.8214 330194............................ 1.7888 1.3191 38.5372 39.9177 43.9910 40.8421 330195............................ 1.7407 1.3191 36.4249 38.6867 40.0206 38.4696 330196............................ 1.2724 1.3191 31.1915 32.5883 33.2171 32.3484 330197............................ 1.1300 0.8220 20.8386 22.3117 23.4291 22.2164

[[Page 23520]]

330198............................ 1.3527 1.2781 25.3622 29.5359 30.5485 28.5487 330199............................ 1.1121 1.3191 34.1354 32.7870 35.0059 33.9687 330201............................ 1.6454 1.3191 29.3745 33.3215 39.3682 33.7813 330202............................ 1.2540 1.3191 30.7990 34.3545 35.0804 33.5414 330203............................ 1.4787 0.9595 24.7422 26.2459 26.5882 25.8191 330204............................ 1.3191 1.3191 30.3699 30.3273 37.6849 32.8372 330205............................ 1.2677 1.0767 29.0622 30.0101 32.1617 30.4707 330208............................ 1.1879 1.3191 30.6158 28.2667 29.6282 29.4819 330209............................ 1.1738 1.0767 27.7071 28.7213 29.7988 28.7477 330211............................ 1.1533 0.8220 20.8224 21.1094 22.9966 21.6469 330212............................

*** 1.3191 24.9434 27.0585 27.2232 26.1185 330213............................ 1.1308 0.8220 20.7967 21.7208 22.5191 21.6931 330214............................ 1.9065 1.3191 32.7647 33.7670 37.8500 34.8451 330215............................ 1.3146 0.8313 19.9226 20.6343 22.5715 21.0552 330218............................ 1.0371 0.9595 20.6012 21.4095 24.1106 22.0618 330219............................ 1.6407 0.8888 28.7448 27.7400 29.3803 28.6143 330221............................ 1.3773 1.3191 34.9345 34.7033 36.5539 35.4233 330222............................ 1.2919 0.8565 23.5491 25.9825 23.9746 24.4778 330223............................ 1.0310 0.8220 18.8253 18.4291 19.4229 18.9058 330224............................ 1.2912 0.9260 22.7847 23.9379 25.7396 24.1533 330225............................ 1.1790 1.2781 29.1744 28.9952 29.2719 29.1527 330226............................ 1.3067 0.9117 23.5405 23.4783 21.8977 22.8832 330229 h.......................... 1.1699 0.8424 18.5590 19.5670 20.6095 19.5838 330230............................ 0.9941 1.3191 32.5997 32.1101 33.3175 32.6586 330231............................ 0.9977 1.3191 30.2184 33.9324 37.0175 33.7403 330232............................ 1.1923 0.8565 21.1277 21.4765 24.2810 22.2924 330233............................ 1.4170 1.3191 39.5133 41.9968 45.5132 42.4372 330234............................ 2.2593 1.3191 37.7135 36.8500 40.6314 38.3961 330235............................ 1.1320 0.9315 21.4643 22.1217 23.3866 22.3225 330236............................ 1.4277 1.3191 31.8491 32.9391 35.6347 33.4921 330238............................ 1.2507 0.9117 18.3846 19.2407 20.8639 19.5443 330239 h.......................... 1.2261 0.8424 19.7561 20.4936 21.5397 20.5927 330240............................ 1.2179 1.3191 37.3866 40.7478 36.7910 38.3109 330241............................ 1.8763 0.9595 26.7598 27.7213 29.0882 27.8974 330242............................ 1.2925 1.3191 30.5172 32.2178 46.0013 35.2529 330245............................ 1.9001 0.8313 20.2037 21.6857 22.7032 21.5626 330246............................ 1.3295 1.2781 31.8857 31.6763 34.6329 32.7279 330247............................ 1.0067 1.3191 25.6063 32.1733 32.2300 29.8298 330249............................ 1.2019 0.9595 19.1469 21.4345 22.9834 21.2588 330250............................ 1.2791 0.9306 22.1272 23.0641 25.1664 23.4900 330259............................ 1.4142 1.2781 27.4131 30.0488 31.9495 29.9063 330261............................ 1.2516 1.3191 30.4771 30.9356 30.7942 30.7386 330263............................ 0.9776 0.8220 20.0831 20.8456 22.4675 21.1560 330264............................ 1.2367 1.0767 26.3652 28.1501 30.0139 28.1122 330265............................ 1.2729 0.9117 18.2547 19.9414 20.4635 19.5583 330267............................ 1.4649 1.3191 29.0499 30.3709 31.5478 30.3522 330268............................ 0.9506 0.8565 18.7991 18.9142 20.9720 19.5863 330270............................ 2.0316 1.3191 36.5976 38.2605 52.4880 42.6074 330273............................ 1.4020 1.3191 28.8548 29.5106 30.3976 29.6096 330276............................ 1.1013 0.8220 20.7973 21.7826 22.2353 21.6210 330277............................ 1.1667 0.9204 21.8866 25.1438 25.3582 24.1682 330279............................ 1.4462 0.8888 23.8793 23.4816 24.9772 24.1439 330285............................ 1.9363 0.9117 26.0446 27.1260 27.9018 27.0364 330286............................ 1.3657 1.2781 31.1344 32.3244 33.3377 32.3174 330290............................ 1.7357 1.3191 35.5617 36.3764 36.9981 36.3009 330293............................

***

* 17.6506 19.0290

* 18.3452 330304............................ 1.2821 1.3191 31.1146 33.4431 34.5111 33.0739 330306............................ 1.4608 1.3191 30.4426 30.7551 35.6640 32.2831 330307............................ 1.2103 0.9855 23.8583 25.4128 27.5699 25.6624 330314............................ 1.2270 1.2781 26.2954 26.0150 25.5597 25.9594 330316............................ 1.2997 1.3191 33.7857 33.1512 34.8623 33.9322 330327............................

***

* 19.3465

*

* 19.3465 330332............................ 1.2570 1.2781 30.5104 31.8389 33.0652 31.9293 330333............................

*** 1.2781 29.7725 33.7637 26.1917 29.6723 330336............................

***

* 32.9548

*

* 32.9548 330339............................ 0.8062 0.8565 20.8424 22.2812 22.6569 21.9390 330340............................ 1.1756 1.2781 29.8140 31.4322 33.5504 31.6312

[[Page 23521]]

330350............................ 1.4934 1.3191 35.5656 39.3541 36.6250 37.1672 330353............................ 1.1504 1.3191 35.6821 38.6962 37.6549 37.3737 330357............................ 1.2908 1.3191 36.5461 34.3965 35.5975 35.5017 330372............................ 1.2505 1.2781 28.2490 30.1505 32.6721 30.3998 330385............................ 1.1112 1.3191 44.3387 42.6671 34.7820 40.7280 330386............................ 1.2069 1.0576 25.2064 25.9228 27.9943 26.4367 330389............................ 1.9214 1.3191 32.2112 34.7552 34.7669 33.9210 330390............................ 1.2676 1.3191 32.7450 33.2628 36.0573 33.8898 330393............................ 1.7382 1.2781 33.0953 34.8213 34.8095 34.2742 330394............................ 1.6408 0.8588 21.3678 23.3505 25.2229 23.3324 330395............................ 1.3921 1.3191 32.1089 35.4619 39.6666 35.4994 330396............................ 1.2486 1.3191 31.2429 32.5345 35.0297 32.9828 330397............................ 1.3537 1.3191 40.0884 34.5110 38.4741 37.5361 330399............................ 1.1709 1.3191 32.1248 33.6753 32.3688 32.7392 330401............................ 1.3161 1.2781 33.8633 35.7435 40.5332 36.7926 330402............................ 0.7916 0.9260

* 21.3302

* 21.3302 330403............................

*** 0.9117

*

* 23.1887 23.1887 340001............................ 1.4809 0.9717 21.6113 23.2436 25.0041 23.2441 340002............................ 1.7358 0.9312 24.0145 25.1099 27.3349 25.5169 340003............................ 1.0930 0.8570 20.8205 21.5562 23.3066 21.9251 340004............................ 1.4023 0.9020 23.3756 24.2055 25.4474 24.3851 340005............................ 0.9977 0.8570 20.8150 22.9830 22.3814 22.0177 340007............................

*** 0.9133 19.5208 21.1519

* 20.3174 340008............................ 1.0820 0.9585 22.7338 24.2089 26.6314 25.0622 340010............................ 1.3214 0.9476 21.3024 23.1349 24.5666 23.0280 340011............................ 1.0509 0.8570 18.1926 18.1843 19.9484 18.7756 340012............................ 1.2823 0.8570 19.6350 22.0583 22.7189 21.4818 340013............................ 1.2354 0.9585 21.0066 22.4787 23.0261 22.1688 340014............................ 1.5332 0.9020 22.6757 24.4831 25.1872 24.1069 340015 h.......................... 1.3596 0.9717 24.3410 24.3870 26.2276 25.0387 340016............................ 1.2110 0.8570 20.2859 22.7574 23.0359 22.0228 340017............................ 1.2648 0.9312 21.7083 22.8879 23.8229 22.8228 340018............................ 1.1294 0.9183 17.3480 20.3840 23.7243 20.2881 340019............................ 0.9618 0.9020 16.7901 17.8768

* 17.3292 340020............................ 1.1895 0.8570 21.3385 24.1955 23.7995 23.1233 340021............................ 1.2956 0.9585 22.9208 23.6884 26.0995 24.2587 340022............................

*** 0.8570 19.9078

*

* 19.9078 340024............................ 1.1553 0.8570 20.4906 21.2671 22.2521 21.3515 340025............................ 1.2401 0.9312 20.2864 20.9915 21.2276 20.8493 340027............................ 1.1523 0.9414 21.0975 22.6107 23.6326 22.4564 340028............................ 1.5451 0.9426 22.2028 24.6836 26.3298 24.3471 340030............................ 2.0360 1.0260 26.7753 27.4664 29.3043 27.9060 340032............................ 1.3877 0.9717 23.2204 24.8031 26.7475 25.0122 340035............................ 1.0281 0.8570 16.4821 21.2407 23.5476 20.1377 340036............................ 1.1712 0.9709 20.8313 22.2089 25.2077 22.9528 340037............................ 1.0024 0.8570 21.9524 22.5089 21.6411 22.0344 340038............................ 1.1871 0.8570 13.9936 14.0203 14.0713 14.0327 340039............................ 1.2862 0.9585 24.8246 25.6605 27.1275 25.9204 340040............................ 1.9063 0.9414 22.4777 24.1523 26.3325 24.3631 340041............................ 1.2302 0.8931 17.6319 23.0497 23.4891 21.2362 340042............................ 1.0903 0.8570 21.1107 22.1107 23.0236 22.0702 340044............................ 0.9395 0.8570 18.2154 21.7089 22.8948 20.8194 340045............................ 0.9726 0.8570 17.4066 14.5004 23.1918 18.0750 340047............................ 1.8926 0.9020 22.5199 25.3727 25.0605 24.3496 340049............................ 2.0329 1.0260 21.2734 22.3082 30.4827 24.7548 340050............................ 1.0881 0.9193 20.3262 21.4511 24.2533 22.0481 340051............................ 1.2288 0.8931 20.3057 21.9069 23.4091 21.9456 340053............................ 1.5911 0.9717 24.9768 26.9361 27.7261 26.5947 340055............................ 1.2318 0.8931 23.2990 24.3728 24.1057 23.9407 340060............................ 1.0613 0.9133 20.8077 22.4303 22.8657 22.0570 340061............................ 1.8009 1.0260 25.1081 26.6657 27.5594 26.4994 340064............................ 1.0787 0.8570 19.4523 22.3631 22.9143 21.5916 340065............................ 1.1887 0.8570 20.3296 20.8413

* 20.5941 340067............................

***

* 22.2565

*

* 22.2565 340069............................ 1.8692 0.9993 24.4650 27.5045 27.4473 26.5163 340070............................ 1.2588 0.8902 22.2605 23.6045 24.9033 23.6142 340071............................ 1.1237 0.9476 19.9561 22.1854 25.4537 22.5747

[[Page 23522]]

340072............................ 1.1835 0.8570 19.2773 21.3320........................... 22.6474 21.0148 340073............................ 1.3746 0.9993 26.6829 29.4189 30.2076 28.9147 340075............................ 1.2112 0.8931 23.2904 24.1297 26.0225 24.4391 340084............................ 1.1875 0.9717 20.8175 21.3227 21.2580 21.1447 340085 h.......................... 1.1572 0.9133 21.7112 23.0890 23.9793 22.8869 340087............................ 1.1889 0.8570 17.8215 18.4202 22.0070 19.3351 340088............................ 1.3425 0.8570 22.8687 24.3299

* 23.5994 340090............................ 1.2312 0.9709 20.3261 21.7173 23.4542 21.9222 340091............................ 1.5335 0.9020 23.1430 24.9411 25.8266 24.6682 340096 h.......................... 1.1818 0.9133 22.1174 23.6345 25.2169 23.6523 340097............................ 1.1843 0.8570 20.8690 22.5775 24.2127 22.5886 340098............................ 1.4546 0.9717 24.2262 25.4823 27.3308 25.7030 340099............................ 1.1671 0.8570 17.5114 20.0178 20.3683 19.3181 340104............................ 0.8280 0.8570 12.9949 14.3252 15.7521 14.3947 340106............................ 1.0782 0.8570 20.1076 22.6979 22.4894 21.8047 340107............................ 1.1794 0.8924 21.0960 22.5583 22.9698 22.2242 340109............................ 1.3188 0.8841 20.4341 22.3826 23.4419 22.1467 340113............................ 1.8523 0.9717 25.0729 26.0776 28.2546 26.5138 340114............................ 1.6227 0.9993 19.9142 25.4533 26.6813 23.7911 340115............................ 1.5773 0.9993 23.8284 25.1907 25.0212 24.7040 340116............................ 1.7011 0.8931 23.9643 26.1641 25.3213 25.1777 340119............................ 1.1252 0.9717 21.2239 22.4821 24.2287 22.6894 340120............................ 1.0360 0.8570 19.9860 21.8548 23.0916 21.7078 340121............................ 1.0374 0.9580 19.9409 20.3701 21.7576 20.7129 340123............................ 1.1858 0.9133 22.3711 23.1879 26.1083 23.9306 340124............................ 1.0791 0.9476 17.5691 18.3866 20.8018 18.8482 340126 h.......................... 1.2269 0.9709 21.4271 23.5405 25.0189 23.3764 340127............................ 1.1717 0.9993 22.9672 24.6096 25.4786 24.4245 340129............................ 1.2519 0.9585 22.3260 24.1356 25.4902 24.1365 340130............................ 1.3631 0.9717 22.7687 23.0937 25.2941 23.7854 340131............................ 1.5298 0.9414 24.1370 25.2989 27.9358 25.8415 340132............................ 1.1782 0.8570 17.8771 20.4222 21.3521 19.8892 340133............................ 0.9920 0.8570 23.1444 22.1588 22.5558 22.6188 340137............................ 0.9669 0.8931 33.1751 29.9903 21.0642 28.4915 340138............................ 0.8241 0.9993 29.5286 27.4767

* 28.5643 340141............................ 1.6446 0.9580 24.2033 24.8132 27.3355 25.5266 340142............................ 1.1805 0.8570 20.4320 22.1298 22.9907 21.8836 340143............................ 1.4579 0.8931 23.0416 24.8904 25.3633 24.4002 340144............................ 1.2329 0.9585 25.4598 25.6538 27.2686 26.1330 340145............................ 1.2957 0.9585 21.8120 23.7028 23.7131 23.0768 340146............................ 1.0505 0.8570 20.7252 18.8354

* 19.6880 340147............................ 1.2003 0.9476 22.6057 23.9998 25.4534 24.0568 340148............................ 1.3349 0.9020 20.8156 22.4205 23.5880 22.2985 340151............................ 1.1033 0.8570 19.2593 22.2613 22.0052 21.1161 340153............................ 1.9092 0.9717 23.7426 25.7078 26.4896 25.3204 340155............................ 1.4341 1.0260 26.3663 28.8758 30.5006 28.6119 340158............................ 1.1034 0.9580 21.7489 23.4724 26.4849 23.8953 340159............................ 1.1424 1.0260 21.2983 22.1872 23.2991 22.2743 340160............................ 1.2720 0.8570 18.7569 19.1330 20.7525 19.5589 340166............................ 1.3649 0.9717 22.8349 25.7398 26.0557 24.9254 340168............................

*** 0.9580 16.8278 16.8076 17.3249 17.0046 340171............................ 1.1811 0.9717 25.9603 27.2074 28.2734 27.2246 340173............................ 1.2448 0.9993 23.7037 26.6128 27.5072 26.0994 340176............................

***

* 26.5277

*

* 26.5277 340178............................

*** 0.9426

*

* 28.7219 28.7219 350002............................ 1.7334 0.7519 20.4398 20.6474 22.0283 21.0339 350003............................ 1.1580 0.7278 21.0585 25.3076 21.8061 22.5764 350004............................

***

* 28.3773 27.5891

* 28.0246 350006............................ 1.6770 0.7278 19.7577 19.5870 19.4985 19.5737 350009............................ 1.0756 0.8778 20.2558 20.7014 23.0873 21.3437 350010............................ 1.0942 0.7278 17.2489 18.5682 19.1965 18.3109 350011............................ 1.9473 0.8778 21.9111 22.3896 23.1947 22.5594 350014............................ 0.9131 0.7278 16.1718 18.5360 17.7565 17.4777 350015............................ 1.6703 0.7519 18.5437 18.6381 19.7027 18.9716 350017............................ 1.4352 0.7278 19.1952 20.1943 21.0243 20.1512 350019 \2\........................ 1.6643 1.1521 21.3589 24.2382 32.2306 26.4362

[[Page 23523]]

350027............................ 1.0413 0.7278 17.6731 14.2262

* 15.5713 350030............................ 0.9514 0.7278 18.8822 19.2282 18.9978 19.0373 350043............................

***

* 18.8378 20.9732

* 19.9618 350058............................ 0.9697 0.7278 15.0196

*

* 15.0196 350070............................ 1.9138 0.8778

* 24.4464 25.2836 24.8833 360001............................ 1.3315 0.9604 22.2387 23.7750 23.9101 23.2970 360002............................ 1.1905 0.8788 20.7586 22.6923 24.5789 22.7274 360003............................ 1.8081 0.9604 24.4144 26.3180 27.5029 26.0650 360006............................ 1.9867 0.9848 24.0814 25.7041 27.9925 25.9633 360007............................

***

* 19.1315

*

* 19.1315 360009............................ 1.5653 0.9263 22.4076 23.2659 23.1012 22.9250 360010............................ 1.1890 0.8979 20.6290 22.0262 23.1178 21.9858 360011............................ 1.3220 0.9848 21.4293 22.4482 25.5340 23.0257 360012............................ 1.3639 0.9848 24.3618 25.5913 27.5470 25.9629 360013............................ 1.0996 0.9263 24.4232 25.1588 26.8129 25.4875 360014............................ 1.1458 0.9848 22.9372 23.8305 25.3861 24.0832 360016............................ 1.4261 0.9604 22.8430 24.6587 26.1283 24.5377 360017............................ 1.7197 0.9848 23.6181 25.4969 27.2910 25.5905 360018............................

***

* 29.9085

*

* 29.9085 360020............................ 1.6198 0.9197 21.5085 22.3795 24.4343 22.8262 360024............................

***

* 22.5356 24.0612 23.5499 23.3173 360025............................ 1.3926 0.9197 21.6676 23.6574 25.5633 23.7829 360026............................ 1.2762 0.9069 20.8825 22.3303 23.5898 22.2676 360027............................ 1.6543 0.9197 23.5907 24.7093 25.4894 24.6187 360029............................ 1.0888 0.9573 20.4924 20.8778 22.7785 21.4073 360031............................

***

* 24.3482 24.4324

* 24.3900 360032 h.......................... 1.1314 0.9263 21.1743 22.9759 23.2638 22.4807 360034............................ 1.1035 0.8788 21.5621 25.1366

* 23.3553 360035............................ 1.7092 0.9848 24.2433 25.6895 27.5220 25.8774 360036............................ 1.2117 0.9197 22.3567 25.0910 27.6094 25.0649 360037............................ 1.3504 0.9197 32.6245 25.1615 24.3982 26.6839 360038............................ 1.4244 0.9604 23.4855 24.8294 22.8009 23.7144 360039............................ 1.4713 0.9848 23.4642 22.5921 24.0218 23.3755 360040............................ 1.1396 0.8788 21.3307 22.8729 24.0942 22.7498 360041............................ 1.4432 0.9197 22.1352 23.2625 24.1080 23.2048 360044............................ 1.0612 0.8788 19.7212 20.4724 21.8411 20.6845 360046............................ 1.1923 0.9604 22.8425 23.8918 25.0775 23.9800 360047............................ 0.9522 0.8788 17.5885 17.1973 21.7248 18.9388 360048............................ 1.7400 0.9573 24.7150 27.2274 28.8107 26.8831 360049............................ 1.1298 0.9197 22.4939 24.2605 25.8367 24.2864 360051............................ 1.6658 0.9069 23.0658 25.1785 25.7556 24.7297 360052............................ 1.5398 0.9069 22.5005 23.3285 24.5405 23.5101 360054............................ 1.2774 0.8788 19.2884 20.3176 22.6157 20.7734 360055............................ 1.3753 0.8788 23.5586 25.1475 26.3112 24.9991 360056............................ 1.5352 0.9604 22.4475 23.4638 23.1024 22.9631 360058............................ 1.1220 0.8788 21.0768 22.7943 23.4434 22.4515 360059............................ 1.4684 0.9197 23.0775 25.5222 25.3516 24.6433 360062............................ 1.5341 0.9848 24.5746 26.8091 28.6518 26.7475 360064............................ 1.5318 0.8788 21.3424 22.8729 22.2393 22.1811 360065............................ 1.2012 0.9197 22.9727 24.0868 26.3036 24.5445 360066............................ 1.5310 0.9263 24.6806 25.2316 27.3362 25.7779 360068............................ 1.8254 0.9573 22.1110 23.7895 25.8414 23.9678 360069............................ 1.1231 0.9573 20.5349 25.7032 24.2444 23.4234 360070............................ 1.6302 0.8957 21.8228 23.1687 24.8863 23.3191 360071 h.......................... 1.2089 0.9263 21.4478 21.6176 22.0786 21.6950 360072............................ 1.3941 0.9848 21.3736 23.0464 24.1825 22.9257 360074............................ 1.2640 0.9573 22.2368 23.6172 24.9055 23.6214 360075............................ 1.1808 0.9197 23.8492 24.7610 26.8453 25.2573 360076............................ 1.3773 0.9604 22.5863 22.5943 25.9369 23.7285 360077............................ 1.5368 0.9197 23.3686 24.7086 25.6505 24.5864 360078............................ 1.2606 0.9197 23.3799 24.6821 26.1313 24.7447 360079............................ 1.7689 0.9604 25.9623 25.8762 26.0935 25.9804 360080............................ 1.0696 0.8788 18.7213 19.5436 20.8309 19.7267 360081............................ 1.3058 0.9573 22.1973 25.1439 27.5695 24.8761 360082............................ 1.3694 0.9197 25.2254 27.4264 27.1197 26.6255 360084............................ 1.5327 0.8957 23.3257 25.2059 25.8415 24.8445 360085............................ 2.0605 0.9848 24.6618 27.5792 29.0081 27.1579

[[Page 23524]]

360086............................ 1.5132 0.9069 21.5983 22.3005 22.1859 22.0265 360087............................ 1.4212 0.9197 23.9638 25.9131 25.4040 25.0901 360089............................ 1.1144 0.8788 21.0229 21.0253 22.7951 21.6142 360090............................ 1.4694 0.9573 22.6236 24.4291 26.7717 24.5859 360091............................ 1.2086 0.9197 23.5759 26.0541 27.5067 25.7352 360092............................ 1.2241 0.9848 21.9732 23.5100 25.6618 23.7647 360093............................ 1.0308 0.8788 21.4623 24.1238 23.2648 22.9528 360094............................

***

* 22.6440 27.1864 26.6348 24.9723 360095............................ 1.2895 0.8788 23.6518 24.6984

* 24.1867 360096............................ 1.0859 0.8788 22.0673 22.2333 24.6317 22.9802 360098............................ 1.4042 0.9197 22.7644 23.6413 24.8447 23.7933 360099............................

*** 0.8788 20.8524

*

* 20.8524 360101............................ 1.3585 0.9197 26.2875 27.7584 26.6208 26.9092 360106............................ 1.0794 0.8788 19.8658 21.6450 24.1588 21.9428 360107............................ 1.0416 0.9197 23.6880 24.5365 25.9697 24.7438 360109............................ 1.0852 0.8788 23.0178 24.3236 25.4184 24.2613 360112............................ 2.0143 1.0628 25.5910 26.7880 28.6784 26.9982 360113............................ 1.2415 0.9604 22.3348 23.5138 25.6493 23.7408 360115............................ 1.2494 0.9197 22.3926 24.0232 24.0052 23.4857 360116............................ 1.2224 0.9604 21.3809 23.4049 18.0655 20.9510 360118............................ 1.4861

* 23.0070 24.2526

* 23.6564 360121............................ 1.2367 0.8788 23.2515 25.2037

* 24.2319 360123............................ 1.4129 0.9197 23.1310 24.1761 22.6523 23.2730 360125............................ 1.1792 0.9197 21.1408 22.6871 22.1096 21.9849 360126............................

***

* 22.2409

*

* 22.2409 360129............................ 0.9317 0.8788 17.9151 19.5336

* 18.7493 360130............................ 1.4471 0.9197 20.1257 21.7015 22.9762 21.5955 360131............................ 1.2314 0.8957 21.7838 23.1730 24.0495 23.0299 360132............................ 1.2426 0.9604 23.4179 25.7991 25.9453 25.1258 360133............................ 1.6206 0.9069 22.0958 23.9457 24.6208 23.6001 360134............................ 1.6811 0.9604 23.6817 25.3013 29.2975 26.0944 360137............................ 1.6781 0.9197 23.8947 25.7647 26.9522 25.5442 360141............................ 1.6446 0.8788 25.1442 31.0127 27.7085 27.9618 360142............................ 0.9699 0.8788 20.6728 21.2084 22.1610 21.3780 360143............................ 1.3211 0.9197 22.2275 23.8938 24.6306 23.6169 360144............................ 1.3179 0.9197 24.7973 26.7160 24.0350 25.1500 360145............................ 1.7297 0.9197 22.4813 23.4743 25.8268 23.9319 360147............................ 1.3504 0.8788 20.0409 22.7172 24.1953 22.4020 360148............................ 1.0603 0.8788 21.3211 24.4873 26.1946 24.0470 360150............................ 1.1923 0.9197 24.8485 25.8703 24.7667 25.1568 360151............................ 1.4859 0.8957 21.7215 22.2179 24.8629 22.8949 360152............................ 1.4689 0.9848 22.9352 24.9894 27.9147 25.0211 360153............................ 0.9512 0.8788 17.3367 19.0844 19.0226 18.4206 360154............................ 0.9805 0.8788 16.2416 17.1274

* 16.6874 360155............................ 1.4857 0.9197 23.0020 23.9466 25.3787 24.1428 360156............................ 1.1333 0.8788 21.2853 22.6709 24.0510 22.6856 360159............................ 1.2322 0.9848 23.3359 25.7108 33.1613 27.1828 360161............................ 1.3645 0.8788 21.5114 22.6005 24.3792 22.8785 360163............................ 1.8834 0.9604 23.1500 25.7966 26.9728 25.2619 360170............................ 1.1824 0.9848 22.2815 22.9359 24.3620 23.3031 360172............................ 1.3907 0.9197 22.7104 23.4727 26.3388 24.1922 360174............................ 1.2111 0.9069 21.7129 22.8167 24.9990 23.2230 360175............................ 1.1979 0.9848 22.7887 24.6152 26.5949 24.7311 360177............................ 1.1457 0.8788 20.8194 23.4256 24.4712 22.9543 360178............................

*** 0.8788 18.2393

*

* 18.2393 360180............................ 2.2595 0.9197 25.1499 26.8720 26.1514 26.0861 360185............................ 1.1807 0.8788 21.1245 21.8641 23.7173 22.2403 360187............................ 1.5760 0.9069 21.9499 23.8362 24.8173 23.5639 360189............................ 1.1222 0.9848 20.0275 24.2512 24.2136 22.8164 360192............................ 1.3138 0.9197 24.9995 26.2976 26.7577 26.0512 360194 h.......................... 1.1529

* 20.3677 22.3297

* 21.3611 360195............................ 1.0716 0.9197 23.1897 25.8043 26.1280 25.1222 360197............................ 1.0908 0.9848 23.1378 24.7539 26.7508 24.9131 360203............................ 1.1451 0.8788 19.3642 21.5564 22.1414 21.0862 360210............................ 1.1668 0.9848 25.0811 26.5665 27.8415 26.5578 360211............................ 1.5541 0.8840 22.4529 23.0884 22.5449 22.6945 360212............................ 1.3654 0.9197 22.8041 24.5310 25.2756 24.2166

[[Page 23525]]

360218............................ 1.1698 0.9848 22.8060 24.4720 27.4288 25.0106 360230............................ 1.6048 0.9197 24.7681 26.6444 27.0223 26.1931 360234............................ 1.3014 0.9604 22.1787 23.3325 24.2539 23.2304 360236............................ 1.1515 0.9604 22.8821 21.3795 35.8144 24.3729 360239............................ 1.3119 0.9069 23.5802 24.4398 25.2474 24.5362 360241............................

*** 0.9197 23.4061 24.8089 24.7001 24.1133 360245............................ 0.5232 0.9197 18.1015 18.7966 19.1885 18.7327 360247............................ 0.3785 0.9848

* 25.1083 19.8892 22.3390 360253............................ 2.2434 0.9069 31.3006 28.2555 30.4276 29.8452 360254............................

***

* 30.0792

*

* 30.0792 360257............................ 1.0766 0.8788

* 17.9652

* 17.9652 360259............................ 1.1777 0.9573

*

* 25.1338 25.1338 360260............................

*** 0.8979

*

* 27.3903 27.3903 360261............................ 1.7759 0.9482

*

* 22.5431 22.5431 360262............................ 1.3387 0.9573

*

* 27.1680 27.1680 360263............................ 1.6685 0.9263

*

* 20.8884 20.8884 370001............................ 1.6782 0.8313 25.5838 26.2391 27.7549 26.5495 370002............................ 1.1821 0.7615 18.9544 19.7718 20.1479 19.6308 370004............................ 1.0932 0.8458 21.5041 24.7694 25.3919 23.7972 370006............................ 1.2069 0.7615 15.6333 16.9469 20.1063 17.6384 370007............................ 1.0399 0.7615 16.7598 17.2084 17.6547 17.2160 370008............................ 1.3885 0.9043 22.1596 22.7419 24.2978 23.1423 370011............................ 1.0810 0.9043 17.1458 19.2266 19.7821 18.6737 370013............................ 1.5187 0.9043 21.1512 22.6451 24.9295 22.9792 370014............................ 1.0403 0.8971 21.8473 24.8138 25.3576 24.0194 370015............................ 0.9737 0.8313 20.3966 21.1833 23.6693 21.7009 370016 h.......................... 1.4747 0.8682 20.4407 24.2737 25.4062 23.3330 370018............................ 1.4098 0.8313 20.8357 23.4286 23.5336 22.5984 370019............................ 1.2184 0.7615 18.1260 19.6761 21.4474 19.7475 370020............................ 1.2243 0.7615 16.8631 17.4835 18.5046 17.6368 370022............................ 1.1976 0.7673 20.2432 18.4217 19.6495 19.4375 370023............................ 1.2396 0.7615 19.3386 20.6002 21.5762 20.5441 370025............................ 1.2545 0.8313 20.2845 22.0287 23.5659 21.9757 370026 h.......................... 1.5077 0.8682 21.9140 22.5734 23.0848 22.5236 370028............................ 1.8453 0.9043 24.1009 24.8661 26.6153 25.1976 370029............................ 1.0293 0.7615 19.5811 22.1163 23.9956 21.8559 370030............................ 1.0428 0.7615 18.6541 20.3315 23.3037 20.7201 370032............................ 1.4479 0.9043 20.0827 21.6029 23.4843 21.7536 370034............................ 1.1924 0.7986 16.1540 17.6247 18.2341 17.3349 370036............................ 1.0216 0.7615 16.5844 16.9222 17.7576 17.1504 370037............................ 1.6563 0.9043 21.0719 23.1256 23.9685 22.7803 370039............................ 1.0902 0.8313 20.3137 21.0793 21.8220 21.0783 370040............................ 1.0053 0.8231 18.9981 21.1061 22.4048 20.8291 370041............................ 0.8812 0.8313 19.0144 22.0082 22.3496 21.1267 370042............................ 0.9473 0.7615 14.0899 15.3613

* 14.7180 370043............................ 0.9286 0.7615 20.2929 21.5588

* 20.9707 370045............................ 0.9116 0.7615 12.6613 14.6370

* 13.6711 370047............................ 1.4244 0.8971 19.4856 19.7112 20.4657 19.9082 370048............................ 1.0975 0.7615 15.4768 17.7273 19.2464 17.4431 370049............................ 1.2985 0.9043 20.4826 21.6878 23.2171 21.8100 370051............................ 1.0467 0.7615 12.0397 14.6254 17.2618 14.4702 370054............................ 1.2568 0.7615 20.3788 21.5521 21.5043 21.1653 370056............................ 1.6060 0.7916 20.4872 21.7647 22.0312 21.4507 370057............................ 0.9425 0.8313 17.3020 18.0426 19.7284 18.3749 370060............................ 0.9342 0.8313 23.1897 23.8007 18.7592 21.7395 370064............................ 0.8954 0.7615 11.9044 14.1879 14.2053 13.4809 370065............................ 1.0179 0.7615 18.3966 20.6537 20.0226 19.6691 370072............................ 0.7985 0.7615 12.5765 14.6387 9.9616 11.8723 370076............................

***

* 19.0230 21.5461

* 20.2863 370078............................ 1.6061 0.8313 22.2318 23.9507 25.4161 23.9078 370080............................ 0.9012 0.7615 16.1444 17.4857 18.0665 17.2314 370082............................

*** 0.7615 12.6060

*

* 12.6060 370084............................ 0.9685 0.7615 16.1278 17.2735 16.6514 16.7384 370089............................ 1.0714 0.7615 18.0505 19.9021 20.4699 19.4850 370091............................ 1.6980 0.8313 24.2117 22.9893 20.8950 22.6316 370093............................ 1.6152 0.9043 23.5685 25.7296 26.9774 25.3740 370094............................ 1.3966 0.9043 20.6507 22.0591 23.1191 21.9907

[[Page 23526]]

370095............................ 0.8800 0.7615 14.3563 16.5310

* 15.4277 370097............................ 1.2850 0.7916 20.3218 21.7150 22.3267 21.5064 370099............................ 1.0065 0.8313 20.2001 20.5217 20.5075 20.4227 370100............................ 0.9736 0.7615 13.0681 14.1883 14.7712 14.0181 370103............................ 0.9494 0.8038 15.6110 16.1408 17.8018 16.5505 370105............................ 1.8469 0.9043 22.4493 22.1584 23.8978 22.8583 370106............................ 1.3329 0.9043 24.1115 24.2393 26.5867 25.0105 370108............................

*** 0.7615 13.8170

*

* 13.8170 370113............................ 1.1317 0.8615 21.4267 23.3011 25.3565 23.3322 370114............................ 1.5494 0.8313 19.4933 21.0603 21.7880 20.8230 370123............................

*** 0.9043 20.5180 22.8174 25.4733 22.7986 370125............................ 0.8500 0.7615 17.9240 17.2013 17.1361 17.4038 370138............................ 1.0187 0.7615 19.0403 19.8308 18.3113 19.0435 370139............................ 0.9394 0.7615 16.3224 17.8900 18.5225 17.5400 370141............................

***

* 24.7859

*

* 24.7859 370149 h.......................... 1.2033 0.9043 18.2260 21.0608 22.3537 20.7832 370153............................ 1.0423 0.7615 17.9692 18.5417 19.8349 18.7951 370154............................

*** 0.7615 17.4760

*

* 17.4760 370158............................ 1.0192 0.9043 17.3412 17.3161 18.5578 17.7592 370166............................ 0.9772 0.8313 21.3628 21.9070 23.1681 22.1327 370169............................ 0.8969 0.7615 16.5607 15.7686 15.8002 16.0704 370176............................ 1.1057 0.8313 22.1456 23.0324 25.0509 23.4362 370177............................ 1.0170 0.7615 14.0279 15.6723 14.7193 14.7923 370178............................ 0.8922 0.7615 12.9635 14.9767 14.6070 14.1857 370179............................ 0.9231 0.8313 21.9673 22.8322 23.5794 22.6918 370183............................ 1.0143 0.8313 17.9270 20.5025 21.8147 20.0076 370186............................ 0.9064 0.7615 16.3879

*

* 16.3879 370192............................ 1.7741 0.9043 24.3832 26.1338 31.4930 27.6466 370196............................ 1.0758 0.9043 23.6334 29.4383 22.6824 25.4359 370199............................ 0.9440 0.9043 20.7075 23.7340 26.0451 23.4652 370200............................ 1.1666 0.7615 16.7164 18.1008 17.6317 17.5059 370201............................ 1.7335 0.9043 18.9906 23.1240 23.3550 21.7730 370202............................ 1.5326 0.8313 24.0239 24.4920 25.1181 24.5965 370203............................ 1.3678 0.9043 19.8772 21.2426 23.5190 21.5182 370206............................ 1.6351 0.9043 22.3471 27.4495 26.0912 25.5795 370207............................

***

* 26.3746

*

* 26.3746 370210............................ 2.0839 0.8313

* 20.0360 21.2682 20.6946 370211............................ 0.9454 0.9043

*

* 26.5344 26.5344 370212............................ 1.5402 0.9043

*

* 21.0758 21.0758 370213............................

*** 0.9043

*

* 29.3777 29.3777 370215............................ 2.4364 0.9043

*

* 32.3589 32.3589 380001............................ 1.1877 1.1229 20.9585 27.8554 29.7467 26.1275 380002............................ 1.1956 1.0284 25.2629 26.3348 27.1861 26.3148 380003............................

*** 1.0284 24.6377

*

* 24.6377 380005............................ 1.3582 1.0284 26.3472 28.0682 30.2211 28.3075 380006............................ 1.1408 1.0284 24.7492 26.0475

* 25.3948 380007............................ 1.9556 1.1229 30.0497 31.5207 33.9969 31.9322 380008............................ 1.1289 1.0328 24.6149 25.4494 25.8356 25.3227 380009............................ 1.8990 1.1229 26.0012 30.4198 31.7042 29.4616 380010............................ 0.9763 1.1229 25.5234 27.5291 30.2957 27.8451 380011............................

*** 1.0284 21.9382

*

* 21.9382 380014............................ 1.8048 1.0711 28.4536 27.7255 29.9648 28.7806 380017............................ 1.7793 1.1229 29.2543 31.7440 32.2447 31.1318 380018............................ 1.7996 1.0284 27.5171 27.8952 28.0701 27.8359 380020............................ 1.3856 1.0810 23.7066 25.8320 28.3563 26.0268 380021............................ 1.4351 1.1229 28.0334 29.3001 29.3295 28.9428 380022............................ 1.2181 1.0328 26.4794 27.8683 29.2642 27.9316 380023............................ 1.1682 1.0284 23.0079 23.7073 26.5439 24.4358 380025............................ 1.2837 1.1229 28.8525 30.2628 33.2105 30.8181 380026............................ 1.1324 1.0284 23.8666 26.5217

* 25.2072 380027............................ 1.2867 1.0492 21.5822 23.8758 25.5161 23.7359 380029............................ 1.2971 1.0445 24.2939 26.2070 26.9966 25.9075 380033............................ 1.6592 1.0810 30.4783 29.7995 30.8767 30.3883 380035............................ 1.0421 1.0284 26.2434 26.4784

* 26.3599 380037............................ 1.2266 1.1229 25.0200 27.1884 30.5818 27.7342 380038............................ 1.2591 1.1229 29.1804 30.5903 34.2303 31.3814 380039............................ 0.9755 1.1229 27.5115 30.1544 32.3959 30.0601

[[Page 23527]]

380040............................ 1.1950 1.0284 21.5958 28.4373 32.0103 27.1504 380047............................ 1.8037 1.0492 26.5017 27.8385 29.8627 28.1638 380050............................ 1.3931 1.0284 23.1332 24.2416 25.6190 24.3627 380051............................ 1.5718 1.0445 26.2384 28.1305 29.7219 28.0410 380052............................ 1.1643 1.0284 21.2567 22.6799 24.9476 22.9567 380056............................ 0.9458 1.0445 22.3571 25.0068 25.1475 24.2275 380060............................ 1.4020 1.1229 27.8551 30.2507 29.5370 29.2476 380061............................ 1.6536 1.1229 27.3827 29.5145 29.8217 28.9273 380066............................ 1.2243 1.0284 23.3581 27.5412

* 25.5211 380070............................ 1.1747 1.1229 34.1039

*

* 34.1039 380072............................ 0.8417 1.0284 21.9516 22.5275

* 22.2419 380075............................ 1.3046 1.0284 25.1930 27.4795 29.0368 27.3082 380081............................ 1.1379 1.0284 22.1822 21.0708 21.8850 21.7195 380082............................ 1.2215 1.1229 28.0668 30.2721 32.4909 30.3569 380089............................ 1.2717 1.1229 29.6989 30.8396 33.4214 31.3234 380090............................ 1.2689 1.0284 31.8702 33.6822 34.4536 33.3615 380091............................ 1.2950 1.1229 31.2807 35.7002 33.8950 33.5968 390001............................ 1.6397 0.8530 21.5154 22.4407 22.5309 22.1581 390002............................ 1.2571 0.8840 22.0646 23.0113 22.4388 22.5092 390003 h.......................... 1.1657 0.8530 19.1857 21.3182 21.6478 20.7084 390004............................ 1.5540 0.9317 21.3475 23.4063 24.3249 23.1020 390005............................ 0.9829 0.8746 19.0727 19.0318

* 19.0497 390006............................ 1.8357 0.9145 23.0378 23.3960 25.1216 23.8687 390008 h.......................... 1.1582 0.8840 19.9417 21.0021 22.2680 21.0752 390009............................ 1.7277 0.8746 21.9459 24.2789 25.5482 23.9471 390010............................ 1.2001 0.8840 19.4377 21.6273 23.5390 21.5537 390011............................ 1.3112 0.8348 18.6548 19.8602 21.9279 20.1129 390012............................ 1.2176 1.1030 28.5114

* 28.5076 28.5093 390013............................ 1.2121 0.9145 22.1679 23.3180 24.0044 23.1713 390016 h.......................... 1.1998 0.8446 18.1536 19.9899 21.9549 20.1569 390017 h..........................

*** 0.8840 19.1962 20.6575

* 19.8788 390018............................

***

* 19.9117

*

* 19.9117 390022............................ 1.3090 1.1030 27.5504 31.0971 29.0710 29.1659 390023............................ 1.2577 1.1030 25.3767 27.1600 31.7149 28.1614 390024............................ 1.0501 1.1030 25.9806 37.4330 35.3959 29.4333 390025............................ 0.5266 1.1030 14.8690 15.0282 17.2977 15.7085 390026............................ 1.2353 1.1030 24.0326 27.0802 29.5157 26.9256 390027............................ 1.5482 1.1030 33.2139 28.9159 35.6568 32.4911 390028............................ 1.5912 0.8840 24.6796 23.6616 25.7246 24.7268 390029............................

***

*

* 24.4276

* 24.4276 390030............................ 1.1837 0.9844 20.0598 20.9859 22.1581 21.0867 390031............................ 1.2104 0.9500 20.3568 21.2949 22.6828 21.4388 390032............................ 1.1735 0.8840 20.8450 20.9971 22.7205 21.5225 390035............................ 1.2222 1.1030 23.2173 24.7281 26.2647 24.7742 390036............................ 1.4446 0.8840 20.5751 23.3858 24.6032 22.8336 390037............................ 1.3365 0.8840 20.1665 22.9008 24.7820 22.6385 390039 h.......................... 1.1565 0.8348 18.4580 17.8461 20.3787 18.9083 390040............................

***

* 20.5371 23.1807

* 21.7860 390041............................ 1.3009 0.8840 21.0074 20.6789 21.5925 21.0799 390042............................ 1.3204 0.8840 22.2351 23.9632 25.6328 23.9486 390043............................ 1.1602 0.8300 19.8641 20.9835 22.2549 21.0509 390044............................ 1.6591 0.9698 22.4235 24.2586 27.1505 24.6634 390045............................ 1.5712 0.8368 20.2082 22.2582 23.0877 21.8830 390046............................ 1.5379 0.9422 23.1271 25.0825 27.6367 25.3031 390048............................ 1.0828 0.9145 20.3523 23.6622 24.7738 22.8564 390049............................ 1.5860 0.9844 24.0933 25.4056 27.1366 25.5929 390050............................ 2.0343 0.8840 22.6951 24.5424 26.6931 24.6339 390052............................ 1.1848 0.8942 22.1380 21.6736 23.6105 22.4994 390054............................ 1.1909 0.8530 19.8602 21.4983 22.8087 21.3801 390055............................

*** 0.8840 23.5292 25.5675 25.6945 24.9860 390056............................ 1.0653 0.8300 21.4239

* 19.5537 20.4834 390057............................ 1.3195 1.1030 24.8235 25.1901 27.9583 26.0368 390058............................ 1.2715 0.9317 22.0113 25.3415 27.4799 24.8349 390061............................ 1.5355 0.9716 24.4550 25.5012 28.4538 26.1704 390062............................ 1.1167 0.8942 17.6303 19.0692 21.4052 19.4592 390063............................ 1.7404 0.8746 21.7120 23.5469 24.7614 23.4097 390065............................ 1.2046 1.0813 23.1384 23.4021 25.9184 24.2223

[[Page 23528]]

390066............................ 1.2713 0.9145 21.7717 23.0891 24.2087 23.0471 390067............................ 1.8233 0.9317 23.5136 25.4576 26.3287 25.0668 390068............................ 1.3022 0.9716 21.1177 25.9890 25.8291 24.3019 390070............................ 1.3629 1.1030 24.4403 26.9235 30.9499 27.4435 390071............................ 0.9895 0.8300 17.8117 20.9443 20.6652 19.7095 390072 h.......................... 1.0397 0.8530 20.0561 22.0155 24.9388 22.3043 390073............................ 1.5559 0.8942 22.7073 24.8013 26.3698 24.6228 390074............................ 1.1407 0.8840 21.8456 21.0941 22.8545 21.9412 390075............................

***

* 19.9775 22.6530 24.6359 22.3701 390076............................ 1.3409 1.1030 21.2039 18.1276 27.9004 21.9007 390079............................ 1.8970 0.8471 19.9169 21.4323 23.3053 21.5091 390080............................ 1.2828 1.1030 23.3742 25.0921 27.2616 25.2851 390081............................ 1.2236 1.0652 28.1056 28.7974 30.3840 29.1503 390084............................ 1.2243 0.8300 18.3551 20.7799 19.8605 19.6630 390086............................ 1.5445 0.8300 19.6488 20.7383 22.5317 20.9944 390090............................ 1.7972 0.8840 22.4688 20.7474 25.2014 22.8601 390091............................ 1.1421 0.8446 19.7361 20.8243 21.5586 20.7010 390093............................ 1.1685 0.8446 19.9209 21.0427 21.4401 20.8186 390095............................ 1.1908 0.8530 18.3939 21.0754 23.6240 20.9725 390096............................ 1.4974 0.9698 22.9502 24.4145 27.0763 24.8874 390097............................ 1.1901 1.1030 24.5304 25.3012 25.6660 25.2008 390100............................ 1.6968 0.9716 23.4155 26.7267 27.7208 26.0717 390101............................ 1.2400 0.9422 20.1271 20.1694 21.2641 20.5324 390102............................ 1.3469 0.8840 20.9807 21.6629 24.8898 22.6239 390103............................ 1.0080 0.8840 21.0637 18.6703 20.6775 20.1561 390104............................ 1.0501 0.8300 16.5081 19.1803 19.6428 18.4897 390107............................ 1.3679 0.8840 21.5852 23.1023 24.1386 23.0080 390108............................ 1.2171 1.1030 23.7842 24.7486 27.2661 25.2833 390109............................ 1.1229 0.8530 17.2667 18.7558 19.9156 18.6551 390110............................ 1.5720 0.8840 22.3968 23.3355 23.9808 23.2737 390111............................ 2.0139 1.1030 30.5814 30.6809 32.6510 31.3439 390112 h.......................... 1.1736 0.8348 15.6710 16.6113 19.2126 17.1537 390113............................ 1.2850 0.8446 20.1160 21.7729 22.2591 21.3940 390114............................ 1.3024 0.8840 23.6162 22.6630 24.0473 23.4341 390115............................ 1.4409 1.1030 24.1951 26.4751 27.7333 26.1536 390116............................ 1.2529 1.1030 24.9581 28.5563 29.7436 27.8303 390117............................ 1.0952 0.8300 19.0983 20.0040 20.3946 19.8418 390118............................ 1.1665 0.8300 17.8460 19.3332 21.5001 19.5328 390119............................ 1.2920 0.8530 20.3034 21.2761 22.2746 21.3271 390121............................ 1.6614 0.8942 20.8017 22.0556 23.1408 22.0024 390122............................ 1.0973 0.8300 18.5130 21.6981 22.5785 20.8388 390123............................ 1.1985 1.1030 23.2232 25.2209 28.6269 25.7365 390125............................ 1.2705 0.8300 18.2411 19.4406 20.9456 19.5654 390127............................ 1.3061 1.1030 25.0836 28.9238 30.9374 28.4999 390128............................ 1.1865 0.8840 21.3668 21.8837 23.0255 22.1158 390130............................ 1.2623 0.8348 19.4835 21.0694 24.0685 21.4556 390131............................ 1.2940 0.8840 19.5296 21.2164 22.5177 21.1193 390132............................ 1.3983 1.1030 24.6889 26.8153 27.7250 26.4427 390133............................ 1.6988 1.1030 25.2110 26.1458 28.7162 26.7622 390135............................

*** 1.1030 24.0445

* 24.4738 24.2670 390136............................ 1.0748 0.8840 21.9531 24.8042 22.1415 22.9715 390137............................ 1.4810 0.8530 19.5457 21.8830 23.4877 21.5609 390138............................ 1.1787 1.0813 21.4705 22.7210 24.2769 22.8713 390139............................ 1.3178 1.1030 26.3622 28.2089 30.4246 28.3708 390142............................ 1.4621 1.1030 29.8874 32.0827 32.3517 31.4330 390145............................ 1.4545 0.8840 20.6580 22.4255 23.8041 22.3138 390146............................ 1.2491 0.8300 21.4580 22.3260 25.2460 23.0540 390147............................ 1.2294 0.8840 22.3135 23.6380 25.0971 23.6939 390150............................ 1.1557 0.8840 20.0261 24.5256 24.1855 22.9524 390151............................ 1.2703 1.0813 24.7843 25.1422 27.1539 25.7127 390152............................ 0.9999 0.8942 21.5474 11.7774

* 15.1275 390153............................ 1.3749 1.1030 25.3391 27.5167 30.0586 27.7812 390154............................ 1.2331 0.8300 19.1300 20.4408 20.6982 20.0794 390156............................ 1.3484 1.0652 25.0801 27.8096 31.2571 28.0054 390157............................ 1.2887 0.8840 20.6933 22.0222 22.7493 21.8431 390160............................ 1.1601 0.8840 19.3598 19.5942 21.4877 20.1709 390162............................ 1.4642 0.9844 24.0291

* 30.0900 26.8901

[[Page 23529]]

390163............................ 1.2667 0.8840 18.8585 19.8863 22.1741 20.2736 390164............................ 2.0562 0.8840 24.2334 25.1277 26.4971 25.3882 390166............................ 1.1534 0.8840 19.8531 20.9510 24.9810 21.8402 390168............................ 1.4369 0.8840 20.6777 21.9344 24.5820 22.5085 390169............................ 1.4033 0.8530 22.7695 24.1682 27.2242 24.7030 390173............................ 1.1624 0.8300 20.6958 21.6562 22.8220 21.7639 390174............................ 1.7303 1.1030 28.4490 30.3725 32.6265 30.5109 390176............................ 1.1510 0.8840 18.0752 17.1387

* 17.5532 390178............................ 1.2958 0.8609 17.2384 19.2731 20.7270 19.1018 390179............................ 1.3648 1.1030 24.0501 24.8350 27.2222 25.3975 390180............................ 1.4462 1.0652 28.4842 30.4264 32.4375 30.5043 390181............................ 1.0361 0.8300

* 25.7357 24.4573 25.1039 390183............................ 1.0850 0.8300 21.6811 22.0117 25.6554 23.0449 390184............................ 1.0849 0.8840 21.1962 21.3407 22.5519 21.7060 390185............................ 1.2694 0.8530 20.4476 21.8871 23.0202 21.7597 390189............................ 1.1071 0.8300 20.1365 21.2711 22.3722 21.3477 390191............................ 1.0835 0.8300 18.5972 19.2308 20.8761 19.5306 390192............................ 1.0157 0.8530 19.1883 20.0395 21.2620 20.1833 390193............................

*** 0.8746 18.9764 18.5516 20.1024 19.2196 390194............................ 1.1011 0.9844 21.5850 23.1814 25.4235 23.4479 390195............................ 1.6321 1.1030 26.2024 28.3480 31.0019 28.5392 390197............................ 1.3925 0.9844 22.8349 24.9234 25.7739 24.4854 390198............................ 1.1641 0.8746 17.3937 16.8529 18.7222 17.6295 390199............................ 1.2174 0.8300 18.9787 19.9653 21.3157 20.1079 390200............................

*** 0.9716 19.4471 23.1486 23.7471 21.9484 390201............................ 1.2961 0.8300 22.7849 24.8222 26.3658 24.6735 390203............................ 1.6357 1.1030 26.9436 28.2741 28.9054 28.0870 390204............................ 1.2498 1.1030 23.9673 25.6342 28.6829 26.1129 390211............................ 1.2717 0.8609 21.0450 22.4472 23.1450 22.2313 390215............................

***

* 25.2617 26.4180 28.0402 26.4046 390217............................ 1.1533 0.8840 21.4058 21.3281 24.3610 22.3261 390219............................ 1.2908 0.8840 20.0594 22.8559 25.1705 22.7113 390220............................ 1.0977 1.1030 23.4385 24.7553 41.6138 28.9098 390222............................ 1.2483 1.0652 24.9345 27.0954 28.7488 26.9594 390223............................ 1.9554 1.1030 22.8725 28.2538 27.6407 26.2383 390224............................ 0.8462 0.8471 16.1289 18.1226 18.7624 17.7120 390225............................ 1.1871 0.9716 20.9232 23.4945 24.9391 23.3545 390226............................ 1.7312 1.1030 25.6917 27.0061 28.5890 27.1866 390228............................ 1.3206 0.8840 21.0164 22.5999 23.3078 22.3536 390231............................ 1.4382 1.1030 24.7757 27.0576 29.2653 27.1070 390233............................ 1.3700 0.9422 21.8043 22.8667 24.8690 23.1907 390235............................

***

* 23.7068

*

* 23.7068 390237............................ 1.5540 0.8530 23.2054 24.6316 26.9533 24.9348 390238............................

***

* 19.2171 26.4748

* 22.5836 390246............................ 1.1671 0.8300 22.0687 23.3275 20.1581 21.8667 390249............................ 0.8767 0.8471 14.7215

*

* 14.7215 390258............................ 1.5307 1.1030 25.0634 27.2038 29.4626 27.3466 390262............................

***

* 21.3264

*

* 21.3264 390265............................ 1.4456 0.8840 20.5948 21.6751 23.4836 21.9520 390266............................ 1.1763 0.8609 18.2424 19.2836 20.3918 19.3171 390267............................ 1.1835 0.8840 21.4801 22.5464 23.1051 22.3821 390268............................ 1.3066 0.8368 23.1124 24.2050 25.0021 24.1351 390270............................ 1.4615 0.8530 22.5258 24.0837 24.1496 23.6565 390278............................ 0.5214 1.1030 21.1387 21.6893 23.6843 22.1694 390279............................ 1.1519 0.8368 16.0510 15.3569 17.0012 16.1304 390285............................ 1.5472 1.1030 30.6300 33.5347 35.0427 33.0866 390286............................ 1.1613 1.1030 25.4499 27.4090 28.1761 27.0003 390287............................ 1.4298 1.1030 32.9709 35.7147 37.6569 35.5140 390288............................

*** 1.1030 28.0957 28.5267 29.7287 28.6956 390289............................ 1.0920 1.1030 25.1658 28.4577 28.8826 27.4320 390290............................ 1.9082 1.1030 31.0967 36.4991 37.9040 35.0787 390291............................

*** 0.8840 21.0057 21.3015

* 21.1542 390294............................

***

* 33.3537

*

* 33.3537 390296............................

***

* 25.6981

*

* 25.6981 390298............................

***

*

* 26.8290

* 26.8290 390299............................

***

*

* 31.9423

* 31.9423 390300............................

***

*

* 40.4697

* 40.4697

[[Page 23530]]

390301............................

*** 0.8530

*

* 30.9838 30.9838 400001............................ 1.2643 0.4686 11.7572 16.1114 13.1847 13.4859 400002............................ 1.7313 0.5178 11.6804 14.8607 16.7583 14.1458 400003............................ 1.3456 0.5178 10.5963 13.0776 13.6751 12.3819 400004............................ 1.1394 0.4686 11.4041 10.4716 14.3108 11.8780 400005............................ 1.1205 0.4686 10.5356 10.2878 10.7207 10.5186 400006............................ 1.1887 0.4686 9.2852 8.9919 9.2265 9.1710 400007............................ 1.1804 0.4686 8.6022 8.7152 9.2463 8.8511 400009............................ 1.0804 0.3186 9.4413 9.2007 9.3116 9.3159 400010............................ 0.8250 0.4736 9.2799 10.9354 10.0962 10.0495 400011............................ 1.0865 0.4686 8.9111 8.5868 8.5534 8.6726 400012............................ 1.3545 0.4686 9.0740 8.3580 8.3802 8.5938 400013............................ 1.2691 0.4686 9.9905 9.5584 10.3347 9.9727 400014............................ 1.3193 0.4016 11.4580 11.7023 12.5363 11.8896 400015............................ 1.3649 0.4686

* 15.6066 17.4086 16.6535 400016............................ 1.3515 0.4686 14.6491 15.3497 14.7607 14.9193 400017............................ 1.1959 0.4686 10.7475 10.1238 10.2734 10.3916 400018............................ 1.1949 0.4686 10.8254 10.7948 11.6165 11.0939 400019............................ 1.3212 0.4686 13.7007 14.9892 13.7754 14.1263 400021............................ 1.3102 0.4646 13.5224 13.8643 14.1533 13.8469 400022............................ 1.3444 0.5178 15.2904 16.0539 16.8806 16.0784 400024............................ 0.8372 0.4016 9.8650 9.1316 12.4649 10.2156 400026............................ 1.0673 0.3186 5.9206 5.2085 5.8200 5.6501 400028............................ 1.2057 0.5178 9.5266 10.3354 10.9808 10.2872 400032............................ 1.1946 0.4686 10.7100 10.7195 10.2652 10.5650 400044............................ 1.2777 0.5178 9.0275 10.7890 13.7509 11.4819 400048............................ 1.0975 0.4686 10.8618 14.0887 10.4266 11.8488 400061............................ 1.7250 0.4686 16.5895 15.1639 20.3206 17.3616 400079............................ 1.1310 0.4736 8.7218 9.4218 12.7825 10.1505 400087............................ 1.1988 0.4686 10.7118 9.5860 10.6849 10.3421 400094............................

***

* 9.2871 8.8646

* 9.1244 400098............................ 1.5719 0.4686 13.8036 13.7938 12.8230 13.4850 400102............................ 1.1198 0.4686 10.9973 10.1795 10.2677 10.4779 400103............................ 1.7425 0.4016 11.5797 12.8288 9.3859 10.9876 400104............................ 1.1364 0.4686 7.1781 8.2758 8.3900 7.8760 400105............................ 1.1274 0.4686 11.5608 12.7725 14.5339 12.8828 400106............................ 1.1815 0.4686 10.1241 9.6902 11.4507 10.3951 400109............................ 1.4714 0.4686 12.8921 14.2169 14.2111 13.7444 400110............................ 1.0965 0.4413 12.0159 11.8458 12.3449 12.0750 400111............................ 1.0774 0.4736 12.7701 13.4777 14.5029 13.5496 400112............................ 1.1915 0.4686 12.2859 8.9469 19.3945 12.3541 400113............................ 1.2040 0.5178 10.4416 10.0830 11.0072 10.4939 400114............................ 1.0880 0.4686 9.7444 12.1920 11.5478 11.0784 400115............................ 1.1179 0.4686 7.0411 9.1132 13.7392 9.2213 400117............................ 1.1002 0.4686 9.7314 10.2911 12.7600 10.8102 400118............................ 1.2310 0.4686 12.4590 11.9324 12.5743 12.3218 400120............................ 1.2997 0.4686 11.8837 11.9714 12.7955 12.2196 400121............................ 1.0671 0.4686 8.3575 8.6665 8.2197 8.4118 400122............................ 1.9548 0.4686 9.6644 9.6463 8.3069 9.4955 400123............................ 1.1994 0.4016 10.5643 11.8135 11.9825 11.4619 400124............................ 2.8727 0.4686 14.3496 17.2258 16.1812 15.8787 400125............................ 1.1319 0.4160 10.6642 10.7425 11.6386 11.0069 400126............................ 1.2093 0.4646

* 13.3932 9.8008 11.0632 410001............................ 1.3081 1.1233 24.0033 27.0309 28.0816 26.3767 410004............................ 1.2319 1.1233 23.6409 25.4578 27.4209 25.5908 410005............................ 1.2822 1.1233 24.6522 27.1171 30.1606 27.3044 410006............................ 1.2503 1.1233 26.1372 27.1842 29.4395 27.6190 410007............................ 1.7094 1.1233 27.7171 30.1360 31.8548 30.0135 410008............................ 1.2098 1.1233 25.4183 28.4245 29.6092 27.8277 410009............................ 1.2932 1.1233 26.9135 27.7337 29.4094 28.0697 410010............................ 1.1636 1.0952 30.3860 30.7826 32.8599 31.3979 410011............................ 1.2966 1.1233 29.7664 28.5875 29.9001 29.4052 410012............................ 1.7532 1.1233 28.1791 32.1679 32.6009 31.1120 410013............................ 1.2276 1.1233 28.9386 31.7482 35.4624 32.1157 420002............................ 1.5184 0.9717 25.1067 27.9312 28.2848 27.1910 420004............................ 1.9550 0.9433 23.4579 26.0279 28.4845 26.0443 420005............................ 1.0179 0.8663 19.5521 19.8167 23.1943 20.8182

[[Page 23531]]

420006............................ 1.0874 0.9433 22.7896 22.8920 24.0811 23.2220 420007............................ 1.5636 0.9183 22.0228 25.0395 25.2650 24.2318 420009............................ 1.3786 0.9807 18.6866 23.8668 25.5079 22.5621 420010............................ 1.1844 0.8988 19.1746 21.6478 23.4562 21.5057 420011............................ 1.1190 1.0138 17.7300 20.8895 21.4030 20.0081 420014............................ 0.9635 0.9057 21.2045 21.5658

* 21.3876 420015............................ 1.2398 1.0138 23.1274 24.7383 26.1298 24.6961 420016............................ 0.9619 0.8663 17.0051 17.3837 17.1229 17.1752 420018............................ 1.7534 0.9057 20.4649 23.6356 24.7324 22.8696 420019............................ 1.1129 0.8663 19.6836 20.5472 22.5312 20.8812 420020............................ 1.2595 0.9317 22.1616 24.6592 25.7225 24.3050 420023............................ 1.6530 1.0138 23.2568 25.1035 26.7263 25.0152 420026............................ 1.8566 0.9057 23.7406 29.2961 27.4814 26.8241 420027............................ 1.5759 0.8887 21.0637 22.8322 24.8624 22.9488 420030............................ 1.2331 0.9317 22.6766 24.2847 26.0079 24.3704 420033............................ 1.1361 1.0138 26.2711 27.5740 31.8759 28.5975 420036............................ 1.2525 0.9585 20.6649 21.9641 22.8294 21.8110 420037............................ 1.2494 1.0138 25.5492 26.8750 29.4156 27.3838 420038............................ 1.2524 1.0138 21.6133 22.6741 24.2259 22.8531 420039............................ 1.0376 0.9183 21.9737 24.0637 25.1148 23.7048 420043 h.......................... 1.0680 0.9183 21.8816 22.9764 23.0555 22.6545 420048............................ 1.2700 0.9057 21.9517 23.1515 24.1910 23.1357 420049............................ 1.2080 0.8869 21.2604 23.2156 23.4769 22.6938 420051............................ 1.4889 0.8988 20.6629 23.9455 24.8026 23.1828 420053............................ 1.1415 0.8663 19.9013 21.1177 22.2825 21.1778 420054............................ 1.0212 0.8663 20.8471 24.0653 24.8931 23.2676 420055............................ 1.0684 0.8663 19.6817 20.3599 21.9764 20.6871 420056............................ 1.4085 0.8663 20.0527 21.1640 21.6963 20.9682 420057............................ 1.0376 0.8988 17.6727 19.7653 23.4311 20.1207 420059............................ 1.0455 0.8663 20.2917 21.4260

* 20.8684 420061............................ 1.1273 0.8663 19.9789 20.8684

* 20.4341 420062............................ 1.0823 0.8663 17.4764 25.6683 25.8389 22.4958 420064............................ 1.1956 0.8869 20.9057 22.1290 23.3610 22.2043 420065............................ 1.3471 0.9433 22.0784 22.8674 24.5715 23.1699 420066............................ 0.9655 0.8988 20.7782 20.5893 23.9048 21.7523 420067............................ 1.2942 0.9316 22.8104 24.6038 25.0345 24.2301 420068............................ 1.3390 0.9317 21.7257 22.2638 23.4248 22.4620 420069............................ 1.0589 0.8663 17.6291 19.6959 20.5546 19.3217 420070............................ 1.2778 0.9057 20.3664 22.4370 23.4355 22.1331 420071............................ 1.3635 0.9807 21.8579 23.1727 24.9418 23.3888 420072............................ 1.0926 0.8663 16.2578 17.5899 18.6742 17.5511 420073............................ 1.3459 0.9057 21.4718 24.0274 24.5813 23.3018 420074............................

***

* 18.7010

*

* 18.7010 420078............................ 1.8001 1.0138 24.3273 25.3032 29.4985 26.4127 420079............................ 1.5104 0.9433 23.3992 25.2939 25.5354 24.7810 420080............................ 1.3725 0.9316 26.7489 28.4569 28.4734 27.9158 420082............................ 1.4774 0.9567 23.6936 26.1221 29.8528 26.5169 420083............................ 1.3224 0.9183 24.8508 25.3043 27.1322 25.7973 420085............................ 1.6210 0.9394 24.4040 25.3180 26.8692 25.5532 420086............................ 1.3930 0.9057 24.5760 25.1372 25.7580 25.1689 420087............................ 1.7766 0.9433 22.4526 23.2230 24.3609 23.3441 420088............................

***

* 23.5174 23.1273

* 23.4240 420089............................ 1.3873 0.9433 23.3240 25.2729 26.0074 24.9015 420091............................ 1.3034 0.8988 23.7936 23.4710 27.0189 24.8440 420093............................ 0.9851 0.9183 21.4678 25.1457 27.4766 24.8258 420097............................

***

*

* 24.7809

* 24.7809 430005............................ 1.2209 0.8475 18.2647 19.9454 21.8605 19.9621 430008 \2\........................ 1.1152 0.8475 20.0124 20.9442 22.9340 21.2902 430011............................ 1.2481 0.8475 19.9835 20.6597

* 20.3142 430012............................ 1.2707 0.9616 21.2588 22.7530 24.0850 22.7129 430013 \2\........................ 1.1784 0.8475 21.3389 22.9675 23.8572 22.7428 430014............................ 1.2515 0.8778 22.0285 25.5387 26.4964 24.6896 430015............................ 1.1338 0.8475 20.5849 23.2035 22.7947 22.1979 430016............................ 1.5813 0.9616 24.2450 26.1495 27.8453 26.0153 430018............................

*** 0.8475 17.9850

*

* 17.9850 430024............................

*** 0.8475 18.8357

*

* 18.8357 430029............................ 0.8995 0.8475 18.9464 20.2708

* 19.6526

[[Page 23532]]

430031 \2\........................ 0.9339 0.8475 15.2321 15.6112 15.9156 15.5961 430033............................

*** 0.8475 21.6254

*

* 21.6254 430047............................ 0.9833 0.8475 18.2774 21.9116 18.8982 19.7432 430048............................ 1.2364 0.8475 20.0607 21.1718 23.0783 21.5127 430054............................ 0.9420 0.9616 17.8871

*

* 17.8871 430064............................ 1.0393 0.8475 14.3407 16.4314 17.5376 16.1075 430077............................ 1.6950 0.9027 21.6786 23.4835 25.1763 23.4802 430089............................ 1.6248 0.9360 19.8572 21.1109 22.5625 21.3078 430090............................ 1.4120 0.9616 25.6873 26.0851 25.7499 25.8502 430091............................ 2.1791 0.9027 22.2824 23.8897 25.0828 23.8977 430092............................ 1.7787 0.8475 19.7354 20.2570 23.8858 21.3414 430093............................ 0.9141 0.9027 23.8820 23.1526 29.5244 25.7876 430094............................ 1.8543 0.9207 20.8743 18.5429 19.0014 19.4190 430095............................ 2.3163 0.9616

* 24.7074 28.1749 26.5823 430096............................ 1.9499 0.8475

*

* 21.7103 21.7103 440001............................ 1.1144 0.7958 18.9833 17.4802 19.3100 18.5533 440002............................ 1.6911 0.8964 22.0178 23.2177 24.6664 23.3294 440003............................ 1.2046 0.9757 21.6336 24.5168 25.9209 24.0777 440006............................ 1.4022 0.9757 24.3173 26.7983 28.5951 26.6300 440007............................ 0.9406 0.7915 14.8015 13.7042 25.8236 17.2437 440008............................ 0.9974 0.8508 20.9237 22.1405 23.4301 22.0908 440009............................ 1.1859 0.7915 19.6564 21.1274 21.5970 20.8327 440010............................ 0.9389 0.7915 16.7270 16.9060 17.1803 16.9489 440011............................ 1.3028 0.8470 20.5036 21.6861 22.5068 21.6145 440012............................ 1.4390 0.8095 21.1213 21.4769 22.3029 21.6368 440015............................ 1.8237 0.8470 23.4485 22.5583 23.7422 23.2495 440016............................ 0.9690 0.7915 20.1504 20.0982 22.1646 20.8341 440017............................ 1.7649 0.8095 21.8033 22.5313 22.9364 22.4333 440018............................ 1.1326 0.7958 21.2242 21.7239 23.3444 22.1229 440019............................ 1.7880 0.8470 21.8854 23.8802 25.2553 23.6676 440020............................ 1.0554 0.9124 21.1075 23.1718 23.9475 22.7656 440023............................ 0.9515 0.7915 15.5410 17.0335 18.2884 16.9816 440024............................ 1.2316 0.8160 19.9751 20.3658 23.2478 21.1469 440025............................ 1.1856 0.7915 19.1478 19.5995 20.6798 19.8282 440026............................

***

* 25.1655 26.9149 26.8986 26.2876 440029............................ 1.3373 0.9757 24.1379 25.8538 28.0779 26.0679 440030............................ 1.2498 0.8758 19.9056 20.0586 26.1060 22.0081 440031............................ 1.0626 0.7915 17.0289 18.0944 19.6685 18.2797 440032............................ 1.0136 0.8095 14.7683 16.0734 18.5277 16.4708 440033............................ 1.0486 0.7915 17.2637 18.7749 20.7917 19.0076 440034............................ 1.5293 0.8470 22.2478 23.1121 23.5403 22.9348 440035............................ 1.3430 0.9492 21.4990 22.3230 24.3752 22.7486 440039............................ 1.9897 0.9757 25.0874 26.4647 28.1729 26.6593 440040............................ 0.9253 0.7915 16.9886 17.7647 17.8510 17.5455 440041............................ 0.9316 0.8160 15.5784 17.4074 17.9409 17.0933 440046............................ 1.1385 0.9757 22.3380 25.5329 26.1341 24.7333 440047............................ 0.8547 0.7915 18.7962 20.4812 21.4280 20.2387 440048............................ 1.8251 0.9346 23.1553 24.3283 27.7560 24.7999 440049............................ 1.5582 0.9346 21.1930 22.9755 25.3043 23.1991 440050............................ 1.2790 0.9312 21.1397 21.8972 23.1362 22.0679 440051............................ 0.9362 0.7915 19.0165 20.7948 21.9108 20.5095 440052............................ 0.9561 0.7915 18.1935 20.1875 21.1133 19.9032 440053............................ 1.2082 0.9757 22.0345 23.9083 25.4345 23.8916 440054............................ 1.1252 0.7915 15.4208 20.5992 21.4400 18.6411 440056............................ 1.1345 0.8758 19.3108 20.4088 22.1068 20.7270 440057............................ 1.0371 0.7915 14.1477 14.6242 16.4451 15.0915 440058............................ 1.1730 0.9099 21.7512 22.6014 22.9263 22.4470 440059............................ 1.5012 0.9492 22.4248 23.9301 26.3531 24.2538 440060............................ 1.0098 0.8799 20.2189 22.7133 23.3014 22.1119 440061............................ 1.0870 0.7915 19.5458 21.2085 21.8274 20.8215 440063............................ 1.5962 0.7958 19.7468 21.8578 22.3256 21.2848 440064............................ 0.9863 0.9099 19.4020 20.9742 22.0955 20.8374 440065............................ 1.2170 0.9757 19.9099 21.4794 22.3247 21.2895 440067............................ 1.1694 0.8470 19.5643 22.1410 23.1089 21.6500 440068............................ 1.1443 0.9099 20.9188 23.1705 24.5971 22.9451 440070............................ 0.9466 0.7915 18.3717 19.0240 19.4372 18.9540 440072............................ 1.1880 0.9108 19.6579 20.9294 27.1443 22.1374

[[Page 23533]]

440073............................ 1.3595 0.9492 20.7181 22.2959 23.9198 22.3108 440081 h.......................... 1.1378 0.8470 18.3141 19.0328 19.7918 19.0786 440082............................ 2.1607 0.9757 26.1497 28.7828 27.9724 27.6484 440083............................ 0.9067 0.7915 15.7015 16.0956 17.3329 16.4160 440084............................ 1.1637 0.7915 15.0510 15.2825 16.3738 15.6128 440091............................ 1.6254 0.9099 23.0296 26.1122 25.6797 24.9494 440102............................ 1.1346 0.7915 16.6548 17.5140 17.5261 17.2560 440104............................ 1.7607 0.9099 21.9870 23.3731 25.3739 23.6244 440105............................ 1.0199 0.7958 19.2902 20.7821 22.3438 20.8223 440109............................ 0.9843 0.7915 17.3578 18.2508 18.6720 18.1156 440110............................ 1.1772 0.8470 19.9715 20.9039 21.3287 20.7233 440111............................ 1.2422 0.9757 24.9883 25.8821 28.5705 26.5016 440114............................ 0.9851 0.7915 20.1152 21.4271 24.0147 21.9369 440115............................ 0.9888 0.7915 18.5389 20.0642 21.7830 20.1587 440120............................ 1.5755 0.8470 22.4031 23.9003 25.7636 24.0777 440125............................ 1.5716 0.8470 21.1018 21.9337 22.3888 21.8259 440130............................ 1.1649 0.7915 20.6363 21.6480 23.4517 21.9020 440131............................ 1.1987 0.9346 21.0640 22.4119 24.9598 22.8950 440132............................ 1.2681 0.7915 18.9580 20.5716 21.5085 20.3655 440133............................ 1.5674 0.9757 23.3600 27.5019 26.2422 25.6963 440135............................ 1.0782 0.9757 23.9749 25.3928 26.6615 25.3742 440137............................ 1.0485 0.7915 16.5529 18.2073 20.6663 18.4329 440141............................ 0.9487 0.7915 19.2607 19.4528 21.3313 20.0578 440142............................ 0.8702 0.9757 17.7587

*

* 17.7587 440144............................ 1.1976 0.7915 19.7938 22.3671 23.3828 21.8222 440145............................ 0.9916 0.7915 18.2019 20.9863 20.7875 19.9424 440147............................

***

* 25.0780 28.9038 31.2003 28.2394 440148............................ 1.1199 0.9492 20.7693 23.0697 24.6412 22.8692 440149............................ 1.0185 0.7915 18.1316 19.8020 20.4562 19.4498 440150............................ 1.3517 0.9757 22.8733 25.4952 26.8308 25.0868 440151............................ 1.0856 0.9492 21.1576 23.3037 23.9808 22.8559 440152............................ 1.8738 0.9346 22.7498 25.9495 26.5513 25.0265 440153............................ 1.0018 0.7915 19.9486 22.7744 22.2846 21.7049 440156............................ 1.4931 0.9099 23.7799 25.6333 26.9689 25.5243 440159............................ 1.4244 0.9346 20.5719 21.1073 22.8645 21.5659 440161............................ 1.8202 0.9757 26.1354 28.6774 28.6854 27.8923 440162............................

***

* 20.3909 16.5305 21.1418 19.2406 440166............................ 1.5235 0.9346 23.1692 27.1355 22.6509 24.5576 440168............................ 0.9905 0.9346 21.2113 22.1764 22.8768 22.0809 440173............................ 1.6407 0.8470 20.8442 20.8723 22.8692 21.5604 440174............................ 0.8745 0.7915 19.2201 20.7960 22.0974 20.6472 440175............................ 1.0488 0.9492 22.3331 24.0005 22.7299 23.0174 440176............................ 1.2854 0.8095 20.4861 22.0079 23.6659 22.0556 440180............................ 1.2061 0.8470 21.2398 21.9781 23.3808 22.2150 440181............................ 0.9106 0.7915 19.6133 21.1406 22.7150 21.1984 440182............................ 0.9022 0.7915 19.3928 20.2630 22.3612 20.6845 440183............................ 1.5283 0.9346 24.9282 27.7769 27.1515 26.6633 440184............................ 0.9990 0.7958 21.4484 20.8219 22.3475 21.5303 440185............................ 1.1611 0.9099 22.1845 23.4172 23.9052 23.2612 440186............................ 1.0310 0.9757 23.0193 24.6773 25.7445 24.4615 440187............................ 1.0821 0.7915 19.9478 21.7637 21.3252 21.0131 440189............................ 1.3728 0.8964 23.2866 24.7851 27.5435 25.2579 440192............................ 1.0167 0.9492 21.3228 25.1119 25.7495 24.1386 440193............................ 1.2566 0.9757 22.0345 24.3911 24.4299 23.6341 440194............................ 1.3630 0.9757 24.4508 26.2498 26.6527 25.8291 440197............................ 1.2605 0.9757 24.2660 26.4999 27.1534 25.9812 440200............................ 0.9405 0.9757 16.7752 17.0633 17.7491 17.1850 440203............................ 0.9753 0.7915

* 17.7639 19.3864 18.5423 440217............................ 1.3463 0.9346 23.3544 25.9667 28.5968 26.1820 440218............................ 0.8931 0.9757 20.1377 26.3741 24.6465 23.5719 440220............................

***

* 21.9117

*

* 21.9117 450002............................ 1.4427 0.8954 24.0411 25.4975 25.7171 25.1126 450005............................ 1.0651 0.8422 21.7110 23.4049 23.5576 22.9913 450007............................ 1.2962 0.8987 18.3738 19.2875 20.7321 19.4904 450008............................ 1.3133 0.8566 20.1816 22.0934 22.9669 21.7810 450010............................ 1.5052 0.8327 20.3023 22.4133 23.7529 22.1525 450011............................ 1.6756 0.8911 22.1472 24.0715 24.8831 23.7169

[[Page 23534]]

450014............................ 1.0286 0.8148 20.6936 22.5001

* 21.5732 450015............................ 1.5729 1.0226 23.9526 24.0730 27.4012 25.2046 450016............................

***

* 20.1232 22.1368

* 21.1548 450018............................ 1.3942 1.0008 22.9019 24.6443 26.7999 24.7633 450020............................ 0.9466 0.9451 19.1087 17.7148 18.3047 18.3252 450021............................ 1.8194 1.0226 25.0769 28.5578 29.1350 27.5806 450023............................ 1.3878 0.8148 19.1645 20.9278 22.0558 20.7053 450024............................ 1.3228 0.8954 20.7727 20.5868 23.6211 21.6539 450028............................ 1.5658 0.9853 22.7775 25.6030 26.8250 25.1270 450029............................ 1.5162 0.8101 19.9198 23.9709 23.2995 22.4069 450031............................ 1.4488 1.0226 21.7621 27.0328 27.9626 25.5466 450032............................ 1.1987 0.8767 20.5217 20.8306 27.0748 22.7202 450033............................ 1.6186 0.9853 26.5990 29.0541 28.5266 28.0983 450034............................ 1.5259 0.8422 21.6097 23.4615 24.1589 23.0888 450035............................ 1.5166 1.0008 24.1860 25.4580 26.2838 25.3196 450037............................ 1.5141 0.8741 23.1179 23.1176 24.2684 23.5229 450039............................ 1.3588 0.9955 22.0058 23.3034 24.7347 23.3847 450040............................ 1.7455 0.8790 21.2990 23.8047 24.9590 23.3165 450042............................ 1.6976 0.8532 21.8886 22.6936 24.1181 22.9317 450044............................ 1.6507 1.0226 24.1127 25.8403 28.8098 26.9711 450046............................ 1.5525 0.8557 20.9239 22.0695 23.4907 22.1959 450047............................ 0.8562 0.9853 21.8840 22.7242 19.8221 21.4269 450050............................ 0.9271 0.8038 19.5171 21.6933 23.3044 21.3893 450051............................ 1.7617 1.0226 24.5533 27.2523 28.0411 26.6907 450052............................ 0.9686 0.8038 17.6543 19.7185 19.7774 19.2138 450053............................ 0.9574 0.8038 18.6556 19.4978 21.9082 20.0823 450054............................ 1.6531 0.8566 23.2915 25.1229 24.2782 24.2283 450055............................ 1.1284 0.8038 18.2235 20.5235 22.1979 20.3131 450056............................ 1.7820 0.9451 24.4197 25.6685 27.0530 25.7808 450058............................ 1.5325 0.8987 22.0158 24.7442 25.9653 24.1658 450059............................ 1.3149 0.9451 22.8792 26.8209 26.6535 25.4407 450064............................ 1.4037 0.9955 19.1271 24.2920 23.8748 22.4752 450068............................ 2.0137 1.0008 24.0925 26.2864 27.9633 26.1666 450072............................ 1.1350 1.0008 20.3683 22.5010 24.0166 22.2336 450073............................ 0.9362 0.8038 19.2398 20.0464 21.7337 20.3411 450078............................ 0.9261 0.8038 14.8285 17.2196 15.8968 15.9697 450079............................ 1.5320 1.0226 24.0085 27.0443 28.1096 26.3674 450080............................ 1.1799 0.8621 21.0353 21.2482 22.9835 21.7735 450081............................ 1.0360 0.8038 19.2632

*

* 19.2632 450083............................ 1.7207 0.9322 22.5063 24.9182 25.8214 24.4447 450085............................ 1.0173 0.8038 18.1922 19.4524 22.0840 19.8958 450087............................ 1.3393 0.9955 24.5976 26.4203 29.1587 26.8455 450090............................ 1.1561 0.8038 17.1073 17.6506 19.4244 18.0792 450092............................ 1.1362 0.8038 16.0199 20.4921 23.2071 19.7031 450094............................ 1.0935 1.0226 25.8313 25.3618 25.2434 25.4570 450096............................ 1.3677 0.8422 19.8012 22.8722 24.1619 22.3082 450097............................ 1.4253 1.0008 22.2467 24.9380 26.4965 24.6105 450098............................ 0.9223 0.8621 20.4795 22.9005 22.6626 21.9800 450099............................ 1.1731 0.9165 21.4482 24.0293 26.6796 24.1168 450101............................ 1.5502 0.8532 20.1473 20.6575 23.6905 21.4670 450102............................ 1.7209 0.9322 20.9900 23.1773 24.5503 22.9587 450104............................ 1.1697 0.8987 19.7126 22.5165 23.8469 22.0194 450107............................ 1.4575 0.8954 23.2209 23.8770 25.9326 24.3252 450108............................ 1.1001 0.8987 18.8084 19.3561 19.4935 19.2181 450109............................

*** 0.8038 15.1459

*

* 15.1459 450113............................

*** 0.8038 37.8944

* 54.6681 43.1390 450119............................ 1.2979 0.8945 20.8840 24.1392 25.7008 23.6793 450121............................ 1.4458 0.9955 24.6090 25.8826 25.7051 25.4063 450123............................ 1.1207 0.8422 17.8629 19.5872 21.2154 19.5002 450124............................ 1.8251 0.9451 24.2788 26.0280 27.4198 26.0262 450126............................ 1.3283 1.0008 24.1961 27.3021 28.3033 26.6832 450128............................ 1.2202 0.8945

* 21.4190 23.3633 22.3457 450130............................ 1.1654 0.8987 19.6199 20.2777 21.5226 20.5273 450131............................ 1.2121 0.8557 20.0434 23.2317 23.7098 22.3750 450132............................ 1.5283 0.9893 22.4680 26.8476 28.6954 25.9595 450133............................ 1.5415 0.9522 25.3928 25.0972 26.8344 25.8308 450135............................ 1.6894 0.9955 22.5673 24.3858 26.0755 24.4084

[[Page 23535]]

450137............................ 1.6059 0.9955 24.9732 27.0081 30.4254 27.6976 450140............................ 0.8835 0.8038 18.3835 22.4695

* 20.3190 450143............................ 1.0330 0.9451 18.4204 19.7487 21.8705 20.0996 450144............................ 1.1455 0.9593 21.3896 20.9599 21.3289 21.2289 450146............................

*** 0.8038 16.6808

*

* 16.6808 450148............................ 1.1489 0.9955 22.1351 23.5037 25.3498 23.7382 450151............................ 1.1987 0.8038 17.9127 20.1356 22.2915 20.0948 450152............................ 1.1854 0.8566 20.0146 21.6351 22.7463 21.4376 450154............................ 1.2665 0.8038 16.5204 18.6058 21.2021 18.7210 450155............................ 1.0266 0.8038 18.4021 17.9306 18.0589 18.1275 450157............................ 1.0057 0.8038 17.8764 17.8812

* 17.8788 450160............................ 0.9248 0.8038 20.7736 21.9118

* 21.3607 450162............................ 1.3639 0.8790 26.0570 31.0645 30.9903 29.3951 450163............................ 0.9730 0.8038 19.8194 20.3280 23.1400 21.0903 450165............................ 1.1177 0.8987 16.1632 20.2414 24.3242 20.2279 450176............................ 1.3178 0.8945 19.1823 20.9392 20.9297 20.4107 450177............................ 1.2130 0.8038 17.2637 19.7657 21.3322 19.4690 450178............................ 0.9642 0.8038 19.1186 20.2992 24.7301 21.2492 450184............................ 1.5254 1.0008 24.0596 25.3935 26.8458 25.4934 450185............................ 0.9793 0.8038 14.3594 15.5838

* 14.9644 450187............................ 1.1635 1.0008 22.6275 24.2400 25.6786 24.2306 450188............................ 0.9262 0.8038 17.6158 18.9586 20.4070 19.0169 450191............................ 1.1247 0.9451 23.2261 25.9078 26.0298 25.1584 450192............................ 1.0805 0.9955 20.1718 22.5118 22.5880 21.7848 450193............................ 2.0537 1.0008 26.6580 29.2751 32.2964 29.4595 450194............................ 1.3506 0.9955 22.7310 22.3348 24.8972 23.2572 450196............................ 1.4168 0.9955 20.1938 23.6170 24.7557 23.2376 450200............................ 1.4482 0.8293 20.4656 22.0923 23.5344 22.0868 450201............................ 0.9125 0.8038 19.5907 20.3350 20.9809 20.3028 450203............................ 1.1655 0.9514 22.9226 23.3953 24.1675 23.5222 450209............................ 1.8856 0.9165 23.4794 24.4977 26.0958 24.6956 450210............................ 0.9537 0.8038 16.7851 19.6340 19.9832 18.8463 450211............................ 1.3415 1.0008 20.0280 20.7982 23.8230 21.4806 450213............................ 1.7482 0.8987 21.1280 21.7930 23.9676 22.3693 450214............................ 1.1722 1.0008 22.4543 23.9112 25.9598 24.1177 450219............................ 0.9721 0.8038 21.0691 20.8255 21.7934 21.2690 450221............................ 1.1435 0.8038 19.6778 20.6887 20.3186 20.2506 450222............................ 1.5561 1.0008 23.5033 26.2975 27.4426 25.8797 450224............................ 1.4143 0.9164 20.4453 22.2250 24.1956 22.3315 450229............................ 1.6333 0.8038 17.9811 19.8279 21.4459 19.7433 450231............................ 1.6297 0.9165 21.3086 23.9532 25.2852 23.5313 450234............................ 0.9831 0.8038 22.3954 23.6695 18.4451 21.2354 450235............................ 0.9124 0.8038 18.7028 19.1453 21.5138 19.8415 450236............................ 1.0405 0.8038 17.7373 19.2987 22.0788 19.5556 450237............................ 1.6743 0.8987 22.4477 25.1504 24.8901 24.1935 450239............................ 0.9310 0.8566 19.3655 21.8595 21.1945 20.7705 450241............................ 0.9436 0.8038 17.4151 18.1155 18.7957 18.0879 450243............................ 1.0022 0.8038 13.0790 14.0589 15.4636 14.1605 450249............................ 0.9833 0.8038 13.1222 16.5616

* 14.7712 450250............................

*** 0.8038 13.3731

*

* 13.3731 450264............................ 0.9236 0.8038 13.5345 15.4111

* 14.4829 450269............................ 1.0146 0.8038 12.6907 14.8204

* 13.7206 450270............................ 1.0976 0.8038 13.9053 15.0879 14.4325 14.4468 450271............................ 1.1532 0.9514 18.3659 19.4299 21.7719 19.9620 450272............................ 1.2039 0.9451 21.4520 23.7933 25.9864 23.7631 450276............................ 0.8990 0.8038 12.8895 16.0264 16.6319 15.2952 450280............................ 1.5066 1.0226 23.1664 27.4523 28.7233 26.4522 450283............................ 1.0602 0.9955 17.1013 20.0069 20.9680 19.5520 450289............................ 1.3288 1.0008 23.7108 27.3864 28.5665 26.5635 450292............................ 1.2940 1.0226 23.4257 23.5330 25.0411 24.0121 450293............................ 0.8704 0.8038 17.7673 20.0898 21.3136 19.7647 450296............................ 1.0400 1.0008 20.4483 29.2006 27.9690 25.4406 450299............................ 1.5781 0.8911 22.9849 25.8183 26.4933 25.0990 450303............................ 0.8372 0.8790 16.1330

*

* 16.1330 450315............................

*** 1.0226 26.4677 27.9780

* 27.2229 450320............................

***

* 26.8089

*

* 26.8089 450327............................

*** 0.8038 14.3848

*

* 14.3848

[[Page 23536]]

450340............................ 1.3755 0.8287 20.0621 22.7826 24.0636 22.3350 450346............................ 1.3855 0.8422 20.1921 21.9717 22.2469 21.4909 450347............................ 1.1384 1.0008 21.7142 22.8133 27.2203 23.9176 450348............................ 0.9886 0.8038 15.6324 17.0198 18.7675 17.1642 450351............................ 1.2212 0.9514 22.2597 23.5895 25.6859 23.9245 450352............................ 1.1057 1.0226 21.8138 23.4297 24.8012 23.3447 450353............................ 1.2803 0.8038 19.5263 20.9271 24.4454 21.5974 450358............................ 2.0076 1.0008 25.9105 29.3408 30.4280 28.6741 450362............................ 0.9855 0.8038 20.6340 22.0223 25.4372 22.7898 450369............................ 1.0166 0.8038 16.5636 17.5360 18.4848 17.6077 450370............................ 1.1704 0.8038 19.0340 22.6815 20.0832 20.4877 450371............................

***

* 17.3415

*

* 17.3415 450373............................ 0.9087 0.8038 17.7955 20.5789 22.2213 20.1017 450374............................ 0.9164 0.8038 15.0670 17.4509 23.2285 18.2702 450378............................ 1.3340 1.0008 25.8048 29.5108 30.7684 28.7797 450379............................ 1.3574 1.0226 29.0865 31.1573 30.6072 30.3060 450381............................ 0.9257 0.9451 19.0584 20.9200 22.0482 20.7572 450388............................ 1.6460 0.8987 22.4441 24.1598 25.8674 24.3854 450389............................ 1.1827 0.9955 20.7160 22.3803 23.8764 22.4221 450393............................

*** 0.9518 23.8237 24.6872 18.4551 22.6427 450395............................ 1.0142 0.8038 19.1938 23.9689 24.8656 22.6314 450399............................ 0.9249 0.8038 19.1571 19.5928 18.2074 18.9826 450400............................ 1.1916 0.8532 20.1376 22.0103 23.1739 21.7697 450403............................ 1.2709 1.0226 24.6215 27.8138 29.3063 27.2736 450411............................ 0.9558 0.8038 16.9558 17.6570 19.6086 18.1139 450417............................ 0.8643 1.0008 16.1957 17.8078 20.0350 18.0319 450418............................ 1.2488 1.0008 25.1306 27.0283 26.8434 26.3230 450419............................ 1.1760 0.9955 26.7662 28.4122 31.0404 28.7694 450422............................ 1.0462 1.0226 29.0032 29.5592 30.6659 29.7888 450424............................ 1.2797 1.0008 22.0682 23.1253 28.3149 24.8057 450431............................ 1.5343 0.9451 22.9545 24.7346 25.2477 24.3602 450438............................ 1.1444 1.0008 19.2165 22.0476 21.9351 21.1413 450446............................ 0.6161 1.0008 14.1684 14.9983 14.3132 14.4984 450447............................ 1.1971 0.9955 21.0247 22.5602 23.5047 22.3940 450451............................ 1.0873 0.9514 21.1046 22.3834 23.3042 22.3121 450460............................ 0.9348 0.8038 17.9487 19.5709 20.5812 19.4136 450462............................ 1.6600 1.0226 24.0081 25.6952 27.8923 25.9496 450464............................

*** 0.8038 16.1987

*

* 16.1987 450469............................ 1.4541 0.9518 24.0794 26.6781 28.7890 26.6238 450473............................

***

* 18.6002

*

* 18.6002 450484............................ 1.3734 1.0008 23.2881 23.0604 25.3527 23.9206 450488............................ 1.1123 0.8741 22.5650 22.3949 23.9144 22.9600 450489............................ 1.0160 0.8038 18.5941 19.6884 21.4771 19.8409 450497............................ 1.0329 0.8038 17.1327 17.6614 18.8344 17.8832 450498............................ 0.8732 0.8038 19.2984 16.4358 17.7822 17.7509 450508............................ 1.4085 0.9164 20.8183 23.5066 23.9572 22.7686 450514............................ 1.1119 0.8422 21.0116 21.4034 22.6552 21.6987 450517............................ 0.9088 0.8038 14.4246 15.2707 22.0440 17.2013 450518............................ 1.6338 0.8422 21.1015 22.2587 24.1194 22.4755 450523............................

***

* 22.3034 28.6387

* 25.2834 450530............................ 1.1553 1.0008 23.3005 26.1998 28.7451 26.1850 450534............................ 0.8962 0.8038 22.5156 20.4715

* 21.4079 450535............................

***

* 23.7255 29.4427

* 26.5477 450537............................ 1.3531 1.0226 22.5972 23.9256 27.5856 24.8361 450539............................ 1.2112 0.8038 18.4299 20.0343 21.0442 19.8677 450545............................

***

* 21.7762 22.8130

* 22.2858 450547............................ 0.9601 0.9955 22.6557 21.8106 21.6542 22.0062 450558............................ 1.7596 0.8038 21.4201 25.0837 26.1551 24.1840 450563............................ 1.3725 0.9955 27.5671 27.9427 28.7289 28.1251 450565............................ 1.2388 0.8038 17.2171 22.1971 23.8847 20.9966 450571............................ 1.4990 0.8287 21.5688 20.9651 22.7703 21.7784 450573............................ 1.1238 0.8038 18.6233 21.6974 20.1479 20.0755 450578............................ 0.9390 0.8038 17.3010 20.0454 20.2695 19.1233 450580............................ 1.1057 0.8038 18.5225 20.4293 21.1574 20.0321 450584............................ 1.0396 0.8038 16.9021 19.0373 21.0808 18.9453 450586............................ 0.9605 0.8038 14.9061 14.6574 16.1003 15.2149 450587............................ 1.1650 0.8038 19.0648 19.9712 20.4512 19.8609

[[Page 23537]]

450591............................ 1.2007 1.0008 19.6229 22.4991 23.9992 22.0639 450596 h.......................... 1.0985 0.9514 24.3714 24.7477 25.3317 24.8345 450597............................ 0.9702 0.8038 19.9596 22.9337 23.1711 22.1268 450603............................

*** 0.8038 20.6138

*

* 20.6138 450605............................ 1.1521 0.8557 22.0210 23.8820 22.2205 22.7037 450609............................ 0.9809 0.8038 16.6870 18.3856

* 17.5807 450610............................ 1.5974 1.0008 24.7706 22.5451 26.8710 24.6655 450614............................

***

* 18.5895

*

* 18.5895 450617............................ 1.3959 1.0008 22.7514 25.2211 26.5026 24.9284 450620............................ 0.9943 0.8038 17.1333 18.1819 17.7138 17.6710 450623............................ 1.0833 0.9955 25.1400 28.3354 28.3552 27.2112 450626............................ 0.9113 0.8038 17.7454 21.4445 26.8375 21.3925 450630............................ 1.5237 1.0008 24.8096 27.8856 29.6796 27.5230 450631............................

***

* 22.8637 24.5409

* 23.7681 450634............................ 1.5840 1.0226 24.8258 27.0412 28.1705 26.8022 450638............................ 1.5909 1.0008 26.3653 29.5385 29.6184 28.6129 450639............................ 1.5269 0.9955 24.2919 27.3593 29.2669 27.0735 450641............................ 0.9690 0.8038 17.4072 17.0805 17.5845 17.3565 450643............................ 1.3272 0.8101 20.2000 20.9674 21.1205 20.7972 450644............................ 1.4121 1.0008 24.4574 27.2047 29.0186 27.0517 450646............................ 1.3665 0.8954 21.8500 22.6541 23.8908 22.8626 450647............................ 1.8080 1.0226 26.8276 28.8881 30.7334 28.8704 450648............................ 0.9048 0.8038 17.3678 18.2826

* 17.7872 450649............................ 0.9413 0.8038 17.5761 18.1118

* 17.8381 450651............................ 1.6207 1.0226 26.9215 28.9829 32.4822 29.5833 450653............................ 1.1208 0.9317 22.7236 21.8654 23.2603 22.6099 450654............................ 0.9014 0.8038 16.3057 19.6054 19.9992 18.6631 450656............................ 1.3925 0.9164 20.7824 22.7284 23.8280 22.4984 450658............................ 0.9005 0.8038 19.6855 19.9597 20.5398 20.0788 450659............................ 1.4288 1.0008 26.0224 28.8671 30.1727 28.5108 450661............................ 1.1620 0.9893 20.0716 21.5537 23.2989 21.6941 450662............................ 1.5437 0.9853 26.3794 24.5815 28.0913 26.3697 450665............................ 0.8590 0.8038 15.8571 17.2566 18.6054 17.2495 450668............................ 1.5024 0.8954 24.0081 26.4508 26.2375 25.5681 450669............................ 1.2076 1.0226 25.0200 25.6411 27.4677 26.1106 450670............................ 1.3351 1.0008 19.9621 22.0495 25.1575 22.3620 450672............................ 1.6955 0.9955 25.3106 26.7785 27.6359 26.6135 450673............................ 1.0764 0.8327 16.3319 19.4030

* 17.7858 450674............................ 0.9403 1.0008 24.8137 26.8081

* 25.8948 450675............................ 1.4122 0.9955 24.8661 26.1555 28.7765 26.7882 450677............................ 1.3184 0.9955 22.9529 24.0218 28.4544 25.1326 450678............................ 1.3836 1.0226 28.1917 30.1134 30.1500 29.5324 450683............................ 1.1313 1.0226 24.5013 24.0080 24.6609 24.3870 450684............................ 1.2141 1.0008 23.8945 26.2906 27.6789 25.9648 450686............................ 1.6245 0.8790 17.9181 21.0565 23.2367 20.7924 450688............................ 1.1771 1.0226 21.7922 23.7796 27.9057 24.4771 450690............................ 1.4853 0.9322 33.1576 28.7529 28.0400 29.1149 450694............................ 1.0990 1.0008 21.4784 22.3081 23.5790 22.4747 450697............................ 1.3237 0.8987 20.8951 21.2662 23.7155 22.0489 450698............................ 0.8758 0.8038 18.1764 18.5436 18.6494 18.4560 450700............................ 0.9198 0.8038 17.3458 18.6373 18.4602 18.1609 450702............................ 1.5061 0.8741 22.2953 24.8628 25.6147 24.3137 450709............................ 1.2645 1.0008 23.4246 25.0932 25.4855 24.7135 450711............................ 1.6067 0.8945 22.1489 24.8277 28.0104 25.1428 450712............................

***

* 18.4547

*

* 18.4547 450715............................ 1.2343 1.0226

* 16.1897 28.0365 20.5948 450716............................ 1.2179 1.0008 24.8614 28.8043 30.8440 28.2641 450718............................ 1.1954 0.9451 24.9162 27.6672 27.3408 26.7229 450723............................ 1.3817 1.0226 24.1618 27.0055 28.0812 26.5571 450724............................

***

* 21.9630

*

* 21.9630 450730............................ 1.2563 1.0226 27.8476 30.7567 29.9430 29.5510 450733............................

***

* 23.8143 25.5624 26.4976 25.4115 450742............................ 1.1492 1.0226 25.1295 26.3414 26.1190 25.8920 450743............................ 1.4553 1.0226 23.7424 24.7397 27.3213 25.3404 450746............................ 0.9449 0.8038 11.1672 16.9209 12.4748 13.1222 450747............................ 1.1996 0.9955 21.5883 24.2674 22.2870 22.7471 450749............................ 1.0081 0.8038 17.8696 18.4095 17.8227 18.0184

[[Page 23538]]

450751............................ 1.2551 0.8293 23.3154 22.9070 19.3265 21.7472 450754............................ 0.9215 0.8038 19.2827 21.3043 20.8968 20.5167 450755............................ 0.9643 0.8790 19.2768 19.5168 18.0092 18.8178 450758............................ 1.2430 1.0226 22.8713 24.0226 25.6548 24.1232 450760............................ 1.1495 0.8954 23.2959 25.7453 24.6349 24.3909 450761............................ 0.8380 0.8038 15.5151 16.2605 15.7483 15.8642 450763............................ 1.1245 0.8038 19.8939 21.4171 22.4905 21.2790 450766............................ 1.8603 1.0226 27.2499 28.8576 30.0441 28.7197 450770............................ 1.1786 0.9451 19.9412 20.1763 20.3656 20.1550 450771............................ 1.6492 1.0226 25.0490 26.0618 31.3924 27.9152 450774............................ 1.7122 1.0008 21.7906 24.8562 24.9683 23.8170 450775............................ 1.1967 1.0008 23.6621 25.3924 24.4006 24.5023 450776............................ 0.9653 0.8038 14.6695

*

* 14.6695 450780............................ 1.9234 0.8987 21.9046 22.8688 23.9516 22.9443 450788............................ 1.5485 0.8557 21.4467 24.2643 25.4172 23.7014 450795............................ 1.1361 1.0008 19.1371 28.1448 23.7510 23.4235 450796............................ 2.1587 0.9165 22.4973 24.7564 27.9734 25.1133 450797............................

*** 1.0008 18.6839 23.8708 20.5379 20.9547 450801............................ 1.4873 0.8293 19.7790 22.2426 23.0373 21.7315 450803............................ 1.2163 1.0008 23.8343 26.3054 30.6093 27.0662 450804............................ 1.8040 1.0008 22.8275 26.0003 26.0980 25.0247 450808............................ 1.6335 0.9451 18.6555 22.8247 23.8067 21.6597 450809............................ 1.5600 0.9451 23.8758 24.7763 26.3659 25.0664 450811............................ 1.8007 0.8945 22.7583 23.1022 25.8491 24.4306 450813............................ 1.1082 0.8038 21.7208 22.1326 25.5949 23.1456 450817............................

***

* 28.4441

*

* 28.4441 450822............................ 1.1421 1.0226 26.7821 29.7067 31.1431 29.3455 450824............................ 2.3620 0.9451 24.5885

* 26.7803 25.7897 450825............................ 1.4475 0.8945 18.8510 18.7069 20.2959 19.3490 450827............................ 1.4188 0.8327 29.5838 21.1788 20.9704 23.0851 450828............................ 1.1739 0.8038 20.9509 21.4128 22.3667 21.5956 450829............................

*** 0.8987 14.4463 18.2860 19.5014 17.2726 450830............................ 0.9282 0.9593 24.7834 26.9917 28.1617 26.6450 450831............................ 1.6369 1.0008

* 20.0581 22.7885 21.7038 450832............................ 1.1025 1.0008 24.8572 26.4725 26.6628 26.1075 450833............................ 1.1371 1.0226 18.3196 26.1256 26.0044 23.5951 450834............................ 1.3563 0.8911 21.7217 22.7691 21.2204 21.8968 450835............................

***

* 24.8374

*

* 24.8374 450838............................ 1.1289 0.8038

* 15.0454 15.8026 15.4717 450839............................ 0.9271 0.8767

* 21.1905 22.9711 22.0566 450840............................ 0.9946 1.0226

* 29.5215 31.1914 30.4233 450841............................ 1.6236 0.9853

* 17.6635 18.9468 18.3289 450842............................

***

*

* 23.0945

* 23.0945 450844............................ 1.2573 1.0008

* 34.4235 28.7296 30.4450 450845............................ 1.8144 0.8954

* 26.5040 27.7461 27.1743 450846............................

***

*

* 24.0791

* 24.0791 450847............................ 1.1792 1.0008

* 26.8892 27.6854 27.3036 450848............................ 1.1875 1.0008

* 26.5609 27.8100 27.1855 450850............................ 1.4887 0.9522

*

* 22.1334 22.1334 450851............................ 2.2455 1.0226

*

* 30.1213 30.1213 450852............................

*** 1.0226

*

* 30.0191 30.0191 460001............................ 1.8903 0.9578 24.8844 25.6932 27.0757 25.8934 460003............................ 1.4892 0.9436 26.5141 24.3527 26.1372 25.6304 460004............................ 1.6546 0.9436 24.3409 25.2191 26.4498 25.3907 460005............................ 1.4234 0.9436 25.0063 22.6809 23.5633 23.6783 460006............................ 1.2864 0.9436 23.4200 24.4350 25.4787 24.4752 460007............................ 1.3119 0.9416 23.3603 24.2875 25.6686 24.4644 460008............................ 1.3319 0.9436 24.8233 24.4453 26.5672 25.2587 460009............................ 1.9172 0.9436 24.5865 25.0984 26.2833 25.3688 460010............................ 2.0750 0.9436 25.1240 26.2331 27.4648 26.2912 460011............................ 1.2723 0.9578 21.2634 22.3601 23.4023 22.3027 460013............................ 1.3340 0.9578 23.1467 23.4765 25.2448 23.9897 460014............................ 1.0825 0.9436 22.6125 23.9400 24.5384 23.7842 460015............................ 1.2767 0.9183 23.1068 24.0939 25.6576 24.3035 460016............................

*** 0.8134 18.7453

*

* 18.7453 460018 h.......................... 0.8785 1.2094 16.7143 18.8942 20.3755 18.6334 460019............................ 1.0897 0.8134 18.1995 20.3625 19.9900 19.5496

[[Page 23539]]

460020............................ 1.0465 0.8134 15.2162 19.4960 19.5669 17.9384 460021............................ 1.6825 1.1249 23.8565 24.9725 26.3420 25.1139 460023............................ 1.1620 0.9578 25.0874 25.0376 25.3094 25.1556 460025............................ 0.9769 0.8134 22.3098 18.7978

* 20.4201 460026............................ 0.9752 0.8134 21.9316 22.7589 24.1547 22.9505 460029............................ 1.0584 0.8134 24.4379

*

* 24.4379 460032............................ 0.9659 0.9578 21.2715 22.8987

* 22.1308 460033............................ 0.9161 0.8134 21.7216 22.7816 22.0248 22.1909 460035............................ 0.9171 0.8134 16.9657 16.9019 17.5723 17.1694 460036............................ 1.2351 0.9578 23.9910 25.2647 27.2865 25.5949 460037............................ 0.8624 0.8134 20.0323 19.8478 21.1035 20.3240 460039............................ 1.0000 0.9048 26.3795 27.5912 28.5656 27.5288 460041............................ 1.3167 0.9436 23.5132 24.0431 25.2744 24.2809 460042............................ 1.3210 0.9436 22.0844 23.5819 22.9949 22.8865 460043............................ 0.9066 0.9578 26.0277 26.6870 28.2089 27.0296 460044............................ 1.2356 0.9436 24.7138 25.7342 26.6795 25.7463 460047............................ 1.6135 0.9436 24.9214 25.1721 25.7920 25.3219 460049............................ 1.9769 0.9436 21.9357 23.0683 24.5164 23.1856 460051............................ 1.1333 0.9436 22.7540 23.4970 25.5881 24.0241 460052............................ 1.4446 0.9578 23.1717 24.0797 25.3163 24.2177 460053............................

***

* 23.2274

*

* 23.2274 470001............................ 1.2123 1.0668 23.5882 24.5499 27.7329 25.2768 470003............................ 1.8981 1.0199 24.1739 24.6660 26.4919 25.1321 470005............................ 1.3303 1.0199 24.9625 25.7288 29.8255 26.8311 470006............................ 1.1851 1.0199 21.6036 26.0884 26.9651 24.9417 470008............................ 1.1624 1.0199 20.7659 21.8951

* 21.3386 470010............................ 1.1493 1.0199 23.2072 22.9777 26.1273 24.1019 470011............................ 1.2027 1.0903 24.6034 25.9246 28.3911 26.3395 470012............................ 1.2167 1.0199 20.5072 22.9159 24.3425 22.6924 470018............................ 1.1669 1.0199 21.2904 25.9300 28.3419 25.0848 470023............................ 1.2183 1.0199 24.1395 26.7486

* 25.4614 470024............................ 1.1449 1.0199 22.4659 23.7745 25.8652 24.1048 490001............................ 1.0907 0.8024 22.3622 21.7111 21.9953 22.0191 490002............................ 1.0623 0.8024 17.5098 18.5220 19.5613 18.6066 490003............................

***

* 20.9783 23.8112 27.3456 23.8351 490004............................ 1.2757 0.9806 22.7154 24.4580 25.4597 24.2345 490005............................ 1.6453 1.0813 25.2213 27.6425 28.5744 27.1963 490006............................ 1.1847 1.0214 13.4277 16.7679

* 15.2211 490007............................ 2.2466 0.8841 22.2526 24.9533 26.2481 24.5292 490009............................ 1.9263 1.0230 25.2181 27.5905 29.1962 27.2686 490011............................ 1.4460 0.8841 20.0136 22.4410 24.5687 22.4266 490012............................ 0.9964 0.8024 15.8346 18.3697 19.2275 17.8014 490013............................ 1.2634 0.8596 19.5094 21.4838 22.2736 21.0913 490015............................

***

* 21.2557 22.5641

* 21.9516 490017............................ 1.3989 0.8841 20.7691 22.9632 24.6845 22.9273 490018............................ 1.2537 0.9806 22.0810 23.2215 24.5196 23.2792 490019 h.......................... 1.1521 1.0935 23.3077 24.4524 25.9761 24.6213 490020............................ 1.2668 0.9319 21.2094 23.6611 24.8001 23.2943 490021............................ 1.4407 0.8706 22.2537 23.5930 24.6440 23.5199 490022............................ 1.4865 1.0935 24.4682 25.0277 28.0749 25.8811 490023............................ 1.2256 1.0935 24.9734 28.8354 29.7774 27.9947 490024............................ 1.6758 0.8450 21.2619 21.7268 23.0982 22.0522 490027............................ 1.1416 0.8024 20.3644 19.8345 18.9409 19.7128 490031............................ 1.1051 0.8024 18.4826 22.4300 22.0579 20.9706 490032............................ 1.8812 0.9319 23.6489 22.8942 25.1381 23.9005 490033............................ 1.0518 1.0935 24.4370 27.6355 30.0909 27.5418 490037............................ 1.1577 0.8024 17.5104 19.0583 21.3035 19.2834 490038............................ 1.1503 0.8024 18.1405 19.6427 22.1374 19.9691 490040............................ 1.5115 1.0935 27.0513 30.1820 32.8738 30.0780 490041............................ 1.4077 0.8841 19.9314 22.2955 24.5738 22.3542 490042............................ 1.2563 0.8024 19.5127 20.5845 21.8749 20.7701 490043............................ 1.1666 1.0935 25.4354 28.2969 30.8871 28.4640 490044............................ 1.3756 0.8841 20.8739 22.1324 20.8351 21.2628 490045............................ 1.3043 1.0935 24.7131 27.2132 28.8279 27.0743 490046............................ 1.5526 0.8841 22.0040 24.6391 25.6328 24.1719 490047............................ 1.0113 0.8998 19.8220 21.9156 22.5424 21.3597 490048............................ 1.4287 0.8450 22.3138 24.1639 25.0097 23.8716

[[Page 23540]]

490050............................ 1.5254 1.0935 26.1521 29.4660 30.5037 28.7334 490052............................ 1.6709 0.8841 19.2480 21.4035 22.8889 21.2086 490053............................ 1.2926 0.8095 18.6541 20.9367 21.8432 20.4783 490057............................ 1.5826 0.8841 22.1612 25.1898 26.1128 24.5153 490059............................ 1.5692 0.9319 23.3895 26.1518 28.7276 26.1974 490060............................ 1.0283 0.8024 20.6028 21.0828 22.4200 21.3908 490063............................ 1.8332 1.0935 31.0162 29.4216 30.3648 30.2236 490066............................ 1.3174 0.8841 22.1034 23.3835 24.7146 23.4575 490067............................ 1.1859 0.9319 20.4058 21.8730 22.9188 21.7183 490069............................ 1.5306 0.9319 20.6957 24.4542 26.8791 24.1400 490071............................ 1.2929 0.9319 25.4678 27.0374 28.4381 27.0687 490073............................ 1.6276 1.0935 27.6711 25.2859 31.7743 27.8898 490075............................ 1.4205 0.8514 22.3230 22.8303 23.8191 23.0000 490077............................ 1.3109 1.0230 22.2643 24.8309 26.0800 24.4773 490079............................ 1.2705 0.9020 19.2196 19.8100 23.4728 20.7435 490084............................ 1.1954 0.8024 19.8598 22.7945 24.6045 22.3588 490088............................ 1.0683 0.8706 19.7549 21.4818 22.4186 21.1984 490089............................ 1.0461 0.8450 21.1522 21.2123 22.6461 21.7546 490090............................ 1.1132 0.8024 20.3015 21.3410 22.2907 21.2854 490092............................ 1.1103 0.9319 23.8364 21.6466 23.8656 23.0587 490093............................ 1.4305 0.8841 20.7388 23.6779 25.0751 23.2941 490094............................ 0.9993 0.9319 21.9886 26.0755 26.5726 25.0296 490097............................ 1.0181 0.8024 18.1022 23.5366 23.8005 21.5573 490098............................ 1.2311 0.8024 19.7116 20.9805 21.7231 20.8214 490101............................ 1.2761 1.0935 28.5200 30.1800 30.4285 29.7644 490104............................ 0.7943 0.9319 28.0286 33.1215 17.3295 24.4559 490105............................ 0.7131 0.8095 40.6821 38.2813 24.7923 34.3492 490106............................ 0.9458 0.9806 31.6541 30.1492 23.0199 28.3157 490107............................ 1.2758 1.0935 26.5312 28.7296 29.7000 28.3786 490108............................ 0.9611 0.8706 28.7277 27.9090 22.4345 26.3471 490109............................ 0.9766 0.9319 28.0978 28.0548 21.9878 25.9914 490110............................ 1.3198 0.8024 23.6080 21.3126 22.5974 22.4319 490111............................ 1.2838 0.8024 19.4041 20.6373 22.0199 20.6805 490112............................ 1.6692 0.9319 23.6028 25.8312 26.6453 25.4222 490113............................ 1.2540 1.0935 28.0893 29.1786 29.5698 28.9669 490114............................ 0.9717 0.8024 19.9725 20.0555 20.7017 20.2462 490115............................ 1.1772 0.8024 19.9151 20.3615 21.4666 20.5969 490116............................ 1.1327 0.8024 19.7007 21.3083 22.9017 21.2429 490117............................ 1.1880 0.8024 15.6078 17.4111 18.0277 17.0302 490118............................ 1.7046 0.9319 25.2230 26.8810 27.4050 26.6600 490119............................ 1.3161 0.8841 21.3883 23.7813 25.2549 23.5234 490120............................ 1.3813 0.8841 22.2389 23.1535 24.4434 23.3020 490122............................ 1.4487 1.0935 27.3509 28.7020 31.0449 29.0227 490123............................ 1.0953 0.8024 20.9506 22.9511 23.9233 22.6075 490124............................

***

* 21.3713 29.7939

* 25.7258 490126............................ 1.2378 0.8024 20.4660 23.1423 22.2859 21.9403 490127............................ 1.0786 0.8024 17.8070 19.4005 20.4289 19.2585 490130............................ 1.3182 0.8841 18.6038 22.0769 22.8512 21.1640 490132............................

*** 0.8024 19.5849

*

* 19.5849 500001............................ 1.5872 1.1573 26.6420 26.7502 29.3707 27.5939 500002............................ 1.4024 1.0459 24.0374 25.0665 25.3347 24.8482 500003............................ 1.2634 1.1573 27.3435 28.4174 29.6341 28.5098 500005............................ 1.8137 1.1573 28.9512 31.4415 32.0972 30.7955 500007............................ 1.2933 1.0459 23.5774 26.1318 28.0476 25.9648 500008............................ 1.9138 1.1573 28.9380 31.0128 31.8837 30.6288 500011............................ 1.3458 1.1573 27.6762 28.3391 30.6508 28.9502 500012............................ 1.5792 1.0459 26.2263 29.2045 30.6856 28.7227 500014............................ 1.6444 1.1573 27.4248 30.1061 33.7536 30.6058 500015............................ 1.3785 1.1573 27.3397 30.1596 32.0592 29.8941 500016............................ 1.6460 1.1573 27.7863 29.3634 31.4221 29.6282 500019............................ 1.2688 1.0459 25.7691 26.9702 28.6669 27.1697 500021............................ 1.3005 1.0794 26.4648 28.5926 30.1690 28.5893 500023............................ 1.1295 1.0459 23.9513 27.3823

* 25.6872 500024............................ 1.6961 1.0794 27.2967 29.3946 30.7917 29.1683 500025............................ 1.7523 1.1573 29.0400 31.7335 34.7252 31.7861 500026............................ 1.4441 1.1573 28.7532 31.4152 33.2937 31.1325 500027............................ 1.5647 1.1573 30.6901 29.5939 34.2175 31.5063

[[Page 23541]]

500030............................ 1.5791 1.1705 29.0487 30.5926 32.7446 30.8324 500031............................ 1.1888 1.0970 26.0740 28.5398 31.2186 28.5887 500033............................ 1.2976 1.0459 25.4345 26.6704 29.4627 27.2338 500036............................ 1.3747 1.0459 25.4753 26.0223 27.0072 26.1929 500037............................ 1.0310 1.0459 23.5414 24.6548 26.9969 25.0377 500039............................ 1.4511 1.1573 26.1409 27.9651 29.8809 28.0919 500041............................ 1.2975 1.1229 24.9004 26.9101 26.5976 26.1814 500044............................ 1.9843 1.0898 27.0880 26.9323 30.3164 28.1645 500049............................ 1.3010 1.0459 26.6407 25.6104 27.1819 26.4960 500050............................ 1.4422 1.1229 25.0907 26.8971 29.9791 27.4347 500051............................ 1.7552 1.1573 26.9538 29.0100 31.9406 29.4441 500053............................ 1.2441 1.0619 26.0112 26.8074 28.4130 27.1467 500054............................ 2.0525 1.0898 27.1965 28.8062 30.8067 28.9786 500055............................

*** 1.0459 25.3095

*

* 25.3095 500058............................ 1.6605 1.0619 27.3411 28.4247 30.4699 28.8635 500060............................ 1.2823 1.1573 31.7480 33.5169 34.1523 33.1768 500064............................ 1.7416 1.1573 29.2539 31.1459 31.5371 30.6791 500065............................ 1.2445 1.0459 26.5880 26.0960

* 26.3295 500071............................ 1.1734 1.0459 23.2071

*

* 23.2071 500074............................

*** 1.0459 21.9019

*

* 21.9019 500079............................ 1.3420 1.0794 27.1775 28.4934 29.6623 28.4444 500084............................ 1.3103 1.1573 26.5864 27.6306 29.3484 27.9397 500086............................ 1.2807 1.0459 25.9705

*

* 25.9705 500092............................ 0.8995 1.0459 20.8601 23.2466

* 22.0417 500104............................ 1.0691 1.1573 26.8007 27.0034

* 26.9067 500108............................ 1.6596 1.0794 27.4156 28.7206 29.4244 28.5667 500110............................ 1.1857 1.0459 24.8448 25.4785 26.4560 25.6025 500118............................ 1.1171 1.0459 26.1971 28.1074

* 27.1693 500119............................ 1.3607 1.0898 25.1576 27.2335 30.9999 27.7928 500122............................ 1.1916 1.0459 26.9006 27.4405 30.1396 28.2069 500124............................ 1.4090 1.1573 24.8357 28.6598 31.5438 28.2647 500129............................ 1.5325 1.0794 27.8351 30.0223 30.7536 29.5772 500134............................ 0.4749 1.1573 21.3921 24.2990 26.8608 24.3808 500139............................ 1.5310 1.0794 27.7281 29.2357 31.6591 29.5383 500141............................ 1.2664 1.1573 28.2968 30.7478 30.5456 29.9289 500143............................ 0.4570 1.0794 19.0982 20.7093 22.1419 20.7552 500147............................ 0.8043 1.0459

* 16.3669 24.5807 16.9814 500148............................ 1.1051 1.0459

* 18.2168 22.2161 20.0814 510001............................ 1.9174 0.8840 21.4247 22.9351 23.4477 22.6536 510002............................ 1.1623 0.8450 20.9822 22.4751 25.9597 23.1031 510006............................ 1.2491 0.8840 21.0214 22.2947 23.5727 22.3142 510007............................ 1.5458 0.9482 23.4411 24.3499 25.2835 24.3672 510008............................ 1.1920 0.9528 22.7595 24.5293 24.6959 24.0287 510012............................ 0.9435 0.7742 16.7710 18.5816 18.2845 17.8391 510013............................ 1.1671 0.7742 19.7937 19.9710 20.8782 20.2065 510015............................ 0.9561 0.8429 17.9040

*

* 17.9040 510022............................ 1.8301 0.8429 22.7534 24.1481 24.2125 23.7112 510023............................ 1.2510 0.7821 17.9267 19.4321 20.4908 19.2664 510024............................ 1.7224 0.8840 21.3662 23.3115 24.0444 22.9061 510026............................ 1.0110 0.7742 16.5389 18.0855 16.6192 17.0257 510028............................ 0.9965 0.8274 24.6544 23.0518 21.7134 23.1596 510029............................ 1.2527 0.8429 19.8202 21.7527 22.0060 21.2311 510030............................ 1.1843 0.8332 19.8220 22.3658 21.5583 21.2766 510031............................ 1.3895 0.8429 20.5743 21.6294 21.7637 21.3498 510033............................ 1.3921 0.8303 19.6921 21.0707 23.0305 21.2329 510038............................ 1.0245 0.7742 16.1016 16.8744 17.2832 16.7659 510039............................ 1.2658 0.7742 17.6173 19.1280 19.5468 18.7692 510043............................ 0.8986 0.7742 15.5857 16.0586

* 15.8328 510046............................ 1.2834 0.8274 19.2802 21.2792 21.2540 20.5978 510047............................ 1.1340 0.8840 22.1953 23.2093 24.0954 23.1668 510048............................ 1.1071 0.7742 16.3761 17.6785 17.5096 17.1529 510050............................ 1.5329 0.7742 18.9990 20.1943 19.9766 19.7250 510053............................ 1.1350 0.7742 18.1054 20.7538 20.8609 19.9625 510055............................ 1.4505 0.9482 27.7422 29.3962 30.7868 29.3287 510058............................ 1.2970 0.8303 20.1104 21.9352 22.6976 21.6021 510059............................ 0.6811 0.8429 18.1543 18.8712 21.9550 19.5138 510061............................ 0.9818 0.9310 14.8848 15.3355

* 15.1074

[[Page 23542]]

510062............................ 1.1655 0.7742 21.3405 21.1568 23.3216 21.9387 510067............................ 1.1669 0.7742 18.0113 22.1582 21.2099 20.4433 510068............................ 1.1126 1.0935 19.9056 20.0007 23.1011 21.0310 510070............................ 1.1882 0.8274 20.0974 21.1895 23.2382 21.5724 510071............................ 1.2853 0.8274 19.4029 21.5439 23.1685 21.4107 510072............................ 1.0629 0.7742 18.4566 19.7990 20.1997 19.5568 510077............................ 1.1621 0.9119 20.9153 22.8104 23.6585 22.4770 510082............................ 1.1043 0.7742 17.2891 16.4742 19.1878 17.5963 510085............................ 1.2020 0.8429 20.6364 22.6563 23.7173 22.3503 510086............................ 1.0874 0.7742 16.3051 17.8234 17.5933 17.2267 510088............................ 0.9820 0.7742 16.4373 18.3401

* 17.3534 510089............................

***

*

*

* 27.7062 27.7062 520002............................ 1.2821 0.9964 22.0838 23.7316 24.9950 23.6544 520003............................ 1.1724 0.9478 20.4234 21.8662

* 21.1608 520004............................ 1.3395 0.9557 22.8530 24.4711 25.4639 24.2888 520008............................ 1.5856 1.0111 26.0931 27.8127 29.8354 27.9737 520009............................ 1.6869 0.9478 21.5169 23.4265 26.1503 23.6455 520010............................ 1.1228 1.1055 26.3965 28.5569 29.2491 28.0349 520011............................ 1.2647 0.9478 22.7880 23.7785 25.2747 23.9992 520013............................ 1.3725 0.9478 23.1173 24.4766 26.6225 24.8211 520014............................ 1.0762 1.0629 20.4281 22.1064

* 21.2683 520015............................ 1.1411

.9478 22.8094 23.0403

* 22.9239 520017............................ 1.1442 0.9478 21.7542 23.4044 24.6676 23.3009 520019............................ 1.2709 0.9478 22.6895 24.9871 25.0377 24.2463 520021............................ 1.3765 1.0698 24.1284 25.4872 26.6935 25.4468 520024............................ 1.0697 0.9478 17.5368 18.5072

* 18.0423 520026............................ 1.0913 1.1055 25.0504 26.1056

* 25.6168 520027............................ 1.2710 1.0111 22.2089 26.2516 27.5490 25.5645 520028............................ 1.2544 1.0416 24.3592 25.7778 25.4164 25.1844 520030............................ 1.7713 0.9964 23.9474 25.3807 27.0185 25.5053 520032............................ 1.1260 1.0629 22.7220 25.3059 25.3696 24.4819 520033............................ 1.3031 0.9478 22.2650 23.9791 24.6125 23.6548 520034............................ 1.1362 0.9478 22.6160 23.6563 23.9850 23.4634 520035............................ 1.2757 0.9478 20.8563 23.2625 24.7767 23.0160 520037............................ 1.7957 0.9964 25.0587 28.6984 29.7234 27.8508 520038............................ 1.2023 1.0111 23.1036 24.6650 26.6470 24.8476 520040............................ 1.3551 1.0111 21.5671 23.8501 25.1096 23.5636 520041............................ 1.1069 1.0629 22.6216 22.8236 22.7596 22.7396 520042............................ 1.0666 0.9478 21.9935 24.0788 23.6326 23.2471 520044............................ 1.3206 0.9478 22.7627 24.9387 26.0191 24.5777 520045............................ 1.4958 0.9478 24.1624 24.5844 26.0030 24.9427 520047............................ 0.9463 0.9478 22.5686 25.5346

* 24.0011 520048............................ 1.6494 0.9478 20.5069 23.1653 25.1724 22.8848 520049............................ 2.1923 0.9478 22.7424 24.1083 25.9256 24.2130 520051............................ 1.6606 1.0111 27.6695 28.8249 28.3040 28.2799 520057............................ 1.1487 0.9478 21.2729 23.3205 25.3745 23.3399 520058............................

*** 1.0224 23.2907

*

* 23.2907 520060............................ 1.3001 0.9478 21.1271 22.0132 23.8817 22.3382 520062............................ 1.2975 1.0111 23.7166 24.9988 28.2215 25.7059 520063............................ 1.1228 1.0111 23.3037 25.3674 27.4101 25.4095 520064............................ 1.4701 1.0111 24.3043 27.1120 28.6101 26.6968 520066............................ 1.5188 1.0416 23.9212 25.8812 27.1657 25.6782 520068............................ 0.8883 0.9478 21.4413 23.4746 24.8184 23.2981 520069............................

***

* 32.6484

*

* 32.6484 520071............................ 1.2141 0.9957 23.4832 26.3154 27.6202 25.7950 520075............................ 1.5364 0.9478 23.7322 26.0600 27.1699 25.6758 520076............................ 1.1767 1.0416 22.2993 24.0879 26.1698 24.2625 520078............................ 1.4830 1.0111 23.4414 25.7662 27.5989 25.6772 520083............................ 1.7454 1.0629 25.7108 27.0012 28.8407 27.2481 520084............................ 1.0616 1.0629 24.7909 25.5777

* 25.1765 520087............................ 1.6953 0.9557 22.8974 24.5280 27.3374 24.8782 520088............................ 1.3362 0.9957 23.8938 26.0882 26.9936 25.7252 520089............................ 1.5475 1.0629 24.4435 26.6013 30.0448 27.0527 520091............................ 1.2659 0.9478 22.8914 24.8269 24.6320 24.0764 520092............................ 1.0263 0.9478 21.8662 23.4043

* 22.6433 520094............................

*** 0.9957 22.3925 25.3166 25.7567 24.5483 520095............................ 1.2045 1.0416 25.1402 28.6376 26.7863 26.8360

[[Page 23543]]

520096............................ 1.3205 0.9957 21.1759 22.9929 24.5758 22.9775 520097............................ 1.3919 0.9478 23.6512 25.1135 26.3321 25.1104 520098............................ 2.0001 1.0629 25.8184 28.0730 30.6150 28.2679 520100............................ 1.2767 0.9561 21.7072 24.5914 26.2161 24.1896 520102............................ 1.0905 0.9957 23.7739 25.6146 26.8234 25.4621 520103............................ 1.6066 1.0111 23.5984 25.5361 27.9147 25.8275 520107............................ 1.2224 0.9478 25.7379 27.7413 28.3431 27.2253 520109............................ 1.0371 0.9478 20.6357 22.4048 24.9379 22.6443 520111............................

***

* 26.9666 26.3095

* 26.6016 520112............................ 1.1078 0.9478 19.1409 20.4034

* 19.7623 520113............................ 1.2717 0.9478 24.0822 26.7926 27.4135 26.1479 520114............................ 1.1620 0.9478 21.9847 22.0536

* 22.0194 520116............................ 1.2099 0.9957 23.9066 26.3057 26.9902 25.8557 520117............................ 1.0283 0.9478 21.9915 22.0023

* 21.9973 520123............................ 1.0715 1.1055 21.2360 22.2430

* 21.7461 520130............................

*** 0.9478 20.0277

*

* 20.0277 520134............................

*** 0.9478 20.8502

*

* 20.8502 520136............................ 1.6003 1.0111 23.2573 25.5145 27.7703 25.5032 520138............................ 1.8350 1.0111 25.1434 26.9047 28.4394 26.8513 520139............................ 1.2505 1.0111 23.7727 25.4424 26.5110 25.3279 520140............................ 1.6615 1.0111 23.9176 26.1616 28.3001 26.0657 520145............................

***

* 25.0770

*

* 25.0770 520151............................ 1.0251 0.9478 20.1995 22.9592

* 21.5728 520152............................ 1.0564 0.9478 22.5440 23.2493 24.9392 23.6620 520154............................ 1.1733 0.9478 23.2635 23.7160

* 23.4910 520156............................ 1.0529 1.1055 23.7157 24.9258

* 24.3330 520160............................ 1.8094 0.9478 22.9475 24.3528 25.7588 24.4208 520161............................ 0.9206 0.9478 22.1857 24.0673

* 23.1340 520170............................ 1.2905 1.0111 25.5470 25.6124 27.2221 26.1781 520173............................ 1.0948 1.0224 24.4723 26.2224 28.0995 26.3133 520177............................ 1.6337 1.0111 27.5560 28.4663 30.7317 29.0456 520178............................ 0.9691 0.9478 22.3193 23.0419 20.2666 21.8785 520189............................ 1.1063 1.0698 23.1658 26.3172 28.4720 26.3169 520192............................

***

* 22.5641

*

* 22.5641 520194............................ 1.5971

*

*

* 24.9408 24.9408 520195............................ 0.3562 1.0111

*

* 36.6973 36.6973 520196............................ 1.5022 0.9478

*

* 35.1043 35.1043 530002............................ 1.1527 0.9207 23.8852 25.2983 26.8356 25.4030 530004............................

***

* 19.7857

*

* 19.7857 530007............................ 1.2447 0.9207 22.3309 19.3476 20.4391 20.6774 530008 \2\........................ 1.2307 0.9207 21.8714 23.8271 23.8589 23.1777 530009............................ 0.9699 0.9207 22.0450 24.2426 26.8316 24.1997 530010 \2\........................ 1.2457 0.9207 21.4890 23.9255 25.8482 23.7290 530011............................ 1.0112 0.9207 22.5720 24.1396 24.8245 23.8464 530012............................ 1.6902 0.9207 22.4716 24.3454 25.2526 24.0014 530014............................ 1.6077 0.9207 21.7314 23.6907 24.5947 23.3995 530015............................ 1.2773 0.9207 25.3915 26.3107 27.6876 26.4934 530016............................ 1.3351 0.9207 21.0666 21.6575

* 21.3685 530017............................ 0.9556 0.9207 19.5630 23.5415 25.3362 22.8987 530023............................ 1.1558 0.9207 22.5535 24.1493 21.3813 22.6451 530025............................ 1.2781 1.0146 25.4693 27.7988 28.6938 27.3568 530026............................

*** 0.9207 21.0732

*

* 21.0732 530031............................ 0.9546 0.9207 16.8825 16.3472

* 16.6017 530032............................ 1.0215 0.9207 19.4449 22.6584 22.9391 21.6640

\1\ Based on salaries adjusted for occupational mix, according to the calculation in section III.C.2. of the preamble to this proposed rule. \2\ These hospitals are assigned a wage index value according to section III.H. of the preamble of this proposed rule. h These hospitals are assigned a wage index value according to section III.G. of the preamble to this proposed rule. *Denotes wage data not available for the provider for that year. **Based on the sum of the salaries and hours computed for Federal FYs 2004, 2005, and 2006. ***Denotes MedPAR data not available for the provider for FY 2004.

[[Page 23544]]

Table 3A.--FY 2006 and 3-Year* Average Hourly Wage for Urban Areas by CBSA

[*Based on the sum of the salaries and hours computed for Federal fiscal years 2004, 2005, and 2006]

FY 2006 3-Year CBSA code

Urban area

average average hourly wage hourly wage

10180.............. Abilene, TX.............. 22.1701 20.4985 10380.............. Aguadilla-Isabela-San

13.2502 11.5908 Sebastin, PR. 10420.............. Akron, OH................ 25.1189 23.9584 10500.............. Albany, GA............... 24.1844 26.6216 10580.............. Albany-Schenectady-Troy, 23.9528 22.6259 NY. 10740.............. Albuquerque, NM.......... 27.1248 25.7999 10780.............. Alexandria, LA........... 22.5148 21.3129 10900.............. Allentown-Bethlehem-

27.5389 25.5680 Easton, PA-NJ. 11020.............. Altoona, PA.............. 25.0167 22.9759 11100.............. Amarillo, TX............. 25.6410 24.0270 11180.............. Ames, IA................. 26.7068 25.0247 11260.............. Anchorage, AK............ 33.8779 32.1826 11300.............. Anderson, IN............. 24.1549 23.0714 11340.............. Anderson, SC............. 24.8624 22.9488 11460.............. Ann Arbor, MI............ 30.4505 29.2076 11500.............. Anniston-Oxford, AL...... 21.4718 20.7611 11540.............. Appleton, WI............. 25.9098 24.1044 11700.............. Asheville, NC............ 26.0511 24.5466 12020.............. Athens-Clarke County, GA. 27.4532 26.1928 12060.............. Atlanta-Sandy Springs-

26.9604 26.0983 Marietta, GA. 12100.............. Atlantic City, NJ........ 32.5013 29.4922 12220.............. Auburn-Opelika, AL....... 22.6976 21.8061 12260.............. Augusta-Richmond County, 26.7647 24.8652 GA-SC. 12420.............. Austin-Round Rock, TX.... 26.4408 25.2181 12540.............. Bakersfield, CA.......... 28.9777 26.6414 12580.............. Baltimore-Towson, MD..... 27.6740 26.1267 12620.............. Bangor, ME............... 27.9343 26.2399 12700.............. Barnstable Town, MA...... 35.0207 33.2353 12940.............. Baton Rouge, LA.......... 24.0727 22.2239 12980.............. Battle Creek, MI......... 26.5543 24.8160 13020.............. Bay City, MI............. 26.1760 25.1852 13140.............. Beaumont-Port Arthur, TX. 23.5603 22.3855 13380.............. Bellingham, WA........... 32.7446 30.8324 13460.............. Bend, OR................. 30.1666 28.0136 13644.............. Bethesda-Frederick-

32.0917 29.4434 Gaithersburg, MD. 13740.............. Billings, MT............. 24.7710 23.5742 13780.............. Binghamton, NY........... 24.0264 22.4051 13820.............. Birmingham-Hoover, AL.... 25.1185 23.9577 13900.............. Bismarck, ND............. 21.0353 20.1696 13980.............. Blacksburg-Christiansburg- 22.3143 21.3890 Radford, VA. 14020.............. Bloomington, IN.......... 23.7061 22.5941 14060.............. Bloomington-Normal, IL... 25.4101 23.7897 14260.............. Boise City-Nampa, ID..... 25.3133 24.3052 14484.............. Boston-Quincy, MA........ 32.2755 30.7174 14500.............. Boulder, CO.............. 27.2574 26.2715 14540.............. Bowling Green, KY........ 23.0011 21.8437 14740.............. Bremerton-Silverdale, WA. 29.8809 28.0919 14860.............. Bridgeport-Stamford-

35.2686 33.7851 Norwalk, CT. 15180.............. Brownsville-Harlingen, TX 27.5656 26.6683 15260.............. Brunswick, GA............ 26.1311 28.6493 15380.............. Buffalo-Niagara Falls, NY 24.8634 24.3177 15500.............. Burlington, NC........... 24.9033 23.6142 15540.............. Burlington-South

26.4165 25.0134 Burlington, VT. 15764.............. Cambridge-Newton-

30.9921 29.2429 Framingham, MA. 15804.............. Camden, NJ............... 29.4132 28.1192 15940.............. Canton-Massillon, OH..... 25.0564 23.6833 15980.............. Cape Coral-Fort Myers, FL 26.1095 25.0250 16180.............. Carson City, NV.......... 28.6158 27.0192 16220.............. Casper, WY............... 25.2526 24.0014 16300.............. Cedar Rapids, IA......... 24.0727 23.2382 16580.............. Champaign-Urbana, IL..... 26.8325 25.4853 16620.............. Charleston, WV........... 23.5802 22.9895 16700.............. Charleston-North

26.3883 24.7642 Charleston, SC. 16740.............. Charlotte-Gastonia-

27.1825 25.6465 Concord, NC-SC. 16820.............. Charlottesville, VA...... 28.6200 26.8014 16860.............. Chattanooga, TN-GA....... 25.4537 24.0895 16940.............. Cheyenne, WY............. 24.5947 23.3995 16974.............. Chicago-Naperville-

30.3410 28.6963 Joliet, IL. 17020.............. Chico, CA................ 29.4447 27.4655

[[Page 23545]]

17140.............. Cincinnati-Middletown, OH- 26.8669 25.0229 KY-IN. 17300.............. Clarksville, TN-KY....... 23.1419 21.5444 17420.............. Cleveland, TN............ 22.8278 21.2133 17460.............. Cleveland-Elyria-Mentor, 25.7303 25.0687 OH. 17660.............. Coeur d'Alene, ID........ 26.9749 25.1364 17780.............. College Station-Bryan, TX 24.9298 23.8550 17820.............. Colorado Springs, CO..... 26.4562 25.5825 17860.............. Columbia, MO............. 23.3470 22.3003 17900.............. Columbia, SC............. 25.3362 24.0049 17980.............. Columbus, GA-AL.......... 23.9764 22.7919 18020.............. Columbus, IN............. 26.8458 25.0573 18140.............. Columbus, OH............. 27.5495 25.7193 18580.............. Corpus Christi, TX....... 23.9399 22.6210 18700.............. Corvallis, OR............ 29.9648 28.7806 19060.............. Cumberland, MD-WV........ 26.0448 22.8828 19124.............. Dallas-Plano-Irving, TX.. 28.6076 26.7125 19140.............. Dalton, GA............... 25.2695 24.8431 19180.............. Danville, IL............. 25.3127 22.9099 19260.............. Danville, VA............. 23.8191 23.0000 19340.............. Davenport-Moline-Rock

24.3842 23.2403 Island, IA-IL. 19380.............. Dayton, OH............... 25.3708 24.4405 19460.............. Decatur, AL.............. 23.7138 22.9734 19500.............. Decatur, IL.............. 22.5852 21.4281 19660.............. Deltona-Daytona Beach-

26.0379 24.0560 Ormond Beach, FL. 19740.............. Denver-Aurora, CO........ 29.9610 28.5110 19780.............. Des Moines, IA........... 26.9975 24.6647 19804.............. Detroit-Livonia-Dearborn, 29.2431 27.2952 MI. 20020.............. Dothan, AL............... 21.6602 20.2540 20100.............. Dover, DE................ 27.4735 25.9428 20220.............. Dubuque, IA.............. 25.5030 23.5042 20260.............. Duluth, MN-WI............ 28.5299 27.0543 20500.............. Durham, NC............... 28.7033 27.3555 20740.............. Eau Claire, WI........... 25.7563 24.1573 20764.............. Edison, NJ............... 31.5082 29.5433 20940.............. El Centro, CA............ 25.1083 23.7136 21060.............. Elizabethtown, KY........ 24.6642 22.6125 21140.............. Elkhart-Goshen, IN....... 26.9005 25.1975 21300.............. Elmira, NY............... 23.1540 22.0419 21340.............. El Paso, TX.............. 25.0500 23.9275 21500.............. Erie, PA................. 24.4677 22.8915 21604.............. Essex County, MA......... 29.4434 27.9641 21660.............. Eugene-Springfield, OR... 30.2425 29.2693 21780.............. Evansville, IN-KY........ 24.4379 22.4627 21820.............. Fairbanks, AK............ 31.8995 29.8198 21940.............. Fajardo, PR.............. 11.6386 10.6772 22020.............. Fargo, ND-MN............. 23.7360 23.9742 22140.............. Farmington, NM........... 23.8264 22.4376 22180.............. Fayetteville, NC......... 26.3708 24.3719 22220.............. Fayetteville-Springdale- 24.0127 22.5998 Rogers, AR-MO. 22380.............. Flagstaff, AZ............ 33.8333 30.2808 22420.............. Flint, MI................ 29.7989 28.6871 22500.............. Florence, SC............. 25.1444 23.2705 22520.............. Florence-Muscle Shoals,

23.2344 21.0532 AL. 22540.............. Fond du Lac, WI.......... 26.9936 25.7252 22660.............. Fort Collins-Loveland, CO 28.2568 26.7964 22744.............. Fort Lauderdale-Pompano

29.1773 27.0873 Beach-Deerfield Beach, FL. 22900.............. Fort Smith, AR-OK........ 23.0272 21.9069 23020.............. Fort Walton Beach-

24.8333 23.4332 Crestview-Destin, FL. 23060.............. Fort Wayne, IN........... 27.4082 25.7154 23104.............. Fort Worth-Arlington, TX. 26.6167 24.9487 23420.............. Fresno, CA............... 29.6215 27.6921 23460.............. Gadsden, AL.............. 22.3074 21.3197 23540.............. Gainesville, FL.......... 26.4676 25.1553 23580.............. Gainesville, GA.......... 24.8893 24.3542 23844.............. Gary, IN................. 26.2014 24.6755 24020.............. Glens Falls, NY.......... 24.0232 22.4577 24140.............. Goldsboro, NC............ 24.5666 23.0280 24220.............. Grand Forks, ND-MN....... 32.2306 26.3170 24300.............. Grand Junction, CO....... 26.8293 25.6655

[[Page 23546]]

24340.............. Grand Rapids-Wyoming, MI. 26.2918 24.9274 24500.............. Great Falls, MT.......... 25.2873 23.4084 24540.............. Greeley, CO.............. 26.8470 25.0779 24580.............. Green Bay, WI............ 26.4060 25.1220 24660.............. Greensboro-High Point, NC 25.5495 24.2161 24780.............. Greenville, NC........... 26.3325 24.3631 24860.............. Greenville, SC........... 28.3616 25.8028 25020.............. Guayama, PR.............. 08.9125 09.5939 25060.............. Gulfport-Biloxi, MS...... 24.9592 23.9056 25180.............. Hagerstown-Martinsburg,

26.6548 25.0347 MD-WV. 25260.............. Hanford-Corcoran, CA..... 28.1814 25.1270 25420.............. Harrisburg-Carlisle, PA.. 26.0656 24.4935 25500.............. Harrisonburg, VA......... 25.4597 24.2345 25540.............. Hartford-West Hartford-

31.0121 29.5959 East Hartford, CT. 25620.............. Hattiesburg, MS.......... 21.3089 19.6542 25860.............. Hickory-Lenoir-Morganton, 24.9837 24.3032 NC. 25980.............. \1\Hinesville-Fort

.------- .------- Stewart, GA. 26100.............. Holland-Grand Haven, MI.. 25.4579 24.5609 26180.............. Honolulu, HI............. 31.3501 29.2509 26300.............. Hot Springs, AR.......... 25.3627 24.1181 26380.............. Houma-Bayou Cane-

22.1079 20.5356 Thibodaux, LA. 26420.............. Houston-Baytown-Sugar

27.9993 26.1356 Land, TX. 26580.............. Huntington-Ashland, WV-KY- 26.5266 25.2510 OH. 26620.............. Huntsville, AL........... 25.5254 23.9276 26820.............. Idaho Falls, ID.......... 26.3236 24.2135 26900.............. Indianapolis, IN......... 27.7571 26.3923 26980.............. Iowa City, IA............ 27.2791 25.4755 27060.............. Ithaca, NY............... 27.5699 25.6624 27100.............. Jackson, MI.............. 26.0171 24.0809 27140.............. Jackson, MS.............. 23.2553 21.9059 27180.............. Jackson, TN.............. 25.0772 23.6035 27260.............. Jacksonville, FL......... 26.0254 24.9544 27340.............. Jacksonville, NC......... 23.0236 22.0702 27500.............. Janesville, WI........... 26.7462 25.0136 27620.............. Jefferson City, MO....... 23.4699 22.4350 27740.............. Johnson City, TN......... 22.2633 21.2152 27780.............. Johnstown, PA............ 23.3540 22.1239 27860.............. Jonesboro, AR............ 22.2913 21.0721 27900.............. Joplin, MO............... 24.0416 22.8597 28020.............. Kalamazoo-Portage, MI.... 29.1036 28.0902 28100.............. Kankakee-Bradley, IL..... 30.7469 28.2579 28140.............. Kansas City, MO-KS....... 26.4479 25.2795 28420.............. Kennewick-Richland-Pasco, 29.7070 27.8472 WA. 28660.............. Killeen-Temple-Fort Hood, 23.9626 23.6807 TX. 28700.............. Kingsport-Bristol-

22.5380 21.6656 Bristol, TN-VA. 28740.............. Kingston, NY............. 25.9063 24.4214 28940.............. Knoxville, TN............ 23.6960 22.7400 29020.............. Kokomo, IN............... 26.7312 24.3627 29100.............. La Crosse, WI-MN......... 26.7369 24.6616 29140.............. Lafayette, IN............ 24.4215 23.5470 29180.............. Lafayette, LA............ 23.5797 22.0745 29340.............. Lake Charles, LA......... 21.9512 20.7252 29404.............. Lake County-Kenosha

29.2180 27.3940 County, IL-WI. 29460.............. Lakeland, FL............. 24.9925 23.4702 29540.............. Lancaster, PA............ 27.1801 25.5025 29620.............. Lansing-East Lansing, MI. 27.3767 25.6366 29700.............. Laredo, TX............... 22.6637 21.9619 29740.............. Las Cruces, NM........... 23.6548 22.8284 29820.............. Las Vegas-Paradise, NV... 31.9355 30.3760 29940.............. Lawrence, KS............. 23.8863 22.7099 30020.............. Lawton, OK............... 22.1442 21.4717 30140.............. Lebanon, PA.............. 24.2087 23.0471 30300.............. Lewiston, ID-WA.......... 27.6345 24.9793 30340.............. Lewiston-Auburn, ME...... 26.1064 24.8965 30460.............. Lexington-Fayette, KY.... 25.3464 22.7343 30620.............. Lima, OH................. 25.7797 24.7454 30700.............. Lincoln, NE.............. 28.5262 27.0530 30780.............. Little Rock-North Little 24.5286 23.3089 Rock, AR. 30860.............. Logan, UT-ID............. 25.6905 24.3475

[[Page 23547]]

30980.............. Longview, TX............. 24.4521 23.4643 31020.............. Longview, WA............. 26.5976 26.1814 31084.............. Los Angeles-Long Beach-

32.9050 31.0454 Glendale, CA. 31140.............. Louisville, KY-IN........ 25.9154 24.2971 31180.............. Lubbock, TX.............. 24.5905 22.7060 31340.............. Lynchburg, VA............ 24.3559 23.5846 31420.............. Macon, GA................ 26.5343 25.0025 31460.............. Madera, CA............... 24.4061 22.5247 31540.............. Madison, WI.............. 29.7363 27.4059 31700.............. Manchester-Nashua, NH.... 28.8847 27.6772 31900.............. \1\Mansfield, OH......... ------- ------- 32420.............. Mayag[uuml]ez, PR........ 11.2362 11.3917 32580.............. McAllen-Edinburg-Pharr,

25.0238 22.9932 TX. 32780.............. Medford, OR.............. 28.6299 27.7062 32820.............. Memphis, TN-MS-AR........ 26.1471 24.2118 32900.............. Merced, CA............... 31.1184 27.6673 33124.............. Miami-Miami Beach-

27.2942 25.9755 Kendall, FL. 33140.............. Michigan City-La Porte,

26.3221 24.7313 IN. 33260.............. Midland, TX.............. 26.6395 25.3824 33340.............. Milwaukee-Waukesha-West

28.2858 26.5793 Allis, WI. 33460.............. Minneapolis-St. Paul-

30.9281 29.1156 Bloomington, MN-WI. 33540.............. Missoula, MT............. 26.4227 24.2896 33660.............. Mobile, AL............... 22.1076 20.9624 33700.............. Modesto, CA.............. 33.0964 31.0034 33740.............. Monroe, LA............... 22.5035 20.9918 33780.............. Monroe, MI............... 26.4882 25.0486 33860.............. Montgomery, AL........... 24.0586 21.7643 34060.............. Morgantown, WV........... 23.6097 22.7263 34100.............. Morristown, TN........... 24.5017 21.6486 34580.............. Mount Vernon-Anacortes,

29.2146 27.8316 WA. 34620.............. Muncie, IN............... 25.0449 23.0977 34740.............. Muskegon-Norton Shores,

27.0713 25.4822 MI. 34820.............. Myrtle Beach-Conway-North 24.8106 23.7419 Myrtle Beach, SC. 34900.............. Napa, CA................. 35.3683 32.9923 34940.............. Naples-Marco Island, FL.. 28.2979 26.9037 34980.............. Nashville-Davidson--

27.2968 26.1014 Murfreesboro, TN. 35004.............. Nassau-Suffolk, NY....... 35.7543 34.1418 35084.............. Newark-Union, NJ-PA...... 34.1064 31.1564 35300.............. New Haven-Milford, CT.... 32.7989 31.1765 35380.............. New Orleans-Metairie-

25.1852 23.9697 Kenner, LA. 35644.............. New York-Wayne-White

36.9026 35.2542 Plains, NY-NJ. 35660.............. Niles-Benton Harbor, MI.. 24.8541 23.3997 35980.............. Norwich-New London, CT... 31.8510 30.4182 36084.............. Oakland-Fremont-Hayward, 42.8742 40.0207 CA. 36100.............. Ocala, FL................ 25.0519 24.4578 36140.............. Ocean City, NJ........... 30.8612 28.5543 36220.............. Odessa, TX............... 27.6769 25.1761 36260.............. Ogden-Clearfield, UT..... 25.2772 24.5654 36420.............. Oklahoma City, OK........ 25.2975 23.7988 36500.............. Olympia, WA.............. 30.5859 28.9079 36540.............. Omaha-Council Bluffs, NE- 26.7314 25.5410 IA. 36740.............. Orlando, FL.............. 26.4250 25.3813 36780.............. Oshkosh-Neenah, WI....... 25.6249 23.9585 36980.............. Owensboro, KY............ 24.6348 22.4970 37100.............. Oxnard-Thousand Oaks-

32.4624 29.7410 Ventura, CA. 37340.............. Palm Bay-Melbourne-

27.4887 25.7496 Titusville, FL. 37460.............. Panama City-Lynn Haven,

22.3439 21.3568 FL. 37620.............. Parkersburg-Marietta, WV- 23.2293 21.7277 OH. 37700.............. Pascagoula, MS........... 22.8397 21.4591 37860.............. Pensacola-Ferry Pass-

22.6287 22.0289 Brent, FL. 37900.............. Peoria, IL............... 24.7421 23.2730 37964.............. Philadelphia, PA......... 30.8573 28.8565 38060.............. Phoenix-Mesa-Scottsdale, 28.3642 26.6530 AZ. 38220.............. Pine Bluff, AR........... 24.3824 22.1870 38300.............. Pittsburgh, PA........... 24.7296 23.2597 38340.............. Pittsfield, MA........... 28.4877 27.1701 38540.............. Pocatello, ID............ 26.1526 24.5528 38660.............. Ponce, PR................ 14.4851 13.0375 38860.............. Portland-South Portland- 29.0440 26.7442 Biddeford, ME.

[[Page 23548]]

38900.............. Portland-Vancouver-

31.4148 29.7614 Beaverton, OR-WA. 38940.............. Port St. Lucie-Fort

28.3669 26.5761 Pierce, FL. 39100.............. Poughkeepsie-Newburgh-

30.1207 29.3034 Middletown, NY. 39140.............. Prescott, AZ............. 27.6508 26.3318 39300.............. Providence-New Bedford-

30.6398 28.8359 Fall River, RI-MA. 39340.............. Provo-Orem, UT........... 26.5574 25.4669 39380.............. Pueblo, CO............... 24.1431 23.0046 39460.............. Punta Gorda, FL.......... 25.9442 24.8140 39540.............. Racine, WI............... 25.2201 23.6789 39580.............. Raleigh-Cary, NC......... 27.1623 25.4788 39660.............. Rapid City, SD........... 25.2538 23.5560 39740.............. Reading, PA.............. 27.1301 24.7239 39820.............. Redding, CA.............. 34.1503 31.2183 39900.............. Reno-Sparks, NV.......... 30.7272 28.3079 40060.............. Richmond, VA............. 26.0695 24.6756 40140.............. Riverside-San Bernardino- 30.8328 29.3251 Ontario, CA. 40220.............. Roanoke, VA.............. 23.4915 22.4289 40340.............. Rochester, MN............ 31.1302 30.1737 40380.............. Rochester, NY............ 25.5065 24.5493 40420.............. Rockford, IL............. 27.9047 25.7304 40484.............. Rockingham County-

29.0055 27.0997 Strafford County, NH. 40580.............. Rocky Mount, NC.......... 24.9648 23.6953 40660.............. Rome, GA................. 26.3370 23.8100 40900.............. Sacramento--Arden-Arcade-- 36.2362 32.0754 Roseville, CA. 40980.............. Saginaw-Saginaw Township 26.5050 25.8822 North, MI. 41060.............. St. Cloud, MN............ 28.0585 26.3196 41100.............. St. George, UT........... 26.3420 25.1139 41140.............. St. Joseph, MO-KS........ 26.7587 25.8174 41180.............. St. Louis, MO-IL......... 25.0452 23.7896 41420.............. Salem, OR................ 29.2207 27.6647 41500.............. Salinas, CA.............. 39.5570 37.1828 41540.............. Salisbury, MD............ 25.3485 24.0517 41620.............. Salt Lake City, UT....... 26.3970 25.4439 41660.............. San Angelo, TX........... 23.1837 21.9567 41700.............. San Antonio, TX.......... 25.1428 23.6255 41740.............. San Diego-Carlsbad-San

31.9401 29.8191 Marcos, CA. 41780.............. Sandusky, OH............. 25.2690 23.6568 41884.............. San Francisco-San Mateo- 41.8804 38.9640 Redwood City, CA. 41900.............. San Germ[aacute]n-Cabo

12.9971 13.4135 Rojo, PR. 41940.............. San Jose-Sunnyvale-Santa 42.2833 39.0995 Clara, CA. 41980.............. San Juan-Caguas-Guaynabo, 13.1085 12.3738 PR. 42020.............. San Luis Obispo-Paso

31.7731 29.7965 Robles, CA. 42044.............. Santa Ana-Anaheim-Irvine, 32.3515 30.4088 CA. 42060.............. Santa Barbara-Santa Maria- 32.2413 28.8239 Goleta, CA. 42100.............. Santa Cruz-Watsonville,

42.4095 37.7929 CA. 42140.............. Santa Fe, NM............. 30.5158 28.6521 42220.............. Santa Rosa-Petaluma, CA.. 37.7122 34.7294 42260.............. Sarasota-Bradenton-

26.6769 25.5601 Venice, FL. 42340.............. Savannah, GA............. 26.5289 24.9832 42540.............. Scranton--Wilkes-Barre,

23.8629 22.4039 PA. 42644.............. Seattle-Bellevue-Everett, 32.3774 30.4447 WA. 43100.............. Sheboygan, WI............ 24.9924 23.3301 43300.............. Sherman-Denison, TX...... 26.6281 25.3544 43340.............. Shreveport-Bossier City, 24.5258 23.6868 LA. 43580.............. Sioux City, IA-NE-SD..... 26.1843 24.0956 43620.............. Sioux Falls, SD.......... 26.9025 25.0103 43780.............. South Bend-Mishawaka, IN- 27.3743 25.4781 MI. 43900.............. Spartanburg, SC.......... 25.6900 24.5737 44060.............. Spokane, WA.............. 30.4868 28.5450 44100.............. Springfield, IL.......... 24.8405 23.3039 44140.............. Springfield, MA.......... 28.7008 27.2255 44180.............. Springfield, MO.......... 23.0819 22.2164 44220.............. Springfield, OH.......... 23.4939 22.7752 44300.............. State College, PA........ 23.4099 22.4626 44700.............. Stockton, CA............. 31.7047 28.5078 44940.............. Sumter, SC............... 23.4355 22.1331 45060.............. Syracuse, NY............. 26.8425 25.0698 45104.............. Tacoma, WA............... 30.0701 28.9533 45220.............. Tallahassee, FL.......... 24.3724 22.7559

[[Page 23549]]

45300.............. Tampa-St. Petersburg-

25.8608 24.1485 Clearwater, FL. 45460.............. Terre Haute, IN.......... 23.2574 22.0638 45500.............. Texarkana, TX-Texarkana, 23.2000 21.8927 AR. 45780.............. Toledo, OH............... 26.7822 25.0440 45820.............. Topeka, KS............... 24.9561 23.6665 45940.............. Trenton-Ewing, NJ........ 30.3180 27.8778 46060.............. Tucson, AZ............... 25.1965 23.6781 46140.............. Tulsa, OK................ 23.2484 22.9280 46220.............. Tuscaloosa, AL........... 24.4051 22.1412 46340.............. Tyler, TX................ 26.0797 24.9826 46540.............. Utica-Rome, NY........... 23.2558 21.9605 46660.............. Valdosta, GA............. 24.8233 22.4638 46700.............. Vallejo-Fairfield, CA.... 41.6513 38.4022 46940.............. Vero Beach, FL........... 26.4579 25.3120 47020.............. Victoria, TX............. 22.7937 21.7127 47220.............. Vineland-Millville-

27.5232 27.0476 Bridgeton, NJ. 47260.............. Virginia Beach-Norfolk-

24.7332 23.2422 Newport News, VA-NC. 47300.............. Visalia-Porterville, CA.. 28.2676 26.4299 47380.............. Waco, TX................. 23.8678 22.0533 47580.............. Warner Robins, GA........ 24.2312 22.6117 47644.............. Warren-Farmington Hills- 27.5791 26.2703 Troy, MI. 47894.............. Washington-Arlington-

30.5916 28.8815 Alexandria, DC-VA-MD-WV. 47940.............. Waterloo-Cedar Falls, IA. 23.9572 22.5445 48140.............. Wausau, WI............... 27.0185 25.5053 48260.............. Weirton-Steubenville, WV- 21.8793 21.4989 OH. 48300.............. Wenatchee, WA............ 28.1544 26.5892 48424.............. West Palm Beach-Boca

28.1452 26.6150 Raton-Boynton Beach, FL. 48540.............. Wheeling, WV-OH.......... 20.0483 19.3905 48620.............. Wichita, KS.............. 25.6152 24.4842 48660.............. Wichita Falls, TX........ 23.2954 21.9177 48700.............. Williamsport, PA......... 23.4090 21.9892 48864.............. Wilmington, DE-MD-NJ..... 29.4490 28.5184 48900.............. Wilmington, NC........... 26.7996 24.9839 49020.............. Winchester, VA-WV........ 28.5744 27.1963 49180.............. Winston-Salem, NC........ 25.0655 24.1158 49340.............. Worcester, MA............ 30.8969 29.3320 49420.............. Yakima, WA............... 28.4267 27.0960 49500.............. Yauco, PR................ 12.3449 12.0750 49620.............. York-Hanover, PA......... 26.3577 24.3575 49660.............. Youngstown-Warren-

24.0832 23.4935 Boardman, OH-PA. 49700.............. Yuba City, CA............ 30.6351 27.8070 49740.............. Yuma, AZ................. 25.7050 23.8047

\1\This area has no average hourly wage because there are no IPPS hospitals in the area.

Table 3B.--FY 2006 and 3-Year* Average Hourly Wage for Rural Areas by CBSA

[*Based on the sum of the salaries and hours computed for Federal fiscal years 2004, 2005, and 2006]

3-Year FY 2006 Average CBSA code

Nonurban area

average Hourly hourly wage Wage

01................. Alabama.................. 20.9677 19.9301 02................. Alaska................... 33.5065 31.4748 03................. Arizona.................. 24.5771 23.5781 04................. Arkansas................. 20.9189 19.6660 05................. California............... 30.3466 27.6453 06................. Colorado................. 26.2370 24.6175 07................. Connecticut.............. 32.9843 31.5388 08................. Delaware................. 26.8747 25.1962 10................. Florida.................. 24.0946 22.8362 11................. Georgia.................. 21.4961 20.5018 12................. Hawaii................... 29.6476 27.4203 13................. Idaho.................... 22.5556 21.6678 14................. Illinois................. 23.1784 21.8542 15................. Indiana.................. 24.1494 22.9960 16................. Iowa..................... 23.7869 22.2470 17................. Kansas................... 22.3594 21.2491

[[Page 23550]]

18................. Kentucky................. 21.7864 20.6370 19................. Louisiana................ 20.8290 19.5920 20................. Maine.................... 24.7292 23.4474 21................. Maryland................. 25.4559 24.0971 22................. Massachusetts \1\........ ........... ........... 23................. Michigan................. 24.8226 23.3712 24................. Minnesota................ 25.6894 24.4485 25................. Mississippi.............. 21.5005 20.3551 26................. Missouri................. 22.1717 20.6813 27................. Montana.................. 24.6808 23.0871 28................. Nebraska................. 24.2446 23.3257 29................. Nevada................... 25.3983 24.4345 30................. New Hampshire............ 29.8455 26.8676 31................. New Jersey \1\........... ........... ........... 32................. New Mexico............... 24.1961 22.4946 33................. New York................. 22.8600 21.6353 34................. North Carolina........... 23.9761 22.5825 35................. North Dakota............. 20.3602 20.0510 36................. Ohio..................... 24.5857 23.0443 37................. Oklahoma................. 21.2973 20.1660 38................. Oregon................... 27.4748 25.9138 39................. Pennsylvania............. 23.2205 21.9390 40................. Puerto Rico \1\.......... ........... ........... 41................. Rhode Island \1\......... ........... ........... 42................. South Carolina........... 24.2359 22.7771 43................. South Dakota............. 23.7080 21.9887 44................. Tennessee................ 22.1430 20.8103 45................. Texas.................... 22.4855 21.0274 46................. Utah..................... 22.7561 21.7771 47................. Vermont.................. 27.4761 24.9413 49................. Virginia................. 22.4489 21.2273 50................. Washington............... 29.2600 27.4343 51................. West Virginia............ 21.6576 20.5854 52................. Wisconsin................ 26.5156 24.7363 53................. Wyoming.................. 25.7561 24.1767

\1\ All counties within the State or territory are classified as urban.

Table 4A.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Urban Areas by CBSA

Urban area (constituent Wage CBSA code

counties)

index GAF

10180................ \2\ Abilene, TX............ 0.8038 0.8611 Callahan County, TX Jones County, TX Taylor County, TX 10380................ Aguadilla-Isabela-San

0.4736 0.5994 Sebastian, PR. Aguada Municipio, PR Aguadilla Municipio, PR Anasco Municipio, PR Isabela Municipio, PR Lares Municipio, PR Moca Municipio, PR Rincon Municipio, PR San Sebastian Municipio, PR 10420................ Akron, OH.................. 0.8979 0.9289 Portage County, OH Summit County, OH 10500................ Albany, GA................. 0.8645 0.9051 Baker County, GA Dougherty County, GA Lee County, GA Terrell County, GA Worth County, GA 10580................ Albany-Schenectady-Troy, NY 0.8565 0.8994 Albany County, NY Rensselaer County, NY

[[Page 23551]]

Saratoga County, NY Schenectady County, NY Schoharie County, NY 10740................ Albuquerque, NM............ 0.9696 0.9791 Bernalillo County, NM Sandoval County, NM Torrance County, NM Valencia County, NM 10780................ Alexandria, LA............. 0.8048 0.8618 Grant Parish, LA Rapides Parish, LA 10900................ Allentown-Bethlehem-Easton, 0.9844 0.9893 PA-NJ (PA Hospitals). Warren County, NJ Carbon County, PA Lehigh County, PA Northampton County, PA 10900................ \2\ Allentown-Bethlehem-

1.0607 1.0412 Easton, PA-NJ (NJ Hospitals). Warren County, NJ Carbon County, PA Lehigh County, PA Northampton County, PA 11020................ Altoona, PA................ 0.8942 0.9263 Blair County, PA 11100................ Amarillo, TX............... 0.9165 0.9420 Armstrong County, TX Carson County, TX Potter County, TX Randall County, TX 11180................ Ames, IA................... 0.9546 0.9687 Story County, IA 11260................ Anchorage, AK.............. 1.2110 1.1401 Anchorage Municipality, AK Matanuska-Susitna Borough, AK 11300................ Anderson, IN............... 0.8634 0.9043 Madison County, IN 11340................ Anderson, SC............... 0.8887 0.9224 Anderson County, SC 11460................ Ann Arbor, MI.............. 1.0885 1.0598 Washtenaw County, MI 11500................ Anniston-Oxford, AL........ 0.7702 0.8363 Calhoun County, AL 11540................ \2\Appleton, WI............ 0.9478 0.9640 Calumet County, WI Outagamie County, WI 11700................ Asheville, NC.............. 0.9312 0.9524 Buncombe County, NC Haywood County, NC Henderson County, NC Madison County, NC 12020................ Athens-Clarke County, GA... 0.9813 0.9872 Clarke County, GA Madison County, GA Oconee County, GA Oglethorpe County, GA 12060................ \1\ Atlanta-Sandy Springs- 0.9637 0.9750 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

[[Page 23552]]

Haralson County, GA Heard County, GA Henry County, GA Jasper County, GA Lamar County, GA Meriwether County, GA Newton County, GA Paulding County, GA Pickens County, GA Pike County, GA Rockdale County, GA Spalding County, GA Walton County, GA 12100................ Atlantic City, NJ.......... 1.1618 1.1082 Atlantic County, NJ 12220................ Auburn-Opelika, AL......... 0.8113 0.8666 Lee County, AL 12260................ Augusta-Richmond County, GA- 0.9567 0.9701 SC. Burke County, GA Columbia County, GA McDuffie County, GA Richmond County, GA Aiken County, SC Edgefield County, SC 12420................ \1\Austin-Round Rock, TX... 0.9451 0.9621 Bastrop County, TX Caldwell County, TX Hays County, TX Travis County, TX Williamson County, TX 12540................ \2\ Bakersfield, CA........ 1.0848 1.0573 Kern County, CA 12580................ \1\ Baltimore-Towson, MD... 0.9892 0.9926 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................. 0.9985 0.9990 Penobscot County, ME 12700................ Barnstable Town, MA........ 1.2518 1.1663 Barnstable County, MA 12940................ Baton Rouge, LA............ 0.8605 0.9022 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........... 0.9492 0.9649 Calhoun County, MI 13020................ Bay City, MI............... 0.9535 0.9679 Bay County, MI 13140................ Beaumont-Port Arthur, TX... 0.8422 0.8890 Hardin County, TX Jefferson County, TX Orange County, TX 13380................ Bellingham, WA............. 1.1705 1.1138 Whatcom County, WA 13460................ Bend, OR................... 1.0783 1.0530 Deschutes County, OR 13644................ \1\ Bethesda-Frederick-

1.1471 1.0985 Gaithersburg, MD. Frederick County, MD Montgomery County, MD 13740................ Billings, MT............... 0.8855 0.9201

[[Page 23553]]

Carbon County, MT Yellowstone County, MT 13780................ Binghamton, NY............. 0.8588 0.9010 Broome County, NY Tioga County, NY 13820................ \1\ Birmingham-Hoover, AL.. 0.8979 0.9289 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............... 0.7519 0.8226 Burleigh County, ND Morton County, ND 13980................ \2\ Blacksburg-

0.8024 0.8601 Christiansburg-Radford, VA. Giles County, VA Montgomery County, VA Pulaski County, VA Radford City, VA 14020................ \2\ Bloomington, IN........ 0.8632 0.9042 Greene County, IN Monroe County, IN Owen County, IN 14060................ Bloomington-Normal, IL..... 0.9083 0.9363 McLean County, IL 14260................ Boise City-Nampa, ID....... 0.9048 0.9338 Ada County, ID Boise County, ID Canyon County, ID Gem County, ID Owyhee County, ID 14484................ \1\ Boston-Quincy, MA...... 1.1537 1.1029 Norfolk County, MA Plymouth County, MA Suffolk County, MA 14500................ Boulder, CO................ 0.9743 0.9823 Boulder County, CO 14540................ Bowling Green, KY.......... 0.8222 0.8745 Edmonson County, KY Warren County, KY 14740................ Bremerton-Silverdale, WA... 1.0681 1.0461 Kitsap County, WA 14860................ Bridgeport-Stamford-

1.2607 1.1719 Norwalk, CT. Fairfield County, CT 15180................ Brownsville-Harlingen, TX.. 0.9853 0.9899 Cameron County, TX 15260................ Brunswick, GA.............. 0.9341 0.9544 Brantley County, GA Glynn County, GA McIntosh County, GA 15380................ \1\ Buffalo-Niagara Falls, 0.8888 0.9224 NY. Erie County, NY Niagara County, NY 15500................ Burlington, NC............. 0.8902 0.9234 Alamance County, NC 15540................ \2\ Burlington-South

1.0199 1.0136 Burlington, VT. Chittenden County, VT Franklin County, VT Grand Isle County, VT 15764................ \1\ Cambridge-Newton-

1.1078 1.0726 Framingham, MA. Middlesex County, MA 15804................ \1\ \2\ Camden, NJ......... 1.0607 1.0412 Burlington County, NJ Camden County, NJ Gloucester County, NJ 15940................ Canton-Massillon, OH....... 0.8957 0.9273 Carroll County, OH Stark County, OH

[[Page 23554]]

15980................ Cape Coral-Fort Myers, FL.. 0.9333 0.9538 Lee County, FL 16180................ Carson City, NV............ 1.0229 1.0156 Carson City, NV 16220................ \2\ Casper, WY............. 0.9207 0.9450 Natrona County, WY 16300................ Cedar Rapids, IA........... 0.8605 0.9022 Benton County, IA Jones County, IA Linn County, IA 16580................ Champaign-Urbana, IL....... 0.9591 0.9718 Champaign County, IL Ford County, IL Piatt County, IL 16620................ Charleston, WV............. 0.8429 0.8896 Boone County, WV Clay County, WV Kanawha County, WV Lincoln County, WV Putnam County, WV 16700................ Charleston-North

0.9433 0.9608 Charleston, SC. Berkeley County, SC Charleston County, SC Dorchester County, SC 16740................ \1\ Charlotte-Gastonia-

0.9717 0.9805 Concord, NC-SC. Anson County, NC Cabarrus County, NC Gaston County, NC Mecklenburg County, NC Union County, NC York County, SC 16820................ Charlottesville, VA........ 1.0230 1.0157 Albemarle County, VA Fluvanna County, VA Greene County, VA Nelson County, VA Charlottesville City, VA 16860................ Chattanooga, TN-GA......... 0.9099 0.9374 Catoosa County, GA Dade County, GA Walker County, GA Hamilton County, TN Marion County, TN Sequatchie County, TN 16940................ \2\ Cheyenne, WY........... 0.9207 0.9450 Laramie County, WY 16974................ \1\ Chicago-Naperville-

1.0846 1.0572 Joliet, IL. Cook County, IL DeKalb County, IL DuPage County, IL Grundy County, IL Kane County, IL Kendall County, IL McHenry County, IL Will County, IL 17020................ \2\ Chico, CA.............. 1.0848 1.0573 Butte County, CA 17140................ \1\ Cincinnati-Middletown, 0.9604 0.9727 OH-KY-IN. Dearborn County, IN Franklin County, IN Ohio County, IN Boone County, KY Bracken County, KY Campbell County, KY Gallatin County, KY Grant County, KY Kenton County, KY Pendleton County, KY Brown County, OH Butler County, OH

[[Continued on page 23555]]

From the Federal Register Online via GPO Access [wais.access.gpo.gov] ]

[[pp. 23555-23604]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2006 Rates

[[Continued from page 23554]]

[[Page 23555]]

Clermont County, OH Hamilton County, OH Warren County, OH 17300................ Clarksville, TN-KY......... 0.8272 0.8782 Christian County, KY Trigg County, KY Montgomery County, TN Stewart County, TN 17420................ Cleveland, TN.............. 0.8160 0.8700 Bradley County, TN Polk County, TN 17460................ \1\ Cleveland-Elyria-

0.9197 0.9443 Mentor, OH. Cuyahoga County, OH Geauga County, OH Lake County, OH Lorain County, OH Medina County, OH 17660................ Coeur d'Alene, ID.......... 0.9642 0.9753 Kootenai County, ID 17780................ College Station-Bryan, TX.. 0.8911 0.9241 Brazos County, TX Burleson County, TX Robertson County, TX 17820................ Colorado Springs, CO....... 0.9457 0.9625 El Paso County, CO Teller County, CO 17860................ Columbia, MO............... 0.8346 0.8835 Boone County, MO Howard County, MO 17900................ Columbia, SC............... 0.9057 0.9344 Calhoun County, SC Fairfield County, SC Kershaw County, SC Lexington County, SC Richland County, SC Saluda County, SC 17980................ Columbus, GA-AL............ 0.8570 0.8997 Russell County, AL Chattahoochee County, GA Harris County, GA Marion County, GA Muscogee County, GA 18020................ Columbus, IN............... 0.9596 0.9722 Bartholomew County, IN 18140................ \1\ Columbus, OH........... 0.9848 0.9896 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......... 0.8557 0.8988 Aransas County, TX Nueces County, TX San Patricio County, TX 18700................ Corvallis, OR.............. 1.0711 1.0482 Benton County, OR 19060................ Cumberland, MD-WV.......... 0.9310 0.9522 Allegany County, MD Mineral County, WV 19124................ \1\ Dallas-Plano-Irving, TX 1.0226 1.0154 Collin County, TX Dallas County, TX Delta County, TX Denton County, TX Ellis County, TX Hunt County, TX Kaufman County, TX

[[Page 23556]]

Rockwall County, TX 19140................ Dalton, GA................. 0.9033 0.9327 Murray County, GA Whitfield County, GA 19180................ Danville, IL............... 0.9048 0.9338 Vermilion County, IL 19260................ Danville, VA............... 0.8514 0.8957 Pittsylvania County, VA Danville City, VA 19340................ Davenport-Moline-Rock

0.8716 0.9102 Island, IA-IL. Henry County, IL Mercer County, IL Rock Island County, IL Scott County, IA 19380................ Dayton, OH................. 0.9069 0.9353 Greene County, OH Miami County, OH Montgomery County, OH Preble County, OH 19460................ Decatur, AL................ 0.8517 0.8959 Lawrence County, AL Morgan County, AL 19500................ \2\ Decatur, IL............ 0.8285 0.8791 Macon County, IL 19660................ Deltona-Daytona Beach-

0.9307 0.9520 Ormond Beach, FL. Volusia County, FL 19740................ \1\ Denver-Aurora, CO...... 1.0710 1.0481 Adams County, CO Arapahoe County, CO Broomfield County, CO Clear Creek County, CO Denver County, CO Douglas County, CO Elbert County, CO Gilpin County, CO Jefferson County, CO Park County, CO 19780................ Des Moines, IA............. 0.9650 0.9759 Dallas County, IA Guthrie County, IA Madison County, IA Polk County, IA Warren County, IA 19804................ \1\ Detroit-Livonia-

1.0453 1.0308 Dearborn, MI. Wayne County, MI 20020................ Dothan, AL................. 0.7743 0.8393 Geneva County, AL Henry County, AL Houston County, AL 20100................ Dover, DE.................. 0.9821 0.9877 Kent County, DE 20220................ Dubuque, IA................ 0.9116 0.9386 Dubuque County, IA 20260................ Duluth, MN-WI.............. 1.0224 1.0153 Carlton County, MN St. Louis County, MN Douglas County, WI 20500................ Durham, NC................. 1.0260 1.0177 Chatham County, NC Durham County, NC Orange County, NC Person County, NC 20740................ \2\ Eau Claire, WI......... 0.9478 0.9640 Chippewa County, WI Eau Claire County, WI 20764................ \1\ Edison, NJ............. 1.1301 1.0874 Middlesex County, NJ Monmouth County, NJ Ocean County, NJ Somerset County, NJ

[[Page 23557]]

20940................ \2\ El Centro, CA.......... 1.0848 1.0573 Imperial County, CA 21060................ Elizabethtown, KY.......... 0.8816 0.9173 Hardin County, KY Larue County, KY 21140................ Elkhart-Goshen, IN......... 0.9616 0.9735 Elkhart County, IN 21300................ Elmira, NY................. 0.8276 0.8785 Chemung County, NY 21340................ El Paso, TX................ 0.8954 0.9271 El Paso County, TX 21500................ Erie, PA................... 0.8746 0.9123 Erie County, PA 21604................ Essex County, MA........... 1.0525 1.0357 Essex County, MA 21660................ Eugene-Springfield, OR..... 1.0810 1.0548 Lane County, OR 21780................ Evansville, IN-KY.......... 0.8735 0.9115 Gibson County, IN Posey County, IN Vanderburgh County, IN Warrick County, IN Henderson County, KY Webster County, KY 21820................ \2\ Fairbanks, AK.......... 1.1977 1.1315 Fairbanks North Star Borough, AK 21940................ Fajardo, PR................ 0.4160 0.5485 Ceiba Municipio, PR Fajardo Municipio, PR Luquillo Municipio, PR 22020................ Fargo, ND-MN (ND Hospitals) 0.8778 0.9146 Clay County, MN Cass County, ND 22020................ \2\ Fargo, ND-MN (MN

0.9183 0.9433 Hospitals). Clay County, MN Cass County, ND 22140................ \2\ Farmington, NM......... 0.8649 0.9054 San Juan County, NM 22180................ Fayetteville, NC........... 0.9426 0.9603 Cumberland County, NC Hoke County, NC 22220................ Fayetteville-Springdale-

0.8615 0.9029 Rogers, AR-MO. Benton County, AR Madison County, AR Washington County, AR McDonald County, MO 22380................ Flagstaff, AZ.............. 1.2094 1.1391 Coconino County, AZ 22420................ Flint, MI.................. 1.0654 1.0443 Genesee County, MI 22500................ Florence, SC............... 0.8988 0.9295 Darlington County, SC Florence County, SC 22520................ Florence-Muscle Shoals, AL. 0.8305 0.8806 Colbert County, AL Lauderdale County, AL 22540................ Fond du Lac, WI............ 0.9649 0.9758 Fond du Lac County, WI 22660................ Fort Collins-Loveland, CO.. 1.0146 1.0100 Larimer County, CO 22744................ \1\ Fort Lauderdale-Pompano 1.0508 1.0345 Beach-Deerfield Beach, FL. Broward County, FL 22900................ Fort Smith, AR-OK.......... 0.8231 0.8752 Crawford County, AR Franklin County, AR Sebastian County, AR Le Flore County, OK Sequoyah County, OK 23020................ Fort Walton Beach-Crestview- 0.8877 0.9217 Destin, FL. Okaloosa County, FL

[[Page 23558]]

23060................ Fort Wayne, IN............. 0.9797 0.9861 Allen County, IN Wells County, IN Whitley County, IN 23104................ \1\ Fort Worth-Arlington, 0.9514 0.9665 TX. Johnson County, TX Parker County, TX Tarrant County, TX Wise County, TX 23420................ \2\ Fresno, CA............. 1.0848 1.0573 Fresno County, CA 23460................ Gadsden, AL................ 0.7974 0.8564 Etowah County, AL 23540................ Gainesville, FL............ 0.9461 0.9628 Alachua County, FL Gilchrist County, FL 23580................ Gainesville, GA............ 0.8897 0.9231 Hall County, GA 23844................ Gary, IN................... 0.9366 0.9561 Jasper County, IN Lake County, IN Newton County, IN Porter County, IN 24020................ Glens Falls, NY............ 0.8587 0.9009 Warren County, NY Washington County, NY 24140................ Goldsboro, NC.............. 0.8781 0.9148 Wayne County, NC 24220................ Grand Forks, ND-MN......... 1.1521 1.1018 Polk County, MN Grand Forks County, ND 24300................ Grand Junction, CO......... 0.9590 0.9717 Mesa County, CO 24340................ Grand Rapids-Wyoming, MI... 0.9398 0.9584 Barry County, MI Ionia County, MI Kent County, MI Newaygo County, MI 24500................ Great Falls, MT............ 0.9074 0.9356 Cascade County, MT 24540................ Greeley, CO................ 0.9597 0.9722 Weld County, CO 24580................ \2\ Green Bay, WI.......... 0.9478 0.9640 Brown County, WI Kewaunee County, WI Oconto County, WI 24660................ Greensboro-High Point, NC.. 0.9133 0.9398 Guilford County, NC Randolph County, NC Rockingham County, NC 24780................ Greenville, NC............. 0.9414 0.9595 Greene County, NC Pitt County, NC 24860................ Greenville, SC............. 1.0138 1.0094 Greenville County, SC Laurens County, SC Pickens County, SC 25020................ Guayama, PR................ 0.3186 0.4569 Arroyo Municipio, PR Guayama Municipio, PR Patillas Municipio, PR 25060................ Gulfport-Biloxi, MS........ 0.8922 0.9249 Hancock County, MS Harrison County, MS Stone County, MS 25180................ Hagerstown-Martinsburg, MD- 0.9528 0.9674 WV. Washington County, MD Berkeley County, WV Morgan County, WV 25260................ \2\ Hanford-Corcoran, CA... 1.0848 1.0573

[[Page 23559]]

Kings County, CA 25420................ Harrisburg-Carlisle, PA.... 0.9317 0.9527 Cumberland County, PA Dauphin County, PA Perry County, PA 25500................ Harrisonburg, VA........... 0.9101 0.9375 Rockingham County, VA Harrisonburg City, VA 25540................ \1\ \2\ Hartford-West

1.1790 1.1194 Hartford-East Hartford, CT. Hartford County, CT Litchfield County, CT Middlesex County, CT Tolland County, CT 25620................ \2\ Hattiesburg, MS........ 0.7685 0.8350 Forrest County, MS Lamar County, MS Perry County, MS 25860................ Hickory-Lenoir-Morganton, 0.8931 0.9255 NC. Alexander County, NC Burke County, NC Caldwell County, NC Catawba County, NC 25980................ Hinesville-Fort Stewart, GA 0.7684 0.8349 Liberty County, GA Long County, GA 26100................ Holland-Grand Haven, MI.... 0.9133 0.9398 Ottawa County, MI 26180................ Honolulu, HI............... 1.1206 1.0811 Honolulu County, HI 26300................ Hot Springs, AR............ 0.9066 0.9351 Garland County, AR 26380................ Houma-Bayou Cane-Thibodaux, 0.7903 0.8512 LA. Lafourche Parish, LA Terrebonne Parish, LA 26420................ \1\ Houston-Baytown-Sugar 1.0008 1.0005 Land, TX. Austin County, TX Brazoria County, TX Chambers County, TX Fort Bend County, TX Galveston County, TX Harris County, TX Liberty County, TX Montgomery County, TX San Jacinto County, TX Waller County, TX 26580................ Huntington-Ashland, WV-KY- 0.9482 0.9642 OH. Boyd County, KY Greenup County, KY Lawrence County, OH Cabell County, WV Wayne County, WV 26620................ Huntsville, AL............. 0.9124 0.9391 Limestone County, AL Madison County, AL 26820................ Idaho Falls, ID............ 0.9409 0.9591 Bonneville County, ID Jefferson County, ID 26900................ \1\ Indianapolis, IN....... 0.9922 0.9947 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.............. 0.9751 0.9829 Johnson County, IA

[[Page 23560]]

Washington County, IA 27060................ Ithaca, NY................. 0.9855 0.9900 Tompkins County, NY 27100................ Jackson, MI................ 0.9300 0.9515 Jackson County, MI 27140................ Jackson, MS................ 0.8313 0.8812 Copiah County, MS Hinds County, MS Madison County, MS Rankin County, MS Simpson County, MS 27180................ Jackson, TN................ 0.8964 0.9278 Chester County, TN Madison County, TN 27260................ \1\ Jacksonville, FL....... 0.9303 0.9517 Baker County, FL Clay County, FL Duval County, FL Nassau County, FL St. Johns County, FL 27340................ \2\ Jacksonville, NC....... 0.8570 0.8997 Onslow County, NC 27500................ Janesville, WI............. 0.9561 0.9697 Rock County, WI 27620................ Jefferson City, MO......... 0.8389 0.8867 Callaway County, MO Cole County, MO Moniteau County, MO Osage County, MO 27740................ Johnson City, TN........... 0.7958 0.8552 Carter County, TN Unicoi County, TN Washington County, TN 27780................ Johnstown, PA.............. 0.8348 0.8837 Cambria County, PA 27860................ Jonesboro, AR.............. 0.7968 0.8559 Craighead County, AR Poinsett County, AR 27900................ Joplin, MO................. 0.8594 0.9014 Jasper County, MO Newton County, MO 28020................ Kalamazoo-Portage, MI...... 1.0403 1.0274 Kalamazoo County, MI Van Buren County, MI 28100................ Kankakee-Bradley, IL....... 1.0991 1.0668 Kankakee County, IL 28140................ \1\ Kansas City, MO-KS..... 0.9454 0.9623 Franklin County, KS Johnson County, KS Leavenworth County, KS Linn County, KS Miami County, KS Wyandotte County, KS Bates County, MO Caldwell County, MO Cass County, MO Clay County, MO Clinton County, MO Jackson County, MO Lafayette County, MO Platte County, MO Ray County, MO 28420................ Kennewick-Richland-Pasco, 1.0619 1.0420 WA. Benton County, WA Franklin County, WA 28660................ Killeen-Temple-Fort Hood, 0.8566 0.8994 TX. Bell County, TX Coryell County, TX Lampasas County, TX 28700................ Kingsport-Bristol-Bristol, 0.8095 0.8653 TN-VA.

[[Page 23561]]

Hawkins County, TN Sullivan County, TN Bristol City, VA Scott County, VA Washington County, VA 28740................ Kingston, NY............... 0.9260 0.9487 Ulster County, NY 28940................ Knoxville, TN.............. 0.8470 0.8925 Anderson County, TN Blount County, TN Knox County, TN Loudon County, TN Union County, TN 29020................ Kokomo, IN................. 0.9555 0.9693 Howard County, IN Tipton County, IN 29100................ La Crosse, WI-MN........... 0.9557 0.9694 Houston County, MN La Crosse County, WI 29140................ Lafayette, IN.............. 0.8730 0.9112 Benton County, IN Carroll County, IN Tippecanoe County, IN 29180................ Lafayette, LA.............. 0.8429 0.8896 Lafayette Parish, LA St. Martin Parish, LA 29340................ Lake Charles, LA........... 0.7847 0.8470 Calcasieu Parish, LA Cameron Parish, LA 29404................ Lake County-Kenosha County, 1.0444 1.0302 IL-WI. Lake County, IL Kenosha County, WI 29460................ Lakeland, FL............... 0.8934 0.9257 Polk County, FL 29540................ Lancaster, PA.............. 0.9716 0.9805 Lancaster County, PA 29620................ Lansing-East Lansing, MI... 0.9786 0.9853 Clinton County, MI Eaton County, MI Ingham County, MI 29700................ Laredo, TX................. 0.8101 0.8657 Webb County, TX 29740................ \2\ Las Cruces, NM......... 0.8649 0.9054 Dona Ana County, NM 29820................ \1\ Las Vegas-Paradise, NV. 1.1416 1.0949 Clark County, NV 29940................ Lawrence, KS............... 0.8538 0.8974 Douglas County, KS 30020................ Lawton, OK................. 0.7916 0.8521 Comanche County, OK 30140................ Lebanon, PA................ 0.8654 0.9057 Lebanon County, PA 30300................ Lewiston, ID-WA (ID

0.9878 0.9916 Hospitals). Nez Perce County, ID Asotin County, WA 30300................ \2\ Lewiston, ID-WA (WA

1.0459 1.0312 Hospitals). Nez Perce County, ID Asotin County, WA 30340................ Lewiston-Auburn, ME........ 0.9332 0.9538 Androscoggin County, ME 30460................ Lexington-Fayette, KY...... 0.9060 0.9346 Bourbon County, KY Clark County, KY Fayette County, KY Jessamine County, KY Scott County, KY Woodford County, KY 30620................ Lima, OH................... 0.9263 0.9489 Allen County, OH 30700................ Lincoln, NE................ 1.0197 1.0134

[[Page 23562]]

Lancaster County, NE Seward County, NE 30780................ Little Rock-North Little

0.8768 0.9139 Rock, AR. Faulkner County, AR Grant County, AR Lonoke County, AR Perry County, AR Pulaski County, AR Saline County, AR 30860................ Logan, UT-ID............... 0.9183 0.9433 Franklin County, ID Cache County, UT 30980................ Longview, TX............... 0.8741 0.9120 Gregg County, TX Rusk County, TX Upshur County, TX 31020................ \2\ Longview, WA........... 1.0459 1.0312 Cowlitz County, WA 31084................ \1\ Los Angeles-Long Beach- 1.1762 1.1175 Glendale, CA. Los Angeles County, CA 31140................ \1\ Louisville, KY-IN...... 0.9264 0.9490 Clark County, IN Floyd County, IN Harrison County, IN Washington County, IN Bullitt County, KY Henry County, KY Jefferson County, KY Meade County, KY Nelson County, KY Oldham County, KY Shelby County, KY Spencer County, KY Trimble County, KY 31180................ Lubbock, TX................ 0.8790 0.9155 Crosby County, TX Lubbock County, TX 31340................ Lynchburg, VA.............. 0.8706 0.9095 Amherst County, VA Appomattox County, VA Bedford County, VA Campbell County, VA Bedford City, VA Lynchburg City, VA 31420................ Macon, GA.................. 0.9485 0.9644 Bibb County, GA Crawford County, GA Jones County, GA Monroe County, GA Twiggs County, GA 31460................ \2\ Madera, CA............. 1.0848 1.0573 Madera County, CA 31540................ Madison, WI................ 1.0629 1.0427 Columbia County, WI Dane County, WI Iowa County, WI 31700................ \2\ Manchester-Nashua, NH.. 1.0668 1.0453 Hillsborough County, NH Merrimack County, NH 31900................ Mansfield, OH.............. 0.8788 0.9153 Richland County, OH 32420................ Mayaguez, PR............... 0.4016 0.5354 Hormigueros Municipio, PR Mayag[uuml]ez Municipio, PR 32580................ McAllen-Edinburg-Pharr, TX. 0.8945 0.9265 Hidalgo County, TX 32780................ \2\ Medford, OR............ 1.0284 1.0194 Jackson County, OR 32820................ \1\ Memphis, TN-MS-AR...... 0.9346 0.9547 Crittenden County, AR

[[Page 23563]]

DeSoto County, MS Marshall County, MS Tate County, MS Tunica County, MS Fayette County, TN Shelby County, TN Tipton County, TN 32900................ Merced, CA................. 1.1123 1.0756 Merced County, CA 33124................ \1\ Miami-Miami Beach-

0.9757 0.9833 Kendall, FL. Miami-Dade County, FL 33140................ Michigan City-La Porte, IN. 0.9409 0.9591 LaPorte County, IN 33260................ Midland, TX................ 0.9522 0.9670 Midland County, TX 33340................ \1\ Milwaukee-Waukesha-West 1.0111 1.0076 Allis, WI. Milwaukee County, WI Ozaukee County, WI Washington County, WI Waukesha County, WI 33460................ \1\ Minneapolis-St. Paul- 1.1055 1.0711 Bloomington, MN-WI. Anoka County, MN Carver County, MN Chisago County, MN Dakota County, MN Hennepin County, MN Isanti County, MN Ramsey County, MN Scott County, MN Sherburne County, MN Washington County, MN Wright County, MN Pierce County, WI St. Croix County, WI 33540................ Missoula, MT............... 0.9535 0.9679 Missoula County, MT 33660................ Mobile, AL................. 0.7902 0.8511 Mobile County, AL 33700................ Modesto, CA................ 1.1885 1.1255 Stanislaus County, CA 33740................ Monroe, LA................. 0.8044 0.8615 Ouachita Parish, LA Union Parish, LA 33780................ Monroe, MI................. 0.9468 0.9633 Monroe County, MI 33860................ Montgomery, AL............. 0.8600 0.9019 Autauga County, AL Elmore County, AL Lowndes County, AL Montgomery County, AL 34060................ Morgantown, WV............. 0.8439 0.8903 Monongalia County, WV Preston County, WV 34100................ Morristown, TN............. 0.8758 0.9132 Grainger County, TN Hamblen County, TN Jefferson County, TN 34580................ \2\ Mount Vernon-Anacortes, 1.0459 1.0312 WA. Skagit County, WA 34620................ Muncie, IN................. 0.8952 0.9270 Delaware County, IN 34740................ Muskegon-Norton Shores, MI. 0.9677 0.9778 Muskegon County, MI 34820................ Myrtle Beach-Conway-North 0.8869 0.9211 Myrtle Beach, SC. Horry County, SC 34900................ Napa, CA................... 1.2643 1.1742 Napa County, CA 34940................ Naples-Marco Island, FL.... 1.0115 1.0079 Collier County, FL 34980................ \1\ Nashville-Davidson--

0.9757 0.9833 Murfreesboro, TN.

[[Page 23564]]

Cannon County, TN Cheatham County, TN Davidson County, TN Dickson County, TN Hickman County, TN Macon County, TN Robertson County, TN Rutherford County, TN Smith County, TN Sumner County, TN Trousdale County, TN Williamson County, TN Wilson County, TN 35004................ \1\ Nassau-Suffolk, NY..... 1.2781 1.1830 Nassau County, NY Suffolk County, NY 35084................ \1\ Newark-Union, NJ-PA.... 1.2192 1.1454 Essex County, NJ Hunterdon County, NJ Morris County, NJ Sussex County, NJ Union County, NJ Pike County, PA 35300................ \2\ New Haven-Milford, CT.. 1.1790 1.1194 New Haven County, CT 35380................ \1\ New Orleans-Metairie- 0.9003 0.9306 Kenner, LA. Jefferson Parish, LA Orleans Parish, LA Plaquemines Parish, LA St. Bernard Parish, LA St. Charles Parish, LA St. John the Baptist Parish, LA St. Tammany Parish, LA 35644................ \1\ New York-Wayne-White

1.3191 1.2088 Plains, NY-NJ. Bergen County, NJ Hudson County, NJ Passaic County, NJ Bronx County, NY Kings County, NY New York County, NY Putnam County, NY Queens County, NY Richmond County, NY Rockland County, NY Westchester County, NY 35660................ \2\ Niles-Benton Harbor, MI 0.8923 0.9249 Berrien County, MI 35980................ \2\ Norwich-New London, CT. 1.1790 1.1194 New London County, CT 36084................ \1\ Oakland-Fremont-

1.5474 1.3485 Hayward, CA. Alameda County, CA Contra Costa County, CA 36100................ Ocala, FL.................. 0.8955 0.9272 Marion County, FL 36140................ Ocean City, NJ............. 1.1031 1.0695 Cape May County, NJ 36220................ Odessa, TX................. 0.9893 0.9927 Ector County, TX 36260................ Ogden-Clearfield, UT....... 0.9048 0.9338 Davis County, UT Morgan County, UT Weber County, UT 36420................ \1\ Oklahoma City, OK...... 0.9043 0.9334 Canadian County, OK Cleveland County, OK Grady County, OK Lincoln County, OK Logan County, OK McClain County, OK Oklahoma County, OK

[[Page 23565]]

36500................ Olympia, WA................ 1.0970 1.0655 Thurston County, WA 36540................ Omaha-Council Bluffs, NE-IA 0.9555 0.9693 Harrison County, IA Mills County, IA Pottawattamie County, IA Cass County, NE Douglas County, NE Sarpy County, NE Saunders County, NE Washington County, NE 36740................ \1\ Orlando, FL............ 0.9446 0.9617 Lake County, FL Orange County, FL Osceola County, FL Seminole County, FL 36780................ \2\ Oshkosh-Neenah, WI..... 0.9478 0.9640 Winnebago County, WI 36980................ Owensboro, KY.............. 0.8806 0.9166 Daviess County, KY Hancock County, KY McLean County, KY 37100................ Oxnard-Thousand Oaks-

1.1604 1.1072 Ventura, CA. Ventura County, CA 37340................ Palm Bay-Melbourne-

0.9826 0.9881 Titusville, FL. Brevard County, FL 37460................ \2\ Panama City-Lynn Haven, 0.8613 0.9028 FL. Bay County, FL 37620................ Parkersburg-Marietta, WV-OH 0.8303 0.8804 (WV Hospitals). Washington County, OH Pleasants County, WV Wirt County, WV Wood County, WV 37620................ \2\ Parkersburg-Marietta, 0.8788 0.9153 WV-OH (OH Hospitals). Washington County, OH Pleasants County, WV Wirt County, WV Wood County, WV 37700................ Pascagoula, MS............. 0.8164 0.8703 George County, MS Jackson County, MS 37860................ \2\ Pensacola-Ferry Pass- 0.8613 0.9028 Brent, FL. Escambia County, FL Santa Rosa County, FL 37900................ Peoria, IL................. 0.8844 0.9193 Marshall County, IL Peoria County, IL Stark County, IL Tazewell County, IL Woodford County, IL 37964................ \1\ Philadelphia, PA....... 1.1030 1.0694 Bucks County, PA Chester County, PA Delaware County, PA Montgomery County, PA Philadelphia County, PA 38060................ \1\ Phoenix-Mesa-

1.0139 1.0095 Scottsdale, AZ. Maricopa County, AZ Pinal County, AZ 38220................ Pine Bluff, AR............. 0.8716 0.9102 Cleveland County, AR Jefferson County, AR Lincoln County, AR 38300................ \1\ Pittsburgh, PA......... 0.8840 0.9190 Allegheny County, PA Armstrong County, PA Beaver County, PA Butler County, PA Fayette County, PA Washington County, PA

[[Page 23566]]

Westmoreland County, PA 38340................ Pittsfield, MA............. 1.0183 1.0125 Berkshire County, MA 38540................ Pocatello, ID.............. 0.9348 0.9549 Bannock County, ID Power County, ID 38660................ Ponce, PR.................. 0.5178 0.6372 Juana Diaz Municipio, PR Ponce Municipio, PR Villalba Municipio, PR 38860................ Portland-South Portland-

1.0382 1.0260 Biddeford, ME. Cumberland County, ME Sagadahoc County, ME York County, ME 38900................ \1\ Portland-Vancouver-

1.1229 1.0826 Beaverton, OR-WA. Clackamas County, OR Columbia County, OR Multnomah County, OR Washington County, OR Yamhill County, OR Clark County, WA Skamania County, WA 38940................ Port St. Lucie-Fort Pierce, 1.0162 1.0111 FL. Martin County, FL St. Lucie County, FL 39100................ Poughkeepsie-Newburgh-

1.0767 1.0519 Middletown, NY. Dutchess County, NY Orange County, NY 39140................ Prescott, AZ............... 0.9884 0.9920 Yavapai County, AZ 39300................ \1\ Providence-New Bedford- 1.0952 1.0643 Fall River, RI-MA. Bristol County, MA Bristol County, RI Kent County, RI Newport County, RI Providence County, RI Washington County, RI 39340................ Provo-Orem, UT............. 0.9578 0.9709 Juab County, UT Utah County, UT 39380................ \2\ Pueblo, CO............. 0.9379 0.9570 Pueblo County, CO 39460................ Punta Gorda, FL............ 0.9274 0.9497 Charlotte County, FL 39540................ \2\ Racine, WI............. 0.9478 0.9640 Racine County, WI 39580................ Raleigh-Cary, NC........... 0.9709 0.9800 Franklin County, NC Johnston County, NC Wake County, NC 39660................ Rapid City, SD............. 0.9027 0.9323 Meade County, SD Pennington County, SD 39740................ Reading, PA................ 0.9698 0.9792 Berks County, PA 39820................ Redding, CA................ 1.2207 1.1463 Shasta County, CA 39900................ Reno-Sparks, NV............ 1.0984 1.0664 Storey County, NV Washoe County, NV 40060................ \1\ Richmond, VA........... 0.9319 0.9528 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

[[Page 23567]]

King and Queen County, VA King William County, VA Louisa County, VA New Kent County, VA Powhatan County, VA Prince George County, VA Sussex County, VA Colonial Heights City, VA Hopewell City, VA Petersburg City, VA Richmond City, VA 40140................ \1\ Riverside-San

1.1021 1.0688 Bernardino-Ontario, CA. Riverside County, CA San Bernardino County, CA 40220................ Roanoke, VA................ 0.8450 0.8911 Botetourt County, VA Craig County, VA Franklin County, VA Roanoke County, VA Roanoke City, VA Salem City, VA 40340................ Rochester, MN.............. 1.1128 1.0759 Dodge County, MN Olmsted County, MN Wabasha County, MN 40380................ \1\ Rochester, NY.......... 0.9117 0.9387 Livingston County, NY Monroe County, NY Ontario County, NY Orleans County, NY Wayne County, NY 40420................ Rockford, IL............... 0.9975 0.9983 Boone County, IL Winnebago County, IL 40484................ \2\ Rockingham County-

1.0668 1.0453 Strafford County, NH. Rockingham County, NH Strafford County, NH 40580................ Rocky Mount, NC............ 0.8924 0.9250 Edgecombe County, NC Nash County, NC 40660................ Rome, GA................... 0.9414 0.9595 Floyd County, GA 40900................ \1\ Sacramento--Arden-

1.2953 1.1939 Arcade--Roseville, CA. El Dorado County, CA Placer County, CA Sacramento County, CA Yolo County, CA 40980................ Saginaw-Saginaw Township

0.9474 0.9637 North, MI. Saginaw County, MI 41060................ St. Cloud, MN.............. 1.0030 1.0021 Benton County, MN Stearns County, MN 41100................ St. George, UT............. 0.9416 0.9596 Washington County, UT 41140................ St. Joseph, MO-KS.......... 0.9565 0.9700 Doniphan County, KS Andrew County, MO Buchanan County, MO DeKalb County, MO 41180................ St. Louis, MO-IL........... 0.8953 0.9271 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

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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.................. 1.0445 1.0303 Marion County, OR Polk County, OR 41500................ Salinas, CA................ 1.4140 1.2677 Monterey County, CA 41540................ \2\ Salisbury, MD.......... 0.9099 0.9374 Somerset County, MD Wicomico County, MD 41620................ Salt Lake City, UT......... 0.9436 0.9610 Salt Lake County, UT Summit County, UT Tooele County, UT 41660................ San Angelo, TX............. 0.8287 0.8793 Irion County, TX Tom Green County, TX 41700................ \1\ San Antonio, TX........ 0.8987 0.9295 Atascosa County, TX Bandera County, TX Bexar County, TX Comal County, TX Guadalupe County, TX Kendall County, TX Medina County, TX Wilson County, TX 41740................ \1\ San Diego-Carlsbad-San 1.1417 1.0950 Marcos, CA. San Diego County, CA 41780................ Sandusky, OH............... 0.9033 0.9327 Erie County, OH 41884................ \1\ San Francisco-San Mateo- 1.4970 1.3182 Redwood City, CA. Marin County, CA San Francisco County, CA San Mateo County, CA 41900................ San German-Cabo Rojo, PR... 0.4646 0.5916 Cabo Rojo Municipio, PR Lajas Municipio, PR Sabana Grande Municipio, PR San German Municipio, PR 41940................ \1\ San Jose-Sunnyvale-

1.5114 1.3269 Santa Clara, CA. San Benito County, CA Santa Clara County, CA 41980................ \1\ San Juan-Caguas-

0.4686 0.5951 Guaynabo, PR. Aguas Buenas Municipio, PR Aibonito Municipio, PR Arecibo Municipio, PR Barceloneta Municipio, PR Barranquitas Municipio, PR Bayam[oacute]n Municipio, PR Caguas Municipio, PR Camuy Municipio, PR Can[oacute]vanas Municipio, PR Carolina Municipio, PR Cata[ntilde]o Municipio, PR Cayey Municipio, PR Ciales Municipio, PR Cidra Municipio, PR Comer[iacute]o Municipio, PR Corozal Municipio, PR Dorado Municipio, PR Florida Municipio, PR Guaynabo Municipio, PR Gurabo Municipio, PR Hatillo Municipio, PR Humacao Municipio, PR

[[Page 23569]]

Juncos Municipio, PR Las Piedras Municipio, PR Lo[iacute]za Municipio, PR Manat[iacute] Municipio, PR Maunabo Municipio, PR Morovis Municipio, PR Naguabo Municipio, PR Naranjito Municipio, PR Orocovis Municipio, PR Quebradillas Municipio, PR R[iacute]o Grande Municipio, PR San Juan Municipio, PR San Lorenzo Municipio, PR Toa Alta Municipio, PR Toa Baja Municipio, PR Trujillo Alto Municipio, PR Vega Alta Municipio, PR Vega Baja Municipio, PR Yabucoa Municipio, PR 42020................ San Luis Obispo-Paso

1.1357 1.0910 Robles, CA. San Luis Obispo County, CA 42044................ \1\ Santa Ana-Anaheim-

1.1564 1.1046 Irvine, CA. Orange County, CA 42060................ Santa Barbara-Santa Maria- 1.1525 1.1021 Goleta, CA. Santa Barbara County, CA 42100................ Santa Cruz-Watsonville, CA. 1.5159 1.3296 Santa Cruz County, CA 42140................ Santa Fe, NM............... 1.0908 1.0613 Santa Fe County, NM 42220................ Santa Rosa-Petaluma, CA.... 1.3480 1.2269 Sonoma County, CA 42260................ Sarasota-Bradenton-Venice, 0.9554 0.9692 FL. Manatee County, FL Sarasota County, FL 42340................ Savannah, GA............... 0.9483 0.9643 Bryan County, GA Chatham County, GA Effingham County, GA 42540................ Scranton--Wilkes-Barre, PA. 0.8530 0.8968 Lackawanna County, PA Luzerne County, PA Wyoming County, PA 42644................ \1\ Seattle-Bellevue-

1.1573 1.1052 Everett, WA. King County, WA Snohomish County, WA 43100................ \2\ Sheboygan, WI.......... 0.9478 0.9640 Sheboygan County, WI 43300................ Sherman-Denison, TX........ 0.9518 0.9667 Grayson County, TX 43340................ Shreveport-Bossier City, LA 0.8767 0.9138 Bossier Parish, LA Caddo Parish, LA De Soto Parish, LA 43580................ Sioux City, IA-NE-SD....... 0.9360 0.9557 Woodbury County, IA Dakota County, NE Dixon County, NE Union County, SD 43620................ Sioux Falls, SD............ 0.9616 0.9735 Lincoln County, SD McCook County, SD Minnehaha County, SD Turner County, SD 43780................ South Bend-Mishawaka, IN-MI 0.9785 0.9852 St. Joseph County, IN Cass County, MI 43900................ Spartanburg, SC............ 0.9183 0.9433 Spartanburg County, SC 44060................ Spokane, WA................ 1.0898 1.0607 Spokane County, WA

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44100................ Springfield, IL............ 0.8879 0.9218 Menard County, IL Sangamon County, IL 44140................ Springfield, MA............ 1.0259 1.0177 Franklin County, MA Hampden County, MA Hampshire County, MA 44180................ Springfield, MO............ 0.8251 0.8766 Christian County, MO Dallas County, MO Greene County, MO Polk County, MO Webster County, MO 44220................ \2\ Springfield, OH........ 0.8788 0.9153 Clark County, OH 44300................ State College, PA.......... 0.8368 0.8851 Centre County, PA 44700................ Stockton, CA............... 1.1333 1.0895 San Joaquin County, CA 44940................ \2\ Sumter, SC............. 0.8663 0.9064 Sumter County, SC 45060................ Syracuse, NY............... 0.9595 0.9721 Madison County, NY Onondaga County, NY Oswego County, NY 45104................ Tacoma, WA................. 1.0794 1.0537 Pierce County, WA 45220................ Tallahassee, FL............ 0.8712 0.9099 Gadsden County, FL Jefferson County, FL Leon County, FL Wakulla County, FL 45300................ \1\ Tampa-St. Petersburg- 0.9292 0.9510 Clearwater, FL. Hernando County, FL Hillsborough County, FL Pasco County, FL Pinellas County, FL 45460................ \2\ Terre Haute, IN........ 0.8632 0.9042 Clay County, IN Sullivan County, IN Vermillion County, IN Vigo County, IN 45500................ Texarkana, TX-Texarkana, AR 0.8293 0.8797 Miller County, AR Bowie County, TX 45780................ Toledo, OH................. 0.9573 0.9706 Fulton County, OH Lucas County, OH Ottawa County, OH Wood County, OH 45820................ Topeka, KS................. 0.8921 0.9248 Jackson County, KS Jefferson County, KS Osage County, KS Shawnee County, KS Wabaunsee County, KS 45940................ Trenton-Ewing, NJ.......... 1.0837 1.0566 Mercer County, NJ 46060................ Tucson, AZ................. 0.9007 0.9309 Pima County, AZ 46140................ Tulsa, OK.................. 0.8313 0.8812 Creek County, OK Okmulgee County, OK Osage County, OK Pawnee County, OK Rogers County, OK Tulsa County, OK Wagoner County, OK 46220................ Tuscaloosa, AL............. 0.8724 0.9108 Greene County, AL

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Hale County, AL Tuscaloosa County, AL 46340................ Tyler, TX.................. 0.9322 0.9531 Smith County, TX 46540................ Utica-Rome, NY............. 0.8313 0.8812 Herkimer County, NY Oneida County, NY 46660................ Valdosta, GA............... 0.8873 0.9214 Brooks County, GA Echols County, GA Lanier County, GA Lowndes County, GA 46700................ Vallejo-Fairfield, CA...... 1.4888 1.3133 Solano County, CA 46940................ Vero Beach, FL............. 0.9458 0.9626 Indian River County, FL 47020................ Victoria, TX............... 0.8148 0.8691 Calhoun County, TX Goliad County, TX Victoria County, TX 47220................ \2\ Vineland-Millville-

1.0607 1.0412 Bridgeton, NJ. Cumberland County, NJ 47260................ \1\ Virginia Beach-Norfolk- 0.8841 0.9191 Newport News, VA-NC. Currituck County, NC Gloucester County, VA Isle of Wight County, VA James City County, VA Mathews County, VA Surry County, VA York County, VA Chesapeake City, VA Hampton City, VA Newport News City, VA Norfolk City, VA Poquoson City, VA Portsmouth City, VA Suffolk City, VA Virginia Beach City, VA Williamsburg City, VA 47300................ \2\ Visalia-Porterville, CA 1.0848 1.0573 Tulare County, CA 47380................ Waco, TX................... 0.8532 0.8970 McLennan County, TX 47580................ Warner Robins, GA.......... 0.8662 0.9063 Houston County, GA 47644................ \1\ Warren-Farmington Hills- 0.9858 0.9903 Troy, MI. Lapeer County, MI Livingston County, MI Macomb County, MI Oakland County, MI St. Clair County, MI 47894................ \1\ Washington-Arlington- 1.0935 1.0631 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

[[Page 23572]]

Manassas Park City, VA Jefferson County, WV 47940................ Waterloo-Cedar Falls, IA... 0.8564 0.8993 Black Hawk County, IA Bremer County, IA Grundy County, IA 48140................ Wausau, WI................. 0.9964 0.9975 Marathon County, WI 48260................ Weirton-Steubenville, WV-OH 0.7821 0.8451 (WV Hospitals). Jefferson County, OH Brooke County, WV Hancock County, WV 48260................ \2\ Weirton-Steubenville, 0.8788 0.9153 WV-OH (OH Hospitals). Jefferson County, OH Brooke County, WV Hancock County, WV 48300................ \2\ Wenatchee, WA.......... 1.0459 1.0312 Chelan County, WA Douglas County, WA 48424................ \1\ West Palm Beach-Boca

1.0061 1.0042 Raton-Boynton Beach, FL. Palm Beach County, FL 48540................ \2\ Wheeling, WV-OH (WV

0.7742 0.8392 Hospitals). Belmont County, OH Marshall County, WV Ohio County, WV 48540................ \2\ Wheeling, WV-OH (OH

0.8788 0.9153 Hospitals). Belmont County, OH Marshall County, WV Ohio County, WV 48620................ Wichita, KS................ 0.9156 0.9414 Butler County, KS Harvey County, KS Sedgwick County, KS Sumner County, KS 48660................ Wichita Falls, TX.......... 0.8327 0.8822 Archer County, TX Clay County, TX Wichita County, TX 48700................ Williamsport, PA........... 0.8368 0.8851 Lycoming County, PA 48864................ Wilmington, DE-MD-NJ....... 1.0652 1.0442 New Castle County, DE Cecil County, MD Salem County, NJ 48900................ Wilmington, NC............. 0.9580 0.9710 Brunswick County, NC New Hanover County, NC Pender County, NC 49020................ Winchester, VA-WV.......... 1.0214 1.0146 Frederick County, VA Winchester City, VA Hampshire County, WV 49180................ Winston-Salem, NC.......... 0.9020 0.9318 Davie County, NC Forsyth County, NC Stokes County, NC Yadkin County, NC 49340................ Worcester, MA.............. 1.1044 1.0704 Worcester County, MA 49420................ \2\ Yakima, WA............. 1.0459 1.0312 Yakima County, WA 49500................ Yauco, PR.................. 0.4413 0.5711 Gu[aacute]nica Municipio, PR Guayanilla Municipio, PR Pe[ntilde]uelas Municipio, PR Yauco Municipio, PR 49620................ York-Hanover, PA........... 0.9422 0.9600 York County, PA 49660................ \2\ Youngstown-Warren-

0.8788 0.9153 Boardman, OH-PA (OH Hospitals). Mahoning County, OH

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Trumbull County, OH Mercer County, PA 49660................ Youngstown-Warren-Boardman, 0.8609 0.9025 OH-PA (PA Hospitals). Mahoning County, OH Trumbull County, OH Mercer County, PA 49700................ Yuba City, CA.............. 1.0951 1.0642 Sutter County, CA Yuba County, CA 49740................ Yuma, AZ................... 0.9188 0.9437 Yuma County, AZ

\1\ Large urban area. \2\ Hospitals geographically located in the area are assigned the statewide rural wage index for FY 2006.

Table 4B.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Rural Areas by CBSA

Wage CBSA code

Nonurban area

index GAF

01................... Alabama.................... 0.7495 0.8208 02................... Alaska..................... 1.1977 1.1315 03................... Arizona.................... 0.8991 0.9298 04................... Arkansas................... 0.7478 0.8195 05................... California................. 1.0848 1.0573 06................... Colorado................... 0.9379 0.9570 07................... Connecticut................ 1.1790 1.1194 08................... Delaware................... 0.9606 0.9728 10................... Florida.................... 0.8613 0.9028 11................... Georgia.................... 0.7684 0.8349 12................... Hawaii..................... 1.0598 1.0406 13................... Idaho...................... 0.8810 0.9169 14................... Illinois................... 0.8285 0.8791 15................... Indiana.................... 0.8632 0.9042 16................... Iowa....................... 0.8563 0.8992 17................... Kansas..................... 0.8032 0.8606 18................... Kentucky................... 0.7788 0.8427 19................... Louisiana.................. 0.7445 0.8171 20................... Maine...................... 0.8840 0.9190 21................... Maryland................... 0.9099 0.9374 22................... Massachusetts \1\.......... 1.0066 1.0045 23................... Michigan................... 0.8923 0.9249 24................... Minnesota.................. 0.9183 0.9433 25................... Mississippi................ 0.7685 0.8350 26................... Missouri................... 0.7927 0.8529 27................... Montana.................... 0.8822 0.9177 28................... Nebraska................... 0.8666 0.9066 29................... Nevada..................... 0.9079 0.9360 30................... New Hampshire.............. 1.0668 1.0453 31................... New Jersey \1\............. 1.0607 1.0412 32................... New Mexico................. 0.8649 0.9054 33................... New York................... 0.8220 0.8744 34................... North Carolina............. 0.8570 0.8997 35................... North Dakota............... 0.7278 0.8045 36................... Ohio....................... 0.8788 0.9153 37................... Oklahoma................... 0.7615 0.8298 38................... Oregon..................... 1.0284 1.0194 39................... Pennsylvania............... 0.8300 0.8802 40................... Puerto Rico \1\............ ......... ......... 41................... Rhode Island \1\........... 0.8807 0.9167 42................... South Carolina............. 0.8663 0.9064 43................... South Dakota............... 0.8475 0.8929 44................... Tennessee.................. 0.7915 0.8520 45................... Texas...................... 0.8038 0.8611 46................... Utah....................... 0.8134 0.8681 47................... Vermont.................... 1.0199 1.0136 49................... Virginia................... 0.8024 0.8601 50................... Washington................. 1.0459 1.0312 51................... West Virginia.............. 0.7742 0.8392 52................... Wisconsin.................. 0.9478 0.9640

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53................... Wyoming.................... 0.9207 0.9450

\1\ All counties within the State are classified as urban, with the exception of Massachusetts. Massachusetts has area(s) designated as rural, however, no short-term, acute care hospitals are located in the area(s) for FY 2006. Massachusetts, New Jersey, and Rhode Island rural floors are imputed as discussed in section III. H. of the preamble of this proposed rule.

Table 4C.--Wage Index and Capital Geographic Adjustment Factor (GAF) for Hospitals That Are Reclassified by CBSA

Wage CBSA code

Area

index GAF

10180................ Abilene, TX................ 0.8038 0.8611 10420................ Akron, OH.................. 0.8979 0.9289 10580................ Albany-Schenectady-Troy, NY 0.8565 0.8994 10740................ Albuquerque, NM............ 0.9558 0.9695 10780................ Alexandria, LA............. 0.8048 0.8618 10900................ Allentown-Bethlehem-Easton, 0.9844 0.9893 PA-NJ. 11020................ Altoona, PA................ 0.8942 0.9263 11100................ Amarillo, TX............... 0.9165 0.9420 11180................ Ames, IA................... 0.9231 0.9467 11460................ Ann Arbor, MI.............. 1.0628 1.0426 11500................ Anniston-Oxford, AL........ 0.7702 0.8363 11700................ Asheville, NC.............. 0.9312 0.9524 12020................ Athens-Clarke County, GA... 0.9684 0.9783 12060................ Atlanta-Sandy Springs-

0.9637 0.9750 Marietta, GA. 12420................ Austin-Round Rock, TX...... 0.9451 0.9621 12620................ Bangor, ME................. 0.9985 0.9990 12700................ Barnstable Town, MA........ 1.2254 1.1494 12940................ Baton Rouge, LA............ 0.8470 0.8925 13020................ Bay City, MI............... 0.9535 0.9679 13780................ Binghamton, NY............. 0.8471 0.8926 13820................ Birmingham-Hoover, AL...... 0.8872 0.9213 14260................ Boise City-Nampa, ID....... 0.9048 0.9338 14484................ Boston-Quincy, MA.......... 1.1233 1.0829 14540................ Bowling Green, KY.......... 0.8222 0.8745 15380................ Buffalo-Niagara Falls, NY.. 0.8888 0.9224 15540................ Burlington-South

0.9306 0.9519 Burlington, VT. 15764................ Cambridge-Newton-

1.0903 1.0610 Framingham, MA. 16180................ Carson City, NV............ 0.9786 0.9853 16220................ Casper, WY................. 0.9207 0.9450 16580................ Champaign-Urbana, IL....... 0.9335 0.9540 16620................ Charleston, WV (WV

0.8274 0.8783 Hospitals). 16620................ Charleston, WV(OH

0.8788 0.9153 Hospitals). 16700................ Charleston-North

0.9317 0.9527 Charleston, SC. 16740................ Charlotte-Gastonia-Concord, 0.9585 0.9714 NC-SC. 16820................ Charlottesville, VA........ 0.9806 0.9867 16860................ Chattanooga, TN-GA......... 0.9099 0.9374 16974................ Chicago-Naperville-Joliet, 1.0698 1.0473 IL. 17140................ Cincinnati-Middletown, OH- 0.9604 0.9727 KY-IN. 17300................ Clarksville, TN-KY......... 0.8092 0.8650 17460................ Cleveland-Elyria-Mentor, OH 0.9197 0.9443 17780................ College Station-Bryan, TX.. 0.8911 0.9241 17860................ Columbia, MO............... 0.8346 0.8835 17900................ Columbia, SC............... 0.9057 0.9344 17980................ Columbus, GA-AL............ 0.8402 0.8876 18140................ Columbus, OH............... 0.9848 0.9896 18700................ Corvallis, OR.............. 1.0328 1.0223 19124................ Dallas-Plano-Irving, TX.... 0.9955 0.9969 19380................ Dayton, OH................. 0.9069 0.9353 19460................ Decatur, AL................ 0.8517 0.8959 19740................ Denver-Aurora, CO.......... 1.0517 1.0351 19780................ Des Moines, IA............. 0.9413 0.9594 19804................ Detroit-Livonia-Dearborn, 1.0453 1.0308 MI. 20260................ Duluth, MN-WI.............. 1.0224 1.0153 20500................ Durham, NC................. 0.9993 0.9995 20764................ Edison, NJ................. 1.1301 1.0874 20940................ El Centro, CA.............. 0.9102 0.9376 21060................ Elizabethtown, KY.......... 0.8286 0.8792 21500................ Erie, PA................... 0.8424 0.8892

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21604................ Essex County, MA........... 1.0668 1.0453 21660................ Eugene-Springfield, OR..... 1.0492 1.0334 21780................ Evansville, IN-KY.......... 0.8508 0.8953 22020................ Fargo, ND-MN (ND, SD

0.8778 0.9146 Hospitals). 22020................ Fargo, ND-MN (MN Hospitals) 0.9183 0.9433 22180................ Fayetteville, NC........... 0.9193 0.9440 22220................ Fayetteville-Springdale-

0.8615 0.9029 Rogers, AR-MO. 22380................ Flagstaff, AZ.............. 1.1713 1.1144 22420................ Flint, MI.................. 1.0654 1.0443 22540................ Fond du Lac, WI............ 0.9478 0.9640 22660................ Fort Collins-Loveland, CO.. 1.0146 1.0100 22744................ Ft Lauderdale-Pompano Beach- 1.0508 1.0345 Deerfield Beach, FL. 22900................ Fort Smith, AR-OK.......... 0.7986 0.8573 23020................ Fort Walton Beach-Crestview- 0.8672 0.9070 Destin, FL. 23060................ Fort Wayne, IN............. 0.9797 0.9861 23104................ Fort Worth-Arlington, TX... 0.9514 0.9665 23540................ Gainesville, FL............ 0.9461 0.9628 23844................ Gary, IN................... 0.9366 0.9561 24340................ Grand Rapids-Wyoming, MI... 0.9398 0.9584 24500................ Great Falls, MT............ 0.9074 0.9356 24540................ Greeley, CO................ 0.9597 0.9722 24580................ Green Bay, WI (MI

0.9439 0.9612 Hospitals). 24580................ Green Bay, WI (WI

0.9478 0.9640 Hospitals). 24780................ Greenville, NC............. 0.9414 0.9595 24860................ Greenville, SC............. 0.9807 0.9867 25060................ Gulfport-Biloxi, MS........ 0.8612 0.9027 25420................ Harrisburg-Carlisle, PA.... 0.9145 0.9406 25500................ Harrisonburg, VA........... 0.8998 0.9302 25540................ Hartford-West Hartford-East 1.1085 1.0731 Hartford, CT (MA Hospitals). 25540................ Hartford-West Hartford-East 1.1790 1.1194 Hartford, CT (CT Hospitals). 25860................ Hickory-Lenoir-Morganton, 0.8931 0.9255 NC. 26100................ Holland-Grand Haven, MI.... 0.9133 0.9398 26180................ Honolulu, HI............... 1.1206 1.0811 26420................ Houston-Baytown-Sugar Land, 1.0008 1.0005 TX. 26580................ Huntington-Ashland, WV-KY- 0.9119 0.9388 OH. 26620................ Huntsville, AL............. 0.9124 0.9391 26900................ Indianapolis, IN........... 0.9776 0.9846 26980................ Iowa City, IA.............. 0.9574 0.9706 27060................ Ithaca, NY................. 0.9204 0.9448 27140................ Jackson, MS................ 0.8182 0.8716 27180................ Jackson, TN................ 0.8799 0.9161 27260................ Jacksonville, FL........... 0.9303 0.9517 27860................ Jonesboro, AR.............. 0.7793 0.8430 27900................ Joplin, MO................. 0.8458 0.8916 28020................ Kalamazoo-Portage, MI...... 1.0403 1.0274 28100................ Kankakee-Bradley, IL....... 1.0991 1.0668 28140................ Kansas City, MO-KS......... 0.9454 0.9623 28420................ Kennewick-Richland-Pasco, 1.0459 1.0312 WA. 28700................ Kingsport-Bristol-Bristol, 0.8095 0.8653 TN-VA. 28740................ Kingston, NY............... 0.8904 0.9236 28940................ Knoxville, TN.............. 0.8470 0.8925 29180................ Lafayette, LA.............. 0.8429 0.8896 29404................ Lake County-Kenosha County, 1.0444 1.0302 IL-WI. 29460................ Lakeland, FL............... 0.8934 0.9257 29620................ Lansing-East Lansing, MI... 0.9786 0.9853 29740................ Las Cruces, NM............. 0.8649 0.9054 29820................ Las Vegas-Paradise, NV..... 1.1249 1.0839 30020................ Lawton, OK................. 0.7673 0.8341 30460................ Lexington-Fayette, KY...... 0.8830 0.9183 30620................ Lima, OH................... 0.9263 0.9489 30700................ Lincoln, NE................ 0.9666 0.9770 30780................ Little Rock-North Little

0.8552 0.8984 Rock, AR. 30980................ Longview, TX............... 0.8621 0.9034 31084................ Los Angeles-Long Beach-

1.1660 1.1109 Santa Ana, CA. 31140................ Louisville, KY-IN.......... 0.9264 0.9490 31180................ Lubbock, TX................ 0.8790 0.9155 31340................ Lynchburg, VA.............. 0.8596 0.9016 31420................ Macon, GA.................. 0.9087 0.9365 31540................ Madison, WI................ 1.0416 1.0283 31700................ Manchester-Nashua, NH...... 1.0668 1.0453

[[Page 23576]]

32780................ Medford, OR................ 1.0284 1.0194 32820................ Memphis, TN-MS-AR.......... 0.9108 0.9380 33124................ Miami-Miami Beach-Kendall, 0.9757 0.9833 FL. 33260................ Midland, TX................ 0.9317 0.9527 33340................ Milwaukee-Waukesha-West

0.9957 0.9971 Allis, WI. 33460................ Minneapolis-St. Paul-

1.0905 1.0611 Bloomington, MN-WI. 33540................ Missoula, MT............... 0.9535 0.9679 33660................ Mobile, AL................. 0.7902 0.8511 33700................ Modesto, CA................ 1.1885 1.1255 33860................ Montgomery, AL............. 0.8276 0.8785 34060................ Morgantown, WV............. 0.8332 0.8825 34980................ Nashville-Davidson--

0.9492 0.9649 Murfreesboro, TN. 35084................ Newark-Union, NJ-PA........ 1.2192 1.1454 35380................ New Orleans-Metairie-

0.9003 0.9306 Kenner, LA. 35644................ New York-Wayne-White

1.3191 1.2088 Plains, NY-NJ. 36084................ Oakland-Fremont-Hayward, CA 1.5474 1.3485 36100................ Ocala, FL.................. 0.8955 0.9272 36140................ Ocean City, NJ............. 1.0289 1.0197 36220................ Odessa, TX................. 0.9593 0.9719 36260................ Ogden-Clearfield, UT....... 0.9048 0.9338 36420................ Oklahoma City, OK.......... 0.9043 0.9334 36500................ Olympia, WA................ 1.0970 1.0655 36540................ Omaha-Council Bluffs, NE-IA 0.9555 0.9693 36740................ Orlando, FL................ 0.9446 0.9617 37860................ Pensacola-Ferry Pass-Brent, 0.8089 0.8648 FL. 37900................ Peoria, IL................. 0.8844 0.9193 37964................ Philadelphia, PA........... 1.1030 1.0694 38220................ Pine Bluff, AR............. 0.8099 0.8656 38300................ Pittsburgh, PA............. 0.8840 0.9190 38340................ Pittsfield, MA............. 1.0199 1.0136 38860................ Portland-South Portland-

0.9884 0.9920 Biddeford, ME. 38900................ Portland-Vancouver-

1.1229 1.0826 Beaverton, OR-WA. 38940................ Port St. Lucie-Fort Pierce, 1.0162 1.0111 FL. 39100................ Poughkeepsie-Newburgh-

1.0576 1.0391 Middletown, NY. 39340................ Provo-Orem, UT............. 0.9578 0.9709 39580................ Raleigh-Cary, NC........... 0.9476 0.9638 39740................ Reading, PA................ 0.9500 0.9655 39820................ Redding, CA................ 1.1909 1.1271 39900................ Reno-Sparks, NV (NV

1.0805 1.0545 Hospitals). 39900................ Reno-Sparks, NV (CA

1.0848 1.0573 Hospitals). 40060................ Richmond, VA............... 0.9319 0.9528 40220................ Roanoke, VA................ 0.8450 0.8911 40340................ Rochester, MN.............. 1.1128 1.0759 40380................ Rochester, NY.............. 0.9117 0.9387 40420................ Rockford, IL............... 0.9667 0.9771 40484................ Rockingham County, NH...... 1.0503 1.0342 40660................ Rome, GA................... 0.9414 0.9595 40900................ Sacramento--Arden-Arcade-- 1.2953 1.1939 Roseville, CA. 40980................ Saginaw-Saginaw Township

0.9090 0.9368 North, MI. 41060................ St. Cloud, MN.............. 0.9785 0.9852 41100................ St. George, UT............. 0.9416 0.9596 41180................ St. Louis, MO-IL........... 0.8953 0.9271 41620................ Salt Lake City, UT......... 0.9436 0.9610 41700................ San Antonio, TX............ 0.8987 0.9295 41884................ San Francisco-San Mateo-

1.4739 1.3043 Redwood City,CA. 41980................ San Juan-Caguas-Guaynabo, 0.4686 0.5951 PR. 42044................ Santa Ana-Anaheim-Irvine, 1.1297 1.0871 CA. 42140................ Santa Fe, NM............... 1.0163 1.0111 42220................ Santa Rosa-Petaluma, CA.... 1.3480 1.2269 42260................ Sarasota-Bradenton-Venice, 0.9554 0.9692 FL. 42340................ Savannah, GA............... 0.9316 0.9526 42644................ Seattle-Bellevue-Everett, 1.1573 1.1052 WA. 43300................ Sherman-Denison, TX........ 0.8971 0.9283 43340................ Shreveport-Bossier City, LA 0.8767 0.9138 43620................ Sioux Falls, SD............ 0.9616 0.9735 43780................ South Bend-Mishawaka, IN-MI 0.9785 0.9852 43900................ Spartanburg, SC............ 0.9183 0.9433 44060................ Spokane, WA................ 1.0722 1.0489 44180................ Springfield, MO............ 0.8251 0.8766 44300................ State College, PA.......... 0.8300 0.8802

[[Page 23577]]

44940................ Sumter, SC................. 0.8663 0.9064 45060................ Syracuse, NY............... 0.9315 0.9526 45104................ Tacoma, WA................. 1.0794 1.0537 45220................ Tallahassee, FL............ 0.8420 0.8889 45300................ Tampa-St. Petersburg-

0.9292 0.9510 Clearwater, FL. 45500................ Texarkana, TX-Texarkana, AR 0.8293 0.8797 45820................ Topeka, KS................. 0.8785 0.9151 46140................ Tulsa, OK.................. 0.8313 0.8812 46220................ Tuscaloosa, AL............. 0.8614 0.9029 46340................ Tyler, TX.................. 0.9164 0.9420 46660................ Valdosta, GA............... 0.8710 0.9098 46700................ Vallejo-Fairfield, CA...... 1.3955 1.2564 47260................ Virginia Beach-Norfolk-

0.8841 0.9191 Newport News, VA. 47380................ Waco, TX................... 0.8532 0.8970 47894................ Washington-Arlington-

1.0813 1.0550 Alexandria DC-VA. 48140................ Wausau, WI................. 0.9964 0.9975 48620................ Wichita, KS................ 0.8946 0.9266 48700................ Williamsport, PA........... 0.8300 0.8802 48864................ Wilmington, DE-MD-NJ....... 1.0652 1.0442 48900................ Wilmington, NC............. 0.9394 0.9581 49020................ Winchester, VA-WV.......... 1.0214 1.0146 49180................ Winston-Salem, NC.......... 0.9020 0.9318 49660................ Youngstown-Warren-Boardman, 0.8446 0.8908 OH-PA (PA Hospitals). 49660................ Youngstown-Warren-Boardman, 0.8788 0.9153 OH-PA (OH Hospitals). 03................... Rural Arizona.............. 0.8991 0.9298 04................... Rural Arkansas............. 0.7478 0.8195 05................... Rural California........... 1.0848 1.0573 07................... Rural Connecticut.......... 1.0448 1.0305 10................... Rural Florida.............. 0.8613 0.9028 13................... Rural Idaho................ 0.8810 0.9169 14................... Rural Illinois............. 0.8285 0.8791 15................... Rural Indiana.............. 0.8632 0.9042 16................... Rural Iowa................. 0.8563 0.8992 17................... Rural Kansas............... 0.8032 0.8606 19................... Rural Louisiana............ 0.7445 0.8171 23................... Rural Michigan............. 0.8923 0.9249 24................... Rural Minnesota............ 0.9183 0.9433 26................... Rural Missouri............. 0.7927 0.8529 30................... Rural New Hampshire........ 1.0668 1.0453 37................... Rural Oklahoma............. 0.7615 0.8298 38................... Rural Oregon............... 1.0284 1.0194 45................... Rural Texas................ 0.8038 0.8611 50................... Rural Washington (ID

1.0061 1.0042 Hospitals). 50................... Rural Washington (WA

1.0459 1.0312 Hospitals). 53................... Rural Wyoming.............. 0.9207 0.9450

Table 4F.--Puerto Rico Wage Index and Capital Geographic Adjustment Factor (GAF) by CBSA

Wage Index - GAF - CBSA Code

Area

Wage Index GAF Reclassified Reclassified Hospitals Hospitals

10380........................ Aguadilla-Isabela-San

1.0196 1.0134 ............ ............ Sebasti[aacute]n, PR. 21940........................ Fajardo, PR................ 0.8956 0.9273 ............ ............ 25020........................ Guayama, PR................ 0.6858 0.7724 ............ ............ 32420........................ Mayag[uuml]ez, PR.......... 0.8647 0.9052 ............ ............ 38660........................ Ponce, PR.................. 1.1147 1.0772 ............ ............ 41900........................ San Germ[aacute]n-Cabo

1.0002 1.0001 ............ ............ Rojo, PR. 41980........................ San Juan-Caguas-Guaynabo,

1.0087 1.0059

1.0087

1.0059 PR. 49500........................ Yauco, PR.................. 0.9500 0.9655 ............ ............

The following list represents all hospitals that are eligible to have their wage index increased by the out-migration adjustment listed in this table. Hospitals cannot receive the out-migration adjustment if they are reclassified under section 1886(d)(10) of the Act or redesignated under section 1886(d)(8)(B) of the Act. Hospitals that have already been reclassified under section 1886(d)(10) of the Act or redesignated under section

[[Page 23578]]

1886(d)(8)(B) of the Act are designated with an asterisk. Hospitals have the opportunity to use the new additional 30-day period to review their individual situation to determine whether to submit a request to withdraw their reclassification/redesignation and receive the out- migration adjustment instead. We will automatically assume that hospitals that have already been reclassified under section 1886(d)(10) of the Act or redesignated under section 1886(d)(8)(B) of the Act wish to retain their reclassification/redesignation status and waive the application of the out-migration adjustment. Hospitals are not required to provide CMS with any type of formal notification that they wish to remain reclassified/redesignated.

Table 4J.--Out-Migration Adjustment--FY 2006

Out- Provider number

migration Qualifying county name adjustment

010005*..................... 0.0259 MARSHALL 010008*..................... 0.0212 CRENSHAW 010009...................... 0.0092 MORGAN 010010...................... 0.0259 MARSHALL 010012*..................... 0.0205 DE KALB 010022*..................... 0.0714 CHEROKEE 010025*..................... 0.0225 CHAMBERS 010029*..................... 0.0107 LEE 010035*..................... 0.0375 CULLMAN 010038...................... 0.0062 CALHOUN 010045*..................... 0.0160 FAYETTE 010047...................... 0.0155 BUTLER 010054...................... 0.0092 MORGAN 010061...................... 0.0506 JACKSON 010072*..................... 0.0310 TALLADEGA 010078...................... 0.0062 CALHOUN 010083*..................... 0.0121 BALDWIN 010085...................... 0.0092 MORGAN 010100*..................... 0.0121 BALDWIN 010101*..................... 0.0310 TALLADEGA 010109...................... 0.0464 PICKENS 010115...................... 0.0093 FRANKLIN 010129...................... 0.0121 BALDWIN 010143*..................... 0.0375 CULLMAN 010146...................... 0.0062 CALHOUN 010150...................... 0.0155 BUTLER 010158*..................... 0.0093 FRANKLIN 040014*..................... 0.0159 WHITE 040019*..................... 0.0697 ST. FRANCIS 040047*..................... 0.0090 RANDOLPH 040066...................... 0.0382 CLARK 040069*..................... 0.0140 MISSISSIPPI 040070...................... 0.0140 MISSISSIPPI 040071*..................... 0.0026 JEFFERSON 040076*..................... 0.1075 HOT SPRING 040100*..................... 0.0159 WHITE 040143...................... 0.0026 JEFFERSON 050008...................... 0.0028 SAN FRANCISCO 050009*..................... 0.0478 NAPA 050013*..................... 0.0478 NAPA 050014*..................... 0.0131 AMADOR 050016...................... 0.0087 SAN LUIS OBISPO 050042*..................... 0.0219 TEHAMA 050046*..................... 0.0156 VENTURA 050047...................... 0.0028 SAN FRANCISCO 050055...................... 0.0028 SAN FRANCISCO 050065*..................... 0.0029 ORANGE 050069*..................... 0.0029 ORANGE 050073*..................... 0.0269 SOLANO 050076*..................... 0.0028 SAN FRANCISCO 050082*..................... 0.0156 VENTURA 050084...................... 0.0555 SAN JOAQUIN 050088...................... 0.0087 SAN LUIS OBISPO 050089*..................... 0.0152 SAN BERNARDINO 050090*..................... 0.0308 SONOMA 050099*..................... 0.0152 SAN BERNARDINO 050101...................... 0.0269 SOLANO 050117...................... 0.0463 MERCED 050118*..................... 0.0555 SAN JOAQUIN 050122...................... 0.0555 SAN JOAQUIN 050129*..................... 0.0152 SAN BERNARDINO 050133......................

0.017 YUBA 050136*..................... 0.0308 SONOMA 050140*..................... 0.0152 SAN BERNARDINO 050150*..................... 0.0316 NEVADA 050152...................... 0.0028 SAN FRANCISCO 050159*..................... 0.0156 VENTURA 050167...................... 0.0555 SAN JOAQUIN 050168*..................... 0.0029 ORANGE 050173*..................... 0.0029 ORANGE 050174*..................... 0.0308 SONOMA 050177*..................... 0.0156 VENTURA 050193*..................... 0.0029 ORANGE 050224*..................... 0.0029 ORANGE 050226*..................... 0.0029 ORANGE 050228*..................... 0.0028 SAN FRANCISCO 050230*..................... 0.0029 ORANGE 050232...................... 0.0087 SAN LUIS OBISPO 050236*..................... 0.0156 VENTURA 050245*..................... 0.0152 SAN BERNARDINO 050253...................... 0.0029 ORANGE 050272*..................... 0.0152 SAN BERNARDINO 050279*..................... 0.0152 SAN BERNARDINO 050291*..................... 0.0308 SONOMA 050298*..................... 0.0152 SAN BERNARDINO 050300*..................... 0.0152 SAN BERNARDINO 050313...................... 0.0555 SAN JOAQUIN 050325...................... 0.0176 TUOLUMNE 050327*..................... 0.0152 SAN BERNARDINO 050331*..................... 0.0308 SONOMA 050335...................... 0.0176 TUOLUMNE 050336...................... 0.0555 SAN JOAQUIN 050348*..................... 0.0029 ORANGE 050366...................... 0.0096 CALAVERAS 050367...................... 0.0269 SOLANO 050385*..................... 0.0308 SONOMA 050394*..................... 0.0156 VENTURA 050407...................... 0.0028 SAN FRANCISCO 050426*..................... 0.0029 ORANGE 050444...................... 0.0463 MERCED 050454...................... 0.0028 SAN FRANCISCO 050457...................... 0.0028 SAN FRANCISCO 050469*..................... 0.0152 SAN BERNARDINO 050476...................... 0.0257 LAKE 050491...................... 0.0029 ORANGE 050494...................... 0.0316 NEVADA 050506...................... 0.0087 SAN LUIS OBISPO 050517*..................... 0.0152 SAN BERNARDINO 050526*..................... 0.0029 ORANGE 050528*..................... 0.0463 MERCED 050535*..................... 0.0029 ORANGE 050539...................... 0.0257 LAKE 050543*..................... 0.0029 ORANGE 050547*..................... 0.0308 SONOMA 050548*..................... 0.0029 ORANGE 050549...................... 0.0156 VENTURA 050550*..................... 0.0029 ORANGE 050551*..................... 0.0029 ORANGE 050567*..................... 0.0029 ORANGE 050568...................... 0.0062 MADERA 050570*..................... 0.0029 ORANGE 050580*..................... 0.0029 ORANGE 050584*..................... 0.0152 SAN BERNARDINO 050585*..................... 0.0029 ORANGE 050586*..................... 0.0152 SAN BERNARDINO 050589*..................... 0.0029 ORANGE 050592*..................... 0.0029 ORANGE 050594*..................... 0.0029 ORANGE 050603*..................... 0.0029 ORANGE 050609*..................... 0.0029 ORANGE 050616*..................... 0.0156 VENTURA 050618*..................... 0.0152 SAN BERNARDINO 050633...................... 0.0087 SAN LUIS OBISPO 050667*..................... 0.0478 NAPA 050668*..................... 0.0028 SAN FRANCISCO 050678*..................... 0.0029 ORANGE 050680...................... 0.0269 SOLANO 050690*..................... 0.0308 SONOMA 050693...................... 0.0029 ORANGE 050695...................... 0.0555 SAN JOAQUIN 050720*..................... 0.0029 ORANGE 050728*..................... 0.0308 SONOMA 060001*..................... 0.0294 WELD 060003*..................... 0.0203 BOULDER 060027*..................... 0.0203 BOULDER 060103*..................... 0.0203 BOULDER 070003*..................... 0.0009 WINDHAM 070006...................... 0.0047 FAIRFIELD 070010...................... 0.0047 FAIRFIELD 070018...................... 0.0047 FAIRFIELD 070020...................... 0.0073 MIDDLESEX 070021*..................... 0.0009 WINDHAM 070028...................... 0.0047 FAIRFIELD 070033*..................... 0.0047 FAIRFIELD

[[Page 23579]]

070034...................... 0.0047 FAIRFIELD 080001...................... 0.0059 NEW CASTLE 080003...................... 0.0059 NEW CASTLE 100014...................... 0.0118 VOLUSIA 100017...................... 0.0118 VOLUSIA 100023*..................... 0.0069 CITRUS 100045*..................... 0.0118 VOLUSIA 100047...................... 0.0021 CHARLOTTE 100062...................... 0.0060 MARION 100068...................... 0.0118 VOLUSIA 100072...................... 0.0118 VOLUSIA 100077...................... 0.0021 CHARLOTTE 100102...................... 0.0133 COLUMBIA 100118*..................... 0.0398 FLAGLER 100156...................... 0.0133 COLUMBIA 100175...................... 0.0231 DE SOTO 100212...................... 0.0060 MARION 100232*..................... 0.0347 PUTNAM 100236...................... 0.0021 CHARLOTTE 100249*..................... 0.0069 CITRUS 100252*..................... 0.0233 OKEECHOBEE 110023*..................... 0.0500 GORDON 110026...................... 0.0220 ELBERT 110027...................... 0.0387 FRANKLIN 110029*..................... 0.0063 HALL 110041*..................... 0.0777 HABERSHAM 110063...................... 0.0290 LIBERTY 110069*..................... 0.0474 HOUSTON 110120...................... 0.0873 POLK 110124...................... 0.0428 WAYNE 110136...................... 0.0261 BALDWIN 110146...................... 0.0642 CAMDEN 110150*..................... 0.0261 BALDWIN 110153*..................... 0.0474 HOUSTON 110187*..................... 0.1172 LUMPKIN 110189*..................... 0.0031 FANNIN 110190...................... 0.0182 MACON 110205*..................... 0.0779 GILMER 130003*..................... 0.0095 NEZ PERCE 130011...................... 0.0218 LATAH 130024...................... 0.0275 BONNER 130049*..................... 0.0349 KOOTENAI 140001...................... 0.0199 FULTON 140012*.....................

0.022 LEE 140026...................... 0.0346 LA SALLE 140033...................... 0.0147 LAKE 140043*..................... 0.0046 WHITESIDE 140058*..................... 0.0081 MORGAN 140084...................... 0.0147 LAKE 140100...................... 0.0147 LAKE 140110*..................... 0.0346 LA SALLE 140129...................... 0.0096 WABASH 140130...................... 0.0147 LAKE 140155...................... 0.0027 KANKAKEE 140160*..................... 0.0286 STEPHENSON 140161*..................... 0.0138 LIVINGSTON 140167*..................... 0.0937 IROQUOIS 140173...................... 0.0046 WHITESIDE 140186...................... 0.0027 KANKAKEE 140199...................... 0.0109 MONTGOMERY 140202...................... 0.0147 LAKE 140205...................... 0.0163 BOONE 140234*..................... 0.0346 LA SALLE 140291*..................... 0.0147 LAKE 150002*..................... 0.0241 LAKE 150004*..................... 0.0241 LAKE 150008*..................... 0.0241 LAKE 150022...................... 0.0249 MONTGOMERY 150030*..................... 0.0201 HENRY 150034...................... 0.0241 LAKE 150035...................... 0.0083 PORTER 150045...................... 0.0416 DE KALB 150060...................... 0.0052 VERMILLION 150062...................... 0.0153 DECATUR 150065*..................... 0.0139 JACKSON 150076*..................... 0.0189 MARSHALL 150088*..................... 0.0196 MADISON 150090*..................... 0.0241 LAKE 150091...................... 0.0573 HUNTINGTON 150102*..................... 0.0160 STARKE 150113*..................... 0.0196 MADISON 150122...................... 0.0199 RIPLEY 150125*..................... 0.0241 LAKE 150126*..................... 0.0241 LAKE 150132*..................... 0.0241 LAKE 150147*..................... 0.0241 LAKE 150156...................... 0.0241 LAKE 160013...................... 0.0218 MUSCATINE 160026*..................... 0.0496 BOONE 160030...................... 0.0032 STORY 160032...................... 0.0272 JASPER 160080*..................... 0.0049 CLINTON 160140...................... 0.0364 PLYMOUTH 170137*..................... 0.0331 DOUGLAS 180012*..................... 0.0083 HARDIN 180049...................... 0.0532 MADISON 180055...................... 0.0532 MADISON 180066*..................... 0.0567 LOGAN 180127*..................... 0.0352 FRANKLIN 180128...................... 0.0282 LAWRENCE 190001*..................... 0.0645 WASHINGTON 190003*..................... 0.0107 IBERIA 190010...................... 0.0401 TANGIPAHOA 190015*..................... 0.0401 TANGIPAHOA 190017...................... 0.0235 ST. LANDRY 190049...................... 0.0645 WASHINGTON 190054...................... 0.0107 IBERIA 190078...................... 0.0235 ST. LANDRY 190086*..................... 0.0129 LINCOLN 190088...................... 0.0705 WEBSTER 190099*.....................

0.039 AVOYELLES 190106*..................... 0.0238 ALLEN 190116...................... 0.0179 MOREHOUSE 190133...................... 0.0238 ALLEN 190144...................... 0.0705 WEBSTER 190147...................... 0.0401 TANGIPAHOA 190148......................

0.039 AVOYELLES 190191*..................... 0.0235 ST. LANDRY 200002*..................... 0.0129 LINCOLN 200013...................... 0.0186 WALDO 200019...................... 0.0067 YORK 200020*..................... 0.0067 YORK 200024*..................... 0.0071 ANDROSCOGGIN 200032......................

0.046 OXFORD 200034*..................... 0.0071 ANDROSCOGGIN 200040...................... 0.0067 YORK 200050*..................... 0.0140 HANCOCK 210001...................... 0.0129 WASHINGTON 210004...................... 0.0040 MONTGOMERY 210016...................... 0.0040 MONTGOMERY 210018...................... 0.0040 MONTGOMERY 210022...................... 0.0040 MONTGOMERY 210023...................... 0.0209 ANNE ARUNDEL 210028...................... 0.0512 ST. MARYS 210043...................... 0.0209 ANNE ARUNDEL 210048...................... 0.0287 HOWARD 210057...................... 0.0040 MONTGOMERY 220001*..................... 0.0056 WORCESTER 220002*..................... 0.0249 MIDDLESEX 220003*..................... 0.0056 WORCESTER 220006...................... 0.0306 ESSEX 220010*..................... 0.0306 ESSEX 220011*..................... 0.0249 MIDDLESEX 220019*..................... 0.0056 WORCESTER 220025*..................... 0.0056 WORCESTER 220028*..................... 0.0056 WORCESTER 220029*..................... 0.0306 ESSEX 220033*..................... 0.0306 ESSEX 220035*..................... 0.0306 ESSEX 220049*..................... 0.0249 MIDDLESEX 220058*..................... 0.0056 WORCESTER 220062*..................... 0.0056 WORCESTER 220063*..................... 0.0249 MIDDLESEX 220070*..................... 0.0249 MIDDLESEX 220076...................... 0.0249 MIDDLESEX 220080*..................... 0.0306 ESSEX 220082*..................... 0.0249 MIDDLESEX 220084*..................... 0.0249 MIDDLESEX 220089*..................... 0.0249 MIDDLESEX 220090*..................... 0.0056 WORCESTER 220095*..................... 0.0056 WORCESTER 220098*..................... 0.0249 MIDDLESEX 220101*..................... 0.0249 MIDDLESEX 220105*..................... 0.0249 MIDDLESEX 220163*..................... 0.0056 WORCESTER 220171*..................... 0.0249 MIDDLESEX 220174*..................... 0.0306 ESSEX 230003...................... 0.0035 OTTAWA 230005...................... 0.0598 LENAWEE 230013...................... 0.0091 OAKLAND 230015...................... 0.0359 ST. JOSEPH 230019...................... 0.0091 OAKLAND 230021...................... 0.0136 BERRIEN 230022*..................... 0.0113 BRANCH 230029...................... 0.0091 OAKLAND 230037*..................... 0.0178 HILLSDALE 230041...................... 0.0099 BAY 230042*..................... 0.0685 ALLEGAN 230047*..................... 0.0082 MACOMB 230069*..................... 0.0487 LIVINGSTON 230071...................... 0.0091 OAKLAND 230072...................... 0.0035 OTTAWA 230075...................... 0.0145 CALHOUN 230078*..................... 0.0136 BERRIEN 230092...................... 0.0389 JACKSON 230093*..................... 0.0079 MECOSTA 230096*..................... 0.0359 ST. JOSEPH 230099*..................... 0.0339 MONROE 230106...................... 0.0030 NEWAYGO 230120...................... 0.0598 LENAWEE 230121*..................... 0.0691 SHIAWASSEE 230130...................... 0.0091 OAKLAND 230151...................... 0.0091 OAKLAND 230174...................... 0.0035 OTTAWA 230184...................... 0.0389 JACKSON 230195*..................... 0.0082 MACOMB 230204*..................... 0.0082 MACOMB 230207...................... 0.0091 OAKLAND 230217*..................... 0.0145 CALHOUN 230222...................... 0.0228 MIDLAND 230223...................... 0.0091 OAKLAND 230227*..................... 0.0082 MACOMB 230254...................... 0.0091 OAKLAND 230257*..................... 0.0082 MACOMB 230264*..................... 0.0082 MACOMB

[[Page 23580]]

230269...................... 0.0091 OAKLAND 230277...................... 0.0091 OAKLAND 230279*..................... 0.0487 LIVINGSTON 230295*..................... 0.0685 ALLEGAN 240011...................... 0.0506 MC LEOD 240013*..................... 0.0226 MORRISON 240014...................... 0.0454 RICE 240018*..................... 0.1196 GOODHUE 240021...................... 0.0897 LE SUEUR 240044...................... 0.0868 WINONA 240064*..................... 0.0138 ITASCA 240069*..................... 0.0419 STEELE 240071*..................... 0.0454 RICE 240089...................... 0.1196 GOODHUE 240133...................... 0.0319 MEEKER 240152*..................... 0.0735 KANABEC 240154...................... 0.0138 ITASCA 240187*..................... 0.0506 MC LEOD 240205...................... 0.0138 ITASCA 240211*..................... 0.0705 PINE 250030...................... 0.0318 LEAKE 250040*..................... 0.0294 JACKSON 250045...................... 0.0042 HANCOCK 250088...................... 0.0122 WILKINSON 250154...................... 0.0318 LEAKE 260011*..................... 0.0007 COLE 260025*..................... 0.0078 MARION 260047*..................... 0.0007 COLE 260073...................... 0.0197 BARTON 260074*..................... 0.0158 RANDOLPH 260097...................... 0.0425 JOHNSON 260127...................... 0.0158 PIKE 280054...................... 0.0137 GAGE 280077*..................... 0.0089 DODGE 280123...................... 0.0137 GAGE 290019*..................... 0.0026 CARSON CITY 290020...................... 0.1013 NYE 300007*..................... 0.0080 HILLSBOROUGH 300011*..................... 0.0080 HILLSBOROUGH 300012*..................... 0.0080 HILLSBOROUGH 300017*..................... 0.0361 ROCKINGHAM 300020*..................... 0.0080 HILLSBOROUGH 300023*..................... 0.0361 ROCKINGHAM 300029*..................... 0.0361 ROCKINGHAM 300034*..................... 0.0080 HILLSBOROUGH 310002*..................... 0.0351 ESSEX 310009*..................... 0.0351 ESSEX 310010...................... 0.0180 MERCER 310011...................... 0.0181 CAPE MAY 310013*..................... 0.0351 ESSEX 310014...................... 0.0156 CAMDEN 310018*..................... 0.0351 ESSEX 310021...................... 0.0180 MERCER 310022...................... 0.0156 CAMDEN 310029...................... 0.0156 CAMDEN 310031*..................... 0.0137 BURLINGTON 310032*..................... 0.0065 CUMBERLAND 310038*..................... 0.0350 MIDDLESEX 310039...................... 0.0350 MIDDLESEX 310044...................... 0.0180 MERCER 310054*..................... 0.0351 ESSEX 310057...................... 0.0137 BURLINGTON 310061...................... 0.0137 BURLINGTON 310070*..................... 0.0350 MIDDLESEX 310076*..................... 0.0351 ESSEX 310078*..................... 0.0351 ESSEX 310083*..................... 0.0351 ESSEX 310086...................... 0.0156 CAMDEN 310092...................... 0.0180 MERCER 310093*..................... 0.0351 ESSEX 310096*..................... 0.0351 ESSEX 310108...................... 0.0350 MIDDLESEX 310110...................... 0.0180 MERCER 310119*..................... 0.0351 ESSEX 320003...................... 0.0630 SAN MIGUEL 320011...................... 0.0442 RIO ARRIBA 320018...................... 0.0063 DONA ANA 320085...................... 0.0063 DONA ANA 330001*..................... 0.0560 ORANGE 330004*..................... 0.0959 ULSTER 330008*..................... 0.0470 WYOMING 330027*..................... 0.0137 NASSAU 330094*..................... 0.0778 COLUMBIA 330106...................... 0.0137 NASSAU 330126...................... 0.0560 ORANGE 330135...................... 0.0560 ORANGE 330167...................... 0.0137 NASSAU 330175...................... 0.0268 CORTLAND 330181*..................... 0.0137 NASSAU 330182*..................... 0.0137 NASSAU 330191*..................... 0.0026 WARREN 330198...................... 0.0137 NASSAU 330205...................... 0.0560 ORANGE 330209...................... 0.0560 ORANGE 330222...................... 0.0003 SARATOGA 330224...................... 0.0959 ULSTER 330225...................... 0.0137 NASSAU 330235*..................... 0.0270 CAYUGA 330259...................... 0.0137 NASSAU 330264...................... 0.0560 ORANGE 330276...................... 0.0063 FULTON 330331...................... 0.0137 NASSAU 330332...................... 0.0137 NASSAU 330333...................... 0.0137 NASSAU 330372...................... 0.0137 NASSAU 330386*..................... 0.1139 SULLIVAN 330402...................... 0.0959 ULSTER 340003...................... 0.0116 SURRY 340015...................... 0.0267 ROWAN 340016...................... 0.1312 JACKSON 340020...................... 0.0207 LEE 340021*..................... 0.0216 CLEVELAND 340027*..................... 0.0126 LENOIR 340037...................... 0.0216 CLEVELAND 340039*..................... 0.0144 IREDELL 340069*..................... 0.0053 WAKE 340070...................... 0.0448 ALAMANCE 340073*..................... 0.0053 WAKE 340085...................... 0.0377 DAVIDSON 340088...................... 0.0115 TRANSYLVANIA 340096...................... 0.0377 DAVIDSON 340097...................... 0.0116 SURRY 340104...................... 0.0216 CLEVELAND 340114*..................... 0.0053 WAKE 340126...................... 0.0161 WILSON 340127*..................... 0.0961 GRANVILLE 340129*..................... 0.0144 IREDELL 340133...................... 0.0302 MARTIN 340138*..................... 0.0053 WAKE 340144*..................... 0.0144 IREDELL 340145*..................... 0.0563 LINCOLN 340173*..................... 0.0053 WAKE 360013*..................... 0.0166 SHELBY 360025*..................... 0.0087 ERIE 360034...................... 0.0263 WAYNE 360036*..................... 0.0263 WAYNE 360040...................... 0.0327 KNOX 360065*..................... 0.0141 HURON 360070...................... 0.0028 STARK 360078*..................... 0.0159 PORTAGE 360084...................... 0.0028 STARK 360086*..................... 0.0168 CLARK 360093...................... 0.0120 DEFIANCE 360095...................... 0.0087 HANCOCK 360096*..................... 0.0031 COLUMBIANA 360099...................... 0.0087 HANCOCK 360100...................... 0.0028 STARK 360107*..................... 0.0213 SANDUSKY 360131...................... 0.0028 STARK 360151...................... 0.0028 STARK 360156...................... 0.0213 SANDUSKY 360175*..................... 0.0159 CLINTON 360177...................... 0.0212 FAYETTE 360185*..................... 0.0031 COLUMBIANA 360187*..................... 0.0168 CLARK 360197*..................... 0.0092 LOGAN 370004*..................... 0.0193 OTTAWA 370014*..................... 0.0831 BRYAN 370015*..................... 0.0463 MAYES 370023...................... 0.0084 STEPHENS 370043...................... 0.0294 MARSHALL 370065...................... 0.0121 CRAIG 370113*..................... 0.0205 DELAWARE 370138...................... 0.0073 TEXAS 370149...................... 0.0356 POTTAWATOMIE 370179*..................... 0.0314 OKFUSKEE 380002...................... 0.0130 JOSEPHINE 380008*..................... 0.0201 LINN 380022*..................... 0.0201 LINN 380029...................... 0.0073 MARION 380051...................... 0.0073 MARION 380056...................... 0.0073 MARION 390011...................... 0.0012 CAMBRIA 390030*..................... 0.0274 SCHUYLKILL 390031*..................... 0.0274 SCHUYLKILL 390044...................... 0.0200 BERKS 390046...................... 0.0098 YORK 390052*..................... 0.0036 CLEARFIELD 390056...................... 0.0042 HUNTINGDON 390065*..................... 0.0501 ADAMS 390066*..................... 0.0259 LEBANON 390086*..................... 0.0036 CLEARFIELD 390096...................... 0.0200 BERKS 390101...................... 0.0098 YORK 390110*..................... 0.0012 CAMBRIA 390130...................... 0.0012 CAMBRIA 390138*..................... 0.0325 FRANKLIN 390146...................... 0.0053 WARREN 390150*..................... 0.0206 GREENE 390151*..................... 0.0325 FRANKLIN 390162...................... 0.0149 NORTHAMPTON 390173...................... 0.0074 INDIANA 390181*..................... 0.0274 SCHUYLKILL 390183*..................... 0.0274 SCHUYLKILL 390201*..................... 0.1127 MONROE 390233...................... 0.0098 YORK 420007...................... 0.0001 SPARTANBURG 420009*..................... 0.0162 OCONEE 420020*..................... 0.0035 GEORGETOWN 420027...................... 0.0210 ANDERSON 420030*..................... 0.0103 COLLETON 420039*..................... 0.0156 UNION 420043...................... 0.0177 CHEROKEE 420062...................... 0.0247 CHESTERFIELD 420068*..................... 0.0097 ORANGEBURG 420070*..................... 0.0101 SUMTER 420083...................... 0.0001 SPARTANBURG

[[Page 23581]]

420093...................... 0.0001 SPARTANBURG 420098...................... 0.0035 GEORGETOWN 430008...................... 0.0504 BROOKINGS 430048...................... 0.0088 LAWRENCE 430094*..................... 0.0088 LAWRENCE 440008*..................... 0.0663 HENDERSON 440016...................... 0.0224 CARROLL 440024...................... 0.0387 BRADLEY 440025...................... 0.0037 GREENE 440033...................... 0.0159 CAMPBELL 440035*..................... 0.0441 MONTGOMERY 440047...................... 0.0499 GIBSON 440050*..................... 0.0037 GREENE 440051...................... 0.0110 MC NAIRY 440056...................... 0.0321 JEFFERSON 440060*..................... 0.0499 GIBSON 440063...................... 0.0011 WASHINGTON 440073*..................... 0.0513 MAURY 440105...................... 0.0011 WASHINGTON 440114...................... 0.0523 LAUDERDALE 440115...................... 0.0499 GIBSON 440143...................... 0.0448 MARSHALL 440148*..................... 0.0568 DE KALB 440153...................... 0.0145 COCKE 440174...................... 0.0372 HAYWOOD 440180*..................... 0.0159 CAMPBELL 440181...................... 0.0407 HARDEMAN 440182...................... 0.0224 CARROLL 440184...................... 0.0011 WASHINGTON 440185*..................... 0.0387 BRADLEY 450032*..................... 0.0416 HARRISON 450039*..................... 0.0097 TARRANT 450050...................... 0.0750 WARD 450059*..................... 0.0073 COMAL 450064*..................... 0.0097 TARRANT 450087*..................... 0.0097 TARRANT 450099*..................... 0.0180 GRAY 450113...................... 0.0195 ANDERSON 450121*..................... 0.0097 TARRANT 450135*..................... 0.0097 TARRANT 450137*..................... 0.0097 TARRANT 450144*..................... 0.0573 ANDREWS 450151...................... 0.0210 FAYETTE 450163...................... 0.0134 KLEBERG 450187*..................... 0.0264 WASHINGTON 450194*..................... 0.0328 CHEROKEE 450214*..................... 0.0368 WHARTON 450224*..................... 0.0411 WOOD 450347*..................... 0.0427 WALKER 450362...................... 0.0486 BURNET 450370...................... 0.0258 COLORADO 450389*..................... 0.0881 HENDERSON 450395...................... 0.0484 POLK 450419*..................... 0.0097 TARRANT 450438*..................... 0.0258 COLORADO 450447*..................... 0.0358 NAVARRO 450451*..................... 0.0551 SOMERVELL 450465...................... 0.0435 MATAGORDA 450547*..................... 0.0411 WOOD 450563*..................... 0.0097 TARRANT 450565...................... 0.0492 PALO PINTO 450596...................... 10.0808 HOOD 450597...................... 0.0077 DE WITT 450623*..................... 0.0492 FANNIN 450626...................... 0.0294 JACKSON 450639*..................... 0.0097 TARRANT 450672*..................... 0.0097 TARRANT 450675*..................... 0.0097 TARRANT 450677*..................... 0.0097 TARRANT 450694*..................... 0.0368 WHARTON 450747*..................... 0.0195 ANDERSON 450755*..................... 0.0484 HOCKLEY 450763...................... 0.0236 HUTCHINSON 450779*..................... 0.0097 TARRANT 450813...................... 0.0195 ANDERSON 450858*..................... 0.0097 TARRANT 460017...................... 0.0392 BOX ELDER 460036*..................... 0.0700 WASATCH 460039*..................... 0.0392 BOX ELDER 470018...................... 0.0287 WINDSOR 470023...................... 0.0118 CALEDONIA 490019...................... 0.1240 CULPEPER 490038...................... 0.0022 SMYTH 490047*..................... 0.0198 PAGE 490084...................... 0.0167 ESSEX 490105*..................... 0.0022 SMYTH 490110...................... 0.0082 MONTGOMERY 500003*..................... 0.0208 SKAGIT 500007...................... 0.0208 SKAGIT 500019...................... 0.0213 LEWIS 500021...................... 0.0055 PIERCE 500024*..................... 0.0023 THURSTON 500039*..................... 0.0174 KITSAP 500041*..................... 0.0118 COWLITZ 500079...................... 0.0055 PIERCE 500108...................... 0.0055 PIERCE 500118...................... 0.0548 MASON 500122*..................... 0.0459 ISLAND 500129...................... 0.0055 PIERCE 500139*..................... 0.0023 THURSTON 500143*..................... 0.0023 THURSTON 510018*..................... 0.0209 JACKSON 510028*..................... 0.0141 FAYETTE 510039...................... 0.0112 OHIO 510047*..................... 0.0275 MARION 510050...................... 0.0112 OHIO 510077*..................... 0.0021 MINGO 510088...................... 0.0141 FAYETTE 520028*..................... 0.0157 GREEN 520035...................... 0.0077 SHEBOYGAN 520042...................... 0.0118 SAUK 520044...................... 0.0077 SHEBOYGAN 520057...................... 0.0118 SAUK 520059*..................... 0.0200 RACINE 520071*..................... 0.0239 JEFFERSON 520076*..................... 0.0181 DODGE 520094*..................... 0.0200 RACINE 520095*..................... 0.0118 SAUK 520096*..................... 0.0200 RACINE 520102*..................... 0.0298 WALWORTH 520116*..................... 0.0239 JEFFERSON 520132...................... 0.0077 SHEBOYGAN

Table 5.--List of Diagnosis-Related Groups (DRGs, Relative Weighting Factors, and Geometric and Arithmetic Mean Length of Stay (LOS)

DRG

MDC

TYPE

DRG Title

Weights Mean LOS Mean LOS

1....................

01 SURG................. CRANIOTOMY AGE >17 W 3.4276

7.6 10.1 CC. 2....................

01 SURG................. CRANIOTOMY AGE >17 W/O 1.9544

3.5

4.6 CC. 3....................

01 SURG *............... CRANIOTOMY AGE 0-17... 1.9830 12.7 12.7 4....................

01 SURG................. NO LONGER VALID....... .0000

.0

.0 5....................

01 SURG................. NO LONGER VALID....... .0000

.0

0 6....................

01 SURG................. CARPAL TUNNEL RELEASE. .7868

2.2

3.1 7....................

01 SURG................. PERIPH & CRANIAL NERVE 2.6679

6.6

9.5 & OTHER NERV SYST PROC W CC. 8....................

01 SURG................. PERIPH & CRANIAL NERVE 1.5008

2.0

2.9 & OTHER NERV SYST PROC W/O CC. 9....................

01 MED.................. SPINAL DISORDERS &

1.3993

4.5

6.3 INJURIES. 10...................

01 MED.................. NERVOUS SYSTEM

1.2219

4.6

6.2 NEOPLASMS W CC. 11...................

01 MED.................. NERVOUS SYSTEM

.8704

2.9

3.8 NEOPLASMS W/O CC. 12...................

01 MED.................. DEGENERATIVE NERVOUS

.8972

4.3

5.5 SYSTEM DISORDERS. 13...................

01 MED.................. MULTIPLE SCLEROSIS &

.8520

4.0

5.0 CEREBELLAR ATAXIA. 14...................

01 MED.................. INTRACRANIAL

1.2533

4.5

5.8 HEMORRHAGE OR STROKE WITH INFARCT. 15...................

01 MED.................. NONSPECIFIC CVA &

.9402

3.7

4.6 PRECEREBRAL OCCLUSION W/O INFARCT. 16...................

01 MED.................. NONSPECIFIC

1.3315

5.0

6.5 CEREBROVASCULAR DISORDERS W CC. 17...................

01 MED.................. NONSPECIFIC

.7191

2.5

3.2 CEREBROVASCULAR DISORDERS W/O CC. 18...................

01 MED.................. CRANIAL & PERIPHERAL

.9891

4.1

5.3 NERVE DISORDERS W CC. 19...................

01 MED.................. CRANIAL & PERIPHERAL

.7058

2.7

3.4 NERVE DISORDERS W/O CC.

[[Page 23582]]

20...................

01 MED.................. NERVOUS SYSTEM

2.7787

8.0 10.4 INFECTION EXCEPT VIRAL MENINGITIS. 21...................

01 MED.................. VIRAL MENINGITIS...... 1.4424

4.9

6.4 22...................

01 MED.................. HYPERTENSIVE

1.1269

4.0

5.2 ENCEPHALOPATHY. 23...................

01 MED.................. NONTRAUMATIC STUPOR & .7695

3.0

3.9 COMA. 24...................

01 MED.................. SEIZURE & HEADACHE AGE .9954

3.6

4.8 >17 W CC. 25...................

01 MED.................. SEIZURE & HEADACHE AGE .6165

2.5

3.1 >17 W/O CC. 26...................

01 MED.................. SEIZURE & HEADACHE AGE 1.8098

3.4

6.3 0-17. 27...................

01 MED.................. TRAUMATIC STUPOR &

1.3455

3.2

5.1 COMA, COMA >1 HR. 28...................

01 MED.................. TRAUMATIC STUPOR &

1.3324

4.4

5.9 COMA, COMA 17 W CC. 29...................

01 MED.................. TRAUMATIC STUPOR &

.7210

2.6

3.4 COMA, COMA 17 W/O CC. 30...................

01 MED *................ TRAUMATIC STUPOR &

.3354

2.0

2.0 COMA, COMA 17 W

.9529

3.0

4.0 CC. 32...................

01 MED.................. CONCUSSION AGE >17 W/O .6185

1.9

2.4 CC. 33...................

01 MED *................ CONCUSSION AGE 0-17... .2106

1.6

1.6 34...................

01 MED.................. OTHER DISORDERS OF

1.0047

3.7

4.8 NERVOUS SYSTEM W CC. 35...................

01 MED.................. OTHER DISORDERS OF

.6253

2.4

3.0 NERVOUS SYSTEM W/O CC. 36...................

02 SURG................. RETINAL PROCEDURES.... .7238

1.3

1.6 37...................

02 SURG................. ORBITAL PROCEDURES.... 1.1761

2.7

4.1 38...................

02 SURG................. PRIMARY IRIS

.6963

2.5

3.5 PROCEDURES. 39...................

02 SURG................. LENS PROCEDURES WITH

.7109

1.7

2.4 OR WITHOUT VITRECTOMY. 40...................

02 SURG................. EXTRAOCULAR PROCEDURES .9624

3.0

4.1 EXCEPT ORBIT AGE >17. 41...................

02 SURG *............... EXTRAOCULAR PROCEDURES .3414

1.6

1.6 EXCEPT ORBIT AGE 0-17. 42...................

02 SURG................. INTRAOCULAR PROCEDURES .7865

2.0

2.8 EXCEPT RETINA, IRIS & LENS. 43...................

02 MED.................. HYPHEMA............... .6146

2.4

3.1 44...................

02 MED.................. ACUTE MAJOR EYE

.6811

3.9

4.8 INFECTIONS. 45...................

02 MED.................. NEUROLOGICAL EYE

.7462

2.5

3.1 DISORDERS. 46...................

02 MED.................. OTHER DISORDERS OF THE .7471

3.2

4.2 EYE AGE >17 W CC. 47...................

02 MED.................. OTHER DISORDERS OF THE .5189

2.3

2.9 EYE AGE >17 W/O CC. 48...................

02 MED *................ OTHER DISORDERS OF THE .3008

2.9

2.9 EYE AGE 0-17. 49...................

03 SURG................. MAJOR HEAD & NECK

1.6375

3.2

4.4 PROCEDURES. 50...................

03 SURG................. SIALOADENECTOMY....... .8661

1.5

1.8 51...................

03 SURG................. SALIVARY GLAND

.8829

1.9

2.8 PROCEDURES EXCEPT SIALOADENECTOMY. 52...................

03 SURG................. CLEFT LIP & PALATE

.8428

1.5

2.0 REPAIR. 53...................

03 SURG................. SINUS & MASTOID

1.3302

2.5

4.0 PROCEDURES AGE >17. 54...................

03 SURG *............... SINUS & MASTOID

.4874

3.2

3.2 PROCEDURES AGE 0-17. 55...................

03 SURG................. MISCELLANEOUS EAR,

.9577

2.1

3.1 NOSE, MOUTH & THROAT PROCEDURES. 56...................

03 SURG................. RHINOPLASTY........... .8623

1.9

2.6 57...................

03 SURG................. T&A PROC, EXCEPT

1.1330

2.6

4.2 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE >17. 58...................

03 SURG *............... T&A PROC, EXCEPT

.2768

1.5

1.5 TONSILLECTOMY &/OR ADENOIDECTOMY ONLY, AGE 0-17. 59...................

03 SURG................. TONSILLECTOMY &/OR

.7950

1.8

2.5 ADENOIDECTOMY ONLY, AGE >17. 60...................

03 SURG *............... TONSILLECTOMY &/OR

.2107

1.5

1.5 ADENOIDECTOMY ONLY, AGE 0-17. 61...................

03 SURG................. MYRINGOTOMY W TUBE

1.2804

3.3

5.4 INSERTION AGE >17. 62...................

03 SURG *............... MYRINGOTOMY W TUBE

.2984

1.3

1.3 INSERTION AGE 0-17. 63...................

03 SURG................. OTHER EAR, NOSE, MOUTH 1.3908

3.0

4.5 & THROAT O.R. PROCEDURES. 64...................

03 MED.................. EAR, NOSE, MOUTH &

1.1606

4.1

6.1 THROAT MALIGNANCY. 65...................

03 MED.................. DYSEQUILIBRIUM........ .5987

2.3

2.8 66...................

03 MED.................. EPISTAXIS............. .5940

2.4

3.1 67...................

03 MED.................. EPIGLOTTITIS.......... .7724

2.9

3.7 68...................

03 MED.................. OTITIS MEDIA & URI AGE .6646

3.2

4.0 >17 W CC. 69...................

03 MED.................. OTITIS MEDIA & URI AGE .4860

2.5

3.0 >17 W/O CC. 70...................

03 MED.................. OTITIS MEDIA & URI AGE .4062

2.1

2.4 0-17. 71...................

03 MED.................. LARYNGOTRACHEITIS..... .7509

3.2

4.0 72...................

03 MED.................. NASAL TRAUMA &

.7479

2.6

3.5 DEFORMITY. 73...................

03 MED.................. OTHER EAR, NOSE, MOUTH .8285

3.3

4.4 & THROAT DIAGNOSES AGE >17. 74...................

03 MED *................ OTHER EAR, NOSE, MOUTH .3393

2.1

2.1 & THROAT DIAGNOSES AGE 0-17. 75...................

04 SURG................. MAJOR CHEST PROCEDURES 3.0699

7.6

9.9 76...................

04 SURG................. OTHER RESP SYSTEM O.R. 2.8748

8.4 11.1 PROCEDURES W CC. 77...................

04 SURG................. OTHER RESP SYSTEM O.R. 1.1897

3.4

4.7 PROCEDURES W/O CC. 78...................

04 MED.................. PULMONARY EMBOLISM.... 1.2411

5.4

6.4 79...................

04 MED.................. RESPIRATORY INFECTIONS 1.6212

6.7

8.4 & INFLAMMATIONS AGE >17 W CC. 80...................

04 MED.................. RESPIRATORY INFECTIONS .8872

4.4

5.5 & INFLAMMATIONS AGE >17 W/O CC. 81...................

04 MED *................ RESPIRATORY INFECTIONS 1.5360

6.1

6.1 & INFLAMMATIONS AGE 0- 17. 82...................

04 MED.................. RESPIRATORY NEOPLASMS. 1.3925

5.1

6.8 83...................

04 MED.................. MAJOR CHEST TRAUMA W

.9818

4.2

5.3 CC. 84...................

04 MED.................. MAJOR CHEST TRAUMA W/O .5736

2.6

3.2 CC. 85...................

04 MED.................. PLEURAL EFFUSION W CC. 1.2401

4.8

6.4

[[Page 23583]]

86...................

04 MED.................. PLEURAL EFFUSION W/O

.6943

2.8

3.6 CC. 87...................

04 MED.................. PULMONARY EDEMA &

1.3592

4.9

6.4 RESPIRATORY FAILURE. 88...................

04 MED.................. CHRONIC OBSTRUCTIVE

.8854

4.0

4.9 PULMONARY DISEASE. 89...................

04 MED.................. SIMPLE PNEUMONIA &

1.0317

4.7

5.7 PLEURISY AGE >17 W CC. 90...................

04 MED.................. SIMPLE PNEUMONIA &

.6085

3.2

3.8 PLEURISY AGE >17 W/O CC. 91...................

04 MED.................. SIMPLE PNEUMONIA &

.8173

3.4

4.4 PLEURISY AGE 0-17. 92...................

04 MED.................. INTERSTITIAL LUNG

1.1859

4.9

6.1 DISEASE W CC. 93...................

04 MED.................. INTERSTITIAL LUNG

.7022

3.1

3.8 DISEASE W/O CC. 94...................

04 MED.................. PNEUMOTHORAX W CC..... 1.1435

4.7

6.2 95...................

04 MED.................. PNEUMOTHORAX W/O CC... .6039

2.9

3.7 96...................

04 MED.................. BRONCHITIS & ASTHMA

.7356

3.6

4.4 AGE >17 W CC. 97...................

04 MED.................. BRONCHITIS & ASTHMA

.5340

2.8

3.4 AGE >17 W/O CC. 98...................

04 MED *................ BRONCHITIS & ASTHMA

.5552

3.7

3.7 AGE 0-17. 99...................

04 MED.................. RESPIRATORY SIGNS &

.7075

2.4

3.1 SYMPTOMS W CC. 100..................

04 MED.................. RESPIRATORY SIGNS &

.5386

1.7

2.1 SYMPTOMS W/O CC. 101..................

04 MED.................. OTHER RESPIRATORY

.8715

3.3

4.3 SYSTEM DIAGNOSES W CC. 102..................

04 MED.................. OTHER RESPIRATORY

.5390

2.0

2.5 SYSTEM DIAGNOSES W/O CC. 103..................

PRE SURG................. HEART TRANSPLANT OR 18.3069 23.5 37.5 IMPLANT OF HEART ASSIST SYSTEM. 104..................

05 SURG................. CARDIAC VALVE & OTH

8.2206 12.7 14.9 MAJOR CARDIOTHORACIC PROC W CARD CATH. 105..................

05 SURG................. CARDIAC VALVE & OTH

6.0149

8.5 10.2 MAJOR CARDIOTHORACIC PROC W/O CARD CATH. 106..................

05 SURG................. CORONARY BYPASS W PTCA 7.0409

9.5 11.2 107..................

05 SURG................. CORONARY BYPASS W

5.4802

9.4 10.7 CARDIAC CATH. 108..................

05 SURG................. OTHER CARDIOTHORACIC 5.7861

8.6 10.9 PROCEDURES. 109..................

05 SURG................. CORONARY BYPASS W/O

4.0452

6.8

7.9 PTCA OR CARDIAC CATH. 110..................

05 SURG................. MAJOR CARDIOVASCULAR 3.8908

5.8

8.4 PROCEDURES W CC. 111..................

05 SURG................. MAJOR CARDIOVASCULAR 2.4927

2.6

3.4 PROCEDURES W/O CC. 112..................

05 SURG................. NO LONGER VALID....... .0000

.0

.0 113..................

05 SURG................. AMPUTATION FOR CIRC

3.1547 10.8 13.7 SYSTEM DISORDERS EXCEPT UPPER LIMB & TOE. 114..................

05 SURG................. UPPER LIMB & TOE

1.7288

6.7

8.9 AMPUTATION FOR CIRC SYSTEM DISORDERS. 115..................

05 SURG................. PRM CARD PACEM IMPL W 3.5839

4.5

6.8 AMI/HR/SHOCK OR AICD LEAD OR GNRTR. 116..................

05 SURG................. OTHER PERMANENT

2.2975

3.0

4.3 CARDIAC PACEMAKER IMPLANT. 117..................

05 SURG................. CARDIAC PACEMAKER

1.3232

2.6

4.2 REVISION EXCEPT DEVICE REPLACEMENT. 118..................

05 SURG................. CARDIAC PACEMAKER

1.6347

2.1

3.0 DEVICE REPLACEMENT. 119..................

05 SURG................. VEIN LIGATION &

1.3473

3.3

5.5 STRIPPING. 120..................

05 SURG................. OTHER CIRCULATORY

2.3814

5.9

9.2 SYSTEM O.R. PROCEDURES. 121..................

05 MED.................. CIRCULATORY DISORDERS 1.6110

5.3

6.6 W AMI & MAJOR COMP, DISCHARGED ALIVE. 122..................

05 MED.................. CIRCULATORY DISORDERS .9818

2.8

3.5 W AMI W/O MAJOR COMP, DISCHARGED ALIVE. 123..................

05 MED.................. CIRCULATORY DISORDERS 1.5321

2.9

4.8 W AMI, EXPIRED. 124..................

05 MED.................. CIRCULATORY DISORDERS 1.4417

3.3

4.4 EXCEPT AMI, W CARD CATH & COMPLEX DIAG. 125..................

05 MED.................. CIRCULATORY DISORDERS 1.0932

2.1

2.7 EXCEPT AMI, W CARD CATH W/O COMPLEX DIAG. 126..................

05 MED.................. ACUTE & SUBACUTE

2.7261

9.4 11.9 ENDOCARDITIS. 127..................

05 MED.................. HEART FAILURE & SHOCK. 1.0330

4.1

5.2 128..................

05 MED.................. DEEP VEIN

.6919

4.4

5.2 THROMBOPHLEBITIS. 129..................

05 MED.................. CARDIAC ARREST,

1.0365

1.7

2.6 UNEXPLAINED. 130..................

05 MED.................. PERIPHERAL VASCULAR

.9412

4.4

5.5 DISORDERS W CC. 131..................

05 MED.................. PERIPHERAL VASCULAR

.5555

3.2

3.9 DISORDERS W/O CC. 132..................

05 MED.................. ATHEROSCLEROSIS W CC.. .6252

2.2

2.8 133..................

05 MED.................. ATHEROSCLEROSIS W/O CC .5323

1.8

2.2 134..................

05 MED.................. HYPERTENSION.......... .6057

2.5

3.1 135..................

05 MED.................. CARDIAC CONGENITAL &

.8969

3.3

4.4 VALVULAR DISORDERS AGE >17 W CC. 136..................

05 MED.................. CARDIAC CONGENITAL &

.6228

2.2

2.8 VALVULAR DISORDERS AGE >17 W/O CC. 137..................

05 MED *................ CARDIAC CONGENITAL &

.8275

3.3

3.3 VALVULAR DISORDERS AGE 0-17. 138..................

05 MED.................. CARDIAC ARRHYTHMIA &

.8313

3.1

3.9 CONDUCTION DISORDERS W CC. 139..................

05 MED.................. CARDIAC ARRHYTHMIA &

.5222

2.0

2.4 CONDUCTION DISORDERS W/O CC. 140..................

05 MED.................. ANGINA PECTORIS....... .5076

2.0

2.4 141..................

05 MED.................. SYNCOPE & COLLAPSE W

.7513

2.7

3.5 CC. 142..................

05 MED.................. SYNCOPE & COLLAPSE W/O .5848

2.0

2.5 CC. 143..................

05 MED.................. CHEST PAIN............ .5655

1.7

2.1

[[Page 23584]]

144..................

05 MED.................. OTHER CIRCULATORY

1.2734

4.1

5.8 SYSTEM DIAGNOSES W CC. 145..................

05 MED.................. OTHER CIRCULATORY

.5843

2.1

2.6 SYSTEM DIAGNOSES W/O CC. 146..................

06 SURG................. RECTAL RESECTION W CC. 2.6565

8.6 10.0 147..................

06 SURG................. RECTAL RESECTION W/O 1.4778

5.2

5.8 CC. 148..................

06 SURG................. MAJOR SMALL & LARGE

3.4400 10.0 12.3 BOWEL PROCEDURES W CC. 149..................

06 SURG................. MAJOR SMALL & LARGE

1.4304

5.4

6.0 BOWEL PROCEDURES W/O CC. 150..................

06 SURG................. PERITONEAL

2.7986

8.9 11.0 ADHESIOLYSIS W CC. 151..................

06 SURG................. PERITONEAL

1.2620

4.0

5.1 ADHESIOLYSIS W/O CC. 152..................

06 SURG................. MINOR SMALL & LARGE

1.8768

6.7

8.0 BOWEL PROCEDURES W CC. 153..................

06 SURG................. MINOR SMALL & LARGE

1.0833

4.5

5.0 BOWEL PROCEDURES W/O CC. 154..................

06 SURG................. STOMACH, ESOPHAGEAL & 4.0333

9.9 13.2 DUODENAL PROCEDURES AGE >17 W CC. 155..................

06 SURG................. STOMACH, ESOPHAGEAL & 1.2855

3.1

4.1 DUODENAL PROCEDURES AGE >17 W/O CC. 156..................

06 SURG *............... STOMACH, ESOPHAGEAL & .8522

6.0

6.0 DUODENAL PROCEDURES AGE 0-17. 157..................

06 SURG................. ANAL & STOMAL

1.3317

4.1

5.8 PROCEDURES W CC. 158..................

06 SURG................. ANAL & STOMAL

.6634

2.1

2.6 PROCEDURES W/O CC. 159..................

06 SURG................. HERNIA PROCEDURES

1.4163

3.8

5.1 EXCEPT INGUINAL & FEMORAL AGE >17 W CC. 160..................

06 SURG................. HERNIA PROCEDURES

.8423

2.2

2.7 EXCEPT INGUINAL & FEMORAL AGE >17 W/O CC. 161..................

06 SURG................. INGUINAL & FEMORAL

1.1998

3.1

4.4 HERNIA PROCEDURES AGE >17 W CC. 162..................

06 SURG................. INGUINAL & FEMORAL

.6763

1.7

2.1 HERNIA PROCEDURES AGE >17 W/O CC. 163..................

06 SURG................. HERNIA PROCEDURES AGE .6711

2.2

2.9 0-17. 164..................

06 SURG................. APPENDECTOMY W

2.2488

6.6

8.0 COMPLICATED PRINCIPAL DIAG W CC. 165..................

06 SURG................. APPENDECTOMY W

1.1833

3.6

4.2 COMPLICATED PRINCIPAL DIAG W/O CC. 166..................

06 SURG................. APPENDECTOMY W/O

1.4517

3.3

4.5 COMPLICATED PRINCIPAL DIAG W CC. 167..................

06 SURG................. APPENDECTOMY W/O

.8918

1.9

2.2 COMPLICATED PRINCIPAL DIAG W/O CC. 168..................

03 SURG................. MOUTH PROCEDURES W CC. 1.2650

3.3

4.9 169..................

03 SURG................. MOUTH PROCEDURES W/O

.7251

1.8

2.3 CC. 170..................

06 SURG................. OTHER DIGESTIVE SYSTEM 2.9522

7.8 11.0 O.R. PROCEDURES W CC. 171..................

06 SURG................. OTHER DIGESTIVE SYSTEM 1.1837

3.1

4.1 O.R. PROCEDURES W/O CC. 172..................

06 MED.................. DIGESTIVE MALIGNANCY W 1.4115

5.1

7.0 CC. 173..................

06 MED.................. DIGESTIVE MALIGNANCY W/ .7442

2.7

3.6 O CC. 174..................

06 MED.................. G.I. HEMORRHAGE W CC.. 1.0138

3.8

4.7 175..................

06 MED.................. G.I. HEMORRHAGE W/O CC .5644

2.4

2.9 176..................

06 MED.................. COMPLICATED PEPTIC

1.1228

4.1

5.2 ULCER. 177..................

06 MED.................. UNCOMPLICATED PEPTIC

.9158

3.6

4.4 ULCER W CC. 178..................

06 MED.................. UNCOMPLICATED PEPTIC

.7014

2.6

3.1 ULCER W/O CC. 179..................

06 MED.................. INFLAMMATORY BOWEL

1.0877

4.5

5.9 DISEASE. 180..................

06 MED.................. G.I. OBSTRUCTION W CC. .9769

4.2

5.4 181..................

06 MED.................. G.I. OBSTRUCTION W/O

.5609

2.8

3.3 CC. 182..................

06 MED.................. ESOPHAGITIS, GASTROENT .8463

3.4

4.5 & MISC DIGEST DISORDERS AGE >17 W CC. 183..................

06 MED.................. ESOPHAGITIS, GASTROENT .5846

2.3

2.9 & MISC DIGEST DISORDERS AGE >17 W/O CC. 184..................

06 MED.................. ESOPHAGITIS, GASTROENT .5700

2.5

3.3 & MISC DIGEST DISORDERS AGE 0-17. 185..................

03 MED.................. DENTAL & ORAL DIS

.8689

3.3

4.5 EXCEPT EXTRACTIONS & RESTORATIONS, AGE >17. 186..................

03 MED *................ DENTAL & ORAL DIS

.3248

2.9

2.9 EXCEPT EXTRACTIONS & RESTORATIONS, AGE 0- 17. 187..................

03 MED.................. DENTAL EXTRACTIONS &

.8435

3.1

4.2 RESTORATIONS. 188..................

06 MED.................. OTHER DIGESTIVE SYSTEM 1.1257

4.2

5.6 DIAGNOSES AGE >17 W CC. 189..................

06 MED.................. OTHER DIGESTIVE SYSTEM .6052

2.4

3.1 DIAGNOSES AGE >17 W/O CC. 190..................

06 MED.................. OTHER DIGESTIVE SYSTEM .6258

3.2

4.4 DIAGNOSES AGE 0-17. 191..................

07 SURG................. PANCREAS, LIVER &

3.9443

9.0 12.8 SHUNT PROCEDURES W CC. 192..................

07 SURG................. PANCREAS, LIVER &

1.6802

4.3

5.7 SHUNT PROCEDURES W/O CC. 193..................

07 SURG................. BILIARY TRACT PROC

3.2837

9.9 12.1 EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC. 194..................

07 SURG................. BILIARY TRACT PROC

1.5786

5.6

6.7 EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC. 195..................

07 SURG................. CHOLECYSTECTOMY W

3.0503

8.8 10.6 C.D.E. W CC. 196..................

07 SURG................. CHOLECYSTECTOMY W

1.6011

4.9

5.7 C.D.E. W/O CC. 197..................

07 SURG................. CHOLECYSTECTOMY EXCEPT 2.5397

7.5

9.2 BY LAPAROSCOPE W/O C.D.E. W CC. 198..................

07 SURG................. CHOLECYSTECTOMY EXCEPT 1.1571

3.7

4.3 BY LAPAROSCOPE W/O C.D.E. W/O CC.

[[Page 23585]]

199..................

07 SURG................. HEPATOBILIARY

2.4077

6.8

9.5 DIAGNOSTIC PROCEDURE FOR MALIGNANCY. 200..................

07 SURG................. HEPATOBILIARY

2.7777

6.4

9.8 DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY. 201..................

07 SURG................. OTHER HEPATOBILIARY OR 3.7156

9.9 13.8 PANCREAS O.R. PROCEDURES. 202..................

07 MED.................. CIRRHOSIS & ALCOHOLIC 1.3463

4.7

6.3 HEPATITIS. 203..................

07 MED.................. MALIGNANCY OF

1.3719

4.9

6.6 HEPATOBILIARY SYSTEM OR PANCREAS. 204..................

07 MED.................. DISORDERS OF PANCREAS 1.1216

4.2

5.6 EXCEPT MALIGNANCY. 205..................

07 MED.................. DISORDERS OF LIVER

1.2026

4.4

6.0 EXCEPT MALIG, CIRR, ALC HEPA W CC. 206..................

07 MED.................. DISORDERS OF LIVER

.7289

3.0

3.9 EXCEPT MALIG, CIRR, ALC HEPA W/O CC. 207..................

07 MED.................. DISORDERS OF THE

1.1730

4.1

5.3 BILIARY TRACT W CC. 208..................

07 MED.................. DISORDERS OF THE

.6880

2.3

2.9 BILIARY TRACT W/O CC. 209..................

08 SURG................. NO LONGER VALID....... .0000 17.1 17.1 210..................

08 SURG................. HIP & FEMUR PROCEDURES 1.9035

6.1

6.9 EXCEPT MAJOR JOINT AGE >17 W CC. 211..................

08 SURG................. HIP & FEMUR PROCEDURES 1.2676

4.4

4.7 EXCEPT MAJOR JOINT AGE >17 W/O CC. 212..................

08 SURG................. HIP & FEMUR PROCEDURES 1.2786

2.4

2.9 EXCEPT MAJOR JOINT AGE 0-17. 213..................

08 SURG................. AMPUTATION FOR

2.0393

7.2

9.7 MUSCULOSKELETAL SYSTEM & CONN TISSUE DISORDERS. 214..................

08 SURG................. NO LONGER VALID....... .0000

.0

.0 215..................

08 SURG................. NO LONGER VALID....... .0000

.0

.0 216..................

08 SURG................. BIOPSIES OF

1.9099

3.3

5.8 MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE. 217..................

08 SURG................. WND DEBRID & SKN GRFT 3.0414

9.3 13.2 EXCEPT HAND, FOR MUSCSKELET & CONN TISS DIS. 218..................

08 SURG................. LOWER EXTREM & HUMER 1.6068

4.3

5.5 PROC EXCEPT HIP, FOOT, FEMUR AGE >17 W CC. 219..................

08 SURG................. LOWER EXTREM & HUMER 1.0427

2.6

3.1 PROC EXCEPT HIP, FOOT, FEMUR AGE >17 W/ O CC. 220..................

08 SURG *............... LOWER EXTREM & HUMER

.5904

5.3

5.3 PROC EXCEPT HIP, FOOT, FEMUR AGE 0-17. 221..................

08 SURG................. NO LONGER VALID....... .0000

.0

.0 222..................

08 SURG................. NO LONGER VALID....... .0000

.0

.0 223..................

08 SURG................. MAJOR SHOULDER/ELBOW 1.1119

2.3

3.2 PROC, OR OTHER UPPER EXTREMITY PROC W CC. 224..................

08 SURG................. SHOULDER, ELBOW OR

.8172

1.6

1.9 FOREARM PROC, EXC MAJOR JOINT PROC, W/O CC. 225..................

08 SURG................. FOOT PROCEDURES....... 1.2189

3.7

5.2 226..................

08 SURG................. SOFT TISSUE PROCEDURES 1.5839

4.5

6.5 W CC. 227..................

08 SURG................. SOFT TISSUE PROCEDURES .8338

2.1

2.6 W/O CC. 228..................

08 SURG................. MAJOR THUMB OR JOINT 1.1414

2.8

4.1 PROC, OR OTH HAND OR WRIST PROC W CC. 229..................

08 SURG................. HAND OR WRIST PROC,

.6957

1.9

2.5 EXCEPT MAJOR JOINT PROC, W/O CC. 230..................

08 SURG................. LOCAL EXCISION &

1.3137

3.7

5.6 REMOVAL OF INT FIX DEVICES OF HIP & FEMUR. 231..................

08 SURG................. NO LONGER VALID....... .0000

.0

.0 232..................

08 SURG................. ARTHROSCOPY........... .9699

1.8

2.8 233..................

08 SURG................. OTHER MUSCULOSKELET

1.9137

4.6

6.8 SYS & CONN TISS O.R. PROC W CC. 234..................

08 SURG................. OTHER MUSCULOSKELET

1.2204

2.0

2.8 SYS & CONN TISS O.R. PROC W/O CC. 235..................

08 MED.................. FRACTURES OF FEMUR.... .7770

3.8

4.8 236..................

08 MED.................. FRACTURES OF HIP &

.7393

3.8

4.6 PELVIS. 237..................

08 MED.................. SPRAINS, STRAINS, &

.6084

3.0

3.7 DISLOCATIONS OF HIP, PELVIS & THIGH. 238..................

08 MED.................. OSTEOMYELITIS......... 1.4237

6.7

8.6 239..................

08 MED.................. PATHOLOGICAL FRACTURES 1.0758

5.0

6.2 & MUSCULOSKELETAL & CONN TISS MALIGNANCY. 240..................

08 MED.................. CONNECTIVE TISSUE

1.4024

5.0

6.7 DISORDERS W CC. 241..................

08 MED.................. CONNECTIVE TISSUE

.6613

3.0

3.7 DISORDERS W/O CC. 242..................

08 MED.................. SEPTIC ARTHRITIS...... 1.1452

5.1

6.7 243..................

08 MED.................. MEDICAL BACK PROBLEMS. .7752

3.6

4.6 244..................

08 MED.................. BONE DISEASES &

.7098

3.6

4.5 SPECIFIC ARTHROPATHIES W CC. 245..................

08 MED.................. BONE DISEASES &

.4555

2.5

3.1 SPECIFIC ARTHROPATHIES W/O CC. 246..................

08 MED.................. NON-SPECIFIC

.5910

2.8

3.6 ARTHROPATHIES. 247..................

08 MED.................. SIGNS & SYMPTOMS OF

.5787

2.6

3.3 MUSCULOSKELETAL SYSTEM & CONN TISSUE. 248..................

08 MED.................. TENDONITIS, MYOSITIS & .8556

3.8

4.8 BURSITIS. 249..................

08 MED.................. AFTERCARE,

.7025

2.7

3.8 MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE.

[[Page 23586]]

250..................

08 MED.................. FX, SPRN, STRN & DISL .6949

3.2

3.9 OF FOREARM, HAND, FOOT AGE >17 W CC. 251..................

08 MED.................. FX, SPRN, STRN & DISL .4752

2.3

2.8 OF FOREARM, HAND, FOOT AGE >17 W/O CC. 252..................

08 MED *................ FX, SPRN, STRN & DISL .2563

1.8

1.8 OF FOREARM, HAND, FOOT AGE 0-17. 253..................

08 MED.................. FX, SPRN, STRN & DISL .7734

3.8

4.6 OF UPARM, LOWLEG EX FOOT AGE >17 W CC. 254..................

08 MED.................. FX, SPRN, STRN & DISL .4588

2.6

3.1 OF UPARM, LOWLEG EX FOOT AGE >17 W/O CC. 255..................

08 MED *................ FX, SPRN, STRN & DISL .2985

2.9

2.9 OF UPARM, LOWLEG EX FOOT AGE 0-17. 256..................

08 MED.................. OTHER MUSCULOSKELETAL .8459

3.9

5.1 SYSTEM & CONNECTIVE TISSUE DIAGNOSES. 257..................

09 SURG................. TOTAL MASTECTOMY FOR

.8958

2.0

2.6 MALIGNANCY W CC. 258..................

09 SURG................. TOTAL MASTECTOMY FOR

.7129

1.5

1.7 MALIGNANCY W/O CC. 259..................

09 SURG................. SUBTOTAL MASTECTOMY

.9650

1.8

2.8 FOR MALIGNANCY W CC. 260..................

09 SURG................. SUBTOTAL MASTECTOMY

.7028

1.2

1.4 FOR MALIGNANCY W/O CC. 261..................

09 SURG................. BREAST PROC FOR NON-

.9710

1.6

2.2 MALIGNANCY EXCEPT BIOPSY & LOCAL EXCISION. 262..................

09 SURG................. BREAST BIOPSY & LOCAL .9783

3.4

4.8 EXCISION FOR NON- MALIGNANCY. 263..................

09 SURG................. SKIN GRAFT &/OR DEBRID 2.1033

8.5 11.4 FOR SKN ULCER OR CELLULITIS W CC. 264..................

09 SURG................. SKIN GRAFT &/OR DEBRID 1.0576

5.0

6.5 FOR SKN ULCER OR CELLULITIS W/O CC. 265..................

09 SURG................. SKIN GRAFT &/OR DEBRID 1.6577

4.4

6.7 EXCEPT FOR SKIN ULCER OR CELLULITIS W CC. 266..................

09 SURG................. SKIN GRAFT &/OR DEBRID .8664

2.3

3.2 EXCEPT FOR SKIN ULCER OR CELLULITIS W/O CC. 267..................

09 SURG................. PERIANAL & PILONIDAL

.8946

2.8

4.2 PROCEDURES. 268..................

09 SURG................. SKIN, SUBCUTANEOUS

1.1389

2.4

3.5 TISSUE & BREAST PLASTIC PROCEDURES. 269..................

09 SURG................. OTHER SKIN, SUBCUT

1.8291

6.2

8.6 TISS & BREAST PROC W CC. 270..................

09 SURG................. OTHER SKIN, SUBCUT

.8270

2.7

3.8 TISS & BREAST PROC W/ O CC. 271..................

09 MED.................. SKIN ULCERS........... 1.0072

5.5

7.0 272..................

09 MED.................. MAJOR SKIN DISORDERS W .9814

4.5

5.9 CC. 273..................

09 MED.................. MAJOR SKIN DISORDERS W/ .5536

2.9

3.7 O CC. 274..................

09 MED.................. MALIGNANT BREAST

1.1223

4.7

6.3 DISORDERS W CC. 275..................

09 MED.................. MALIGNANT BREAST

.5302

2.4

3.2 DISORDERS W/O CC. 276..................

09 MED.................. NON-MALIGANT BREAST

.6879

3.5

4.5 DISORDERS. 277..................

09 MED.................. CELLULITIS AGE >17 W

.8652

4.6

5.6 CC. 278..................

09 MED.................. CELLULITIS AGE >17 W/O .5371

3.4

4.1 CC. 279..................

09 MED *................ CELLULITIS AGE 0-17... .7810

4.2

4.2 280..................

09 MED.................. TRAUMA TO THE SKIN,

.7309

3.2

4.1 SUBCUT TISS & BREAST AGE >17 W CC. 281..................

09 MED.................. TRAUMA TO THE SKIN,

.4897

2.3

2.9 SUBCUT TISS & BREAST AGE >17 W/O CC. 282..................

09 MED *................ TRAUMA TO THE SKIN,

.2596

2.2

2.2 SUBCUT TISS & BREAST AGE 0-17. 283..................

09 MED.................. MINOR SKIN DISORDERS W .7398

3.5

4.6 CC. 284..................

09 MED.................. MINOR SKIN DISORDERS W/ .4563

2.4

3.0 O CC. 285..................

10 SURG................. AMPUTAT OF LOWER LIMB 2.1793

8.2 10.5 FOR ENDOCRINE, NUTRIT,& METABOL DISORDERS. 286..................

10 SURG................. ADRENAL & PITUITARY

1.9353

4.0

5.5 PROCEDURES. 287..................

10 SURG................. SKIN GRAFTS & WOUND

1.9237

7.8 10.3 DEBRID FOR ENDOC, NUTRIT & METAB DISORDERS. 288..................

10 SURG................. O.R. PROCEDURES FOR

2.0358

3.2

4.1 OBESITY. 289..................

10 SURG................. PARATHYROID PROCEDURES .9314

1.7

2.6 290..................

10 SURG................. THYROID PROCEDURES.... .8875

1.6

2.1 291..................

10 SURG................. THYROGLOSSAL

1.1155

1.5

2.8 PROCEDURES. 292..................

10 SURG................. OTHER ENDOCRINE,

2.6316

7.3 10.3 NUTRIT & METAB O.R. PROC W CC. 293..................

10 SURG................. OTHER ENDOCRINE,

1.3434

3.2

4.5 NUTRIT & METAB O.R. PROC W/O CC. 294..................

10 MED.................. DIABETES AGE >35...... .7642

3.3

4.3 295..................

10 MED.................. DIABETES AGE 0-35..... .7250

2.9

3.7 296..................

10 MED.................. NUTRITIONAL & MISC

.8175

3.7

4.8 METABOLIC DISORDERS AGE >17 W CC. 297..................

10 MED.................. NUTRITIONAL & MISC

.4845

2.5

3.1 METABOLIC DISORDERS AGE >17 W/O CC. 298..................

10 MED.................. NUTRITIONAL & MISC

.5246

2.5

4.0 METABOLIC DISORDERS AGE 0-17. 299..................

10 MED.................. INBORN ERRORS OF

1.0293

3.7

5.2 METABOLISM. 300..................

10 MED.................. ENDOCRINE DISORDERS W 1.0918

4.6

6.0 CC. 301..................

10 MED.................. ENDOCRINE DISORDERS W/ .6113

2.7

3.4 O CC. 302..................

11 SURG................. KIDNEY TRANSPLANT..... 3.1542

7.0

8.2

[[Page 23587]]

303..................

11 SURG................. KIDNEY, URETER & MAJOR 2.2358

5.9

7.4 BLADDER PROCEDURES FOR NEOPLASM. 304..................

11 SURG................. KIDNEY, URETER & MAJOR 2.3647

6.1

8.6 BLADDER PROC FOR NON- NEOPL W CC. 305..................

11 SURG................. KIDNEY, URETER & MAJOR 1.1580

2.6

3.2 BLADDER PROC FOR NON- NEOPL W/O CC. 306..................

11 SURG................. PROSTATECTOMY W CC.... 1.2674

3.6

5.5 307..................

11 SURG................. PROSTATECTOMY W/O CC.. .6192

1.7

2.1 308..................

11 SURG................. MINOR BLADDER

1.6518

4.0

6.2 PROCEDURES W CC. 309..................

11 SURG................. MINOR BLADDER

.9082

1.6

2.0 PROCEDURES W/O CC. 310..................

11 SURG................. TRANSURETHRAL

1.1948

3.1

4.5 PROCEDURES W CC. 311..................

11 SURG................. TRANSURETHRAL

.6425

1.5

1.9 PROCEDURES W/O CC. 312..................

11 SURG................. URETHRAL PROCEDURES, 1.1170

3.2

4.8 AGE >17 W CC. 313..................

11 SURG................. URETHRAL PROCEDURES,

.6756

1.8

2.2 AGE >17 W/O CC. 314..................

11 SURG *............... URETHRAL PROCEDURES,

.5004

2.3

2.3 AGE 0-17. 315..................

11 SURG................. OTHER KIDNEY & URINARY 2.0801

3.6

6.8 TRACT O.R. PROCEDURES. 316..................

11 MED.................. RENAL FAILURE......... 1.2673

4.9

6.4 317..................

11 MED.................. ADMIT FOR RENAL

.7965

2.4

3.5 DIALYSIS. 318..................

11 MED.................. KIDNEY & URINARY TRACT 1.1535

4.2

5.8 NEOPLASMS W CC. 319..................

11 MED.................. KIDNEY & URINARY TRACT .6388

2.1

2.8 NEOPLASMS W/O CC. 320..................

11 MED.................. KIDNEY & URINARY TRACT .8644

4.2

5.2 INFECTIONS AGE >17 W CC. 321..................

11 MED.................. KIDNEY & URINARY TRACT .5644

3.0

3.6 INFECTIONS AGE >17 W/ O CC. 322..................

11 MED.................. KIDNEY & URINARY TRACT .5569

2.9

3.5 INFECTIONS AGE 0-17. 323..................

11 MED.................. URINARY STONES W CC, &/ .8200

2.3

3.1 OR ESW LITHOTRIPSY. 324..................

11 MED.................. URINARY STONES W/O CC. .5045

1.6

1.9 325..................

11 MED.................. KIDNEY & URINARY TRACT .6417

2.9

3.7 SIGNS & SYMPTOMS AGE >17 W CC. 326..................

11 MED.................. KIDNEY & URINARY TRACT .4385

2.1

2.6 SIGNS & SYMPTOMS AGE >17 W/O CC. 327..................

11 MED *................ KIDNEY & URINARY TRACT .3742

3.1

3.1 SIGNS & SYMPTOMS AGE 0-17. 328..................

11 MED.................. URETHRAL STRICTURE AGE .7085

2.6

3.5 >17 W CC. 329..................

11 MED.................. URETHRAL STRICTURE AGE .4712

1.5

1.8 >17 W/O CC. 330..................

11 MED *................ URETHRAL STRICTURE AGE .3222

1.6

1.6 0-17. 331..................

11 MED.................. OTHER KIDNEY & URINARY 1.0606

4.1

5.5 TRACT DIAGNOSES AGE >17 W CC. 332..................

11 MED.................. OTHER KIDNEY & URINARY .6119

2.4

3.1 TRACT DIAGNOSES AGE >17 W/O CC. 333..................

11 MED.................. OTHER KIDNEY & URINARY .9788

3.6

5.4 TRACT DIAGNOSES AGE 0- 17. 334..................

12 SURG................. MAJOR MALE PELVIC

1.4366

3.5

4.3 PROCEDURES W CC. 335..................

12 SURG................. MAJOR MALE PELVIC

1.0980

2.4

2.7 PROCEDURES W/O CC. 336..................

12 SURG................. TRANSURETHRAL

.8409

2.5

3.3 PROSTATECTOMY W CC. 337..................

12 SURG................. TRANSURETHRAL

.5737

1.7

1.9 PROSTATECTOMY W/O CC. 338..................

12 SURG................. TESTES PROCEDURES, FOR 1.3738

3.9

6.2 MALIGNANCY. 339..................

12 SURG................. TESTES PROCEDURES, NON- 1.1809

3.2

5.1 MALIGNANCY AGE >17. 340..................

12 SURG *............... TESTES PROCEDURES, NON- .2864

2.4

2.4 MALIGNANCY AGE 0-17. 341..................

12 SURG................. PENIS PROCEDURES...... 1.2585

1.9

3.2 342..................

12 SURG................. CIRCUMCISION AGE >17.. .8721

2.5

3.4 343..................

12 SURG *............... CIRCUMCISION AGE 0-17. .1557

1.7

1.7 344..................

12 SURG................. OTHER MALE

1.2458

1.7

2.7 REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY. 345..................

12 SURG................. OTHER MALE

1.1474

3.1

4.8 REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR MALIGNANCY. 346..................

12 MED.................. MALIGNANCY, MALE

1.0439

4.2

5.7 REPRODUCTIVE SYSTEM, W CC. 347..................

12 MED.................. MALIGNANCY, MALE

.6080

2.2

3.0 REPRODUCTIVE SYSTEM, W/O CC. 348..................

12 MED.................. BENIGN PROSTATIC

.7191

3.2

4.1 HYPERTROPHY W CC. 349..................

12 MED.................. BENIGN PROSTATIC

.4223

1.9

2.4 HYPERTROPHY W/O CC. 350..................

12 MED.................. INFLAMMATION OF THE

.7274

3.5

4.5 MALE REPRODUCTIVE SYSTEM. 351..................

12 MED *................ STERILIZATION, MALE... .2389

1.3

1.3 352..................

12 MED.................. OTHER MALE

.7388

2.9

4.0 REPRODUCTIVE SYSTEM DIAGNOSES. 353..................

13 SURG................. PELVIC EVISCERATION, 1.8474

4.7

6.3 RADICAL HYSTERECTOMY & RADICAL VULVECTOMY. 354..................

13 SURG................. UTERINE, ADNEXA PROC 1.5238

4.6

5.7 FOR NON-OVARIAN/ ADNEXAL MALIG W CC. 355..................

13 SURG................. UTERINE, ADNEXA PROC

.8834

2.8

3.1 FOR NON-OVARIAN/ ADNEXAL MALIG W/O CC. 356..................

13 SURG................. FEMALE REPRODUCTIVE

.7429

1.7

1.9 SYSTEM RECONSTRUCTIVE PROCEDURES. 357..................

13 SURG................. UTERINE & ADNEXA PROC 2.2212

6.5

8.1 FOR OVARIAN OR ADNEXAL MALIGNANCY. 358..................

13 SURG................. UTERINE & ADNEXA PROC 1.1428

3.2

4.0 FOR NON-MALIGNANCY W CC.

[[Page 23588]]

359..................

13 SURG................. UTERINE & ADNEXA PROC .7936

2.2

2.4 FOR NON-MALIGNANCY W/ O CC. 360..................

13 SURG................. VAGINA, CERVIX & VULVA .8559

2.0

2.6 PROCEDURES. 361..................

13 SURG................. LAPAROSCOPY &

1.0844

2.2

3.0 INCISIONAL TUBAL INTERRUPTION. 362..................

13 SURG *............... ENDOSCOPIC TUBAL

.3053

1.4

1.4 INTERRUPTION. 363..................

13 SURG................. D&C, CONIZATION &

.9742

2.7

3.8 RADIO-IMPLANT, FOR MALIGNANCY. 364..................

13 SURG................. D&C, CONIZATION EXCEPT .8710

3.0

4.2 FOR MALIGNANCY. 365..................

13 SURG................. OTHER FEMALE

2.0317

5.3

7.7 REPRODUCTIVE SYSTEM O.R. PROCEDURES. 366..................

13 MED.................. MALIGNANCY, FEMALE

1.2296

4.8

6.5 REPRODUCTIVE SYSTEM W CC. 367..................

13 MED.................. MALIGNANCY, FEMALE

.5734

2.3

3.0 REPRODUCTIVE SYSTEM W/ O CC. 368..................

13 MED.................. INFECTIONS, FEMALE

1.1668

5.2

6.7 REPRODUCTIVE SYSTEM. 369..................

13 MED.................. MENSTRUAL & OTHER

.6297

2.4

3.2 FEMALE REPRODUCTIVE SYSTEM DISORDERS. 370..................

14 SURG................. CESAREAN SECTION W CC. .8956

4.1

5.2 371..................

14 SURG................. CESAREAN SECTION W/O

.6037

3.1

3.4 CC. 372..................

14 MED.................. VAGINAL DELIVERY W

.5047

2.6

3.2 COMPLICATING DIAGNOSES. 373..................

14 MED.................. VAGINAL DELIVERY W/O

.3562

2.0

2.2 COMPLICATING DIAGNOSES. 374..................

14 SURG................. VAGINAL DELIVERY W

.6762

2.4

2.7 STERILIZATION &/OR D&C. 375..................

14 SURG *............... VAGINAL DELIVERY W

.5829

4.4

4.4 O.R. PROC EXCEPT STERIL &/OR D&C. 376..................

14 MED.................. POSTPARTUM & POST

.5215

2.6

3.4 ABORTION DIAGNOSES W/ O O.R. PROCEDURE. 377..................

14 SURG................. POSTPARTUM & POST

1.6547

2.9

4.5 ABORTION DIAGNOSES W O.R. PROCEDURE. 378..................

14 MED.................. ECTOPIC PREGNANCY..... .7508

1.9

2.3 379..................

14 MED.................. THREATENED ABORTION... .3590

2.0

2.8 380..................

14 MED.................. ABORTION W/O D&C...... .3913

1.6

2.1 381..................

14 SURG................. ABORTION W D&C,

.6059

1.7

2.3 ASPIRATION CURETTAGE OR HYSTEROTOMY. 382..................

14 MED.................. FALSE LABOR........... .2071

1.3

1.4 383..................

14 MED.................. OTHER ANTEPARTUM

.5053

2.6

3.7 DIAGNOSES W MEDICAL COMPLICATIONS. 384..................

14 MED.................. OTHER ANTEPARTUM

.3187

1.8

2.6 DIAGNOSES W/O MEDICAL COMPLICATIONS. 385..................

15 MED *................ NEONATES, DIED OR

1.3909

1.8

1.8 TRANSFERRED TO ANOTHER ACUTE CARE FACILITY. 386..................

15 MED *................ EXTREME IMMATURITY OR 4.5865 17.9 17.9 RESPIRATORY DISTRESS SYNDROME, NEONATE. 387..................

15 MED *................ PREMATURITY W MAJOR

3.1325 13.3 13.3 PROBLEMS. 388..................

15 MED *................ PREMATURITY W/O MAJOR 1.8900

8.6

8.6 PROBLEMS. 389..................

15 MED *................ FULL TERM NEONATE W

3.2177

4.7

4.7 MAJOR PROBLEMS. 390..................

15 MED *................ NEONATE W OTHER

1.1388

3.4

3.4 SIGNIFICANT PROBLEMS. 391..................

15 MED *................ NORMAL NEWBORN........ .1542

3.1

3.1 392..................

16 SURG................. SPLENECTOMY AGE >17... 3.0278

6.5

9.2 393..................

16 SURG *............... SPLENECTOMY AGE 0-17.. 1.3624

9.1

9.1 394..................

16 SURG................. OTHER O.R. PROCEDURES 1.9019

4.5

7.4 OF THE BLOOD AND BLOOD FORMING ORGANS. 395..................

16 MED.................. RED BLOOD CELL

.8303

3.2

4.3 DISORDERS AGE >17. 396..................

16 MED *................ RED BLOOD CELL

2.5374

4.1

4.1 DISORDERS AGE 0-17. 397..................

16 MED.................. COAGULATION DISORDERS. 1.3113

3.8

5.2 398..................

16 MED.................. RETICULOENDOTHELIAL & 1.2212

4.5

5.8 IMMUNITY DISORDERS W CC. 399..................

16 MED.................. RETICULOENDOTHELIAL & .6665

2.7

3.3 IMMUNITY DISORDERS W/ O CC. 400..................

17 SURG................. NO LONGER VALID....... .0000

.0

.0 401..................

17 SURG................. LYMPHOMA & NON-ACUTE 2.9643

8.0 11.3 LEUKEMIA W OTHER O.R. PROC W CC. 402..................

17 SURG................. LYMPHOMA & NON-ACUTE 1.1793

2.8

4.1 LEUKEMIA W OTHER O.R. PROC W/O CC. 403..................

17 MED.................. LYMPHOMA & NON-ACUTE 1.8406

5.8

8.1 LEUKEMIA W CC. 404..................

17 MED.................. LYMPHOMA & NON-ACUTE

.9244

3.0

4.2 LEUKEMIA W/O CC. 405..................

17 MED *................ ACUTE LEUKEMIA W/O

1.9316

4.9

4.9 MAJOR O.R. PROCEDURE AGE 0-17. 406..................

17 SURG................. MYELOPROLIF DISORD OR 2.7989

7.0

9.9 POORLY DIFF NEOPL W MAJ O.R.PROC W CC. 407..................

17 SURG................. MYELOPROLIF DISORD OR 1.2325

3.0

3.8 POORLY DIFF NEOPL W MAJ O.R.PROC W/O CC. 408..................

17 SURG................. MYELOPROLIF DISORD OR 2.2303

4.8

8.2 POORLY DIFF NEOPL W OTHER O.R.PROC. 409..................

17 MED.................. RADIOTHERAPY.......... 1.2066

4.3

5.8 410..................

17 MED.................. CHEMOTHERAPY W/O ACUTE 1.1022

3.0

3.8 LEUKEMIA AS SECONDARY DIAGNOSIS. 411..................

17 MED.................. HISTORY OF MALIGNANCY .3645

2.5

3.3 W/O ENDOSCOPY. 412..................

17 MED.................. HISTORY OF MALIGNANCY .8442

1.8

2.8 W ENDOSCOPY.

[[Page 23589]]

413..................

17 MED.................. OTHER MYELOPROLIF DIS 1.3035

5.0

6.8 OR POORLY DIFF NEOPL DIAG W CC. 414..................

17 MED.................. OTHER MYELOPROLIF DIS .7784

3.0

4.0 OR POORLY DIFF NEOPL DIAG W/O CC. 415..................

18 SURG................. O.R. PROCEDURE FOR

3.9753 11.0 14.8 INFECTIOUS & PARASITIC DISEASES. 416..................

18 MED.................. SEPTICEMIA AGE >17.... 1.6705

5.6

7.5 417..................

18 MED.................. SEPTICEMIA AGE 0-17... 1.2962

3.6

5.3 418..................

18 MED.................. POSTOPERATIVE & POST- 1.1035

4.9

6.4 TRAUMATIC INFECTIONS. 419..................

18 MED.................. FEVER OF UNKNOWN

.8526

3.4

4.4 ORIGIN AGE >17 W CC. 420..................

18 MED.................. FEVER OF UNKNOWN

.6088

2.7

3.4 ORIGIN AGE >17 W/O CC. 421..................

18 MED.................. VIRAL ILLNESS AGE >17. .7680

3.1

4.1 422..................

18 MED.................. VIRAL ILLNESS & FEVER .6185

2.6

3.7 OF UNKNOWN ORIGIN AGE 0-17. 423..................

18 MED.................. OTHER INFECTIOUS &

1.9163

6.0

8.4 PARASITIC DISEASES DIAGNOSES. 424..................

19 SURG................. O.R. PROCEDURE W

2.2400

7.3 11.7 PRINCIPAL DIAGNOSES OF MENTAL ILLNESS. 425..................

19 MED.................. ACUTE ADJUSTMENT

.6187

2.6

3.5 REACTION & PSYCHOSOCIAL DYSFUNCTION. 426..................

19 MED.................. DEPRESSIVE NEUROSES... .4655

3.0

4.1 427..................

19 MED.................. NEUROSES EXCEPT

.5159

3.2

4.7 DEPRESSIVE. 428..................

19 MED.................. DISORDERS OF

.6944

4.6

7.2 PERSONALITY & IMPULSE CONTROL. 429..................

19 MED.................. ORGANIC DISTURBANCES & .7893

4.3

5.6 MENTAL RETARDATION. 430..................

19 MED.................. PSYCHOSES............. .6306

5.6

7.7 431..................

19 MED.................. CHILDHOOD MENTAL

.5194

4.0

5.9 DISORDERS. 432..................

19 MED.................. OTHER MENTAL DISORDER .6322

2.9

4.3 DIAGNOSES. 433..................

20 MED.................. ALCOHOL/DRUG ABUSE OR .2774

2.2

3.0 DEPENDENCE, LEFT AMA. 434..................

20 MED.................. NO LONGER VALID....... .0000

.0

.0 435..................

20 MED.................. NO LONGER VALID....... .0000

.0

.0 436..................

20 MED.................. NO LONGER VALID....... .0000

.0

.0 437..................

20 MED.................. NO LONGER VALID....... .0000

.0

.0 438..................

20 ..................... NO LONGER VALID....... .0000

.0

.0 439..................

21 SURG................. SKIN GRAFTS FOR

1.9204

5.4

8.8 INJURIES. 440..................

21 SURG................. WOUND DEBRIDEMENTS FOR 1.9346

5.9

9.2 INJURIES. 441..................

21 SURG................. HAND PROCEDURES FOR

.9334

2.3

3.4 INJURIES. 442..................

21 SURG................. OTHER O.R. PROCEDURES 2.5647

6.0

8.9 FOR INJURIES W CC. 443..................

21 SURG................. OTHER O.R. PROCEDURES .9911

2.6

3.4 FOR INJURIES W/O CC. 444..................

21 MED.................. TRAUMATIC INJURY AGE

.7540

3.2

4.1 >17 W CC. 445..................

21 MED.................. TRAUMATIC INJURY AGE

.5016

2.3

2.8 >17 W/O CC. 446..................

21 MED *................ TRAUMATIC INJURY AGE 0- .2995

2.4

2.4 17. 447..................

21 MED.................. ALLERGIC REACTIONS AGE .5572

1.9

2.6 >17. 448..................

21 MED *................ ALLERGIC REACTIONS AGE .0985

2.9

2.9 0-17. 449..................

21 MED.................. POISONING & TOXIC

.8509

2.6

3.7 EFFECTS OF DRUGS AGE >17 W CC. 450..................

21 MED.................. POISONING & TOXIC

.4288

1.6

2.0 EFFECTS OF DRUGS AGE >17 W/O CC. 451..................

21 MED *................ POISONING & TOXIC

.2658

2.1

2.1 EFFECTS OF DRUGS AGE 0-17. 452..................

21 MED.................. COMPLICATIONS OF

1.0388

3.5

4.9 TREATMENT W CC. 453..................

21 MED.................. COMPLICATIONS OF

.5278

2.2

2.8 TREATMENT W/O CC. 454..................

21 MED.................. OTHER INJURY,

.8128

2.9

4.1 POISONING & TOXIC EFFECT DIAG W CC. 455..................

21 MED.................. OTHER INJURY,

.4700

1.7

2.2 POISONING & TOXIC EFFECT DIAG W/O CC. 456..................

22 ..................... NO LONGER VALID....... .0000

.0

.0 457..................

22 MED.................. NO LONGER VALID....... .0000

.0

.0 458..................

22 SURG................. NO LONGER VALID....... .0000

.0

.0 459..................

22 SURG................. NO LONGER VALID....... .0000

.0

.0 460..................

22 MED.................. NO LONGER VALID....... .0000

.0

.0 461..................

23 SURG................. O.R. PROC W DIAGNOSES 1.3957

3.0

5.1 OF OTHER CONTACT W HEALTH SERVICES. 462..................

23 MED.................. REHABILITATION........ .8496

8.8 10.7 463..................

23 MED.................. SIGNS & SYMPTOMS W CC. .6946

3.1

3.9 464..................

23 MED.................. SIGNS & SYMPTOMS W/O

.5057

2.4

2.9 CC. 465..................

23 MED.................. AFTERCARE W HISTORY OF .6015

2.4

3.6 MALIGNANCY AS SECONDARY DIAGNOSIS. 466..................

23 MED.................. AFTERCARE W/O HISTORY .6922

2.7

4.7 OF MALIGNANCY AS SECONDARY DIAGNOSIS. 467..................

23 MED.................. OTHER FACTORS

.4789

2.0

2.7 INFLUENCING HEALTH STATUS. 468.................. ......... ..................... EXTENSIVE O.R.

3.9877

9.7 13.2 PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 469.................. ......... **................... PRINCIPAL DIAGNOSIS

.0000

.0

.0 INVALID AS DISCHARGE DIAGNOSIS. 470.................. ......... **................... UNGROUPABLE........... .0000

.0

.0 471..................

08 SURG................. BILATERAL OR MULTIPLE 3.1328

4.5

5.1 MAJOR JOINT PROCS OF LOWER EXTREMITY. 472..................

22 SURG................. NO LONGER VALID....... .0000

.0

.0 473..................

17 MED.................. ACUTE LEUKEMIA W/O

3.4949

7.6 12.9 MAJOR O.R. PROCEDURE AGE >17.

[[Page 23590]]

474..................

04 SURG................. NO LONGER VALID....... .0000

.0

.0 475..................

04 MED.................. RESPIRATORY SYSTEM

3.5930

8.1 11.3 DIAGNOSIS WITH VENTILATOR SUPPORT. 476.................. ......... SURG................. PROSTATIC O.R.

2.1792

7.4 10.5 PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 477.................. ......... SURG................. NON-EXTENSIVE O.R.

2.0539

5.8

8.7 PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 478..................

05 SURG................. OTHER VASCULAR

2.4118

4.7

7.2 PROCEDURES W CC. 479..................

05 SURG................. OTHER VASCULAR

1.4433

2.1

2.8 PROCEDURES W/O CC. 480..................

PRE SURG................. LIVER TRANSPLANT AND/ 8.9426 13.7 17.9 OR INTESTINAL TRANSPLANT. 481..................

PRE SURG................. BONE MARROW TRANSPLANT 6.2341 18.3 21.8 482..................

PRE SURG................. TRACHEOSTOMY FOR FACE, 3.3281

9.7 12.1 MOUTH & NECK DIAGNOSES. 483..................

PRE SURG................. NO LONGER VALID....... .0000

.0

.0 484..................

24 SURG................. CRANIOTOMY FOR

5.1050

9.3 12.8 MULTIPLE SIGNIFICANT TRAUMA. 485..................

24 SURG................. LIMB REATTACHMENT, HIP 3.4619

8.3 10.2 AND FEMUR PROC FOR MULTIPLE SIGNIFICANT TRA. 486..................

24 SURG................. OTHER O.R. PROCEDURES 4.7225

8.5 12.4 FOR MULTIPLE SIGNIFICANT TRAUMA. 487..................

24 MED.................. OTHER MULTIPLE

1.9309

5.3

7.3 SIGNIFICANT TRAUMA. 488..................

25 SURG................. HIV W EXTENSIVE O.R. 4.4100 11.7 16.4 PROCEDURE. 489..................

25 MED.................. HIV W MAJOR RELATED

1.8294

6.0

8.5 CONDITION. 490..................

25 MED.................. HIV W OR W/O OTHER

1.0638

3.9

5.4 RELATED CONDITION. 491..................

08 SURG................. MAJOR JOINT & LIMB

1.6734

2.6

3.1 REATTACHMENT PROCEDURES OF UPPER EXTREMITY. 492..................

17 MED.................. CHEMOTHERAPY W ACUTE 3.5856

8.8 13.6 LEUKEMIA OR W USE OF HI DOSE CHEMOAGENT. 493..................

07 SURG................. LAPAROSCOPIC

1.8413

4.6

6.1 CHOLECYSTECTOMY W/O C.D.E. W CC. 494..................

07 SURG................. LAPAROSCOPIC

1.0275

2.1

2.7 CHOLECYSTECTOMY W/O C.D.E. W/O CC. 495..................

PRE SURG................. LUNG TRANSPLANT....... 8.5766 13.9 17.3 496..................

08 SURG................. COMBINED ANTERIOR/

6.2260

6.6

9.0 POSTERIOR SPINAL FUSION. 497..................

08 SURG................. SPINAL FUSION EXCEPT 3.6385

5.0

5.9 CERVICAL W CC. 498..................

08 SURG................. SPINAL FUSION EXCEPT 2.7792

3.4

3.8 CERVICAL W/O CC. 499..................

08 SURG................. BACK & NECK PROCEDURES 1.3903

3.1

4.3 EXCEPT SPINAL FUSION W CC. 500..................

08 SURG................. BACK & NECK PROCEDURES .9033

1.8

2.2 EXCEPT SPINAL FUSION W/O CC. 501..................

08 SURG................. KNEE PROCEDURES W PDX 2.6488

8.5 10.4 OF INFECTION W CC. 502..................

08 SURG................. KNEE PROCEDURES W PDX 1.4419

4.9

5.8 OF INFECTION W/O CC. 503..................

08 SURG................. KNEE PROCEDURES W/O

1.2014

2.9

3.8 PDX OF INFECTION. 504..................

22 SURG................. EXTEN. BURNS OR FULL 11.6990 21.6 27.3 THICKNESS BURN W/MV 96+HRS W/SKIN GFT. 505..................

22 MED.................. EXTEN. BURNS OR FULL 2.3035

2.4

4.7 THICKNESS BURN W/MV 96+HRS W/O SKIN GFT. 506..................

22 SURG................. FULL THICKNESS BURN W 4.1098 11.2 15.9 SKIN GRAFT OR INHAL INJ W CC OR SIG TRAUMA. 507..................

22 SURG................. FULL THICKNESS BURN W 1.7419

5.9

8.5 SKIN GRFT OR INHAL INJ W/O CC OR SIG TRAUMA. 508..................

22 MED.................. FULL THICKNESS BURN W/ 1.2672

5.1

7.3 O SKIN GRFT OR INHAL INJ W CC OR SIG TRAUMA. 509..................

22 MED.................. FULL THICKNESS BURN W/ .8233

3.6

5.2 O SKIN GRFT OR INH INJ W/O CC OR SIG TRAUMA. 510..................

22 MED.................. NON-EXTENSIVE BURNS W 1.1808

4.4

6.5 CC OR SIGNIFICANT TRAUMA. 511..................

22 MED.................. NON-EXTENSIVE BURNS W/ .7452

2.7

4.1 O CC OR SIGNIFICANT TRAUMA. 512..................

PRE SURG................. SIMULTANEOUS PANCREAS/ 5.3328 10.7 12.8 KIDNEY TRANSPLANT. 513..................

PRE SURG................. PANCREAS TRANSPLANT... 5.9670

8.9 10.0 514..................

05 SURG................. NO LONGER VALID....... .0000

.0

.0 515..................

05 SURG................. CARDIAC DEFIBRILLATOR 5.5196

2.6

4.3 IMPLANT W/O CARDIAC CATH. 516..................

05 SURG................. NO LONGER VALID....... .0000

.0

.0 517..................

05 SURG................. PERC CARDIO PROC W NON- 2.0601

1.8

2.6 DRUG ELUTING STENT W/ O AMI. 518..................

05 SURG................. PERC CARDIO PROC W/O 1.7772

2.3

3.5 CORONARY ARTERY STENT OR AMI. 519..................

08 SURG................. CERVICAL SPINAL FUSION 2.4826

3.0

4.8 W CC. 520..................

08 SURG................. CERVICAL SPINAL FUSION 1.6774

1.6

2.0 W/O CC. 521..................

20 MED.................. ALCOHOL/DRUG ABUSE OR .6935

4.2

5.6 DEPENDENCE W CC. 522..................

20 MED.................. ALC/DRUG ABUSE OR

.4767

7.7

9.6 DEPEND W REHABILITATION THERAPY W/O CC. 523..................

20 MED.................. ALC/DRUG ABUSE OR

.3785

3.2

3.9 DEPEND W/O REHABILITATION THERAPY W/O CC. 524..................

01 MED.................. TRANSIENT ISCHEMIA.... .7274

2.6

3.2 525..................

05 SURG................. OTHER HEART ASSIST

11.5451

7.3 13.9 SYSTEM IMPLANT. 526..................

05 SURG................. NO LONGER VALID....... .0000

.0

.0 527..................

05 SURG................. PERCUTNEOUS

2.3161

1.6

2.2 CARDIOVASULAR PROC W DRUG ELUTING STENT W/ O AMI.

[[Page 23591]]

528..................

01 SURG................. INTRACRANIAL VASCULAR 7.0396 13.8 17.2 PROC W PDX HEMORRHAGE. 529..................

01 SURG................. VENTRICULAR SHUNT

2.3118

5.3

8.3 PROCEDURES W CC. 530..................

01 SURG................. VENTRICULAR SHUNT

1.2020

2.4

3.1 PROCEDURES W/O CC. 531..................

01 SURG................. SPINAL PROCEDURES W CC 3.1221

6.5

9.6 532..................

01 SURG................. SPINAL PROCEDURES W/O 1.4172

2.8

3.7 CC. 533..................

01 SURG................. EXTRACRANIAL

1.5728

2.4

3.7 PROCEDURES W CC. 534..................

01 SURG................. EXTRACRANIAL

1.0198

1.5

1.8 PROCEDURES W/O CC. 535..................

05 SURG................. CARDIAC DEFIB IMPLANT 8.0777

8.0 10.4 W CARDIAC CATH W AMI/ HF/SHOCK. 536..................

05 SURG................. CARDIAC DEFIB IMPLANT 6.9110

5.9

7.7 W CARDIAC CATH W/O AMI/HF/SHOCK. 537..................

08 SURG................. LOCAL EXCIS & REMOV OF 1.8333

4.8

6.9 INT FIX DEV EXCEPT HIP & FEMUR W CC. 538..................

08 SURG................. LOCAL EXCIS & REMOV OF .9815

2.1

2.8 INT FIX DEV EXCEPT HIP & FEMUR W/O CC. 539..................

17 SURG................. LYMPHOMA & LEUKEMIA W 3.2371

7.0 10.8 MAJOR OR PROCEDURE W CC. 540..................

17 SURG................. LYMPHOMA & LEUKEMIA W 1.1892

2.6

3.6 MAJOR OR PROCEDURE W/ O CC. 541..................

PRE SURG................. ECMO OR TRACH W MV

19.6693 38.0 45.4 96+HRS OR PDX EXC FACE, MTH, FACE&NECK DX W/MAJ OR. 542..................

PRE SURG................. TRACH W MV 96+HRS OR 12.7797 29.0 34.9 PDX EXC FACE, MTH, FACE&NECK DX W/O MJ OR. 543..................

01 SURG................. CRANIOTOMY W/IMPLANT 4.4062

8.5 12.2 OF CHEMO AGENT OR ACUTE COMPLX CNS PDX. 544..................

08 SURG................. MAJOR JOINT

1.9612

4.1

4.6 REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY. 545..................

08 SURG................. REVISION OF HIP OR

2.4781

4.5

5.2 KNEE REPLACEMENT. 546..................

08 SURG................. SPINAL FUSION EXC CERV 5.0779

7.2

9.1 WITH PDX OF CURVATURE OF THE SPINE OR MALIG. 547..................

05 SURG................. PERCUTANEOUS

2.8246

4.4

5.6 CARDIOVASCULAR PROC W AMI W CC. 548..................

05 SURG................. PERCUTANEOUS

2.0984

2.7

3.0 CARDIOVASCULAR PROC W AMI W/O CC. 549..................

05 SURG................. PERCUTANEOUS

3.2154

4.1

5.2 CARDIOVASCULAR PROC W DRUG ELUTING STENT W AMI W CC. 550..................

05 SURG................. PERCUTANEOUS

2.5116

2.5 2.9 CARDIOVASCULAR PROC W DRUG ELUTING STENT W AMI W/O CC.

*Medicare data has been supplemented by data from 19 States for low-volume DRGs. **DRGs 469 and 470 contain cases which could not be assigned to valid DRGs. Note: Geometric mean is used only to determine payment for transfer cases. Note: Arithmetic means are presented for informational purposes only. Note: Relative weights are based on Medicare patient data and may not be appropriate for other patients.

Table 6A.--New Diagnosis Codes

Diagnosis code Description CC MDC

DRG

259.5......... Androgen

N

10 300, 301 insensitivity syndrome. 276.50........ Volume

Y

10 296, 297, 298 depletion,

15 387,\1\ 3891 unspecified.

\2\ 25 490 276.51........ Dehydration..... Y

10 296, 297, 298 15 387,\1\ 389 \1\ \2\ 52 490 276.52........ Hypovolemia..... Y

10 296, 297, 298 15 387,\1\ 389 \1\ \2\ 52 490 278.02........ Overweight...... N

10 296, 297, 298 287.30........ Primary

Y

16 397 thrombocytopeni a, unspecified. 287.31........ Immune

Y

16 397 thrombocytopeni c purpura. 287.32........ Evans' syndrome. Y

16 397 287.33........ Congenital and Y

16 397 hereditary thrombocytopeni c purpura. 287.39........ Other primary Y

16 397 thrombocytopeni a. 291.82........ Alcohol induced N

20 521, 522, 523 sleep disorders. 292.85........ Drug induced N

20 521, 522, 523 sleep disorders. 327.00........ Organic

N

19 432 insomnia, unspecified. 327.01........ Insomnia due to N

19 432 medical condition classified elsewhere. 327.02........ Insomnia due to N

19 432 mental disorder. 327.09........ Other organic N

19 432 insomnia. 327.10........ Organic

N

19 432 hypersomnia, unspecified. 327.11........ Idiopathic

N

19 432 hypersomnia with long sleep time. 327.12........ Idiopathic

N

19 432 hypersomnia without long sleep time.

[[Page 23592]]

327.13........ Recurrent

N

19 432 hypersomnia. 327.14........ Hypersomnia due N

19 432 to medical condition. 327.15........ Hypersomnia due N

19 432 to mental disorder. 327.19........ Other organic N

19 432 hypersomnia. 327.20........ Organic sleep N

PRE 482 apnea,

3 73, 74 unspecified. 327.21........ Primary central N

PRE 482 sleep apnea.

1 34, 35 327.22........ High altitude N

PRE 482 periodic

4 99, 100 breathing. 327.23........ Obstructive N

PRE 482 sleep apnea

3 73, 74 (adult) (pediatric). 327.24........ Idiopathic sleep N

PRE 482 related non-

3 73, 74 obstructive alveolar hypoventilation. 327.26........ Sleep related N

PRE 482 hypoventilation/

3 73, 74 hypoxemia in conditions classifiable elsewhere. 327.27........ Central sleep N

PRE 482 apnea in

1 34, 35 conditions classified elsewhere. 327.29........ Other organic N

PRE 482 sleep apnea.

3 73, 74 362.03........ Nonproliferative N

2 46, 47, 48 diabetic retinopathy NOS. 362.04........ Mild

N

2 46, 47, 48 nonproliferativ e diabetic retinopathy. 362.05........ Moderate

N

2 46, 47, 48 nonproliferativ e diabetic retinopathy. 362.06........ Severe

N

2 46, 47, 48 nonproliferativ e diabetic retinopathy. 362.07........ Diabetic macular N

2 46, 47, 48 edema. 426.82........ Long QT syndrome N

5 138, 139 443.82........ Erythromelalgia. N

5 130, 131 525.40........ Complete

N

PRE 482 edentulism,

3 185, 186, 187 unspecified. 525.41........ Complete

N

PRE 482 edentulism,

3 185, 186, 187 class I. 525.42........ Complete

N

PRE 482 edentulism,

3 185, 186, 187 class II. 525.43........ Complete

N

PRE 482 edentulism,

3 185, 186, 187 class III. 525.44........ Complete

N

PRE 482 edentulism,

3 185, 186, 187 class IV. 525.50........ Partial

N

PRE 482 edentulism,

3 185, 186, 187 unspecified. 525.51........ Partial

N

PRE 482 edentulism,

3 185, 186, 187 class I. 525.52........ Partial

N

PRE 482 edentulism,

3 185, 186, 187 class II. 525.53........ Partial

N

PRE 482 edentulism,

3 185, 186, 187 class III. 525.54........ Partial

N

PRE 482 edentulism,

3 185, 186, 187 class IV. 567.21........ Peritonitis Y

6 188, 189, 190 (acute)

15 387,\1\ 389 \1\ generalized. 567.22........ Peritoneal

Y

6 188, 189, 190 abscess.

15 387,\1\ 389 \1\ 567.23........ Spontaneous Y

6 188, 189, 190 bacterial

15 387,\1\ 389 \1\ peritonitis. 567.29........ Other

Y

6 188, 189, 190 suppurative

15 387,\1\ 389 \1\ peritonitis. 567.38........ Other

Y

6 188, 189, 190 retroperitoneal

15 387,\1\ 389 \1\ abscess. 567.39........ Other

Y

6 188, 189, 190 retroperitoneal

15 387,\1\ 389 \1\ infections. 567.81........ Choleperitonitis Y

6 188, 189, 190 15 387,\1\ 389 \1\ 567.82........ Sclerosing

Y

6 188, 189, 190 mesenteritis.

15 387,\1\ 389 \1\ 567.89........ Other specified Y

6 188, 189, 190 peritonitis.

15 387,\1\ 389 \1\ 585.1......... Chronic kidney Y

PRE 512, 513 disease, Stage

11 315, 316 I. 585.2......... Chronic kidney Y

PRE 512, 513 disease, Stage

11 315, 316 II (mild). 585.3......... Chronic kidney Y

PRE 512, 513 disease, Stage

11 315, 316 III (moderate).

[[Page 23593]]

585.4......... Chronic kidney Y

PRE 512, 513 disease, Stage

11 315, 316 IV (severe). 585.5......... Chronic kidney Y

PRE 512, 513 disease, Stage

11 315, 316 V. 585.6......... End stage renal Y

PRE 512, 513 disease.

11 315, 316 585.9......... Chronic kidney Y

PRE 512, 513 disease,

11 315, 316 unspecified. 599.60........ Urinary

Y

15 331, 332, 333 obstruction, 11

387,\1\ 389 \1\ unspecified. 599.69........ Urinary

Y

11 331, 332, 333 obstruction,

15 387,\1\ 389 \1\ not elsewhere classified. 651.70........ Multiple

N

14 469 gestation following (elective) fetal reduction, unspecified as to episode of care or not applicable. 651.71........ Multiple

N

14 370, 371, 372, 373, gestation

374, 375 following (elective) fetal reduction, delivered, with or without mention of antepartum condition. 651.73........ Multiple

N

14 383, 384 gestation following (elective) fetal reduction, antepartum condition or complication. 760.77........ Anticonvulsants. N

15 390 760.78........ Antimetabolic N

15 390 agents. 763.84........ Meconium passage N

15 390 during delivery. 770.10........ Fetal and

N

15 387,\3\ 389 \3\ newborn aspiration, unspecified. 770.11........ Meconium

N

15 387,\3\ 389 \3\ aspiration without respiratory symptoms. 770.12........ Meconium

Y

15 387,\3\ 389 \3\ aspiration with respiratory symptoms. 770.17........ Other fetal and N

15 387,\3\ 389 \3\ newborn aspiration without respiratory symptoms. 770.18........ Other fetal and Y

15 387,\3\ 389 \3\ newborn aspiration with respiratory symptoms. 779.84........ Meconium

N

15 390 staining. 780.95........ Other excessive N

23 463, 464 crying. 799.01........ Asphyxia........ Y

4 101, 102 799.02........ Hypoxemia....... Y

4 101, 102 996.40........ Unspecified Y

8 249 mechanical complication of internal orthopedic device, implant, and graft. 996.41........ Mechanical

Y

8 249 loosening of prosthetic joint. 996.42........ Dislocation of Y

8 249 prosthetic joint. 996.43........ Prosthetic joint Y

8 249 implant failure. 996.44........ Peri-prosthetic Y

8 249 fracture around prosthetic joint. 996.45........ Peri-prosthetic Y

8 249 osteolysis. 996.46........ Articular

Y

8 249 bearing surface wear of prosthetic joint. 996.47........ Other mechanical Y

8 249 complication of prosthetic joint implant. 996.49........ Other mechanical Y

8 249 complication of other internal orthopedic device, implant, and graft. V12.42........ Person history, N

23 467 Infections of the central nervous system. V12.60........ Person history, N

23 467 Unspecified disease of respiratory system. V12.61........ Person history, N

23 467 Pneumonia (recurrent). V12.69........ Person history, N

23 467 Other diseases of respiratory system. V13.02........ Person history, N

23 467 Urinary (tract) infection. V13.03........ Person history, N

23 467 Nephrotic syndrome. V15.88........ History of fall. N

23 467 V17.81........ Family history, N

23 467 Osteoporosis. V17.89........ Family history, N

23 467 Other musculoskeletal diseases. V18.9......... Family history, N

23 467 Genetic disease carrier. V26.31........ Testing for N

23 467 genetic disease carrier status. V26.32........ Other genetic N

23 467 testing. V26.33........ Genetic

N

23 467 counseling. V46.13........ Encounter for Y

23 467 weaning from respirator [ventilator]. V46.14........ Mechanical

Y

23 467 complication of respirator [ventilator]. V49.84........ Bed confinement N

23 467 status. V59.70........ Egg (oocyte) N

23 467 (ovum) donor, unspecified. V59.71........ Egg (oocyte) N

23 467 (ovum) donor, under age 35,anonymous recipient. V59.72........ Egg (oocyte) N

23 467 (ovum) donor, under age 35, designated recipient. V59.73........ Egg (oocyte) N

23 467 (ovum) donor, age 35 and over,anonymous recipient. V59.74........ Egg (oocyte) N

23 467 (ovum) donor, age 35 and over, designated recipient. V62.84........ Suicidal

N

19 425 ideation. V64.00........ Vaccination not N

23 467 carried out, unspecified reason. V64.01........ Vaccination not N

23 467 carried out because of acute illness. V64.02........ Vaccination not N

23 467 carried out because of chronic illness or condition. V64.03........ Vaccination not N

23 467 carried out because of immune compromised state. V64.04........ Vaccination not N

23 467 carried out because of allergy to vaccine or component. V64.05........ Vaccination not N

23 467 carried out because of caregiver refusal. V64.06........ Vaccination not N

23 467 carried out because of patient refusal. V64.07........ Vaccination not N

23 467 carried out for religious reasons. V64.08........ Vaccination not N

23 467 carried out because patient had disease being vaccinated against. V64.09........ Vaccination not N

23 467 carried out for other reason. V69.5......... Behavioral

N

23 467 insomnia of childhood.

[[Page 23594]]

V72.86........ Encounter for N

23 467 blood typing. V85.0......... Body Mass Index N

23 467 less than 19, adult. V85.1......... Body Mass Index N

23 467 between 19-24, adult. V85.21........ Body Mass Index N

23 467 25.0-25.9, adult. V85.22........ Body Mass Index N

23 467 26.0-26.9, adult. V85.23........ Body Mass Index N

23 467 27.0-27.9, adult. V85.24........ Body Mass Index N

23 467 28.0-28.9, adult. V85.25........ Body Mass Index N

23 467 29.0-29.9, adult. V85.30........ Body Mass Index N

23 467 30.0-30.9, adult. V85.31........ Body Mass Index N

23 467 31.0-31.9, adult. V85.32........ Body Mass Index N

23 467 32.0-32.9, adult. V85.33........ Body Mass Index N

23 467 33.0-33.9, adult. V85.34........ Body Mass Index N

23 467 34.0-34.9, adult. V85.35........ Body Mass Index N

23 467 35.0-35.9, adult. V85.36........ Body Mass Index N

23 467 36.0-36.9, adult. V85.37........ Body Mass Index N

23 467 37.0-37.9, adult. V85.38........ Body Mass Index N

23 467 38.0-38.9, adult. V85.39........ Body Mass Index N

23 467 39.0-39.9, adult. V85.4......... Body Mass Index N

10 296, 297, 298 40 and over, adult.

\1\ Secondary diagnosis of major problem in DRGs 387 and 389. \2\ Principal diagnosis of significant HIV-related condition. \3\ Principal or secondary diagnosis of major problem.

Table 6B.--New Procedure Codes

Procedure code

Description OR MDC

DRG

00.40......... Procedure on N single vessel. 00.41......... Procedure on two N vessels. 00.42......... Procedure on N three vessels. 00.43......... Procedure on N four or more vessels. 00.45......... Insertion of one N vascular stent. 00.46......... Insertion of two N vascular stents. 00.47......... Insertion of N three vascular stents. 00.48......... Insertion of N four or more vascular stents. 00.70......... Revision of hip Y

8 471, 545 replacement,

10 292, 293 both acetabular

21 442, 443 and femoral

24 485 components. 00.71......... Revision of hip Y

8 471, 545 replacement,

10 292, 293 acetabular

21 2 442, 443 component.

4 485 00.72......... Revision of hip Y

8 471, 545 replacement,

10 292, 293 femoral

21 442, 443 component.

24 485 00.73......... Revision of hip Y

8 471, 545 replacement,

10 292, 293 acetabular

21 442, 443 liner and/or

24 485 femoral head only. 00.80......... Revision of knee Y

8 471, 545 replacement,

21 442, 443 total (all

24 486 components). 00.81......... Revision of knee Y

8 471, 545 replacement,

21 442, 443 tibial

24 486 component. 00.82......... Revision of knee Y

8 471, 545 replacement,

21 442, 443 femoral

24 486 component. 00.83......... Revision of knee Y

8 471, 545 replacement,

21 442, 443 patellar

24 486 component. 00.84......... Revision of Y

8 471, 545 total knee

21 442, 443 replacement,

24 486 tibial insert (liner). 37.41......... Implantation of Y

5 110, 111 prosthetic cardiac support device around the heart.

[[Page 23595]]

37.49......... Other repair of Y

5 110, 111 heart and

21 442, 443 pericardium.

24 486 84.56......... Insertion of N (cement) spacer. 84.57......... Removal of

N (cement) spacer. 86.97......... Insertion or Y

1 7, 8 replacement of single array rechargeable neurostimulator pulse generator. 86.98......... Insertion or Y

1 7, 8 replacement of dual array rechargeable neurostimulator pulse generator.

Table 6C.--Invalid Diagnosis Codes

Diagnosis code

Description CC MDC

DRG

276.5......... Volume depletion Y

10 296, 297, 298 15 387,\1\ 3891 \2\ 25 490 287.3......... Primary

Y

16 397 thrombocytopeni a. 567.2......... Other

Y

6 188, 189, 190 suppurative

15 387,\1\ 389 \1\ peritonitis. 67.8.......... Other specified Y

6 188, 189, 190 peritonitis.

15 387,\1\ 389 \1\ 585........... Chronic renal Y

PRE 512, 513 failure.

11 315,316 599.6......... Urinary

Y

11 331, 332, 333 obstruction,

15 387,\1\ 389 \1\ unspecified. 770.1......... Meconium

Y

15 387,\3\ 389 \3\ aspiration syndrome. 799.0......... Asphyxia........ N

4 101, 102 996.4......... Mechanical

Y

8 249 complication of internal orthopedic device, implant, and graft. V12.6......... Diseases of the N

23 467 respiratory system. V17.8......... Other

N

23 467 musculoskeletal diseases. V26.3......... Genetic

N

23 467 counseling and testing. V64.0......... Vaccination not N

23 467 carried out because of contradiction.

\1\ Secondary Diagnosis of Major Problem \2\ Principal diagnosis of Significant HIV Related Condition \3\ Principal or Secondary Diagnosis of Major Problem

Table 6D.--Invalid Procedure Codes

Procedure Code Description OR MDC

DRG

36.02......... Single vessel Y

5 106, 516, 517, 518, percutaneous

526, 527 transluminal coronary angioplasty [PTCA] or coronary atherectomy with mention of thrombolytic agent. 36.05......... Multiple vessel Y

5 106, 516, 517, 518, percutaneous

526, 527 transluminal coronary angioplasty [PTCA] or coronary atherectomy performed during the same operation, with or without mention of thrombolytic agent. 37.4.......... Repair of heart Y

5 110, 111 and pericardium.

21 442, 443 24 486

Table 6E.--Revised Diagnosis Code Titles

Diagnosis Code Description CC MDC

DRG

403.00........ Hypertensive Y

11 331, 332, 333 kidney disease, malignant, without chronic kidney disease. 403.01........ Hypertensive Y

11 315, 316 kidney disease, malignant, with chronic kidney disease. 403.10........ Hypertensive N

11 331, 332, 333 kidney disease, benign, without chronic kidney disease. 403.11........ Hypertensive Y

11 315, 316 kidney disease, benign, with chronic kidney disease. 403.90........ Hypertensive N

11 331, 332, 333 kidney disease, unspecified, without chronic kidney disease. 403.91........ Hypertensive Y

11 315, 316 kidney disease, unspecified, with chronic kidney disease. 404.00........ Hypertensive Y

5 134 heart and kidney disease, malignant, without heart failure or chronic kidney disease. 404.01........ Hypertensive Y

5 115, 121, 124, 127, heart and

...... 535 kidney disease,

15 1387, 389 \1\ malignant, with heart failure. 404.02........ Hypertensive Y

11 315, 316 heart and kidney disease, malignant, with chronic kidney disease.

[[Page 23596]]

404.03........ Hypertensive Y

5 115, 121, 124, 127, heart and

...... 535 kidney disease,

15 387, 389 \1\ malignant, with heart failure and chronic kidney disease. 404.10........ Hypertensive N

5 134 heart and kidney disease, benign, without heart failure or chronic kidney disease. 404.11........ Hypertensive Y

5 115, 121, 124, 127, heart and

...... 535 kidney disease,

15 387, 389 \1\ benign, with heart failure. 404.12........ Hypertensive Y

11 315, 316 heart and kidney disease, benign, with chronic kidney disease. 404.13........ Hypertensive Y

5 115, 121, 124, 127, heart and

...... 535 kidney disease,

15 387, 3891 benign, with heart failure and chronic kidney disease. 404.90........ Hypertensive N

5 34 heart and kidney disease, unspecified, without heart failure or chronic kidney disease. 404.91........ Hypertensive Y

5 115, 121, 124, 127, heart and

...... 535 kidney disease,

15 387, 389 \1\ unspecified, with heart failure. 404.92........ Hypertensive Y

11 315, 316 heart and kidney disease, unspecified, with chronic kidney disease. 404.93........ Hypertensive Y

5 115, 121, 124, 127, heart and

...... 535 kidney disease,

15 387, 389 \1\ unspecified, with heart failure and chronic kidney disease. 728.87........ Muscle weakness N

8 247 (generalized). 780.51........ Insomnia with N

PRE 482 sleep apnea,

3 73, 74 unspecified. 780.52........ Insomnia,

N

19 432 unspecified. 780.53........ Hypersomnia with N

PRE 482 sleep apnea,

3 73, 74 unspecified. 780.54........ Hypersomnia, N

19 432 unspecified. 780.57........ Unspecified N

PRE 482 sleep apnea.

3 73, 74

\1\ Major problem in DRGs 387 and 389.

Table 6F.--Revised Procedure Code Titles

Procedure Code Description OR MDC

DRG

36.01......... Percutaneous Y

5 106, 516, 517, 518, transluminal

526, 527 coronary angioplasty [PTCA] or coronary atherectomy. 37.79......... Revision or Y

1 7, 8 relocation of

5 117 cardiac device

9 269, 270 pocket.

21 442, 443 24 486 81.53......... Revision of hip Y

8 471, 545 replacement,

10 292, 293 not otherwise

21 442, 443 specified.

24 485 81.55......... Revision of knee Y

8 471, 545 replacement,

21 442, 443 not otherwise

24 486 specified.

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

Exclusions List. Each of the principal diagnoses is shown with an asterisk, and the revisions to the CC Exclusions List are provided in an indented column immediately following the affected principal diagnosis.]

*185 59960 59969 *1880 59960 59969 *1881 59960 59969 *1882 59960 59969 *1883 59960 59969 *1884 59960 59969 *1885 59960 59969 *1886 59960 59969

[[Page 23597]]

*1887 59960 59969 *1888 59960 59969 *1889 59960 59969 *1892 59960 59969 *1893 59960 59969 *1894 59960 59969 *1898 59960 59969 *1899 59960 59969 *25040 5851 5852 5853 5854 5855 5856 5859 *25041 5851 5852 5853 5854 5855 5856 5859 *25042 5851 5852 5853 5854 5855 5856 5859 *25043 5851 5852 5853 5854 5855 5856 5859 *25080 5851 5852 5853 5854 5855 5856 5859 *25081 5851 5852 5853 5854 5855 5856 5859 *25082 5851 5852 5853 5854 5855 5856 5859 *25083 5851 5852 5853 5854 5855 5856 5859 *25090 5851 5852 5853 5854 5855 5856 5859 *25091 5851 5852 5853 5854 5855 5856 5859 *25092 5851 5852 5853 5854 5855 5856 5859 *25093 5851 5852 5853 5854 5855 5856 5859 *2595 24200 24201 24210 24211 24220 24221 24230 24231 24240 24241 24280 24281 24290 24291 25001 25002 25003 25011 25012 25013 25021 25022 25023 25031 25032 25033 25041 25042 25043 25051 25052 25053 25061 25062 25063 25071 25072 25073 25081 25082 25083 25091 25092 25093 2510 2513 2521 2532 2535 2541 2550 2553 2554 2555 2556 2580 2581 2588 2589 2592 *27410 5851 5852 5853 5854 5855 5856 5859 *27411 59960 59969 *27419 5851 5852 5853 5854 5855

[[Page 23598]]

5856 5859 *2760 27650 27651 27652 *2761 27650 27651 27652 *2762 27650 27651 27652 *2763 27650 27651 27652 *2764 27650 27651 27652 *27650 2760 2761 2762 2763 2764 27650 27651 27652 2766 2767 2769 *27651 2760 2761 2762 2763 2764 27650 27651 27652 2766 2767 2769 *27652 2760 2761 2762 2763 2764 27650 27651 27652 2766 2767 2769 *2766 27650 27651 27652 *2767 27650 27651 27652 *2768 27650 27651 27652 *2769 27650 27651 27652 *2860 28730 28731 28732 28733 28739 *2861 28730 28731 28732 28733 28739 *2862 28730 28731 28732 28733 28739 *2863 28730 28731 28732 28733 28739 *2864 28730 28731 28732 28733 28739 *2865 28730 28731 28732 28733 28739 *2866 28730 28731 28732 28733 28739 *2867 28730 28731 28732 28733 28739 *2869 28730 28731 28732 28733 28739 *2870 28730 28731 28732 28733 28739 *2871 28730 28731 28732 28733 28739 *2872 28730 28731 28732 28733 28739 *28730 2860 2861 2862 2863 2864 2865 2866 2867 2869 2870 2871 2872 28730 28731 28732 28733 28739 2874 2875 2878 2879 *28731 2860 2861 2862 2863 2864 2865 2866 2867 2869 2870 2871 2872 28730 28731 28732 28733 28739 2874 2875 2878 2879 *28732 2860 2861 2862 2863 2864 2865 2866

[[Page 23599]]

2867 2869 2870 2871 2872 28730 28731 28732 28733 28739 2874 2875 2878 2879 *28733 2860 2861 2862 2863 2864 2865 2866 2867 2869 2870 2871 2872 28730 28731 28732 28733 28739 2874 2875 2878 2879 *28739 2860 2861 2862 2863 2864 2865 2866 2867 2869 2870 2871 2872 28730 28731 28732 28733 28739 2874 2875 2878 2879 *2874 28730 28731 28732 28733 28739 *2875 28730 28731 28732 28733 28739 *2878 28730 28731 28732 28733 28739 *2879 28730 28731 28732 28733 28739 *28981 28730 28731 28732 28733 28739 *28982 28730 28731 28732 28733 28739 *28989 28730 28731 28732 28733 28739 *2899 28730 28731 28732 28733 28739 *29182 2910 2911 2912 2913 2914 29181 29189 2919 2920 29211 29212 2922 29281 29282 29283 29284 29289 2929 29381 29382 29383 29384 30300 30301 30302 30390 30391 30392 30400 30401 30402 30410 30411 30412 30420 30421 30422 30440 30441 30442 30450 30451 30452 30460 30461 30462 30470 30471 30472 30480 30481 30482 30490 30491 30492 30500 30501 30502 30530 30531 30532 30540 30541 30542 30550 30551 30552 30560 30561 30562 30570 30571 30572 30590 30591 30592 *29285 2910 2911 2912 2913 2914 29181 29189 2919 2920 29211 29212 2922 29281 29282

[[Page 23600]]

29283 29284 29289 2929 29381 29382 29383 29384 30300 30301 30302 30390 30391 30392 30400 30401 30402 30410 30411 30412 30420 30421 30422 30440 30441 30442 30450 30451 30452 30460 30461 30462 30470 30471 30472 30480 30481 30482 30490 30491 30492 30500 30501 30502 30530 30531 30532 30540 30541 30542 30550 30551 30552 30560 30561 30562 30570 30571 30572 30590 30591 30592 7105 *34461 59960 59969 *42682 4260 42612 42613 42653 42654 4266 4267 42681 42689 4269 4270 4271 4272 42731 42732 42741 42742 *51881 79901 79902 *51882 79901 79902 *51883 79901 79902 *51884 79901 79902 *5670 56721 56722 56723 56729 56733 56739 56781 56782 56789 *5671 56721 56722 56723 56729 56733 56739 56781 56782 56789 *56721 5670 5671 56721 56722 56723 56729 56733 56739 56781 56782 56789 5679 *56722 5670 5671 56721 56722 56723 56729 56733 56739 56781 56782 56789 5679 *56723 5670 5671 56721 56722 56723 56729 56733 56739 56781 56782 56789 5679 *56729 5670 5671 56721 56722 56723 56729 56733 56739 56781 56782 56789 5679 *56733 5670 5671 56721 56722 56723 56729 56733 56739 56781 56782 56789 5679 *56739 5670 5671 56721 56722 56723 56729 56733 56739 56781 56782 56789 5679 *56781 5670 5671 56721

[[Page 23601]]

56722 56723 56729 56733 56739 56781 56782 56789 5679 *56782 5670 5671 56721 56722 56723 56729 56733 56739 56781 56782 56789 5679 *56789 5670 5671 56721 56722 56723 56729 56733 56739 56781 56782 56789 5679 *5679 56721 56722 56723 56729 56733 56739 56781 56782 56789 *56989 56721 56722 56723 56729 56733 56739 56781 56782 56789 *5699 56721 56722 56723 56729 56733 56739 56781 56782 56789 *5800 5851 5852 5853 5854 5855 5856 5859 *5804 5851 5852 5853 5854 5855 5856 5859 *58081 5851 5852 5853 5854 5855 5856 5859 *58089 5851 5852 5853 5854 5855 5856 5859 *5809 5851 5852 5853 5854 5855 5856 5859 *5810 5851 5852 5853 5854 5855 5856 5859 *5811 5851 5852 5853 5854 5855 5856 5859 *5812 5851 5852 5853 5854 5855 5856 5859 *5813 5851 5852 5853 5854 5855 5856 5859 *58181 5851 5852 5853 5854 5855 5856 5859 *58189 5851 5852 5853 5854 5855 5856 5859 *5819 5851 5852 5853 5854 5855 5856 5859 *5820 5851 5852 5853 5854 5855 5856 5859 *5821 5851 5852 5853 5854 5855 5856 5859 *5822 5851 5852 5853 5854 5855 5856 5859 *5824 5851 5852 5853 5854 5855 5856 5859 *58281 5851 5852 5853 5854

[[Page 23602]]

5855 5856 5859 *58289 5851 5852 5853 5854 5855 5856 5859 *5829 5851 5852 5853 5854 5855 5856 5859 *5830 5851 5852 5853 5854 5855 5856 5859 *5831 5851 5852 5853 5854 5855 5856 5859 *5832 5851 5852 5853 5854 5855 5856 5859 *5834 5851 5852 5853 5854 5855 5856 5859 *5836 5851 5852 5853 5854 5855 5856 5859 *5837 5851 5852 5853 5854 5855 5856 5859 *58381 5851 5852 5853 5854 5855 5856 5859 *58389 5851 5852 5853 5854 5855 5856 5859 *5839 5851 5852 5853 5854 5855 5856 5859 *5845 5851 5852 5853 5854 5855 5856 5859 *5846 5851 5852 5853 5854 5855 5856 5859 *5847 5851 5852 5853 5854 5855 5856 5859 *5848 5851 5852 5853 5854 5855 5856 5859 *5849 5851 5852 5853 5854 5855 5856 5859 *5851 5800 5804 58081 58089 5809 5810 5811 5812 5813 58181 58189 5819 5834 5845 5846 5847 5848 5849 5851 5852 5853 5854 5855 5856 5859 59010 59011 5902 5903 59080 59081 5909 591 *5852 5800 5804 58081 58089 5809 5810 5811 5812 5813 58181 58189 5819 5834 5845 5846 5847 5848 5849 5851 5852 5853 5854 5855 5856 5859 59010 59011 5902 5903 59080 59081 5909

[[Page 23603]]

591 *5853 5800 5804 58081 58089 5809 5810 5811 5812 5813 58181 58189 5819 5834 5845 5846 5847 5848 5849 5851 5852 5853 5854 5855 5856 5859 59010 59011 5902 5903 59080 59081 5909 591 *5854 5800 5804 58081 58089 5809 5810 5811 5812 5813 58181 58189 5819 5834 5845 5846 5847 5848 5849 5851 5852 5853 5854 5855 5856 5859 59010 59011 5902 5903 59080 59081 5909 591 *5855 5800 5804 58081 58089 5809 5810 5811 5812 5813 58181 58189 5819 5834 5845 5846 5847 5848 5849 5851 5852 5853 5854 5855 5856 5859 59010 59011 5902 5903 59080 59081 5909 591 *5856 5800 5804 58081 58089 5809 5810 5811 5812 5813 58181 58189 5819 5834 5845 5846 5847 5848 5849 5851 5852 5853 5854 5855 5856 5859 59010 59011 5902 5903 59080 59081 5909 591 *5859 5800 5804 58081 58089 5809 5810 5811 5812 5813 58181 58189 5819 5834 5845 5846 5847 5848 5849 5851 5852 5853 5854 5855 5856 5859 59010 59011 5902 5903 59080 59081 5909 591 *586 5851 5852 5853 5854 5855 5856 5859 *587 5851 5852 5853 5854 5855 5856 5859 *5880 5851 5852 5853 5854 5855 5856 5859 *5881 5851 5852

[[Page 23604]]

5853 5854 5855 5856 5859 *58881 5851 5852 5853 5854 5855 5856 5859 *58889 5851 5852 5853 5854 5855 5856 5859 *5889 5851 5852 5853 5854 5855 5856 5859 *5890 5851 5852 5853 5854 5855 5856 5859 *5891 5851 5852 5853 5854 5855 5856 5859 *5899 5851 5852 5853 5854 5855 5856 5859 *59000 5851 5852 5853 5854 5855 5856 5859 *59001 5851 5852 5853 5854 5855 5856 5859 *59010 5851 5852 5853 5854 5855 5856 5859 *59011 5851 5852 5853 5854 5855 5856 5859 *5902 5851 5852 5853 5854 5855 5856 5859 *5903 5851 5852 5853 5854 5855 5856 5859 *59080 5851 5852 5853 5854 5855 5856 5859 *59081 5851 5852 5853 5854 5855 5856 5859 *5909 5851 5852 5853 5854 5855 5856 5859 *591 5851 5852 5853 5854 5855 5856 5859 *5921 59960 59969 *5929 59960 59969 *5930 5851 5852 5853 5854 5855 5856 5859 *5931 5851 5852 5853 5854 5855 5856 5859 *5932 5851 5852 5853 5854 5855 5856 5859 *5933 59960 59969 *5934 59960 59969 *5935 59960 59969 *59389 5851 5852 5853 5854 5855 5856 5859 59960 59969 *5939 5851 5852 5853 5854 5855 5856 5859 59960 59969 *5940 59960 59969 *5941 59960 59969

[[Continued on page 23605]]

From the Federal Register Online via GPO Access [wais.access.gpo.gov] ]

[[pp. 23605-23654]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2006 Rates

[[Continued from page 23604]]

[[Page 23605]]

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

[[Page 23606]]

5859 59960 59969 *59989 5851 5852 5853 5854 5855 5856 5859 59960 59969 *5999 5851 5852 5853 5854 5855 5856 5859 59960 59969 *60000 59960 59969 *60001 59960 59969 *60010 59960 59969 *60011 59960 59969 *60020 59960 59969 *60021 59960 59969 *6003 59960 59969 *60090 59960 59969 *60091 59960 59969 *6010 59960 59969 *6011 59960 59969 *6012 59960 59969 *6013 59960 59969 *6014 59960 59969 *6018 59960 59969 *6019 59960 59969 *6020 59960 59969 *6021 59960 59969 *6022 59960 59969 *6023 59960 59969 *6028 59960 59969 *6029 59960 59969 *7530 5851 5852 5853 5854 5855 5856 5859 59960 59969 *75310 5851 5852 5853 5854 5855 5856 5859 59960 59969 *75311 5851 5852 5853 5854 5855 5856 5859 59960 59969 *75312 5851 5852 5853 5854 5855 5856 5859 59960 59969 *75313 5851 5852 5853 5854 5855 5856 5859 59960 59969 *75314 5851 5852 5853 5854 5855 5856 5859 59960 59969 *75315 5851 5852 5853 5854 5855 5856 5859 59960 59969 *75316 5851 5852 5853 5854 5855 5856 5859 59960 59969 *75317 5851 5852 5853 5854 5855 5856 5859 59960 59969 *75319 5851 5852 5853 5854 5855 5856 5859 59960 59969 *75320 5851 5852 5853 5854 5855 5856 5859 59960

[[Page 23607]]

59969 *75321 5851 5852 5853 5854 5855 5856 5859 59960 59969 *75322 5851 5852 5853 5854 5855 5856 5859 59960 59969 *75323 5851 5852 5853 5854 5855 5856 5859 59960 59969 *75329 5851 5852 5853 5854 5855 5856 5859 59960 59969 *7533 5851 5852 5853 5854 5855 5856 5859 59960 59969 *7534 59960 59969 *7535 59960 59969 *7536 59960 59969 *7537 59960 59969 *7538 59960 59969 *7539 5851 5852 5853 5854 5855 5856 5859 59960 59969 *7685 77012 77018 *7686 77012 77018 *7689 77012 77018 *769 77012 77018 *7700 77012 77018 *77010 7685 769 7700 77012 77018 7702 7703 7704 7705 7707 77084 *77011 7685 769 7700 77012 77018 7702 7703 7704 7705 7707 77084 *77012 7685 769 7700 77012 77018 7702 7703 7704 7705 7707 77084 *77017 7685 769 7700 77012 77018 7702 7703 7704 7705 7707 77084 *77018 7685 769 7700 77012 77018 7702 7703 7704 7705 7707 77084 *7702 77012 77018 *7703 77012 77018 *7704 77012 77018 *7705 77012 77018 *7706 77012 77018 *7707 77012 77018 *77081 77012 77018 *77082 77012 77018 *77083 77012 77018 *77084 77012 77018 *77089 77012 77018 *7709 77012 77018 *77981 77012 77018 *77982 77012 77018 *77983 77012 77018 *77984 76501

[[Page 23608]]

76502 76503 76504 76505 76506 76507 76508 7670 76711 7685 769 7700 77012 77018 7702 7703 7704 7705 7707 77084 7710 7711 7713 77181 77183 77210 77211 77212 77213 77214 7722 7724 7725 7730 7731 7732 7733 7734 7740 7741 7742 77430 77431 77439 7744 7745 7747 7751 7752 7753 7754 7755 7756 7757 7760 7761 7762 7763 7771 7772 7775 7776 7780 7790 7791 7797 *77989 77012 77018 *78091 79901 79902 *78092 79901 79902 *78093 79901 79902 *78094 79901 79902 *78095 04082 44024 78001 78003 7801 78031 78039 7817 7854 78550 78551 78552 78559 7863 78820 78829 7895 7907 7911 7913 79901 79902 7991 7994 *78099 79901 79902 *7881 59960 59969 *7980 79901 79902 *79901 79901 79902 7991 *79902 79901 79902 7991 *7991 79901 79902 *79981 79901 79902 *79989 79901 79902 *99640 99640 99641 99642 99643 99644 99645 99646 99647 99649 99657 99660 99666 99667 99669 99670 99677 99678 99679 *99641 99640 99641 99642 99643 99644 99645 99646 99647 99649 99657 99660 99666 99667 99669 99670 99677 99678 99679 *99642 99640 99641 99642 99643 99644 99645 99646 99647 99649 99657 99660 99666 99667 99669 99670 99677 99678 99679 *99643 99640 99641 99642 99643 99644 99645 99646 99647

[[Page 23609]]

99649 99657 99660 99666 99667 99669 99670 99677 99678 99679 *99644 99640 99641 99642 99643 99644 99645 99646 99647 99649 99657 99660 99666 99667 99669 99670 99677 99678 99679 *99645 99640 99641 99642 99643 99644 99645 99646 99647 99649 99657 99660 99666 99667 99669 99670 99677 99678 99679 *99646 99640 99641 99642 99643 99644 99645 99646 99647 99649 99657 99660 99666 99667 99669 99670 99677 99678 99679 *99647 99640 99641 99642 99643 99644 99645 99646 99647 99649 99657 99660 99666 99667 99669 99670 99677 99678 99679 *99649 99640 99641 99642 99643 99644 99645 99646 99647 99649 99657 99660 99666 99667 99669 99670 99677 99678 99679 *99666 99640 99641 99642 99643 99644 99645 99646 99647 99649 *99667 99640 99641 99642 99643 99644 99645 99646 99647 99649 *99677 99640 99641 99642 99643 99644 99645 99646 99647 99649 *99678 99640 99641 99642 99643 99644 99645 99646 99647 99649 *99791 99640 99641 99642 99643 99644 99645 99646 99647 99649 *99799 99640 99641 99642 99643 99644 99645 99646 99647 99649 *99881 99640 99641 99642 99643 99644 99645 99646 99647 99649 *99883 99640 99641 99642 99643 99644 99645 99646 99647 99649 *99889 99640 99641 99642 99643 99644 99645 99646 99647 99649 *9989 99640 99641

[[Page 23610]]

99642 99643 99644 99645 99646 99647 99649 *V460 V4613 V4614 *V4611 V4613 V4614 *V4612 V4613 V4614 *V4613 V4611 V4612 V4613 V4614 *V4614 V4611 V4612 V4613 V4614 *V462 V4613 V4614 *V468 V4613 V4614 *V469 V4613 V4614

Table 6H.--Deletions to the CC Exclusions List [CCs that are deleted from the list are in Table 6H-Deletions to the CC

Exclusions List. Each of the principal diagnoses is shown with an asterisk, and the revisions to the CC Exclusions List are provided in an indented column immediately following the affected] principal diagnosis.

*185 5996 *1880 5996 *1881 5996 *1882 5996 *1883 5996 *1884 5996 *1885 5996 *1886 5996 *1887 5996 *1888 5996 *1889 5996 *1892 5996 *1893 5996 *1894 5996 *1898 5996 *1899 5996 *25040 585 *25041 585 *25042 585 *25043 585 *25080 585 *25081 585 *25082 585 *25083 585 *25090 585 *25091 585 *25092 585 *25093 585 *27410 585 *27411 5996 *27419 585 *2760 2765 *2761 2765 *2762 2765 *2763 2765 *2764 2765 *2765 2760 2761 2762 2763 2764 2765 2766 2767 2769 *2766 2765 *2767 2765 *2768 2765 *2769 2765 *2860 2873 *2861 2873 *2862 2873 *2863 2873 *2864 2873 *2865 2873 *2866 2873 *2867 2873 *2869 2873 *2870 2873 *2871 2873 *2872 2873 *2873 2860 2861 2862 2863 2864 2865 2866 2867 2869 2870 2871 2872 2873 2874 2875 2878 2879 *2874 2873 *2875 2873 *2878 2873 *2879 2873 *28981 2873 *28982 2873 *28989 2873 *2899 2873 *34461 5996 *5670 5672

[[Page 23611]]

5678 *5671 5672 5678 *5672 5670 5671 5672 5678 5679 *5678 5670 5671 5672 5678 5679 *5679 5672 5678 *56989 5672 5678 *5699 5672 5678 *5800 585 *5804 585 *58081 585 *58089 585 *5809 585 *5810 585 *5811 585 *5812 585 *5813 585 *58181 585 *58189 585 *5819 585 *5820 585 *5821 585 *5822 585 *5824 585 *58281 585 *58289 585 *5829 585 *5830 585 *5831 585 *5832 585 *5834 585 *5836 585 *5837 585 *58381 585 *58389 585 *5839 585 *5845 585 *5846 585 *5847 585 *5848 585 *5849 585 *585 5800 5804 58081 58089 5809 5810 5811 5812 5813 58181 58189 5819 5834 5845 5846 5847 5848 5849 585 59010 59011 5902 5903 59080 59081 5909 591 *586 585 *587 585 *5880 585 *5881 585 *58881 585 *58889 585 *5889 585 *5890 585 *5891 585 *5899 585 *59000 585 *59001 585 *59010 585 *59011 585 *5902 585 *5903 585 *59080 585 *59081 585 *5909 585 *591 585 *5921 5996 *5929 5996 *5930 585 *5931 585 *5932 585 *5933 5996 *5934 5996 *5935 5996 *59389 585 5996 *5939 585 5996 *5940 5996 *5941 5996 *5942 5996 *5948 5996 *5949 5996 *5950 5996 *5951 5996 *5952 5996 *5953

[[Page 23612]]

5996 *5954 5996 *59581 5996 *59582 5996 *59589 5996 *5959 5996 *5960 5996 *59651 5996 *59652 5996 *59653 5996 *59654 5996 *59655 5996 *59659 5996 *5968 5996 *5969 5996 *5970 5996 *59780 5996 *59781 5996 *59789 5996 *59800 5996 *59801 5996 *5981 5996 *5982 5996 *5988 5996 *5989 5996 *5990 5996 *5991 5996 *5992 5996 *5993 5996 *5994 5996 *5995 5996 *5996 5921 5935 5950 5951 5952 5954 59581 59582 59589 5959 5970 5981 5982 5990 5994 5996 78820 78829 *5997 585 5996 *59981 585 5996 *59982 585 5996 *59983 585 5996 *59984 585 5996 *59989 585 5996 *5999 585 5996 *60000 5996 *60001 5996 *60010 5996 *60011 5996 *60020 5996 *60021 5996 *6003 5996 *60090 5996 *60091 5996 *6010 5996 *6011 5996 *6012 5996 *6013 5996 *6014 5996 *6018 5996 *6019 5996 *6020 5996 *6021 5996 *6022 5996 *6023 5996 *6028 5996 *6029 5996 *7530 585 5996 *75310 585 5996 *75311 585 5996 *75312 585 5996 *75313 585 5996 *75314 585 5996 *75315 585 5996 *75316 585 5996 *75317 585 5996 *75319 585 5996 *75320 585 5996 *75321 585 5996 *75322 585 5996 *75323 585 5996 *75329 585 5996 *7533 585 5996 *7534 5996 *7535 5996 *7536

[[Page 23613]]

5996 *7537 5996 *7538 5996 *7539 585 5996 *7685 7701 *7686 7701 *7689 7701 *769 7701 *7700 7701 *7701 7685 769 7700 7701 7702 7703 7704 7705 7707 77084 *7702 7701 *7703 7701 *7704 7701 *7705 7701 *7706 7701 *7707 7701 *77081 7701 *77082 7701 *77083 7701 *77084 7701 *77089 7701 *7709 7701 *77981 7701 *77982 7701 *77983 7701 *77989 7701 *7881 5996 *7990 7991 *9964 9964 99657 99660 99666 99667 99669 99670 99677 99678 99679 *99666 9964 *99667 9964 *99677 9964 *99678 9964 *99791 9964 *99799 9964 *99881 9964 *99883 9964 *99889 9964 *9989 9964

Table 7A.--Medicare Prospective Payment System Selected Percentile Lengths of Stay [FY 2004 MedPAR Update December 2004 GROUPER V22.0]

Number of Arithmetic 10th

25th

50th

75

90th DRG

discharges means LOS percentile percentile percentile percentile percentile

1............................................................ 23,272 9.8371

3

5

8

13

19 2............................................................ 10,351 4.5604

1

2

4

6

9 3............................................................

4 9.5000

1

1

8

14

15 6............................................................

410 3.0512

1

1

2

4

7 7............................................................ 15,592 9.2952

2

4

7

12

19 8............................................................

3,701 2.8652

1

1

2

4

7 9............................................................

1,945 6.1594

1

3

5

7

12 10........................................................... 19,511 6.0234

2

3

5

8

12 11...........................................................

3,279 3.7600

1

2

3

5

7 12........................................................... 54,431 5.3747

2

3

4

6

10 13...........................................................

7,337 4.9162

2

3

4

6

8 14........................................................... 236,958 5.6626

2

3

4

7

11 15........................................................... 76,129 4.5225

1

2

4

6

8 16........................................................... 16,264 6.3451

2

3

5

8

12 17...........................................................

3,008 3.2114

1

2

2

4

6 18........................................................... 33,082 5.2590

2

3

4

7

10 19...........................................................

8,568 3.4383

1

2

3

4

6 20...........................................................

6,532 9.8403

3

5

8

12

19 21...........................................................

2,197 6.3245

2

3

5

8

13 22...........................................................

3,316 5.2223

2

2

4

7

10 23........................................................... 10,732 3.8906

1

2

3

5

7 24........................................................... 63,863 4.7303

1

2

4

6

9 25........................................................... 28,153 3.1246

1

2

3

4

6 26...........................................................

18 6.2778

1

2

3

4

8 27...........................................................

5,387 5.1142

1

1

3

6

11 28........................................................... 17,558 5.7440

1

3

4

7

12 29...........................................................

6,274 3.3202

1

1

3

4

6

[[Page 23614]]

30...........................................................

1 19.0000

19

19

19

19

19 31...........................................................

5,090 3.9800

1

2

3

5

8 32...........................................................

1,982 2.4001

1

1

2

3

5 34........................................................... 27,872 4.7722

1

2

4

6

9 35...........................................................

7,895 3.0011

1

1

3

4

6 36...........................................................

1,472 1.6019

1

1

1

1

3 37...........................................................

1,241 4.1281

1

1

3

5

9 38...........................................................

56 3.5179

1

1

2

4

6 39...........................................................

448 2.3772

1

1

1

2

5 40...........................................................

1,383 4.1063

1

1

4

5

8 42...........................................................

1,145 2.7721

1

1

2

4

6 43...........................................................

125 3.1440

1

1

2

4

6 44...........................................................

1,160 4.7836

2

3

4

6

8 45...........................................................

2,803 3.0756

1

2

2

4

6 46...........................................................

3,819 4.1712

1

2

3

5

8 47...........................................................

1,335 2.8854

1

1

2

4

5 49...........................................................

2,478 4.3906

1

2

3

5

8 50...........................................................

2,170 1.8143

1

1

1

2

3 51...........................................................

190 2.7632

1

1

1

3

6 52...........................................................

165 1.9818

1

1

1

2

4 53...........................................................

2,225 3.9542

1

1

2

5

9 54...........................................................

1 7.0000

7

7

7

7

7 55...........................................................

1,354 3.1300

1

1

2

4

7 56...........................................................

435 2.5724

1

1

1

3

6 57...........................................................

698 4.1547

1

1

2

5

9 59...........................................................

102 2.5392

1

1

1

2

6 60...........................................................

8 3.2500

1

1

2

4

4 61...........................................................

219 5.4064

1

1

3

7

12 63...........................................................

2,842 4.4838

1

2

3

5

9 64...........................................................

3,343 6.0464

1

2

4

8

13 65........................................................... 41,424 2.7728

1

1

2

3

5 66...........................................................

8,007 3.1309

1

1

2

4

6 67...........................................................

419 3.6826

1

2

3

4

7 68........................................................... 17,328 3.9720

1

2

3

5

7 69...........................................................

4,816 3.0328

1

2

3

4

5 70...........................................................

25 2.3600

1

1

2

3

4 71...........................................................

68 4.0000

1

2

3

5

7 72...........................................................

1,066 3.4531

1

2

3

4

7 73...........................................................

7,935 4.3806

1

2

3

6

9 74...........................................................

4 2.5000

2

2

2

3

3 75........................................................... 45,034 9.8129

3

5

7

12

20 76........................................................... 47,341 10.8198

3

5

8

13

21 77...........................................................

2,153 4.6716

1

2

4

6

9 78........................................................... 45,631 6.2559

2

4

6

8

10 79........................................................... 170,684 8.1939

3

4

7

10

15 80...........................................................

7,724 5.3718

2

3

4

7

10 81...........................................................

4 11.5000

8

8

11

13

14 82........................................................... 65,161 6.6908

2

3

5

9

13 83...........................................................

6,950 5.2373

2

3

4

7

10 84...........................................................

1,472 3.1454

1

2

3

4

6 85........................................................... 21,878 6.2321

2

3

5

8

12 86...........................................................

1,861 3.6239

1

2

3

5

7 87........................................................... 82,727 6.4131

2

3

5

8

12 88........................................................... 413,844 4.9009

2

3

4

6

9 89........................................................... 550,707 5.6477

2

3

5

7

10 90........................................................... 45,868 3.8123

2

2

3

5

7 91...........................................................

45 4.3556

1

2

3

5

9 92........................................................... 16,495 5.9978

2

3

5

8

11 93...........................................................

1,598 3.8273

1

2

3

5

7 94........................................................... 13,338 6.1223

2

3

5

8

12 95...........................................................

1,612 3.6340

1

2

3

5

7 96........................................................... 59,134 4.3754

2

2

4

5

8 97........................................................... 27,017 3.3864

1

2

3

4

6 98...........................................................

8 2.5000

1

2

2

3

3 99........................................................... 21,547 3.1101

1

1

2

4

6 100..........................................................

6,953 2.1151

1

1

2

3

4 101.......................................................... 23,105 4.2502

1

2

3

5

8 102..........................................................

5,237 2.4921

1

1

2

3

5 103..........................................................

724 37.3798

8

12

23

48

79 104.......................................................... 20,953 14.4988

6

8

12

18

25

[[Page 23615]]

105.......................................................... 31,568 9.9544

4

6

8

12

18 106..........................................................

3,499 11.2138

5

7

9

13

19 107.......................................................... 70,111 10.5005

5

7

9

12

17 108..........................................................

8,878 9.8314

1

5

8

12

19 109.......................................................... 50,742 7.7661

4

5

6

9

13 110.......................................................... 57,167 8.3880

1

3

7

11

17 111.......................................................... 10,077 3.4273

1

1

3

5

7 113.......................................................... 37,263 12.5945

4

6

10

16

24 114..........................................................

8,514 8.4514

2

4

7

11

16 115.......................................................... 22,137 6.8327

1

2

5

9

14 116.......................................................... 118,685 4.2655

1

1

3

6

9 117..........................................................

5,151 4.2386

1

1

2

5

10 118..........................................................

7,605 3.0473

1

1

2

4

7 119..........................................................

993 5.4945

1

1

3

7

13 120.......................................................... 36,309 9.0439

1

3

6

12

20 121.......................................................... 159,575 6.2485

2

3

5

8

12 122.......................................................... 61,768 3.3855

1

2

3

4

6 123.......................................................... 33,656 4.7990

1

1

3

6

11 124.......................................................... 130,770 4.3991

1

2

3

6

9 125.......................................................... 95,808 2.7249

1

1

2

3

5 126..........................................................

5,823 11.2705

3

6

9

14

21 127.......................................................... 695,800 5.1260

2

3

4

6

10 128..........................................................

5,181 5.1662

2

3

5

6

9 129..........................................................

3,762 2.5944

1

1

1

3

6 130.......................................................... 89,126 5.4275

1

3

5

7

10 131.......................................................... 23,839 3.8048

1

2

4

5

7 132.......................................................... 117,297 2.8049

1

1

2

3

5 133..........................................................

7,287 2.1806

1

1

2

3

4 134.......................................................... 42,414 3.1069

1

2

2

4

6 135..........................................................

7,439 4.2879

1

2

3

5

8 136..........................................................

1,133 2.7643

1

1

2

3

5 138.......................................................... 207,068 3.9126

1

2

3

5

7 139.......................................................... 78,609 2.4367

1

1

2

3

5 140.......................................................... 38,178 2.4370

1

1

2

3

5 141.......................................................... 121,892 3.4612

1

2

3

4

6 142.......................................................... 52,279 2.4785

1

1

2

3

5 143.......................................................... 249,312 2.0936

1

1

2

3

4 144.......................................................... 99,715 5.6964

1

2

4

7

12 145..........................................................

6,187 2.6198

1

1

2

3

5 146.......................................................... 10,769 9.8862

5

6

8

12

17 147..........................................................

2,634 5.8193

3

4

6

7

9 148.......................................................... 135,681 12.0864

5

7

9

15

22 149.......................................................... 19,915 5.9490

3

4

6

7

9 150.......................................................... 22,708 10.8769

4

6

9

14

20 151..........................................................

5,353 5.1362

1

2

5

7

10 152..........................................................

5,007 8.0429

3

5

7

9

14 153..........................................................

2,092 4.9809

2

3

5

6

8 154.......................................................... 28,497 13.0520

3

6

10

16

25 155..........................................................

6,161 4.1344

1

2

3

6

8 156..........................................................

6 24.1667

1

5

9

27

27 157..........................................................

8,260 5.7196

1

2

4

7

12 158..........................................................

4,106 2.6086

1

1

2

3

5 159.......................................................... 19,174 5.1209

1

2

4

7

10 160.......................................................... 11,988 2.6625

1

1

2

3

5 161.......................................................... 10,428 4.3945

1

2

3

6

9 162..........................................................

5,497 2.0806

1

1

1

3

4 163..........................................................

10 2.9000

1

1

2

3

6 164..........................................................

5,945 7.9862

3

5

7

10

14 165..........................................................

2,523 4.2089

2

3

4

5

7 166..........................................................

4,933 4.5046

1

2

3

5

9 167..........................................................

4,634 2.2169

1

1

2

3

4 168..........................................................

1,544 4.9087

1

2

3

6

10 169..........................................................

756 2.2844

1

1

2

3

5 170.......................................................... 17,471 10.7718

2

5

8

14

22 171..........................................................

1,484 4.0964

1

2

3

5

8 172.......................................................... 32,879 6.8401

2

3

5

9

14 173..........................................................

2,392 3.5920

1

1

3

5

7 174.......................................................... 267,905 4.7020

2

3

4

6

9 175.......................................................... 32,657 2.8910

1

2

2

4

5 176.......................................................... 14,560 5.1422

2

3

4

6

10

[[Page 23616]]

177..........................................................

8,554 4.4329

2

2

4

5

8 178..........................................................

2,909 3.1158

1

2

3

4

5 179.......................................................... 14,429 5.8559

2

3

5

7

11 180.......................................................... 92,193 5.3215

2

3

4

7

10 181.......................................................... 25,897 3.3265

1

2

3

4

6 182.......................................................... 292,198 4.4293

1

2

3

5

8 183.......................................................... 86,576 2.8664

1

1

2

4

5 184..........................................................

78 3.2821

1

2

2

4

6 185..........................................................

5,680 4.4905

1

2

3

5

9 186..........................................................

4 2.0000

1

1

1

3

3 187..........................................................

621 4.1723

1

2

3

5

8 188.......................................................... 90,968 5.5332

1

2

4

7

11 189.......................................................... 13,182 3.0882

1

1

2

4

6 190..........................................................

69 4.3768

1

2

3

5

8 191.......................................................... 10,411 12.6933

3

6

9

16

26 192..........................................................

1,322 5.6899

1

3

5

7

10 193..........................................................

4,514 12.0549

5

7

10

15

22 194..........................................................

521 6.6756

3

4

6

8

11 195..........................................................

3,249 10.6190

4

6

9

13

19 196..........................................................

701 5.7275

2

4

5

7

9 197.......................................................... 17,317 9.0988

3

5

7

11

17 198..........................................................

4,645 4.3208

2

3

4

6

7 199..........................................................

1,425 9.5298

2

4

7

13

19 200..........................................................

936 9.6976

1

4

7

12

20 201..........................................................

2,665 13.7471

3

6

10

18

28 202.......................................................... 27,281 6.1787

2

3

5

8

12 203.......................................................... 31,656 6.4850

2

3

5

8

13 204.......................................................... 72,845 5.5246

2

3

4

7

11 205.......................................................... 31,474 5.8950

2

3

4

7

12 206..........................................................

2,081 3.8847

1

2

3

5

8 207.......................................................... 35,754 5.2393

1

2

4

7

10 208..........................................................

9,758 2.9364

1

1

2

4

6 209.......................................................... 461,222 4.5677

3

3

4

5

7 210.......................................................... 128,455 6.6967

3

4

6

8

11 211.......................................................... 26,708 4.6708

3

3

4

5

7 212..........................................................

10 2.9000

1

1

3

4

4 213.......................................................... 10,257 9.1059

2

4

7

12

18 216.......................................................... 17,656 5.7608

1

1

3

8

14 217.......................................................... 17,622 12.4479

3

5

9

15

26 218.......................................................... 28,708 5.4480

2

3

4

7

10 219.......................................................... 21,361 3.1063

1

2

3

4

5 220..........................................................

4 2.7500

2

2

3

3

3 223.......................................................... 13,425 3.2055

1

1

2

4

6 224.......................................................... 10,889 1.8875

1

1

1

2

3 225..........................................................

6,514 5.1650

1

2

4

7

11 226..........................................................

6,660 6.3380

1

2

4

8

13 227..........................................................

5,074 2.6139

1

1

2

3

5 228..........................................................

2,640 4.1258

1

1

3

5

9 229..........................................................

1,201 2.5129

1

1

2

3

5 230..........................................................

2,565 5.5922

1

2

4

7

12 232..........................................................

729 2.8230

1

1

1

3

6 233.......................................................... 15,118 6.6726

1

2

5

9

14 234..........................................................

7,676 2.7952

1

1

2

4

6 235..........................................................

4,970 4.6463

1

2

4

6

9 236.......................................................... 42,408 4.4748

1

3

4

5

8 237..........................................................

2,022 3.6682

1

2

3

4

7 238..........................................................

9,869 8.2633

3

4

6

10

15 239.......................................................... 42,943 6.0632

2

3

5

7

11 240.......................................................... 12,653 6.6177

2

3

5

8

13 241..........................................................

2,696 3.7066

1

2

3

5

7 242..........................................................

2,742 6.5864

2

3

5

8

12 243.......................................................... 101,477 4.5166

1

2

4

6

8 244.......................................................... 15,792 4.4924

1

2

4

6

8 245..........................................................

5,840 3.1334

1

1

3

4

6 246..........................................................

1,430 3.5664

1

2

3

4

7 247.......................................................... 21,671 3.3172

1

2

3

4

6 248.......................................................... 15,118 4.8397

1

3

4

6

9 249.......................................................... 14,026 3.8285

1

1

3

5

8 250..........................................................

4,155 3.8876

1

2

3

5

7 251..........................................................

2,148 2.7514

1

1

3

3

5

[[Page 23617]]

252..........................................................

1 1.0000

1

1

1

1

1 253.......................................................... 24,857 4.5324

2

3

4

5

8 254.......................................................... 10,420 3.0461

1

2

3

4

5 255..........................................................

1 7.0000

7

7

7

7

7 256..........................................................

7,152 5.0301

1

2

4

6

10 257.......................................................... 13,512 2.6104

1

1

2

3

5 258.......................................................... 12,042 1.7498

1

1

1

2

3 259..........................................................

2,903 2.7689

1

1

1

3

7 260..........................................................

2,991 1.4055

1

1

1

1

2 261..........................................................

1,603 2.2052

1

1

1

2

4 262..........................................................

636 4.8428

1

2

4

7

10 263.......................................................... 23,809 10.7403

3

5

8

13

21 264..........................................................

3,922 6.2358

2

3

5

8

12 265..........................................................

4,307 6.5677

1

2

4

8

14 266..........................................................

2,304 3.1788

1

1

2

4

7 267..........................................................

272 4.1838

1

1

3

5

10 268..........................................................

1,004 3.5508

1

1

2

4

7 269.......................................................... 10,686 8.3273

2

4

6

11

16 270..........................................................

2,639 3.8151

1

1

3

5

8 271.......................................................... 21,054 6.7875

2

3

5

8

12 272..........................................................

5,942 5.8009

2

3

4

7

11 273..........................................................

1,349 3.6449

1

2

3

5

7 274..........................................................

2,288 6.2592

2

3

5

8

12 275..........................................................

228 3.2456

1

1

2

4

7 276..........................................................

1,447 4.4630

1

2

4

6

8 277.......................................................... 112,318 5.5013

2

3

5

7

10 278.......................................................... 33,865 4.0567

2

2

3

5

7 279..........................................................

6 4.6667

1

3

5

6

6 280.......................................................... 19,272 4.0080

1

2

3

5

7 281..........................................................

7,093 2.8429

1

1

2

4

5 283..........................................................

6,274 4.5695

1

2

3

6

9 284..........................................................

1,833 3.0295

1

1

2

4

6 285..........................................................

7,623 10.0454

3

5

8

12

19 286..........................................................

2,703 5.4802

2

2

4

6

10 287..........................................................

6,114 9.8368

3

5

7

12

19 288.......................................................... 10,450 4.1090

2

2

3

4

7 289..........................................................

6,894 2.5582

1

1

1

2

5 290.......................................................... 10,859 2.1325

1

1

1

2

4 291..........................................................

64 2.7969

1

1

1

2

5 292..........................................................

7,331 10.0308

2

4

8

13

20 293..........................................................

368 4.4674

1

2

3

6

9 294.......................................................... 98,963 4.2920

1

2

3

5

8 295..........................................................

4,102 3.6675

1

2

3

4

7 296.......................................................... 254,706 4.7202

1

2

4

6

9 297.......................................................... 45,347 3.0710

1

2

3

4

6 298..........................................................

81 3.9383

1

1

2

4

7 299..........................................................

1,478 5.1604

1

2

4

6

10 300.......................................................... 21,343 5.8673

2

3

5

7

11 301..........................................................

3,901 3.4107

1

2

3

4

6 302..........................................................

9,649 8.1898

4

5

6

9

14 303.......................................................... 23,760 7.3943

3

4

6

9

14 304.......................................................... 13,826 8.4735

2

3

6

11

18 305..........................................................

3,087 3.2096

1

2

3

4

6 306..........................................................

6,350 5.4737

1

2

3

8

12 307..........................................................

2,066 2.0736

1

1

2

2

3 308..........................................................

7,093 6.1095

1

2

4

8

14 309..........................................................

3,559 2.0014

1

1

1

2

4 310.......................................................... 26,035 4.5265

1

2

3

6

10 311..........................................................

6,480 1.8782

1

1

1

2

3 312..........................................................

1,456 4.8365

1

1

3

6

11 313..........................................................

508 2.2165

1

1

2

3

4 314..........................................................

1 2.0000

2

2

2

2

2 315.......................................................... 36,565 6.7584

1

1

4

9

16 316.......................................................... 180,999 6.2874

2

3

5

8

12 317..........................................................

2,766 3.4678

1

1

2

4

7 318..........................................................

5,927 5.7441

1

2

4

7

11 319..........................................................

383 2.7546

1

1

2

3

6 320.......................................................... 218,684 5.0953

2

3

4

6

9 321.......................................................... 31,401 3.5963

1

2

3

4

6 322..........................................................

61 3.4918

2

2

3

4

6

[[Page 23618]]

323.......................................................... 20,482 3.0937

1

1

2

4

6 324..........................................................

5,421 1.8843

1

1

1

2

3 325..........................................................

9,615 3.6813

1

2

3

5

7 326..........................................................

2,584 2.6207

1

1

2

3

5 327..........................................................

5 2.6000

1

1

2

3

5 328..........................................................

606 3.4719

1

1

3

5

7 329..........................................................

72 1.8333

1

1

1

2

3 331.......................................................... 54,798 5.4332

1

2

4

7

11 332..........................................................

4,389 3.1246

1

1

2

4

6 333..........................................................

252 5.4921

1

2

3

7

13 334..........................................................

9,810 4.3009

2

2

3

5

7 335.......................................................... 11,931 2.6866

1

2

3

3

4 336.......................................................... 31,264 3.2999

1

2

2

4

7 337.......................................................... 25,156 1.9182

1

1

2

2

3 338..........................................................

652 6.1748

1

2

3

9

14 339..........................................................

1,253 5.1173

1

1

3

7

11 340..........................................................

2 5.0000

4

4

6

6

6 341..........................................................

3,185 3.1586

1

1

2

3

7 342..........................................................

565 3.4248

1

2

2

4

8 344..........................................................

2,693 2.7037

1

1

1

2

6 345..........................................................

1,461 4.8077

1

1

3

6

11 346..........................................................

3,966 5.7307

1

3

4

7

11 347..........................................................

247 3.0202

1

1

2

4

7 348..........................................................

4,171 4.0897

1

2

3

5

8 349..........................................................

575 2.3583

1

1

2

3

4 350..........................................................

7,137 4.4541

2

2

4

5

8 352..........................................................

975 4.0133

1

2

3

5

8 353..........................................................

2,735 6.3192

2

3

4

7

12 354..........................................................

7,612 5.6967

2

3

4

6

10 355..........................................................

4,937 3.0614

2

2

3

4

4 356.......................................................... 23,993 1.9281

1

1

2

2

3 357..........................................................

5,570 8.1269

3

4

6

10

15 358.......................................................... 20,798 3.9629

2

2

3

4

7 359.......................................................... 28,741 2.4058

1

2

2

3

4 360.......................................................... 14,764 2.5880

1

1

2

3

4 361..........................................................

272 3.0184

1

1

2

3

7 362..........................................................

2 1.0000

1

1

1

1

1 363..........................................................

2,128 3.7810

1

2

2

4

8 364..........................................................

1,451 4.1909

1

2

3

5

9 365..........................................................

1,622 7.7404

2

3

5

9

17 366..........................................................

4,789 6.4792

2

3

5

8

13 367..........................................................

456 2.9934

1

1

2

4

6 368..........................................................

3,924 6.6351

2

3

5

8

13 369..........................................................

3,613 3.2419

1

1

2

4

6 370..........................................................

1,843 5.1557

2

3

4

5

8 371..........................................................

2,244 3.3944

2

3

3

4

5 372..........................................................

1,164 3.1847

2

2

2

3

5 373..........................................................

4,871 2.2373

1

2

2

3

3 374..........................................................

156 2.7436

2

2

2

3

4 375..........................................................

6 4.0000

1

2

2

6

6 376..........................................................

388 3.3711

1

2

2

4

6 377..........................................................

77 4.4805

1

1

3

4

8 378..........................................................

196 2.3163

1

1

2

3

4 379..........................................................

508 2.8130

1

1

2

3

6 380..........................................................

91 2.1099

1

1

1

2

4 381..........................................................

212 2.2642

1

1

1

2

4 382..........................................................

43 1.4419

1

1

1

2

2 383..........................................................

2,473 3.6526

1

1

2

4

7 384..........................................................

132 2.5606

1

1

1

3

5 385..........................................................

1 1.0000

1

1

1

1

1 389..........................................................

1 21.0000

21

21

21

21

21 390..........................................................

1 1.0000

1

1

1

1

1 392..........................................................

2,203 9.1770

2

4

6

11

19 393..........................................................

1 4.0000

4

4

4

4

4 394..........................................................

2,820 7.3553

1

2

5

9

16 395.......................................................... 116,129 4.2575

1

2

3

5

8 396..........................................................

9 4.4444

1

1

2

3

6 397.......................................................... 18,482 5.1407

1

2

4

6

10 398.......................................................... 18,288 5.7016

2

3

4

7

11 399..........................................................

1,640 3.3250

1

2

3

4

6

[[Page 23619]]

401..........................................................

6,328 11.0390

2

5

9

14

22 402..........................................................

1,401 4.0293

1

1

3

5

9 403.......................................................... 31,865 7.9367

2

3

6

10

16 404..........................................................

3,802 4.1528

1

2

3

5

8 406..........................................................

2,224 9.9150

2

4

7

12

21 407..........................................................

584 3.8253

1

2

3

5

7 408..........................................................

2,170 8.1949

1

2

5

10

19 409..........................................................

1,808 5.7954

1

3

4

6

12 410.......................................................... 28,417 3.8214

1

2

3

5

6 411..........................................................

12 3.2500

1

2

2

4

4 412..........................................................

12 2.7500

1

1

1

3

4 413..........................................................

5,198 6.7563

2

3

5

9

13 414..........................................................

573 4.0244

1

2

3

5

8 415.......................................................... 50,827 14.0035

4

6

11

18

28 416.......................................................... 239,006 7.3769

2

3

6

9

14 417..........................................................

23 5.2174

1

2

3

5

10 418.......................................................... 28,508 6.1657

2

3

5

8

12 419.......................................................... 16,282 4.3857

1

2

3

5

8 420..........................................................

2,941 3.3747

1

2

3

4

6 421.......................................................... 11,882 4.0613

1

2

3

5

7 422..........................................................

52 3.7115

1

1

2

4

7 423..........................................................

8,637 8.2173

2

3

6

10

17 424..........................................................

1,071 11.7274

2

4

8

14

22 425.......................................................... 14,779 3.4569

1

1

3

4

7 426..........................................................

4,313 4.1203

1

2

3

5

8 427..........................................................

1,505 4.7375

1

2

3

5

9 428..........................................................

773 7.2549

1

2

5

8

15 429.......................................................... 25,479 5.4228

2

3

4

6

10 430.......................................................... 71,439 7.6737

2

3

6

9

15 431..........................................................

304 5.8947

1

2

4

7

12 432..........................................................

420 4.2548

1

2

3

5

8 433..........................................................

5,191 2.9626

1

1

2

3

6 439..........................................................

1,739 8.7993

1

3

5

10

19 440..........................................................

5,613 8.7825

2

3

6

10

18 441..........................................................

779 3.3813

1

1

2

4

7 442.......................................................... 18,017 8.6810

2

3

6

11

18 443..........................................................

3,385 3.4003

1

1

3

4

7 444..........................................................

5,892 4.0324

1

2

3

5

8 445..........................................................

2,346 2.8372

1

1

2

4

5 447..........................................................

6,264 2.5686

1

1

2

3

5 448..........................................................

1 2.0000

2

2

2

2

2 449.......................................................... 38,802 3.6742

1

1

3

4

7 450..........................................................

7,805 1.9867

1

1

1

2

4 451..........................................................

3 1.6667

1

1

1

3

3 452.......................................................... 27,634 4.8762

1

2

3

6

10 453..........................................................

5,437 2.7993

1

1

2

3

5 454..........................................................

3,837 4.1058

1

2

3

5

8 455..........................................................

846 2.2222

1

1

2

3

4 461..........................................................

2,722 5.1267

1

1

3

6

12 462..........................................................

7,761 10.1584

4

6

8

13

18 463.......................................................... 31,045 3.8939

1

2

3

5

7 464..........................................................

7,661 2.9141

1

1

2

4

5 465..........................................................

219 3.6347

1

1

2

4

7 466..........................................................

1,377 4.7117

1

1

2

5

9 467..........................................................

1,015 2.6788

1

1

2

3

5 468.......................................................... 50,481 12.8082

3

6

10

16

25 471.......................................................... 15,614 5.0496

3

3

4

5

8 473..........................................................

8,778 12.4026

2

3

7

18

32 475.......................................................... 116,534 11.0157

2

5

9

14

21 476..........................................................

3,025 10.4998

2

4

9

14

21 477.......................................................... 29,407 8.5221

1

3

6

11

18 478.......................................................... 113,660 7.1046

1

2

5

9

15 479.......................................................... 24,603 2.7884

1

1

2

4

6 480..........................................................

802 17.9102

7

9

13

22

36 481..........................................................

1,066 21.8208

10

16

20

25

35 482..........................................................

5,076 11.4967

4

6

9

14

21 484..........................................................

449 12.7506

2

6

10

17

25 485..........................................................

3,420 9.6038

4

5

7

11

18 486..........................................................

2,562 12.3478

2

6

10

16

25 487..........................................................

4,644 7.0540

1

3

5

9

14

[[Page 23620]]

488..........................................................

786 16.3422

4

7

13

22

35 489.......................................................... 13,461 8.3538

2

3

6

10

17 490..........................................................

5,204 5.3918

1

2

4

7

11 491.......................................................... 19,789 3.1423

1

2

3

3

5 492..........................................................

4,012 13.6269

3

5

6

23

31 493.......................................................... 61,628 6.0515

1

3

5

8

12 494.......................................................... 25,626 2.6772

1

1

2

4

5 495..........................................................

307 17.4072

8

9

13

19

31 496..........................................................

3,261 8.9877

3

4

6

11

18 497.......................................................... 29,453 6.0617

3

4

5

7

10 498.......................................................... 19,400 3.7954

2

3

3

5

6 499.......................................................... 35,676 4.3236

1

2

3

5

9 500.......................................................... 48,323 2.2420

1

1

2

3

4 501..........................................................

3,122 9.9308

4

5

8

13

18 502..........................................................

717 5.6987

2

3

5

7

9 503..........................................................

5,909 3.8284

1

2

3

5

7 504..........................................................

187 27.1818

8

16

23

36

49 505..........................................................

179 4.6704

1

1

1

6

11 506..........................................................

1,004 15.9273

3

7

13

21

33 507..........................................................

307 8.4919

1

3

7

11

18 508..........................................................

641 7.2044

1

3

5

9

15 509..........................................................

168 5.1607

1

2

3

6

11 510..........................................................

1,755 6.4160

1

2

4

8

14 511..........................................................

635 4.0787

1

1

2

5

8 512..........................................................

513 12.7719

7

8

10

14

23 513..........................................................

227 9.9824

5

7

8

12

16 515.......................................................... 27,312 4.2899

1

1

2

6

11 516.......................................................... 38,732 4.7893

2

2

4

6

9 517.......................................................... 66,287 2.5801

1

1

1

3

6 518.......................................................... 41,113 3.4800

1

1

2

4

8 519.......................................................... 11,506 4.8233

1

1

3

6

11 520.......................................................... 15,266 2.0074

1

1

1

2

4 521.......................................................... 32,148 5.4742

2

3

4

7

11 522..........................................................

5,646 9.3666

3

4

7

12

19 523.......................................................... 15,866 3.8769

1

2

3

5

7 524.......................................................... 118,949 3.1907

1

2

3

4

6 525..........................................................

315 13.4222

1

3

8

16

32 526.......................................................... 55,877 4.3572

1

2

3

5

8 527.......................................................... 192,230 2.2326

1

1

1

2

5 528..........................................................

1,770 17.1090

6

10

15

22

30 529..........................................................

4,032 7.9923

1

2

5

10

18 530..........................................................

2,363 3.1240

1

1

2

4

6 531..........................................................

4,799 9.4049

2

4

7

12

20 532..........................................................

2,622 3.7227

1

1

3

5

8 533.......................................................... 47,609 3.7364

1

1

2

4

9 534.......................................................... 45,285 1.7909

1

1

1

2

3 535.......................................................... 13,002 8.2678

1

3

7

11

17 536.......................................................... 19,606 5.4113

1

2

4

7

12 537..........................................................

8,641 6.7775

1

3

5

8

14 538..........................................................

5,604 2.8164

1

1

2

4

6 539..........................................................

5,020 10.7639

2

4

7

14

23 540..........................................................

1,510 3.5808

1

1

3

4

7 541.......................................................... 22,369 42.8902

17

25

35

52

76 542.......................................................... 24,376 32.5434

12

18

27

40

58 543..........................................................

5,415 11.9830

2

5

10

16

24

12,140,152

Table 7B.--Medicare Prospective Payment System Selected Percentile Lengths of Stay [FY 2004 MedPAR Update December 2004 GROUPER V23.0]

Number of Arithmetic 10th

25th

50th

75th

90th DRG

discharges mean LOS percentile percentile percentile percentile percentile

1............................................................ 23,271 9.8373

3

5

8

13

19 2............................................................ 10,351 4.5604

1

2

4

6

9 3............................................................

4 9.5000

1

1

8

14

15 6............................................................

410 3.0512

1

1

2

4

7 7............................................................ 15,592 9.2952

2

4

7

12

19

[[Page 23621]]

8............................................................

3,701 2.8652

1

1

2

4

7 9............................................................

1,945 6.1594

1

3

5

7

12 10........................................................... 19,511 6.0234

2

3

5

8

12 11...........................................................

3,279 3.7600

1

2

3

5

7 12........................................................... 54,431 5.3747

2

3

4

6

10 13...........................................................

7,337 4.9162

2

3

4

6

8 14........................................................... 236,958 5.6626

2

3

4

7

11 15........................................................... 76,129 4.5225

1

2

4

6

8 16........................................................... 16,264 6.3451

2

3

5

8

12 17...........................................................

3,008 3.2114

1

2

2

4

6 18........................................................... 33,082 5.2590

2

3

4

7

10 19...........................................................

8,568 3.4383

1

2

3

4

6 20...........................................................

6,532 9.8403

3

5

8

12

19 21...........................................................

2,197 6.3245

2

3

5

8

13 22...........................................................

3,316 5.2223

2

2

4

7

10 23........................................................... 10,732 3.8906

1

2

3

5

7 24........................................................... 63,863 4.7303

1

2

4

6

9 25........................................................... 28,153 3.1246

1

2

3

4

6 26...........................................................

18 6.2778

1

2

3

4

8 27...........................................................

5,387 5.1142

1

1

3

6

11 28........................................................... 17,558 5.7440

1

3

4

7

12 29...........................................................

6,274 3.3202

1

1

3

4

6 30...........................................................

1 19.0000

19

19

19

19

19 31...........................................................

5,090 3.9800

1

2

3

5

8 32...........................................................

1,982 2.4001

1

1

2

3

5 34........................................................... 27,872 4.7722

1

2

4

6

9 35........................................................... 17,895 3.0011

1

1

3

4

6 36...........................................................

1,472 1.6019

1

1

1

1

3 37...........................................................

1,241 4.1281

1

1

3

5

9 38...........................................................

56 3.5179

1

1

2

4

6 39...........................................................

448 2.3772

1

1

1

2

5 40...........................................................

1,383 4.1063

1

1

4

5

8 42...........................................................

1,145 2.7721

1

1

2

4

6 43...........................................................

125 3.1440

1

1

2

4

6 44...........................................................

1,160 4.7836

2

3

4

6

8 45...........................................................

2,803 3.0756

1

2

2

4

6 46...........................................................

3,819 4.1712

1

2

3

5

8 47...........................................................

1,335 2.8854

1

1

2

4

5 49...........................................................

2,478 4.3906

1

2

3

5

8 50...........................................................

2,170 1.8143

1

1

1

2

3 51...........................................................

190 2.7632

1

1

1

3

6 52...........................................................

165 1.9818

1

1

1

2

4 53...........................................................

2,225 3.9542

1

1

2

5

9 54...........................................................

1 7.0000

7

7

7

7

7 55...........................................................

1,354 3.1300

1

1

2

4

7 56...........................................................

435 2.5724

1

1

1

3

6 57...........................................................

698 4.1547

1

1

2

5

9 59...........................................................

102 2.5392

1

1

1

2

6 60...........................................................

8 3.2500

1

1

2

4

4 61...........................................................

219 5.4064

1

1

3

7

12 63...........................................................

2,842 4.4838

1

2

3

5

9 64...........................................................

3,343 6.0464

1

2

4

8

13 65........................................................... 41,424 2.7728

1

1

2

3

5 66...........................................................

8,007 3.1309

1

1

2

4

6 67...........................................................

419 3.6826

1

2

3

4

7 68........................................................... 17,328 3.9720

1

2

3

5

7 69...........................................................

4,816 3.0328

1

2

3

4

5 70...........................................................

25 2.3600

1

1

2

3

4 71...........................................................

68 4.0000

1

2

3

5

7 72...........................................................

1,066 3.4531

1

2

3

4

7 73...........................................................

7,935 4.3806

1

2

3

6

9 74...........................................................

4 2.5000

2

2

2

3

3 75........................................................... 45,031 9.8127

3

5

7

12

20 76........................................................... 47,341 10.8198

3

5

8

13

21 77...........................................................

2,153 4.6716

1

2

4

6

9 78........................................................... 45,631 6.2559

2

4

6

8

10 79........................................................... 170,684 8.1939

3

4

7

10

15 80...........................................................

7,724 5.3718

2

3

4

7

10 81...........................................................

4 11.5000

8

8

11

13

14 82........................................................... 65,161 6.6908

2

3

5

9

13

[[Page 23622]]

83...........................................................

6,950 5.2373

2

3

4

7

10 84...........................................................

1,472 3.1454

1

2

3

4

6 85........................................................... 21,878 6.2321

2

3

5

8

12 86...........................................................

1,861 3.6239

1

2

3

5

7 87........................................................... 82,727 6.4131

2

3

5

8

12 88........................................................... 413,844 4.9009

2

3

4

6

9 89........................................................... 550,707 5.6477

2

3

5

7

10 90........................................................... 45,868 3.8123

2

2

3

5

7 91...........................................................

45 4.3556

1

2

3

5

9 92........................................................... 16,495 5.9978

2

3

5

8

11 93...........................................................

1,598 3.8273

1

2

3

5

7 94........................................................... 13,338 6.1223

2

3

5

8

12 95...........................................................

1,612 3.6340

1

2

3

5

7 96........................................................... 59,134 4.3754

2

2

4

5

8 97........................................................... 27,017 3.3864

1

2

3

4

6 98...........................................................

8 2.5000

1

2

2

3

3 99........................................................... 21,547 3.1101

1

1

2

4

6 100..........................................................

6,953 2.1151

1

1

2

3

4 101.......................................................... 23,105 4.2502

1

2

3

5

8 102..........................................................

5,237 2.4921

1

1

2

3

5 103..........................................................

724 37.3798

8

12

23

48

79 104.......................................................... 20,929 14.5053

6

8

12

18

25 105.......................................................... 31,544 9.9561

4

6

8

12

18 106..........................................................

3,499 11.2138

5

7

9

13

19 107.......................................................... 70,111 10.5005

5

7

9

12

17 108..........................................................

7,947 10.6922

4

6

9

13

19 109.......................................................... 50,742 7.7661

4

5

6

9

13 110.......................................................... 57,167 8.3880

1

3

7

11

17 111.......................................................... 10,077 3.4273

1

1

3

5

7 113.......................................................... 37,263 12.5945

4

6

10

16

24 114..........................................................

8,514 8.4514

2

4

7

11

16 115.......................................................... 22,137 6.8327

1

2

5

9

14 116.......................................................... 118,685 4.2655

1

1

3

6

9 117..........................................................

5,151 4.2386

1

1

2

5

10 118..........................................................

7,605 3.0473

1

1

2

4

7 119..........................................................

993 5.4945

1

1

3

7

13 120.......................................................... 36,309 9.0439

1

3

6

12

20 121.......................................................... 159,575 6.2485

2

3

5

8

12 122.......................................................... 61,768 3.3855

1

2

3

4

6 123.......................................................... 33,656 4.7990

1

1

3

6

11 124.......................................................... 130,770 4.3991

1

2

3

6

9 125.......................................................... 95,808 2.7249

1

1

2

3

5 126..........................................................

5,823 11.2705

3

6

9

14

21 127.......................................................... 695,800 5.1260

2

3

4

6

10 128..........................................................

5,181 5.1662

2

3

5

6

9 129..........................................................

3,762 2.5944

1

1

1

3

6 130.......................................................... 89,126 5.4275

1

3

5

7

10 131.......................................................... 23,839 3.8048

1

2

4

5

7 132.......................................................... 117,297 2.8049

1

1

2

3

5 133..........................................................

7,287 2.1806

1

1

2

3

4 134.......................................................... 42,414 3.1069

1

2

2

4

6 135..........................................................

7,439 4.2879

1

2

3

5

8 136..........................................................

1,133 2.7643

1

1

2

3

5 138.......................................................... 207,068 3.9126

1

2

3

5

7 139.......................................................... 78,609 2.4367

1

1

2

3

5 140.......................................................... 38,178 2.4370

1

1

2

3

5 141.......................................................... 121,892 3.4612

1

2

3

4

6 142.......................................................... 52,279 2.4785

1

1

2

3

5 143.......................................................... 249,312 2.0936

1

1

2

3

4 144.......................................................... 99,715 5.6964

1

2

4

7

12 145..........................................................

6,187 2.6198

1

1

2

3

5 146.......................................................... 10,769 9.8862

5

6

8

12

17 147..........................................................

2,634 5.8193

3

4

6

7

9 148.......................................................... 135,681 12.0864

5

7

9

15

22 149.......................................................... 19,915 5.9490

3

4

6

7

9 150.......................................................... 22,708 10.8769

4

6

9

14

20 151..........................................................

5,353 5.1362

1

2

5

7

10 152..........................................................

5,007 8.0429

3

5

7

9

14 153..........................................................

2,092 4.9809

2

3

5

6

8 154.......................................................... 28,496 13.0519

3

6

10

16

25

[[Page 23623]]

155..........................................................

6,161 4.1344

1

2

3

6

8 156..........................................................

6 24.1667

1

5

9

27

27 157..........................................................

8,260 5.7196

1

2

4

7

12 158..........................................................

4,106 2.6086

1

1

2

3

5 159.......................................................... 19,174 5.1209

1

2

4

7

10 160.......................................................... 11,988 2.6625

1

1

2

3

5 161.......................................................... 10,428 4.3945

1

2

3

6

9 162..........................................................

5,497 2.0806

1

1

1

3

4 163..........................................................

10 2.9000

1

1

2

3

6 164..........................................................

5,945 7.9862

3

5

7

10

14 165..........................................................

2,523 4.2089

2

3

4

5

7 166..........................................................

4,933 4.5046

1

2

3

5

9 167..........................................................

4,634 2.2169

1

1

2

3

4 168..........................................................

1,544 4.9087

1

2

3

6

10 169..........................................................

756 2.2844

1

1

2

3

5 170.......................................................... 17,471 10.7718

2

5

8

14

22 171..........................................................

1,484 4.0964

1

2

3

5

8 172.......................................................... 32,879 6.8401

2

3

5

9

14 173..........................................................

2,392 3.5920

1

1

3

5

7 174.......................................................... 267,905 4.7020

2

3

4

6

9 175.......................................................... 32,657 2.8910

1

2

2

4

5 176.......................................................... 14,560 5.1422

2

3

4

6

10 177..........................................................

8,554 4.4329

2

2

4

5

8 178..........................................................

2,909 3.1158

1

2

3

4

5 179.......................................................... 14,429 5.8559

2

3

5

7

11 180.......................................................... 92,193 5.3215

2

3

4

7

10 181.......................................................... 25,897 3.3265

1

2

3

4

6 182.......................................................... 292,198 4.4293

1

2

3

5

8 183.......................................................... 86,576 2.8664

1

1

2

4

5 184..........................................................

78 3.2821

1

2

2

4

6 185..........................................................

5,680 4.4905

1

2

3

5

9 186..........................................................

4 2.0000

1

1

1

3

3 187..........................................................

621 4.1723

1

2

3

5

8 188.......................................................... 90,968 5.5332

1

2

4

7

11 189.......................................................... 13,182 3.0882

1

1

2

4

6 190..........................................................

69 4.3768

1

2

3

5

8 191.......................................................... 10,411 12.6933

3

6

9

16

26 192..........................................................

1,322 5.6899

1

3

5

7

10 193..........................................................

4,514 12.0549

5

7

10

15

22 194..........................................................

521 6.6756

3

4

6

8

11 195..........................................................

3,249 10.6190

4

6

9

13

19 196..........................................................

701 5.7275

2

4

5

7

9 197.......................................................... 17,316 9.0988

3

5

7

11

17 198..........................................................

4,645 4.3208

2

3

4

6

7 199..........................................................

1,425 9.5298

2

4

7

13

19 200..........................................................

936 9.6976

1

4

7

12

20 201..........................................................

2,665 13.7471

3

6

10

18

28 202.......................................................... 27,281 6.1787

2

3

5

8

12 203.......................................................... 31,656 6.4850

2

3

5

8

13 204.......................................................... 72,845 5.5246

2

3

4

7

11 205.......................................................... 31,474 5.8950

2

3

4

7

12 206..........................................................

2,081 3.8847

1

2

3

5

8 207.......................................................... 35,754 5.2393

1

2

4

7

10 208..........................................................

9,758 2.9364

1

1

2

4

6 210.......................................................... 128,455 6.6967

3

4

6

8

11 211.......................................................... 26,708 4.6708

3

3

4

5

7 212..........................................................

10 2.9000

1

1

3

4

4 213.......................................................... 10,257 9.1059

2

4

7

12

18 216.......................................................... 17,656 5.7608

1

1

3

8

14 217.......................................................... 17,622 12.4479

3

5

9

15

26 218.......................................................... 28,708 5.4480

2

3

4

7

10 219.......................................................... 21,361 3.1063

1

2

3

4

5 220..........................................................

4 2.7500

2

2

3

3

3 223.......................................................... 13,425 3.2055

1

1

2

4

6 224.......................................................... 10,889 1.8875

1

1

1

2

3 225..........................................................

6,514 5.1650

1

2

4

7

11 226..........................................................

6,660 6.3380

1

2

4

8

13 227..........................................................

5,074 2.6139

1

1

2

3

5 228..........................................................

2,640 4.1258

1

1

3

5

9 229..........................................................

1,201 2.5129

1

1

2

3

5

[[Page 23624]]

230..........................................................

2,565 5.5922

1

2

4

7

12 232..........................................................

729 2.8230

1

1

1

3

6 233.......................................................... 15,118 6.6726

1

2

5

9

14 234..........................................................

7,676 2.7952

1

1

2

4

6 235..........................................................

4,970 4.6463

1

2

4

6

9 236.......................................................... 42,408 4.4748

1

3

4

5

8 237..........................................................

2,022 3.6682

1

2

3

4

7 238..........................................................

9,869 8.2633

3

4

6

10

15 239.......................................................... 42,943 6.0632

2

3

5

7

11 240.......................................................... 12,653 6.6177

2

3

5

8

13 241..........................................................

2,696 3.7066

1

2

3

5

7 242..........................................................

2,742 6.5864

2

3

5

8

12 243.......................................................... 101,477 4.5166

1

2

4

6

8 244.......................................................... 15,792 4.4924

1

2

4

6

8 245..........................................................

5,840 3.1334

1

1

3

4

6 246..........................................................

1,430 3.5664

1

2

3

4

7 247.......................................................... 21,671 3.3172

1

2

3

4

6 248.......................................................... 15,118 4.8397

1

3

4

6

9 249.......................................................... 14,026 3.8285

1

1

3

5

8 250..........................................................

4,155 3.8876

1

2

3

5

7 251..........................................................

2,148 2.7514

1

1

3

3

5 252..........................................................

1 1.0000

1

1

1

1

1 253.......................................................... 24,857 4.5324

2

3

4

5

8 254.......................................................... 10,420 3.0461

1

2

3

4

5 255..........................................................

1 7.0000

7

7

7

7

7 256..........................................................

7,152 5.0301

1

2

4

6

10 257.......................................................... 13,512 2.6104

1

1

2

3

5 258.......................................................... 12,042 1.7498

1

1

1

2

3 259..........................................................

2,903 2.7689

1

1

1

3

7 260..........................................................

2,991 1.4055

1

1

1

1

2 261..........................................................

1,603 2.2052

1

1

1

2

4 262..........................................................

636 4.8428

1

2

4

7

10 263.......................................................... 23,809 10.7403

3

5

8

13

21 264..........................................................

3,922 6.2358

2

3

5

8

12 265..........................................................

4,307 6.5677

1

2

4

8

14 266..........................................................

2,304 3.1788

1

1

2

4

7 267..........................................................

272 4.1838

1

1

3

5

10 268..........................................................

1,004 3.5508

1

1

2

4

7 269.......................................................... 10,686 8.3273

2

4

6

11

16 270..........................................................

2,639 3.8151

1

1

3

5

8 271.......................................................... 21,054 6.7875

2

3

5

8

12 272..........................................................

5,942 5.8009

2

3

4

7

11 273..........................................................

1,349 3.6449

1

2

3

5

7 274..........................................................

2,288 6.2592

2

3

5

8

12 275..........................................................

228 3.2456

1

1

2

4

7 276..........................................................

1,447 4.4630

1

2

4

6

8 277.......................................................... 112,318 5.5013

2

3

5

7

10 278.......................................................... 33,865 4.0567

2

2

3

5

7 279..........................................................

6 4.6667

1

3

5

6

6 280.......................................................... 19,272 4.0080

1

2

3

5

7 281..........................................................

7,093 2.8429

1

1

2

4

5 283..........................................................

6,274 4.5695

1

2

3

6

9 284..........................................................

1,833 3.0295

1

1

2

4

6 285..........................................................

7,623 10.0454

3

5

8

12

19 286..........................................................

2,703 5.4802

2

2

4

6

10 287..........................................................

6,114 9.8368

3

5

7

12

19 288.......................................................... 10,450 4.1090

2

2

3

4

7 289..........................................................

6,894 2.5582

1

1

1

2

5 290.......................................................... 10,859 2.1325

1

1

1

2

4 291..........................................................

64 2.7969

1

1

1

2

5 292..........................................................

7,331 10.0308

2

4

8

13

20 293..........................................................

368 4.4674

1

2

3

6

9 294.......................................................... 98,963 4.2920

1

2

3

5

8 295..........................................................

4,102 3.6675

1

2

3

4

7 296.......................................................... 254,706 4.7202

1

2

4

6

9 297.......................................................... 45,347 3.0710

1

2

3

4

6 298..........................................................

81 3.9383

1

1

2

4

7 299..........................................................

1,478 5.1604

1

2

4

6

10 300.......................................................... 21,343 5.8673

2

3

5

7

11 301..........................................................

3,901 3.4107

1

2

3

4

6

[[Page 23625]]

302..........................................................

9,649 8.1898

4

5

6

9

14 303.......................................................... 23,760 7.3943

3

4

6

9

14 304.......................................................... 13,826 8.4735

2

3

6

11

18 305..........................................................

3,087 3.2096

1

2

3

4

6 306..........................................................

6,350 5.4737

1

2

3

8

12 307..........................................................

2,066 2.0736

1

1

2

2

3 308..........................................................

7,093 6.1095

1

2

4

8

14 309..........................................................

3,559 2.0014

1

1

1

2

4 310.......................................................... 26,035 4.5265

1

2

3

6

10 311..........................................................

6,480 1.8782

1

1

1

2

3 312..........................................................

1,456 4.8365

1

1

3

6

11 313..........................................................

508 2.2165

1

1

2

3

4 314..........................................................

1 2.0000

2

2

2

2

2 315.......................................................... 36,565 6.7584

1

1

4

9

16 316.......................................................... 180,999 6.2874

2

3

5

8

12 317..........................................................

2,766 3.4678

1

1

2

4

7 318..........................................................

5,927 5.7441

1

2

4

7

11 319..........................................................

383 2.7546

1

1

2

3

6 320.......................................................... 218,684 5.0953

2

3

4

6

9 321.......................................................... 31,401 3.5963

1

2

3

4

6 322..........................................................

61 3.4918

2

2

3

4

6 323.......................................................... 20,482 3.0937

1

1

2

4

6 324..........................................................

5,421 1.8843

1

1

1

2

3 325..........................................................

9,615 3.6813

1

2

3

5

7 326..........................................................

2,584 2.6207

1

1

2

3

5 327..........................................................

5 2.6000

1

1

2

3

5 328..........................................................

606 3.4719

1

1

3

5

7 329..........................................................

72 1.8333

1

1

1

2

3 331.......................................................... 54,798 5.4332

1

2

4

7

11 332..........................................................

4,389 3.1246

1

1

2

4

6 333..........................................................

252 5.4921

1

2

3

7

13 334..........................................................

9,810 4.3009

2

2

3

5

7 335.......................................................... 11,931 2.6866

1

2

3

3

4 336.......................................................... 31,264 3.2999

1

2

2

4

7 337.......................................................... 25,156 1.9182

1

1

2

2

3 338..........................................................

652 6.1748

1

2

3

9

14 339..........................................................

1,253 5.1173

1

1

3

7

11 340..........................................................

2 5.0000

4

4

6

6

6 341..........................................................

3,185 3.1586

1

1

2

3

7 342..........................................................

565 3.4248

1

2

2

4

8 344..........................................................

2,693 2.7037

1

1

1

2

6 345..........................................................

1,461 4.8077

1

1

3

6

11 346..........................................................

3,966 5.7307

1

3

4

7

11 347..........................................................

247 3.0202

1

1

2

4

7 348..........................................................

4,171 4.0897

1

2

3

5

8 349..........................................................

575 2.3583

1

1

2

3

4 350..........................................................

7,137 4.4541

2

2

4

5

8 352..........................................................

975 4.0133

1

2

3

5

8 353..........................................................

2,735 6.3192

2

3

4

7

12 354..........................................................

7,612 5.6967

2

3

4

6

10 355..........................................................

4,937 3.0614

2

2

3

4

4 356.......................................................... 23,993 1.9281

1

1

2

2

3 357..........................................................

5,570 8.1269

3

4

6

10

15 358.......................................................... 20,798 3.9629

2

2

3

4

7 359.......................................................... 28,741 2.4058

1

2

2

3

4 360.......................................................... 14,764 2.5880

1

1

2

3

4 361..........................................................

272 3.0184

1

1

2

3

7 362..........................................................

2 1.0000

1

1

1

1

1 363..........................................................

2,128 3.7810

1

2

2

4

8 364..........................................................

1,451 4.1909

1

2

3

5

9 365..........................................................

1,622 7.7404

2

3

5

9

17 366..........................................................

4,789 6.4792

2

3

5

8

13 367..........................................................

456 2.9934

1

1

2

4

6 368..........................................................

3,924 6.6351

2

3

5

8

13 369..........................................................

3,613 3.2419

1

1

2

4

6 370..........................................................

1,843 5.1557

2

3

4

5

8 371..........................................................

2,244 3.3944

2

3

3

4

5 372..........................................................

1,164 3.1847

2

2

2

3

5 373..........................................................

4,871 2.2373

1

2

2

3

3 374..........................................................

156 2.7436

2

2

2

3

4

[[Page 23626]]

375..........................................................

6 4.0000

1

2

2

6

6 376..........................................................

388 3.3711

1

2

2

4

6 377..........................................................

77 4.4805

1

1

3

4

8 378..........................................................

196 2.3163

1

1

2

3

4 379..........................................................

508 2.8130

1

1

2

3

6 380..........................................................

91 2.1099

1

1

1

2

4 381..........................................................

212 2.2642

1

1

1

2

4 382..........................................................

43 1.4419

1

1

1

2

2 383..........................................................

2,473 3.6526

1

1

2

4

7 384..........................................................

132 2.5606

1

1

1

3

5 385..........................................................

1 1.0000

1

1

1

1

1 389..........................................................

1 21.0000

21

21

21

21

21 390..........................................................

1 1.0000

1

1

1

1

1 392..........................................................

2,203 9.1770

2

4

6

11

19 393..........................................................

1 4.0000

4

4

4

4

4 394..........................................................

2,820 7.3553

1

2

5

9

16 395.......................................................... 116,129 4.2575

1

2

3

5

8 396..........................................................

9 4.4444

1

1

2

3

6 397.......................................................... 18,482 5.1407

1

2

4

6

10 398.......................................................... 18,288 5.7016

2

3

4

7

11 399..........................................................

1,640 3.3250

1

2

3

4

6 401..........................................................

6,328 11.0390

2

5

9

14

22 402..........................................................

1,401 4.0293

1

1

3

5

9 403.......................................................... 31,865 7.9367

2

3

6

10

16 404..........................................................

3,802 4.1528

1

2

3

5

8 406..........................................................

2,224 9.9150

2

4

7

12

21 407..........................................................

584 3.8253

1

2

3

5

7 408..........................................................

2,170 8.1949

1

2

5

10

19 409..........................................................

1,808 5.7954

1

3

4

6

12 410.......................................................... 28,417 3.8214

1

2

3

5

6 411..........................................................

12 3.2500

1

2

2

4

4 412..........................................................

12 2.7500

1

1

1

3

4 413..........................................................

5,198 6.7563

2

3

5

9

13 414..........................................................

573 4.0244

1

2

3

5

8 415.......................................................... 50,826 14.0037

4

6

11

18

28 416.......................................................... 239,006 7.3769

2

3

6

9

14 417..........................................................

23 5.2174

1

2

3

5

10 418.......................................................... 28,508 6.1657

2

3

5

8

12 419.......................................................... 16,282 4.3857

1

2

3

5

8 420..........................................................

2,941 3.3747

1

2

3

4

6 421.......................................................... 11,882 4.0613

1

2

3

5

7 422..........................................................

52 3.7115

1

1

2

4

7 423..........................................................

8,637 8.2173

2

3

6

10

17 424..........................................................

1,071 11.7274

2

4

8

14

22 425.......................................................... 14,779 3.4569

1

1

3

4

7 426..........................................................

4,313 4.1203

1

2

3

5

8 427..........................................................

1,505 4.7375

1

2

3

5

9 428..........................................................

773 7.2549

1

2

5

8

15 429.......................................................... 25,479 5.4228

2

3

4

6

10 430.......................................................... 71,439 7.6737

2

3

6

9

15 431..........................................................

304 5.8947

1

2

4

7

12 432..........................................................

420 4.2548

1

2

3

5

8 433..........................................................

5,191 2.9626

1

1

2

3

6 439..........................................................

1,739 8.7993

1

3

5

10

19 440..........................................................

5,613 8.7825

2

3

6

10

18 441..........................................................

779 3.3813

1

1

2

4

7 442.......................................................... 18,017 8.6810

2

3

6

11

18 443..........................................................

3,384 3.3992

1

1

3

4

7 444..........................................................

5,892 4.0324

1

2

3

5

8 445..........................................................

2,346 2.8372

1

1

2

4

5 447..........................................................

6,264 2.5686

1

1

2

3

5 448..........................................................

1 2.0000

2

2

2

2

2 449.......................................................... 38,802 3.6742

1

1

3

4

7 450..........................................................

7,805 1.9867

1

1

1

2

4 451..........................................................

3 1.6667

1

1

1

3

3 452.......................................................... 27,634 4.8762

1

2

3

6

10 453..........................................................

5,437 2.7993

1

1

2

3

5 454..........................................................

3,837 4.1058

1

2

3

5

8 455..........................................................

846 2.2222

1

1

2

3

4 461..........................................................

2,722 5.1267

1

1

3

6

12

[[Page 23627]]

462..........................................................

7,761 10.1584

4

6

8

13

18 463.......................................................... 31,045 3.8939

1

2

3

5

7 464..........................................................

7,661 2.9141

1

1

2

4

5 465..........................................................

219 3.6347

1

1

2

4

7 466..........................................................

1,377 4.7117

1

1

2

5

9 467..........................................................

1,015 2.6788

1

1

2

3

5 468.......................................................... 50,458 12.8082

3

6

10

16

25 471.......................................................... 15,614 5.0496

3

3

4

5

8 473..........................................................

8,778 12.4026

2

3

7

18

32 475.......................................................... 116,534 11.0157

2

5

9

14

21 476..........................................................

3,025 10.4998

2

4

9

14

21 477.......................................................... 29,425 8.5246

1

3

6

11

18 478.......................................................... 113,660 7.1046

1

2

5

9

15 479.......................................................... 24,603 2.7884

1

1

2

4

6 480..........................................................

802 17.9102

7

9

13

22

36 481..........................................................

1,066 21.8208

10

16

20

25

35 482..........................................................

5,076 11.4967

4

6

9

14

21 484..........................................................

449 12.7506

2

6

10

17

25 485..........................................................

3,420 9.6038

4

5

7

11

18 486..........................................................

2,562 12.3478

2

6

10

16

25 487..........................................................

4,644 7.0540

1

3

5

9

14 488..........................................................

786 16.3422

4

7

13

22

35 489.......................................................... 13,461 8.3538

2

3

6

10

17 490..........................................................

5,204 5.3918

1

2

4

7

11 491.......................................................... 19,789 3.1423

1

2

3

3

5 492..........................................................

4,012 13.6269

3

5

6

23

31 493.......................................................... 61,628 6.0515

1

3

5

8

12 494.......................................................... 25,626 2.6772

1

1

2

4

5 495..........................................................

304 17.3092

8

9

13

19

31 496..........................................................

3,261 8.9877

3

4

6

11

18 497.......................................................... 27,838 5.8368

3

3

5

7

10 498.......................................................... 19,057 3.7703

2

3

3

5

6 499.......................................................... 35,676 4.3236

1

2

3

5

9 500.......................................................... 48,323 2.2420

1

1

2

3

4 501..........................................................

3,122 9.9308

4

5

8

13

18 502..........................................................

717 5.6987

2

3

5

7

9 503..........................................................

5,909 3.8284

1

2

3

5

7 504..........................................................

187 27.1818

8

16

23

36

49 505..........................................................

179 4.6704

1

1

1

6

11 506..........................................................

1,004 15.9273

3

7

13

21

33 507..........................................................

307 8.4919

1

3

7

11

18 508..........................................................

641 7.2044

1

3

5

9

15 509..........................................................

168 5.1607

1

2

3

6

11 510..........................................................

1,755 6.4160

1

2

4

8

14 511..........................................................

635 4.0787

1

1

2

5

8 512..........................................................

513 12.7719

7

8

10

14

23 513..........................................................

227 9.9824

5

7

8

12

16 515.......................................................... 44,478 4.3401

1

1

2

6

10 517.......................................................... 66,287 2.5801

1

1

1

3

6 518.......................................................... 42,044 3.4580

1

1

2

4

8 519.......................................................... 11,506 4.8233

1

1

3

6

11 520.......................................................... 15,266 2.0074

1

1

1

2

4 521.......................................................... 32,148 5.4742

2

3

4

7

11 522..........................................................

5,646 9.3666

3

4

7

12

19 523.......................................................... 15,866 3.8769

1

2

3

5

7 524.......................................................... 118,949 3.1907

1

2

3

4

6 525..........................................................

313 13.4952

1

3

8

16

32 527.......................................................... 192,230 2.2326

1

1

1

2

5 528..........................................................

1,770 17.1090

6

10

15

22

30 529..........................................................

4,032 7.9923

1

2

5

10

18 530..........................................................

2,363 3.1240

1

1

2

4

6 531..........................................................

4,799 9.4049

2

4

7

12

20 532..........................................................

2,622 3.7227

1

1

3

5

8 533.......................................................... 47,609 3.7364

1

1

2

4

9 534.......................................................... 45,285 1.7909

1

1

1

2

3 535..........................................................

7,387 10.3013

3

5

8

13

20 536..........................................................

8,055 7.6500

2

4

6

9

14 537..........................................................

8,641 6.7775

1

3

5

8

14 538..........................................................

5,604 2.8164

1

1

2

4

6 539..........................................................

5,020 10.7639

2

4

7

14

23

[[Page 23628]]

540..........................................................

1,510 3.5808

1

1

3

4

7 541.......................................................... 22,435 42.7921

17

24

35

52

76 542.......................................................... 24,376 32.5434

12

18

27

40

58 543..........................................................

5,415 11.9830

2

5

10

16

24 544.......................................................... 418,885 4.5100

3

3

4

5

7 545.......................................................... 42,337 5.1387

3

3

4

6

8 546..........................................................

1,958 9.1062

3

5

7

11

18 547.......................................................... 26,797 5.5682

2

3

4

7

10 548.......................................................... 11,935 3.0404

1

2

3

4

5 549.......................................................... 35,690 5.2044

2

3

4

6

10 550.......................................................... 20,187 2.8595

1

2

3

4

5

12,140,152

Table 8A.--Statewide Average Operating Cost-to-Charge Ratios--March 2005

State

Urban Rural

Alabama........................................... 0.279 0.348 Alaska............................................ 0.454 0.784 Arizona........................................... 0.295 0.392 Arkansas.......................................... 0.359 0.383 California........................................ 0.251 0.354 Colorado.......................................... 0.328 0.483 Connecticut....................................... 0.458 0.522 Delaware.......................................... 0.546 0.548 District of Columbia.............................. 0.386 ......... Florida........................................... 0.257 0.304 Georgia........................................... 0.373 0.426 Hawaii............................................ 0.404 0.479 Idaho............................................. 0.487 0.577 Illinois.......................................... 0.337 0.442 Indiana........................................... 0.439 0.47 Iowa.............................................. 0.407 0.505 Kansas............................................ 0.313 0.471 Kentucky.......................................... 0.401 0.404 Louisiana......................................... 0.306 0.369 Maine............................................. 0.504 0.489 Maryland.......................................... 0.762 0.827 Massachusetts..................................... 0.485 ......... Michigan.......................................... 0.396 0.496 Minnesota......................................... 0.404 0.531 Mississippi....................................... 0.354 0.391 Missouri.......................................... 0.346 0.408 Montana........................................... 0.437 0.481 Nebraska.......................................... 0.371 0.503 Nevada............................................ 0.245 0.558 New Hampshire..................................... 0.467 0.508 New Jersey........................................ 0.196 ......... New Mexico........................................ 0.428 0.414 New York.......................................... 0.372 0.526 North Carolina.................................... 0.454 0.439 North Dakota...................................... 0.418 0.467 Ohio.............................................. 0.389 0.543 Oklahoma.......................................... 0.332 0.423 Oregon............................................ 0.499 0.481 Pennsylvania...................................... 0.299 0.472 Puerto Rico....................................... 0.443 ......... Rhode Island...................................... 0.439 ......... South Carolina.................................... 0.313 0.34 South Dakota...................................... 0.385 0.498 Tennessee......................................... 0.337 0.402 Texas............................................. 0.309 0.38 Utah.............................................. 0.428 0.598 Vermont........................................... 0.577 0.635 Virginia.......................................... 0.386 0.398 Washington........................................ 0.454 0.497 West Virginia..................................... 0.492 0.472 Wisconsin......................................... 0.458 0.497 Wyoming........................................... 0.442 0.614

Table 8B.--Statewide Average Capital Cost-to-Charge Ratios--March 2005

State

Ratio

Alabama...................................................... 0.027 Alaska....................................................... 0.044 Arizona...................................................... 0.029 Arkansas..................................................... 0.03 California................................................... 0.019 Colorado..................................................... 0.03 Connecticut.................................................. 0.035 Delaware..................................................... 0.047 District of Columbia......................................... 0.029 Florida...................................................... 0.026 Georgia...................................................... 0.035 Hawaii....................................................... 0.034 Idaho........................................................ 0.041 Illinois..................................................... 0.03 Indiana...................................................... 0.041 Iowa......................................................... 0.033 Kansas....................................................... 0.033 Kentucky..................................................... 0.033 Louisiana.................................................... 0.032 Maine........................................................ 0.036 Maryland..................................................... 0.016 Massachusetts................................................ 0.036 Michigan..................................................... 0.037 Minnesota.................................................... 0.034 Mississippi.................................................. 0.032 Missouri..................................................... 0.029 Montana...................................................... 0.039 Nebraska..................................................... 0.039 Nevada....................................................... 0.019 New Hampshire................................................ 0.037 New Jersey................................................... 0.015 New Mexico................................................... 0.036 New York..................................................... 0.033 North Carolina............................................... 0.039 North Dakota................................................. 0.041 Ohio......................................................... 0.032 Oklahoma..................................................... 0.031 Oregon....................................................... 0.038 Pennsylvania................................................. 0.026 Puerto Rico.................................................. 0.033 Rhode Island................................................. 0.022 South Carolina............................................... 0.03 South Dakota................................................. 0.04 Tennessee.................................................... 0.034 Texas........................................................ 0.03 Utah......................................................... 0.039 Vermont...................................................... 0.045 Virginia..................................................... 0.039 Washington................................................... 0.037 West Virginia................................................ 0.033 Wisconsin.................................................... 0.038 Wyoming...................................................... 0.046

Table 9A.--Hospitals Reclassifications and Redesignations by Individual Hospitals and CBSA--FY 2006

Geographic Reclassified Provider number

CBSA

CBSA

Lugar

010005......................

01

13820 .......... 010008......................

01

33860 .......... 010012......................

01

16860 .......... 010022......................

01

40660 LUGAR

[[Page 23629]]

010025......................

01

17980 .......... 010029......................

12220

17980 .......... 010035......................

01

13820 .......... 010044......................

01

13820 .......... 010045......................

01

13820 .......... 010065......................

01

33860 .......... 010072......................

01

11500 LUGAR 010083......................

01

37860 .......... 010100......................

01

37860 .......... 010101......................

01

11500 LUGAR 010118......................

01

33860 .......... 010120......................

01

33660 .......... 010126......................

01

33860 .......... 010143......................

01

13820 .......... 010158......................

01

19460 .......... 030013......................

49740

20940 .......... 030033......................

03

22380 .......... 040014......................

04

30780 .......... 040017......................

04

44180 .......... 040019......................

04

32820 .......... 040020......................

27860

32820 .......... 040027......................

04

44180 .......... 040039......................

04

27860 .......... 040041......................

04

30780 .......... 040047......................

04

27860 .......... 040069......................

04

32820 .......... 040071......................

38220

30780 .......... 040072......................

04

30780 .......... 040076......................

04

30780 .......... 040078......................

26300

30780 .......... 040080......................

04

27860 .......... 040088......................

04

43340 .......... 040091......................

04

45500 .......... 040100......................

04

30780 .......... 040119......................

04

30780 .......... 050006......................

05

39820 .......... 050009......................

34900

46700 .......... 050013......................

34900

46700 .......... 050014......................

05

40900 .......... 050022......................

40140

42044 .......... 050042......................

05

39820 .......... 050046......................

37100

31084 .......... 050054......................

40140

42044 .......... 050065......................

42044

31084 .......... 050069......................

42044

31084 .......... 050071......................

41940

36084 .......... 050073......................

46700

36084 .......... 050076......................

41884

36084 .......... 050082......................

37100

31084 .......... 050089......................

40140

31084 .......... 050090......................

42220

41884 .......... 050099......................

40140

31084 .......... 050102......................

40140

42044 .......... 050118......................

44700

33700 .......... 050129......................

40140

31084 .......... 050136......................

42220

41884 .......... 050140......................

40140

31084 .......... 050150......................

05

40900 .......... 050159......................

37100

31084 .......... 050168......................

42044

31084 .......... 050173......................

42044

31084 .......... 050174......................

42220

41884 .......... 050177......................

37100

31084 .......... 050193......................

42044

31084 .......... 050224......................

42044

31084 .......... 050226......................

42044

31084 .......... 050228......................

41884

36084 .......... 050230......................

42044

31084 .......... 050236......................

37100

31084 .......... 050243......................

40140

42044 ..........

[[Page 23630]]

050245......................

40140

31084 .......... 050251......................

05

39900 .......... 050272......................

40140

31084 .......... 050279......................

40140

31084 .......... 050291......................

42220

41884 .......... 050292......................

40140

42044 .......... 050298......................

40140

31084 .......... 050300......................

40140

31084 .......... 050327......................

40140

31084 .......... 050329......................

40140

42044 .......... 050331......................

42220

41884 .......... 050348......................

42044

31084 .......... 050385......................

42220

41884 .......... 050390......................

40140

42044 .......... 050394......................

37100

31084 .......... 050419......................

05

39820 .......... 050423......................

40140

42044 .......... 050426......................

42044

31084 .......... 050430......................

05

39900 .......... 050510......................

41884

36084 .......... 050517......................

40140

31084 .......... 050526......................

42044

31084 .......... 050534......................

40140

42044 .......... 050535......................

42044

31084 .......... 050541......................

41884

36084 .......... 050543......................

42044

31084 .......... 050547......................

42220

41884 .......... 050548......................

42044

31084 .......... 050550......................

42044

31084 .......... 050551......................

42044

31084 .......... 050567......................

42044

31084 .......... 050569......................

05

42220 .......... 050570......................

42044

31084 .......... 050573......................

40140

42044 .......... 050580......................

42044

31084 .......... 050584......................

40140

31084 .......... 050585......................

42044

31084 .......... 050586......................

40140

31084 .......... 050589......................

42044

31084 .......... 050592......................

42044

31084 .......... 050594......................

42044

31084 .......... 050603......................

42044

31084 .......... 050609......................

42044

31084 .......... 050616......................

37100

31084 .......... 050667......................

34900

46700 .......... 050668......................

41884

36084 .......... 050678......................

42044

31084 .......... 050684......................

40140

42044 .......... 050686......................

40140

42044 .......... 050690......................

42220

41884 .......... 050693......................

42044

31084 .......... 050694......................

40140

42044 .......... 050701......................

40140

42044 .......... 050709......................

40140

31084 .......... 050718......................

40140

42044 .......... 050720......................

42044

31084 .......... 050728......................

42220

41884 .......... 060001......................

24540

19740 .......... 060003......................

14500

19740 .......... 060023......................

24300

39340 .......... 060027......................

14500

19740 .......... 060044......................

06

19740 .......... 060049......................

06

22660 .......... 060096......................

06

19740 .......... 060103......................

14500

19740 .......... 070003......................

07

25540 LUGAR 070021......................

07

25540 LUGAR 070033......................

14860

35644 .......... 080004......................

20100

48864 .......... 080007......................

08

36140 ..........

[[Page 23631]]

100022......................

33124

22744 .......... 100023......................

10

36740 .......... 100024......................

10

33124 .......... 100045......................

19660

36740 .......... 100049......................

10

29460 .......... 100081......................

10

23020 LUGAR 100109......................

10

36740 .......... 100118......................

10

27260 .......... 100139......................

10

23540 LUGAR 100150......................

10

33124 .......... 100157......................

29460

45300 .......... 100176......................

48424

38940 .......... 100217......................

46940

38940 .......... 100232......................

10

27260 .......... 100239......................

45300

42260 .......... 100249......................

10

36100 .......... 100252......................

10

38940 .......... 100292......................

10

23020 LUGAR 110001......................

19140

12060 .......... 110002......................

11

12060 .......... 110003......................

11

27260 .......... 110023......................

11

12060 .......... 110025......................

15260

27260 .......... 110029......................

23580

12060 .......... 110038......................

11

45220 .......... 110040......................

11

12060 LUGAR 110041......................

11

12020 .......... 110052......................

11

16860 LUGAR 110054......................

40660

12060 .......... 110069......................

47580

31420 .......... 110075......................

11

42340 .......... 110088......................

11

12060 LUGAR 110095......................

11

46660 .......... 110117......................

11

12060 LUGAR 110122......................

46660

45220 .......... 110125......................

11

31420 .......... 110128......................

11

42340 .......... 110150......................

11

31420 .......... 110153......................

47580

31420 .......... 110168......................

40660

12060 .......... 110187......................

11

12060 LUGAR 110189......................

11

12060 .......... 110205......................

11

12060 .......... 120028......................

12

26180 .......... 130002......................

13

14260 .......... 130003......................

30300

50 .......... 130049......................

17660

44060 .......... 140012......................

14

16974 .......... 140015......................

14

41180 .......... 140032......................

14

41180 .......... 140034......................

14

41180 .......... 140040......................

14

37900 .......... 140043......................

14

40420 .......... 140046......................

14

41180 .......... 140058......................

14

41180 .......... 140061......................

14

41180 .......... 140064......................

14

37900 .......... 140110......................

14

16974 .......... 140143......................

14

37900 .......... 140160......................

14

40420 .......... 140161......................

14

16974 .......... 140164......................

14

41180 .......... 140189......................

14

16580 .......... 140233......................

40420

16974 .......... 140234......................

14

37900 .......... 140236......................

14

28100 LUGAR 140291......................

29404

16974 .......... 150002......................

23844

16974 .......... 150004......................

23844

16974 .......... 150006......................

33140

43780 ..........

[[Page 23632]]

150008......................

23844

16974 .......... 150011......................

15

26900 .......... 150015......................

33140

16974 .......... 150030......................

15

26900 LUGAR 150048......................

15

17140 .......... 150065......................

15

26900 .......... 150069......................

15

17140 .......... 150076......................

15

43780 .......... 150088......................

11300

26900 .......... 150090......................

23844

16974 .......... 150102......................

15

23844 LUGAR 150112......................

18020

26900 .......... 150113......................

11300

26900 .......... 150125......................

23844

16974 .......... 150126......................

23844

16974 .......... 150132......................

23844

16974 .......... 150133......................

15

23060 .......... 150146......................

15

23060 .......... 150147......................

23844

16974 .......... 160001......................

16

11180 .......... 160016......................

16

19780 .......... 160026......................

16

11180 LUGAR 160057......................

16

26980 .......... 160080......................

16

40420 .......... 160089......................

16

19780 .......... 160147......................

16

11180 .......... 170006......................

17

27900 .......... 170010......................

17

46140 .......... 170012......................

17

48620 .......... 170013......................

17

48620 .......... 170020......................

17

48620 .......... 170022......................

17

28140 .......... 170023......................

17

48620 .......... 170033......................

17

48620 .......... 170058......................

17

28140 .......... 170068......................

17

11100 .......... 170120......................

17

27900 .......... 170142......................

17

45820 .......... 170175......................

17

48620 .......... 180005......................

18

26580 .......... 180011......................

18

30460 .......... 180012......................

21060

31140 .......... 180013......................

14540

34980 .......... 180017......................

18

21060 .......... 180018......................

18

30460 .......... 180019......................

18

17140 .......... 180024......................

18

31140 .......... 180027......................

18

17300 .......... 180028......................

18

26580 .......... 180029......................

18

28700 .......... 180044......................

18

26580 .......... 180048......................

18

31140 .......... 180066......................

18

34980 .......... 180069......................

18

26580 .......... 180075......................

18

14540 LUGAR 180078......................

18

26580 .......... 180080......................

18

28940 .......... 180093......................

18

21780 .......... 180102......................

18

17300 .......... 180104......................

18

17300 .......... 180116......................

18

14 .......... 180124......................

14540

34980 .......... 180127......................

18

31140 .......... 180132......................

18

30460 .......... 180139......................

18

30460 .......... 190001......................

19

35380 .......... 190003......................

19

29180 .......... 190015......................

19

35380 .......... 190086......................

19

43340 .......... 190099......................

19

12940 ..........

[[Page 23633]]

190106......................

19

10780 .......... 190131......................

12940

35380 .......... 190155......................

19

12940 LUGAR 190164......................

19

10780 .......... 190191......................

19

12940 .......... 190223......................

19

12940 LUGAR 200002......................

20

38860 .......... 200020......................

38860

40484 .......... 200024......................

30340

38860 .......... 200034......................

30340

38860 .......... 200039......................

20

38860 .......... 200050......................

20

12620 .......... 200063......................

20

38860 .......... 220001......................

49340

14484 .......... 220002......................

15764

14484 .......... 220003......................

49340

14484 .......... 220010......................

21604

14484 .......... 220011......................

15764

14484 .......... 220019......................

49340

14484 .......... 220025......................

49340

14484 .......... 220028......................

49340

14484 .......... 220029......................

21604

14484 .......... 220033......................

21604

14484 .......... 220035......................

21604

14484 .......... 220049......................

15764

14484 .......... 220058......................

49340

14484 .......... 220060......................

14484

12700 .......... 220062......................

49340

14484 .......... 220063......................

15764

14484 .......... 220070......................

15764

14484 .......... 220077......................

44140

25540 .......... 220080......................

21604

14484 .......... 220082......................

15764

14484 .......... 220084......................

15764

14484 .......... 220089......................

15764

14484 .......... 220090......................

49340

14484 .......... 220095......................

49340

14484 .......... 220098......................

15764

14484 .......... 220101......................

15764

14484 .......... 220105......................

15764

14484 .......... 220133......................

15764

14484 .......... 220163......................

49340

14484 .......... 220171......................

15764

14484 .......... 220174......................

21604

14484 .......... 230022......................

23

11460 .......... 230030......................

23

40980 .......... 230035......................

23

24340 LUGAR 230037......................

23

11460 .......... 230042......................

23

26100 LUGAR 230047......................

47644

19804 .......... 230054......................

23

24580 .......... 230069......................

47644

22420 .......... 230077......................

40980

22420 .......... 230080......................

23

40980 .......... 230093......................

23

24340 .......... 230096......................

23

28020 .......... 230099......................

33780

11460 .......... 230105......................

23

13020 .......... 230121......................

23

29620 LUGAR 230134......................

23

26100 LUGAR 230195......................

47644

19804 .......... 230204......................

47644

19804 .......... 230208......................

23

24340 LUGAR 230217......................

12980

29620 .......... 230227......................

47644

19804 .......... 230235......................

23

40980 LUGAR 230257......................

47644

19804 .......... 230264......................

47644

19804 .......... 230279......................

47644

22420 .......... 230295......................

23

26100 LUGAR

[[Page 23634]]

240013......................

24

33460 .......... 240018......................

24

33460 .......... 240030......................

24

41060 .......... 240031......................

41060

33460 .......... 240036......................

41060

33460 .......... 240052......................

24

22020 .......... 240064......................

24

20260 .......... 240069......................

24

40340 .......... 240071......................

24

40340 .......... 240075......................

24

41060 .......... 240088......................

24

41060 .......... 240093......................

24

33460 .......... 240105......................

24

40340 LUGAR 240150......................

24

40340 LUGAR 240152......................

24

33460 .......... 240187......................

24

33460 .......... 240211......................

24

33460 .......... 250004......................

25

32820 .......... 250006......................

25

32820 .......... 250009......................

25

27180 .......... 250023......................

25

25060 LUGAR 250031......................

25

27140 .......... 250034......................

25

32820 .......... 250040......................

37700

25060 .......... 250042......................

25

32820 .......... 250069......................

25

46220 .......... 250079......................

25

27140 .......... 250081......................

25

27140 .......... 250082......................

25

38220 .......... 250094......................

25620

25060 .......... 250097......................

25

12940 .......... 250099......................

25

27140 .......... 250100......................

25

46220 .......... 250104......................

25

27140 .......... 250117......................

25

25060 LUGAR 260009......................

26

28140 .......... 260011......................

27620

17860 .......... 260017......................

26

41180 .......... 260022......................

26

16 .......... 260025......................

26

41180 .......... 260047......................

27620

17860 .......... 260049......................

26

44180 LUGAR 260064......................

26

17860 .......... 260074......................

126

17860 .......... 260094......................

26

44180 .......... 260110......................

26

41180 .......... 260113......................

26

14 .......... 260116......................

26

14 .......... 260183......................

26

41180 .......... 260186......................

26

17860 .......... 270003......................

27

24500 .......... 270011......................

27

24500 .......... 270017......................

27

33540 .......... 270051......................

27

33540 .......... 280009......................

28

30700 .......... 280023......................

28

30700 .......... 280032......................

28

30700 .......... 280057......................

28

30700 .......... 280061......................

28

53 .......... 280065......................

28

24540 .......... 280077......................

28

36540 .......... 290002......................

29

16180 LUGAR 290006......................

29

39900 .......... 290008......................

29

29820 .......... 290019......................

16180

39900 .......... 300003......................

30

31700 .......... 300005......................

30

31700 .......... 300007......................

31700

15764 .......... 300011......................

31700

15764 .......... 300012......................

31700

15764 ..........

[[Page 23635]]

300014......................

40484

31700 .......... 300017......................

40484

21604 .......... 300018......................

40484

31700 .......... 300019......................

30

15764 .......... 300020......................

31700

15764 .......... 300023......................

40484

21604 .......... 300029......................

40484

21604 .......... 300034......................

31700

15764 .......... 310002......................

35084

35644 .......... 310009......................

35084

35644 .......... 310013......................

35084

35644 .......... 310015......................

35084

35644 .......... 310018......................

35084

35644 .......... 310031......................

15804

20764 .......... 310032......................

47220

48864 .......... 310038......................

20764

35644 .......... 310048......................

20764

35084 .......... 310054......................

35084

35644 .......... 310070......................

20764

35644 .......... 310076......................

35084

35644 .......... 310078......................

35084

35644 .......... 310083......................

35084

35644 .......... 310093......................

35084

35644 .......... 310096......................

35084

35644 .......... 310119......................

35084

35644 .......... 320005......................

22140

10740 .......... 320006......................

32

42140 .......... 320013......................

32

42140 .......... 320014......................

32

29740 .......... 320033......................

32

42140 LUGAR 320063......................

32

36220 .......... 320065......................

32

36220 .......... 330001......................

39100

35644 .......... 330004......................

28740

39100 .......... 330008......................

33

15380 LUGAR 330027......................

35004

35644 .......... 330038......................

33

40380 LUGAR 330062......................

33

27060 LUGAR 330073......................

33

40380 LUGAR 330085......................

33

45060 .......... 330094......................

33

28740 .......... 330136......................

33

45060 .......... 330157......................

33

45060 .......... 330181......................

35004

35644 .......... 330182......................

35004

35644 .......... 330191......................

24020

10580 .......... 330229......................

27460

21500 .......... 330235......................

33

45060 LUGAR 330239......................

27460

21500 .......... 330250......................

33

15540 .......... 330277......................

33

27060 .......... 330359......................

33

39100 LUGAR 330386......................

33

39100 LUGAR 340004......................

24660

49180 .......... 340008......................

34

16740 .......... 340010......................

24140

39580 .......... 340013......................

34

16740 .......... 340018......................

34

43900 LUGAR 340021......................

34

16740 .......... 340023......................

11700

24860 .......... 340027......................

34

24780 .......... 340039......................

34

16740 .......... 340050......................

34

22180 .......... 340051......................

34

25860 .......... 340068......................

34

48900 .......... 340069......................

39580

20500 .......... 340071......................

34

39580 LUGAR 340073......................

39580

20500 .......... 340091......................

24660

49180 .......... 340109......................

34

47260 ..........

[[Page 23636]]

340114......................

39580

20500 .......... 340115......................

34

20500 .......... 340124......................

34

39580 LUGAR 340127......................

34

20500 LUGAR 340129......................

34

16740 .......... 340131......................

34

24780 .......... 340136......................

34

20500 LUGAR 340138......................

39580

20500 .......... 340144......................

34

16740 .......... 340145......................

34

16740 LUGAR 340147......................

40580

39580 .......... 340173......................

39580

20500 .......... 350009......................

35

22020 .......... 360008......................

36

26580 .......... 360010......................

36

10420 .......... 360011......................

36

18140 .......... 360013......................

36

30620 .......... 360014......................

36

18140 .......... 360019......................

10420

17460 .......... 360020......................

10420

17460 .......... 360025......................

41780

17460 .......... 360027......................

10420

17460 .......... 360036......................

36

17460 .......... 360039......................

36

18140 .......... 360054......................

36

16620 .......... 360065......................

36

17460 .......... 360078......................

10420

17460 .......... 360079......................

19380

17140 .......... 360086......................

44220

19380 .......... 360096......................

36

49660 LUGAR 360107......................

36

17460 .......... 360112......................

45780

11460 .......... 360125......................

36

17460 LUGAR 360150......................

10420

17460 .......... 360159......................

36

18140 .......... 360175......................

36

18140 .......... 360185......................

36

49660 LUGAR 360187......................

44220

19380 .......... 360197......................

36

18140 .......... 360211......................

48260

38300 .......... 360238......................

36

49660 LUGAR 360241......................

10420

17460 .......... 360245......................

36

17460 LUGAR 370004......................

37

27900 .......... 370014......................

37

43300 .......... 370015......................

37

46140 .......... 370018......................

37

46140 .......... 370022......................

37

30020 .......... 370025......................

37

46140 .......... 370034......................

37

22900 .......... 370047......................

37

43300 .......... 370049......................

37

36420 .......... 370099......................

37

46140 .......... 370103......................

37

45 .......... 370113......................

37

22220 .......... 370179......................

37

46140 .......... 380001......................

38

38900 .......... 380008......................

38

18700 LUGAR 380022......................

38

18700 LUGAR 380027......................

38

21660 .......... 380047......................

13460

21660 .......... 380050......................

38

32780 .......... 380070......................

38

38900 .......... 390006......................

39

25420 .......... 390013......................

39

25420 .......... 390016......................

39

49660 .......... 390030......................

39

10900 .......... 390031......................

39

39740 LUGAR 390048......................

39

25420 .......... 390052......................

39

11020 ..........

[[Page 23637]]

390065......................

39

47894 .......... 390066......................

30140

25420 .......... 390071......................

39

48700 LUGAR 390079......................

39

13780 .......... 390081......................

37964

48864 .......... 390086......................

39

44300 .......... 390091......................

39

49660 .......... 390093......................

39

49660 .......... 390110......................

27780

38300 .......... 390113......................

39

49660 .......... 390133......................

10900

37964 .......... 390138......................

39

47894 .......... 390150......................

39

38300 LUGAR 390151......................

39

47894 .......... 390156......................

37964

48864 .......... 390180......................

37964

48864 .......... 390222......................

37964

48864 .......... 390224......................

39

13780 LUGAR 390244......................

39

48700 LUGAR 390246......................

39

48700 .......... 390249......................

39

13780 LUGAR 400048......................

25020

41980 .......... 410001......................

39300

14484 .......... 410004......................

39300

14484 .......... 410005......................

39300

14484 .......... 410006......................

39300

14484 .......... 410007......................

39300

14484 .......... 410008......................

39300

14484 .......... 410009......................

39300

14484 .......... 410011......................

39300

14484 .......... 410012......................

39300

14484 .......... 410013......................

39300

14484 .......... 420009......................

42

24860 LUGAR 420020......................

42

16700 .......... 420028......................

42

44940 LUGAR 420030......................

42

16700 .......... 420036......................

42

16740 .......... 420039......................

42

43900 LUGAR 420067......................

42

42340 .......... 420068......................

42

16700 .......... 420069......................

42

44940 LUGAR 420070......................

44940

17900 .......... 420071......................

42

24860 .......... 420080......................

42

42340 .......... 420085......................

34820

48900 .......... 430012......................

43

43620 .......... 430014......................

43

22020 .......... 430094......................

43

53 .......... 440008......................

44

21780 .......... 440020......................

44

26620 .......... 440035......................

17300

34980 .......... 440050......................

44

11700 .......... 440058......................

44

16860 .......... 440059......................

44

34980 .......... 440060......................

44

27180 .......... 440067......................

34100

28940 .......... 440068......................

44

16860 .......... 440072......................

44

32820 .......... 440073......................

44

34980 .......... 440148......................

44

34980 .......... 440151......................

44

34980 .......... 440175......................

44

34980 .......... 440180......................

44

28940 .......... 440185......................

17420

16860 .......... 440192......................

44

34980 .......... 450007......................

45

41700 .......... 450032......................

45

43340 .......... 450039......................

23104

19124 .......... 450059......................

41700

12420 .......... 450064......................

23104

19124 ..........

[[Page 23638]]

450073......................

45

10180 .......... 450080......................

45

30980 .......... 450087......................

23104

19124 .......... 450098......................

45

30980 .......... 450099......................

45

11100 .......... 450121......................

23104

19124 .......... 450135......................

23104

19124 .......... 450137......................

23104

19124 .......... 450144......................

45

36220 .......... 450148......................

23104

19124 .......... 450187......................

45

26420 .......... 450192......................

45

19124 .......... 450194......................

45

19124 .......... 450196......................

45

19124 .......... 450211......................

45

26420 .......... 450214......................

45

26420 .......... 450224......................

45

46340 .......... 450283......................

45

19124 LUGAR 450286......................

45

17780 LUGAR 450347......................

45

26420 .......... 450351......................

45

23104 .......... 450389......................

45

19124 LUGAR 450400......................

45

47380 .......... 450419......................

23104

19124 .......... 450438......................

45

26420 .......... 450447......................

45

19124 .......... 450451......................

45

23104 .......... 450484......................

45

26420 .......... 450508......................

45

46340 .......... 450547......................

45

19124 .......... 450563......................

23104

19124 .......... 450623......................

45

19124 LUGAR 450639......................

23104

19124 .......... 450653......................

45

33260 .......... 450656......................

45

46340 .......... 450672......................

23104

19124 .......... 450675......................

23104

19124 .......... 450677......................

23104

19124 .......... 450694......................

45

26420 .......... 450747......................

45

19124 .......... 450755......................

45

31180 .......... 450770......................

45

12420 LUGAR 450779......................

23104

19124 .......... 450830......................

45

36220 .......... 450839......................

45

43340 .......... 450858......................

23104

19124 .......... 450872......................

23104

19124 .......... 450880......................

23104

19124 .......... 460004......................

36260

41620 .......... 460005......................

36260

41620 .......... 460007......................

46

41100 .......... 460011......................

46

39340 .......... 460021......................

41100

29820 .......... 460036......................

46

39340 .......... 460039......................

46

36260 .......... 460041......................

36260

41620 .......... 460042......................

36260

41620 .......... 470001......................

47

30 .......... 470011......................

47

15764 .......... 470012......................

47

38340 .......... 490004......................

25500

16820 .......... 490005......................

49020

47894 .......... 490006......................

49

49020 LUGAR 490013......................

49

31340 .......... 490018......................

49

16820 .......... 490047......................

49

25500 LUGAR 490079......................

49

49180 .......... 490092......................

49

40060 .......... 490105......................

49

28700 .......... 490106......................

49

16820 ..........

[[Page 23639]]

490109......................

47260

40060 .......... 500002......................

50

28420 .......... 500003......................

34580

42644 .......... 500016......................

48300

42644 .......... 500024......................

36500

45104 .......... 500031......................

50

36500 .......... 500039......................

14740

42644 .......... 500041......................

31020

38900 .......... 500072......................

50

42644 .......... 500139......................

36500

45104 .......... 500143......................

36500

45104 .......... 510001......................

34060

38300 .......... 510002......................

51

40220 .......... 510006......................

51

38300 .......... 510018......................

51

16620 LUGAR 510024......................

34060

38300 .......... 510028......................

51

16620 .......... 510030......................

51

34060 .......... 510046......................

51

16620 .......... 510047......................

51

38300 .......... 510070......................

51

16620 .......... 510071......................

51

16620 .......... 510077......................

51

26580 .......... 520002......................

52

48140 .......... 520021......................

29404

16974 .......... 520028......................

52

31540 LUGAR 520037......................

52

48140 .......... 520059......................

39540

29404 .......... 520060......................

52

22540 LUGAR 520066......................

27500

31540 .......... 520071......................

52

33340 LUGAR 520076......................

52

31540 .......... 520088......................

22540

33340 .......... 520094......................

39540

33340 .......... 520095......................

52

31540 .......... 520096......................

39540

33340 .......... 520102......................

52

33340 LUGAR 520107......................

52

24580 .......... 520113......................

52

24580 .......... 520116......................

52

33340 LUGAR 520152......................

52

24580 .......... 520173......................

52

20260 .......... 520189......................

29404

16974 .......... 530002......................

53

16220 .......... 530025......................

53

22660

Table 9B.--Hospital Reclassifications and Redesignations by Individual Hospital Under Section 508 of Pub. L. 108- 173

Wage index CBSA Provider number

Geographic

508

Own wage index CBSA reclassification

010150........................................................

01

17980 .............. 020008........................................................

02 ................

1.2841 050494........................................................

05

42220 .............. 050549........................................................

37100

42220 .............. 060057........................................................

06

19740 .............. 060075........................................................

06 ................

1.1709 070001........................................................

35300

35004 .............. 070005........................................................

35300

35004 .............. 070010........................................................

14860

35644 .............. 070016........................................................

35300

35004 .............. 070017........................................................

35300

35004 .............. 070019........................................................

35300

35004 .............. 070022........................................................

35300

35004 .............. 070028........................................................

14860

35644 .............. 070031........................................................

35300

35004 .............. 070036........................................................

25540 ................

1.2926

[[Page 23640]]

070039........................................................

35300

35004 .............. 120025........................................................

12

26180 .............. 150034........................................................

23844

16974 .............. 160040........................................................

47940

16300 .............. 160064........................................................

16 ................

1.0228 160067........................................................

47940

16300 .............. 160110........................................................

47940

16300 .............. 190218........................................................

19

43340 .............. 220046........................................................

38340

14484 .............. 230003........................................................

26100

28020 .............. 230004........................................................

34740

28020 .............. 230013........................................................

47644

22420 .............. 230019........................................................

47644

22420 .............. 230020........................................................

19804

11460 .............. 230024........................................................

19804

11460 .............. 230029........................................................

47644

22420 .............. 230036........................................................

23

22420 .............. 230038........................................................

24340

28020 .............. 230053........................................................

19804

11460 .............. 230059........................................................

24340

28020 .............. 230066........................................................

34740

28020 .............. 230071........................................................

47644

22420 .............. 230072........................................................

26100

28020 .............. 230089........................................................

19804

11460 .............. 230092........................................................

27100

24340 .............. 230097........................................................

23

28020 .............. 230104........................................................

19804

11460 .............. 230106........................................................

24340

28020 .............. 230119........................................................

19804

11460 .............. 230130........................................................

47644

22420 .............. 230135........................................................

19804

11460 .............. 230146........................................................

19804

11460 .............. 230151........................................................

47644

22420 .............. 230165........................................................

19804

11460 .............. 230174........................................................

26100

28020 .............. 230176........................................................

19804

11460 .............. 230207........................................................

47644

22420 .............. 230223........................................................

47644

22420 .............. 230236........................................................

24340

28020 .............. 230254........................................................

47644

22420 .............. 230269........................................................

47644

22420 .............. 230270........................................................

19804

11460 .............. 230273........................................................

19804

11460 .............. 230277........................................................

47644

22420 .............. 250002........................................................

25

25060 .............. 250122........................................................

25

25060 .............. 270021........................................................

27

13740 .............. 270023........................................................

33540

13740 .............. 270032........................................................

27

13740 .............. 270050........................................................

27

13740 .............. 270057........................................................

27

13740 .............. 310021........................................................

45940

35644 .............. 310028........................................................

35084

35644 .............. 310050........................................................

35084

35644 .............. 310051........................................................

35084

35644 .............. 310060........................................................

10900

35644 .............. 310115........................................................

10900

35644 .............. 310120........................................................

35084

35644 .............. 330049........................................................

39100

35644 .............. 330067........................................................

39100

35300 .............. 330106........................................................

35004 ................

1.4734 330126........................................................

39100

35644 .............. 330135........................................................

39100

35644 .............. 330205........................................................

39100

35644 .............. 330264........................................................

39100

35004 .............. 340002........................................................

11700

16740 .............. 350002........................................................

13900

22020 .............. 350003........................................................

35

22020 .............. 350006........................................................

35

22020 ..............

[[Page 23641]]

350010........................................................

35

22020 .............. 350014........................................................

35

22020 .............. 350015........................................................

13900

22020 .............. 350017........................................................

35

22020 .............. 350030........................................................

35

22020 .............. 350061........................................................

35

22020 .............. 380090........................................................

38 ................

1.2316 390001........................................................

42540

10900 .............. 390003........................................................

39

10900 .............. 390054........................................................

42540

29540 .............. 390072........................................................

39

10900 .............. 390095........................................................

42540

10900 .............. 390109........................................................

42540

10900 .............. 390119........................................................

42540

10900 .............. 390137........................................................

42540

10900 .............. 390169........................................................

42540

10900 .............. 390185........................................................

42540

29540 .............. 390192........................................................

42540

10900 .............. 390237........................................................

42540

10900 .............. 390270........................................................

42540

29540 .............. 410010........................................................

39300 ................

1.1746 430005........................................................

43

39660 .............. 430015........................................................

43

43620 .............. 430048........................................................

43

43620 .............. 430060........................................................

43

43620 .............. 430064........................................................

43

43620 .............. 430077........................................................

39660

43620 .............. 430091........................................................

39660

43620 .............. 450010........................................................

48660

32580 .............. 450072........................................................

26420

26420 .............. 450591........................................................

26420

26420 .............. 470003........................................................

15540

14484 .............. 490001........................................................

49

31340 .............. 490024........................................................

40220

19260 .............. 530015........................................................

53 ................

0.9897 070006*.......................................................

14860

35644 .............. 070018*.......................................................

14860

35644 .............. 070034*.......................................................

14860

35644 .............. 140155*.......................................................

28100

16974 .............. 140186*.......................................................

28100

16974 .............. 250078*.......................................................

25620

25060 .............. 270002*.......................................................

27

33540 .............. 270012*.......................................................

24500

33540 .............. 270084*.......................................................

27

33540 .............. 330023*.......................................................

39100

35644 .............. 330067*.......................................................

39100

35644 .............. 350019*.......................................................

24220

22020 .............. 430008*.......................................................

43

43620 .............. 430013*.......................................................

43

43620 .............. 430031*.......................................................

43

43620 .............. 530008*.......................................................

53

16220 .............. 530010*.......................................................

53

16220

Table 9C.--Hospitals Redesignated as Rural Under Section 1886(d)(8)(E) of the Act

Geographic Redesignated Provider number

CBSA

rural area

030007..................................

39140

03 040075..................................

22220

04 050192..................................

23420

05 050469..................................

40140

05 050528..................................

32900

05 050618..................................

40140

05 070004..................................

25540

07 100048..................................

37860

10 100134..................................

27260

10 130018..................................

26820

13

[[Page 23642]]

140167..................................

14

14 150051..................................

14020

15 150078..................................

23844

15 170137..................................

29940

17 190048..................................

26380

19 230078..................................

35660

23 240037..................................

33460

24 260006..................................

41140

26 300009..................................

31700

30 370054..................................

36420

37 380040..................................

13460

38 380084..................................

41420

38 390181..................................

39

39 390183..................................

39

39 390201..................................

39

39 450052..................................

45

45 450078..................................

10180

45 450243..................................

10180

45 450276..................................

48660

45 450348..................................

45

45 500023..................................

28420

50 500037..................................

49420

50 500122..................................

50

50 500147..................................

42644

50 500148..................................

48300

50

Table 10.--Geometric Mean Plus the Lesser of .75 of the National Adjusted Operating Standardized Payment Amount (Increased to Reflect the Difference Between Costs and Charges) or .75 of One Standard Deviation

of Mean Charges by Diagnosis-Related Group (DRG)--March 2005 \1\

DRG

Cases Threshold

1............................................. 23,252 $53,083 2............................................. 10,344 $37,759 3.............................................

4 $48,426 6.............................................

410 $15,918 7............................................. 15,583 $41,465 8.............................................

3,699 $30,770 9.............................................

1,942 $26,987 10............................................ 19,496 $24,514 11............................................

3,278 $17,942 12............................................ 54,365 $17,418 13............................................

7,327 $16,737 14............................................ 236,739 $24,767 15............................................ 76,007 $18,842 16............................................ 16,254 $26,229 17............................................

3,005 $14,673 18............................................ 33,048 $19,757 19............................................

8,553 $14,440 20............................................

6,528 $41,346 21............................................

2,195 $28,454 22............................................

3,315 $23,057 23............................................ 10,714 $15,561 24............................................ 63,800 $19,706 25............................................ 28,130 $12,635 26............................................

18 $25,170 27............................................

5,385 $26,078 28............................................ 17,543 $26,266 29............................................

6,262 $14,651 31............................................

5,087 $19,123 32............................................

1,981 $12,778 34............................................ 27,853 $19,761 35............................................

7,887 $12,867 36............................................

1,469 $14,560 37............................................

1,237 $23,489 38............................................

56 $14,212 39............................................

447 $14,248 40............................................

1,382 $19,777 42............................................

1,144 $16,384 43............................................

125 $11,950 44............................................

1,159 $13,657 45............................................

2,798 $15,147 46............................................

3,816 $15,156 47............................................

1,334 $10,768 49............................................

2,474 $32,109 50............................................

2,161 $17,332 51............................................

190 $18,236 52............................................

165 $17,220 53............................................

2,223 $26,424 55............................................

1,353 $18,794 56............................................

435 $17,620 57............................................

697 $22,175 59............................................

102 $15,452 60............................................

8 $16,595 61............................................

219 $25,804 63............................................

2,841 $27,928 64............................................

3,339 $23,367 65............................................ 41,395 $12,285 66............................................

8,002 $11,762 67............................................

418 $15,509 68............................................ 17,310 $13,327 69............................................

4,810 $9,913 70............................................

25 $8,304 71............................................

68 $15,084 72............................................

1,065 $15,307 73............................................

7,925 $16,547 74............................................

4 $7,279 75............................................ 45,004 $47,996 76............................................ 47,304 $43,717 77............................................

2,153 $24,202 78............................................ 45,589 $24,850 79............................................ 170,543 $30,457 80............................................

7,717 $17,767 81............................................

4 $37,091 82............................................ 65,088 $27,672 83............................................

6,944 $19,629 84............................................

1,470 $11,706 85............................................ 21,855 $24,898 86............................................

1,859 $14,235 87............................................ 82,642 $27,783 88............................................ 413,274 $17,776 89............................................ 550,119 $20,636 90............................................ 45,801 $12,316 91............................................

45 $16,785 92............................................ 16,483 $23,911 93............................................

1,596 $14,444 94............................................ 13,330 $23,013 95............................................

1,609 $12,307 96............................................ 59,079 $14,840

[[Page 23643]]

97............................................ 26,996 $10,870 98............................................

8 $8,495 99............................................ 21,531 $14,399 100...........................................

6,934 $11,081 101........................................... 23,083 $17,487 102...........................................

5,236 $11,147 103...........................................

724 $214,160 104........................................... 20,904 $117,844 105........................................... 31,499 $89,729 106...........................................

3,492 $108,656 107........................................... 69,982 $85,171 108...........................................

7,942 $85,326 109........................................... 50,600 $65,918 110........................................... 57,121 $59,055 111........................................... 10,070 $44,900 113........................................... 37,225 $44,754 114...........................................

8,509 $31,122 115........................................... 22,119 $58,803 116........................................... 118,448 $43,379 117...........................................

5,146 $26,461 118...........................................

7,591 $33,464 119...........................................

993 $26,580 120........................................... 36,272 $36,812 121........................................... 159,450 $30,813 122........................................... 61,715 $19,625 123........................................... 33,617 $27,218 124........................................... 130,598 $28,749 125........................................... 95,641 $22,067 126...........................................

5,822 $42,108 127........................................... 695,047 $20,505 128...........................................

5,170 $13,906 129...........................................

3,751 $20,637 130........................................... 89,029 $18,640 131........................................... 23,806 $11,216 132........................................... 117,219 $12,597 133...........................................

7,276 $10,986 134........................................... 42,382 $12,400 135...........................................

7,433 $17,747 136...........................................

1,133 $12,797 138........................................... 206,854 $16,622 139........................................... 78,506 $10,671 140........................................... 38,098 $10,335 141........................................... 121,790 $15,337 142........................................... 52,218 $12,040 143........................................... 249,138 $11,604 144........................................... 99,593 $25,098 145...........................................

6,178 $11,899 146........................................... 10,762 $44,908 147...........................................

2,627 $29,912 148........................................... 135,543 $51,340 149........................................... 19,884 $28,508 150........................................... 22,692 $45,073 151...........................................

5,351 $25,703 152...........................................

5,006 $34,651 153...........................................

2,089 $21,823 154........................................... 28,473 $55,952 155...........................................

6,159 $25,835 156...........................................

6 $52,265 157...........................................

8,254 $26,362 158...........................................

4,104 $13,493 159........................................... 19,160 $28,111 160........................................... 11,968 $17,182 161........................................... 10,417 $23,781 162...........................................

5,486 $13,865 163...........................................

10 $14,004 164...........................................

5,941 $39,874 165...........................................

2,518 $23,716 166...........................................

4,928 $28,877 167...........................................

4,623 $17,916 168...........................................

1,544 $25,383 169...........................................

754 $14,788 170........................................... 17,464 $44,402 171...........................................

1,483 $24,371 172........................................... 32,853 $27,512 173...........................................

2,388 $15,475 174........................................... 267,618 $20,328 175........................................... 32,616 $11,567 176........................................... 14,542 $22,357 177...........................................

8,545 $18,625 178...........................................

2,903 $14,386 179........................................... 14,417 $21,872 180........................................... 92,094 $19,340 181........................................... 25,878 $11,462 182........................................... 291,824 $16,956 183........................................... 86,469 $12,060 184...........................................

78 $10,539 185...........................................

5,678 $17,264 186...........................................

4 $6,213 187...........................................

621 $17,068 188........................................... 90,890 $22,183 189........................................... 13,170 $12,414 190...........................................

69 $12,679 191........................................... 10,395 $54,119 192...........................................

1,322 $33,415 193...........................................

4,505 $50,334 194...........................................

520 $32,038 195...........................................

3,247 $49,676 196...........................................

699 $32,386 197........................................... 17,294 $41,808 198...........................................

4,629 $24,029 199...........................................

1,422 $38,851 200...........................................

936 $39,812 201...........................................

2,664 $51,676 202........................................... 27,245 $26,568 203........................................... 31,633 $27,380 204........................................... 72,764 $22,089 205........................................... 31,436 $23,369 206...........................................

2,075 $14,944 207........................................... 35,719 $23,543 208...........................................

9,747 $14,208 210........................................... 128,257 $35,917 211........................................... 26,620 $24,559 212...........................................

10 $26,686 213........................................... 10,256 $34,143 216........................................... 17,645 $36,166 217........................................... 17,611 $42,611 218........................................... 28,683 $32,278 219........................................... 21,323 $20,929 220...........................................

4 $31,838 223........................................... 13,414 $22,467 224........................................... 10,864 $16,561 225...........................................

6,508 $24,064 226...........................................

6,656 $29,923 227...........................................

5,068 $16,786 228...........................................

2,639 $23,112 229...........................................

1,198 $14,205 230...........................................

2,564 $26,523 232...........................................

721 $19,464 233........................................... 15,107 $35,245 234...........................................

7,659 $25,357 235...........................................

4,964 $14,917 236........................................... 42,358 $14,238 237...........................................

2,019 $12,305 238...........................................

9,863 $27,442 239........................................... 42,910 $21,095 240........................................... 12,638 $25,924 241...........................................

2,693 $13,360 242...........................................

2,742 $22,347 243........................................... 101,378 $15,581 244........................................... 15,777 $14,369 245...........................................

5,832 $9,431 246...........................................

1,429 $12,106 247........................................... 21,645 $11,781 248........................................... 15,098 $17,268 249........................................... 14,017 $13,881 250...........................................

4,149 $13,866 251...........................................

2,146 $9,765 253........................................... 24,829 $15,141 254........................................... 10,404 $9,271 256...........................................

7,144 $16,671 257........................................... 13,494 $17,881 258........................................... 12,014 $14,270 259...........................................

2,898 $19,381 260...........................................

2,981 $14,202 261...........................................

1,603 $19,576 262...........................................

636 $19,862 263........................................... 23,791 $33,555 264...........................................

3,921 $20,803 265...........................................

4,304 $29,777 266...........................................

2,303 $17,605 267...........................................

272 $18,035 268...........................................

1,003 $23,142 269........................................... 10,670 $31,752 270...........................................

2,635 $16,856 271........................................... 21,019 $19,407 272...........................................

5,931 $19,148 273...........................................

1,348 $11,532 274...........................................

2,287 $23,181 275...........................................

228 $11,152 276...........................................

1,445 $13,974 277........................................... 112,171 $17,127 278........................................... 33,823 $10,861 279...........................................

6 $17,172 280........................................... 19,255 $14,562 281...........................................

7,092 $9,993 283...........................................

6,268 $14,563 284...........................................

1,829 $9,200 285...........................................

7,615 $35,872 286...........................................

2,702 $35,486 287...........................................

6,107 $32,104 288........................................... 10,432 $37,872 289...........................................

6,881 $18,298 290........................................... 10,827 $17,619

[[Page 23644]]

291...........................................

64 $18,543 292...........................................

7,321 $41,142 293...........................................

367 $27,840 294........................................... 98,864 $15,044 295...........................................

4,096 $14,601 296........................................... 254,455 $16,168 297........................................... 45,318 $9,887 298...........................................

81 $9,998 299...........................................

1,478 $20,010 300........................................... 21,321 $21,770 301...........................................

3,896 $12,544 302...........................................

9,646 $52,723 303........................................... 23,740 $39,286 304........................................... 13,816 $38,375 305...........................................

3,084 $23,623 306...........................................

6,341 $25,247 307...........................................

2,061 $12,398 308...........................................

7,089 $30,158 309...........................................

3,555 $18,659 310........................................... 26,019 $23,711 311...........................................

6,468 $13,013 312...........................................

1,454 $22,529 313...........................................

507 $14,119 315........................................... 36,526 $35,138 316........................................... 180,759 $25,061 317...........................................

2,756 $16,124 318...........................................

5,923 $23,425 319...........................................

382 $13,277 320........................................... 218,425 $17,103 321........................................... 31,366 $11,424 322...........................................

61 $11,164 323........................................... 20,454 $16,793 324...........................................

5,414 $10,413 325...........................................

9,600 $13,014 326...........................................

2,574 $9,069 327...........................................

5 $5,743 328...........................................

606 $14,673 329...........................................

71 $10,155 331........................................... 54,748 $20,954 332...........................................

4,387 $12,467 333...........................................

251 $18,573 334...........................................

9,802 $28,443 335........................................... 11,919 $21,877 336........................................... 31,235 $16,658 337........................................... 25,130 $11,427 338...........................................

652 $27,712 339...........................................

1,253 $23,286 340...........................................

2 $18,734 341...........................................

3,183 $25,976 342...........................................

563 $17,354 344...........................................

2,691 $25,572 345...........................................

1,461 $22,328 346...........................................

3,962 $21,235 347...........................................

247 $12,515 348...........................................

4,171 $14,696 349...........................................

575 $8,797 350...........................................

7,134 $14,636 352...........................................

973 $14,967 353...........................................

2,725 $32,476 354...........................................

7,603 $29,914 355...........................................

4,922 $17,549 356........................................... 23,932 $14,960 357...........................................

5,563 $38,097 358........................................... 20,763 $22,658 359........................................... 28,654 $15,907 360........................................... 14,748 $17,209 361...........................................

272 $22,454 362...........................................

2 $11,608 363...........................................

2,127 $19,999 364...........................................

1,449 $17,758 365...........................................

1,620 $32,955 366...........................................

4,786 $24,830 367...........................................

455 $12,018 368...........................................

3,920 $23,343 369...........................................

3,610 $12,832 370...........................................

1,838 $17,389 371...........................................

2,236 $11,866 372...........................................

1,162 $9,834 373...........................................

4,860 $7,061 374...........................................

156 $13,290 375...........................................

6 $33,543 376...........................................

388 $10,147 377...........................................

77 $25,958 378...........................................

195 $15,828 379...........................................

507 $7,202 380...........................................

91 $7,834 381...........................................

212 $12,620 382...........................................

43 $4,126 383...........................................

2,472 $9,812 384...........................................

132 $6,300 392...........................................

2,202 $45,471 394...........................................

2,818 $31,480 395........................................... 115,973 $16,480 396...........................................

9 $15,832 397........................................... 18,425 $24,257 398........................................... 18,256 $24,100 399...........................................

1,634 $13,682 401...........................................

6,325 $43,589 402...........................................

1,401 $24,076 403........................................... 31,827 $30,787 404...........................................

3,799 $18,943 406...........................................

2,222 $42,772 407...........................................

583 $24,742 408...........................................

2,170 $33,802 409...........................................

1,807 $24,850 410........................................... 28,395 $22,712 411...........................................

12 $7,141 412...........................................

12 $16,545 413...........................................

5,193 $26,451 414...........................................

572 $16,081 415........................................... 50,799 $51,864 416........................................... 238,848 $29,646 417...........................................

23 $20,595 418........................................... 28,478 $21,320 419........................................... 16,269 $17,124 420...........................................

2,939 $12,324 421........................................... 11,866 $14,876 422...........................................

52 $10,935 423...........................................

8,631 $29,978 424...........................................

1,071 $36,011 425........................................... 14,758 $12,572 426...........................................

4,309 $9,562 427...........................................

1,504 $10,543 428...........................................

769 $13,558 429........................................... 25,454 $15,545 430........................................... 71,402 $12,774 431...........................................

304 $10,532 432...........................................

420 $12,850 433...........................................

5,189 $5,613 439...........................................

1,738 $30,816 440...........................................

5,606 $30,736 441...........................................

779 $18,744 442........................................... 18,000 $37,969 443...........................................

3,382 $20,255 444...........................................

5,891 $14,879 445...........................................

2,345 $10,336 447...........................................

6,258 $10,696 449........................................... 38,766 $16,579 450...........................................

7,787 $8,697 451...........................................

3 $5,847 452........................................... 27,610 $20,394 453...........................................

5,431 $10,730 454...........................................

3,835 $15,920 455...........................................

846 $9,717 461...........................................

2,722 $27,440 462...........................................

7,751 $16,591 463........................................... 31,026 $13,855 464...........................................

7,651 $10,292 465...........................................

219 $12,019 466...........................................

1,377 $12,550 467...........................................

1,013 $9,726 468........................................... 50,411 $55,817 470...........................................

32 $13,204 471........................................... 15,474 $55,297 473...........................................

8,761 $39,707 475........................................... 116,437 $51,182 476...........................................

3,018 $36,994 477........................................... 29,401 $33,866 478........................................... 113,571 $40,296 479........................................... 24,583 $29,518 480...........................................

800 $120,367 481...........................................

1,065 $86,015 482...........................................

5,070 $49,484 484...........................................

449 $74,694 485...........................................

3,412 $50,963 486...........................................

2,562 $66,540 487...........................................

4,640 $32,711 488...........................................

786 $58,001 489........................................... 13,453 $29,620 490...........................................

5,203 $21,034 491........................................... 19,730 $32,883 492...........................................

4,005 $44,873 493........................................... 61,564 $35,020 494........................................... 25,546 $20,780 495...........................................

303 $109,115 496...........................................

3,255 $92,679 497........................................... 27,777 $59,046 498........................................... 19,008 $49,170 499........................................... 35,640 $27,782 500........................................... 48,213 $18,126 501...........................................

3,120 $43,064 502...........................................

717 $28,008 503...........................................

5,905 $24,316

[[Page 23645]]

504...........................................

187 $136,123 505...........................................

179 $27,684 506...........................................

1,004 $51,873 507...........................................

307 $32,100 508...........................................

641 $24,619 509...........................................

168 $14,897 510...........................................

1,755 $21,890 511...........................................

633 $12,748 512...........................................

513 $81,413 513...........................................

227 $97,844 515........................................... 44,389 $88,758 517........................................... 66,155 $40,225 518........................................... 42,015 $35,092 519........................................... 11,497 $43,638 520........................................... 15,218 $33,659 521........................................... 32,138 $13,596 522...........................................

5,642 $9,515 523........................................... 15,863 $7,639 524........................................... 118,842 $14,823 525...........................................

313 $139,715 527........................................... 191,680 $44,147 528...........................................

1,767 $102,318 529...........................................

4,030 $37,957 530...........................................

2,362 $24,232 531...........................................

4,796 $45,158 532...........................................

2,622 $29,368 533........................................... 47,549 $31,277 534........................................... 45,166 $20,426 535...........................................

7,384 $123,742 536...........................................

8,047 $108,821 537...........................................

8,640 $33,393 538...........................................

5,598 $20,028 539...........................................

5,014 $44,863 540...........................................

1,509 $23,964 541........................................... 22,410 $242,891 542........................................... 24,343 $155,852 543...........................................

5,403 $62,826 544........................................... 417,780 $37,604 545........................................... 42,280 $44,313 546...........................................

1,954 $77,955 547........................................... 26,756 $49,899 548........................................... 11,898 $41,613 549........................................... 35,640 $55,680 550........................................... 20,130 $47,573

\1\ Cases are taken from the FY 2004 MedPAR file; DRGs are from GROUPER Version 23.0.

Table 11.--Proposed FY 2006 LTC-DRGs, Relative Weights, Geometric Average Length of Stay, and 5/6ths of the Geometric Average Length of Stay

5/6ths of Geometric the Relative average geometric

LTC-DRG

Description weight length of average stay length of stay

1.............. \5\ CRANIOTOMY

1.6862

38.0

31.7 AGE >17 W CC. 2.............. \7\ CRANIOTOMY

1.6862

38.0

31.7 AGE >17 W/O CC. 3.............. \7\ CRANIOTOMY

1.6862

38.0

31.7 AGE 0-17. 6.............. \7\ CARPAL

0.4502

18.8

15.7 TUNNEL RELEASE. 7.............. PERIPH & CRANIAL 1.3854

37.5

31.3 NERVE & OTHER NERV SYST PROC W CC. 8.............. \3\ PERIPH &

0.7586

24.5

20.4 CRANIAL NERVE & OTHER NERV SYST PROC W/O CC. 9.............. SPINAL DISORDERS 0.9617

33.2

27.7 & INJURIES. 10............. NERVOUS SYSTEM

0.7441

24.2

20.2 NEOPLASMS W CC. 11............. \2\ NERVOUS

0.5834

21.0

17.5 SYSTEM NEOPLASMS W/O CC. 12............. DEGENERATIVE

0.6903

25.5

21.3 NERVOUS SYSTEM DISORDERS. 13............. MULTIPLE

0.6625

23.0

19.2 SCLEROSIS & CEREBELLAR ATAXIA. 14............. INTERCRANIAL

0.7758

25.9

21.6 HEMORRHAGE OR STROKE WITH INFARCT. 15............. NONSPECIFIC CVA

0.7398

27.0

22.5 & PRECEREBRAL OCCULUSION WITHOUT INFARCT. 16............. NONSPECIFIC

0.7507

23.5

19.6 CEREBROVASCULAR DISORDERS W CC. 17............. \1\ NONSPECIFIC

0.4502

18.8

15.7 CEREBROVASCULAR DISORDERS W/O CC. 18............. CRANIAL &

0.7242

23.6

19.7 PERIPHERAL NERVE DISORDERS W CC. 19............. CRANIAL &

0.4809

21.2

17.7 PERIPHERAL NERVE DISORDERS W/O CC. 20............. NERVOUS SYSTEM

1.0284

27.1

22.6 INFECTION EXCEPT VIRAL MENINGITIS. 21............. \3\ VIRAL

0.7586

24.5

20.4 MENINGITIS. 22............. \4\ HYPERTENSIVE 1.1679

29.6

24.7 ENCEPHALOPATHY. 23............. NONTRAUMATIC

0.8101

25.4

21.2 STUPOR & COMA. 24............. SEIZURE &

0.6262

22.4

18.7 HEADACHE AGE >17 W CC. 25............. \1\ SEIZURE &

0.4502

18.8

15.7 HEADACHE AGE >17 W/O CC. 26............. \7\ SEIZURE &

0.4502

18.8

15.7 HEADACHE AGE 0- 17. 27............. TRAUMATIC STUPOR 0.9658

27.7

23.1 & COMA, COMA >1 HR. 28............. TRAUMATIC STUPOR 0.9042

30.2

25.2 & COMA, COMA 17 W CC. 29............. \1\ TRAUMATIC

0.4502

18.8

15.7 STUPOR & COMA, COMA 17 W/O CC. 30............. \7\ TRAUMATIC

0.4502

18.8

15.7 STUPOR & COMA, COMA 17 W CC. 32............. \7\ CONCUSSION

0.4502

18.8

15.7 AGE >17 W/O CC. 33............. \7\ CONCUSSION

0.4502

18.8

15.7 AGE 0-17. 34............. OTHER DISORDERS

0.8056

25.2

21 OF NERVOUS SYSTEM W CC. 35............. OTHER DISORDERS

0.5758

24.0

20 OF NERVOUS SYSTEM W/O CC. 36............. \7\ RETINAL

1.1679

29.6

24.7 PROCEDURES. 37............. \7\ ORBITAL

1.1679

29.6

24.7 PROCEDURES.

[[Page 23646]]

38............. \7\ PRIMARY IRIS 1.1679

29.6

24.7 PROCEDURES. 39............. \7\ LENS

1.1679

29.6

24.7 PROCEDURES WITH OR WITHOUT VITRECTOMY. 40............. \4\ EXTRAOCULAR

1.1679

29.6

24.7 PROCEDURES EXCEPT ORBIT AGE >17. 41............. \7\ EXTRAOCULAR

1.1679

29.6

24.7 PROCEDURES EXCEPT ORBIT AGE 0-17. 42............. \7\ INTRAOCULAR

1.1679

29.6

24.7 PROCEDURES EXCEPT RETINA, IRIS & LENS. 43............. \7\ HYPHEMA..... 1.1679

29.6

24.7 44............. \2\ ACUTE MAJOR

0.5834

21.0

17.5 EYE INFECTIONS. 45............. \7\ NEUROLOGICAL 1.1679

29.6

24.7 EYE DISORDERS. 46............. \2\ OTHER

0.5834

21.0

17.5 DISORDERS OF THE EYE AGE >17 W CC. 47............. \7\ OTHER

1.1679

29.6

24.7 DISORDERS OF THE EYE AGE >17 W/O CC. 48............. \7\ OTHER

1.1679

29.6

24.7 DISORDERS OF THE EYE AGE 0- 17. 49............. \7\ MAJOR HEAD & 1.1679

29.6

24.7 NECK PROCEDURES. 50............. \7\

1.1679

29.6

24.7 SIALOADENECTOMY. 51............. \7\ SALIVARY

1.1679

29.6

24.7 GLAND PROCEDURES EXCEPT SIALOADENECTOMY. 52............. \7\ CLEFT LIP &

1.1679

29.6

24.7 PALATE REPAIR. 53............. \7\ SINUS &

1.1679

29.6

24.7 MASTOID PROCEDURES AGE >17. 54............. \7\ SINUS &

1.1679

29.6

24.7 MASTOID PROCEDURES AGE 0-17. 55............. \7\

1.1679

29.6

24.7 MISCELLANEOUS EAR, NOSE, MOUTH & THROAT PROCEDURES. 56............. \7\ RHINOPLASTY. 1.1679

29.6

24.7 57............. \7\ T&A PROC,

0.4502

18.8

15.7 EXCEPT TONSILLECTOMY &/ OR ADENOIDECTOMY ONLY, AGE >17. 58............. \7\ T&A PROC,

0.4502

18.8

15.7 EXCEPT TONSILLECTOMY &/ OR ADENOIDECTOMY ONLY, AGE 0-17. 59............. \7\

0.4502

18.8

15.7 TONSILLECTOMY &/ OR ADENOIDECTOMY ONLY, AGE >17. 60............. \7\

0.4502

18.8

15.7 TONSILLECTOMY &/ OR ADENOIDECTOMY ONLY, AGE 0-17. 61............. \3\ MYRINGOTOMY

0.7586

24.5

20.4 W TUBE INSERTION AGE >17. 62............. \7\ MYRINGOTOMY

0.4502

18.8

15.7 W TUBE INSERTION AGE 0- 17. 63............. \4\ OTHER EAR,

1.1679

29.6

24.7 NOSE, MOUTH & THROAT O.R. PROCEDURES. 64............. EAR, NOSE, MOUTH 1.1477

26.2

21.8 & THROAT MALIGNANCY. 65............. \1\

0.4502

18.8

15.7 DYSEQUILIBRIUM. 66............. \7\ EPISTAXIS... 0.4502

18.8

15.7 67............. \3\ EPIGLOTTITIS 0.7586

24.5

20.4 68............. OTITIS MEDIA &

0.5134

18.0

15 URI AGE >17 W CC. 69............. \1\ OTITIS MEDIA 0.4502

18.8

15.7 & URI AGE >17 W/O CC. 70............. \7\ OTITIS MEDIA 0.4502

18.8

15.7 & URI AGE 0-17. 71............. \7\

0.5834

21.0

17.5 LARYNGOTRACHEIT IS. 72............. \7\ NASAL TRAUMA 0.5834

21.0

17.5 & DEFORMITY. 73............. OTHER EAR, NOSE, 0.6360

20.4

17 MOUTH & THROAT DIAGNOSES AGE >17. 74............. \7\ OTHER EAR,

0.4502

18.8

15.7 NOSE, MOUTH & THROAT DIAGNOSES AGE 0- 17. 75............. \5\ MAJOR CHEST

1.6862

38.0

31.7 PROCEDURES. 76............. OTHER RESP

2.5324

43.6

36.3 SYSTEM O.R. PROCEDURES W CC. 77............. \5\ OTHER RESP

1.6862

38.0

31.7 SYSTEM O.R. PROCEDURES W/O CC. 78............. PULMONARY

0.6955

21.9

18.3 EMBOLISM. 79............. RESPIRATORY

0.8252

22.8

19 INFECTIONS & INFLAMMATIONS AGE >17 W CC. 80............. RESPIRATORY

0.5993

21.5

17.9 INFECTIONS & INFLAMMATIONS AGE >17 W/O CC. 81............. \7\ RESPIRATORY

0.4502

18.8

15.7 INFECTIONS & INFLAMMATIONS AGE 0-17. 82............. RESPIRATORY

0.7138

20.1

16.8 NEOPLASMS. 83............. \2\ MAJOR CHEST

0.5834

21.0

17.5 TRAUMA W CC. 84............. \7\ MAJOR CHEST

0.5834

21.0

17.5 TRAUMA W/O CC. 85............. PLEURAL EFFUSION 0.7308

21.2

17.7 W CC. 86............. \2\ PLEURAL

0.5834

21.0

17.5 EFFUSION W/O CC. 87............. PULMONARY EDEMA

1.0797

25.3

21.1 & RESPIRATORY FAILURE. 88............. CHRONIC

0.6620

19.6

16.3 OBSTRUCTIVE PULMONARY DISEASE. 89............. SIMPLE PNEUMONIA 0.7027

20.8

17.3 & PLEURISY AGE >17 W CC. 90............. SIMPLE PNEUMONIA 0.5004

17.8

14.8 & PLEURISY AGE >17 W/O CC. 91............. \7\ SIMPLE

0.4502

18.8

15.7 PNEUMONIA & PLEURISY AGE 0- 17. 92............. INTERSTITIAL

0.6764

20.2

16.8 LUNG DISEASE W CC. 93............. \2\ INTERSTITIAL 0.5834

21.0

17.5 LUNG DISEASE W/ O CC. 94............. PNEUMOTHORAX W

0.5913

17.0

14.2 CC. 95............. \1\ PNEUMOTHORAX 0.4502

18.8

15.7 W/O CC. 96............. BRONCHITIS &

0.6436

19.4

16.2 ASTHMA AGE >17 W CC. 97............. \2\ BRONCHITIS & 0.5834

21.0

17.5 ASTHMA AGE >17 W/O CC. 98............. \7\ BRONCHITIS & 0.5834

21.0

17.5 ASTHMA AGE 0-17. 99............. RESPIRATORY

0.9262

23.3

19.4 SIGNS & SYMPTOMS W CC. 100............ \3\ RESPIRATORY

0.7586

24.5

20.4 SIGNS & SYMPTOMS W/O CC. 101............ OTHER

0.8143

21.1

17.6 RESPIRATORY SYSTEM DIAGNOSES W CC. 102............ \1\ OTHER

0.4502

18.8

15.7 RESPIRATORY SYSTEM DIAGNOSES W/O CC. 103............ \6\ HEART

0.0000

1.0

0.8 TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM.

[[Page 23647]]

104............ \7\ CARDIAC

1.1679

29.6

24.7 VALVE & OTH MAJOR CARDIOTHORACIC PROC W CARD CATH. 105............ \7\ CARDIAC

1.1679

29.6

24.7 VALVE & OTH MAJOR CARDIOTHORACIC PROC W/O CARD CATH. 106............ \7\ CORONARY

1.1679

29.6

24.7 BYPASS W PTCA. 107............ \7\ CORONARY

1.1679

29.6

24.7 BYPASS W CARDIAC CATH. 108............ \7\ OTHER

1.1679

29.6

24.7 CARDIOTHORACIC PROCEDURES. 109............ \7\ CORONARY

1.1679

29.6

24.7 BYPASS W/O PTCA OR CARDIAC CATH. 110............ \4\ MAJOR

1.1679

29.6

24.7 CARDIOVASCULAR PROCEDURES W CC. 111............ \7\ MAJOR

1.1679

29.6

24.7 CARDIOVASCULAR PROCEDURES W/O CC. 113............ AMPUTATION FOR

1.4877

39.2

32.7 CIRC SYSTEM DISORDERS EXCEPT UPPER LIMB & TOE. 114............ UPPER LIMB & TOE 1.2453

33.2

27.7 AMPUTATION FOR CIRC SYSTEM DISORDERS. 115............ \5\ PRM CARD

1.6862

38.0

31.7 PACEM IMPL W AMI,HRT FAIL OR SHK,OR AICD LEAD OR GNRTR P. 116............ \4\ OTH PERM

1.1679

29.6

24.7 CARD PACEMAK IMPL OR PTCA W CORONARY ARTERY STENT IMPLNT. 117............ 5CARDIAC

1.6862

38.0

31.7 PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT. 118............ \4\ CARDIAC

1.1679

29.6

24.7 PACEMAKER DEVICE REPLACEMENT. 119............ \3\ VEIN

0.7586

24.5

20.4 LIGATION & STRIPPING. 120............ OTHER

1.1050

31.8

26.5 CIRCULATORY SYSTEM O.R. PROCEDURES. 121............ CIRCULATORY

0.8200

22.6

18.8 DISORDERS W AMI & MAJOR COMP, DISCHARGED ALIVE. 122............ \2\ CIRCULATORY

0.5834

21.0

17.5 DISORDERS W AMI W/O MAJOR COMP, DISCHARGED ALIVE. 123............ CIRCULATORY

0.8678

18.7

15.6 DISORDERS W AMI, EXPIRED. 124............ \4\ CIRCULATORY

1.1679

29.6

24.7 DISORDERS EXCEPT AMI, W CARD CATH & COMPLEX DIAG. 125............ \3\ CIRCULATORY

0.7586

24.5

20.4 DISORDERS EXCEPT AMI, W CARD CATH W/O COMPLEX DIAG. 126............ ACUTE & SUBACUTE 0.8467

25.3

21.1 ENDOCARDITIS. 127............ HEART FAILURE &

0.6890

21.1

17.6 SHOCK. 128............ \2\ DEEP VEIN

0.5834

21.0

17.5 THROMBOPHLEBITI S. 129............ \7\ CARDIAC

1.1679

29.6

24.7 ARREST, UNEXPLAINED. 130............ PERIPHERAL

0.6755

23.1

19.3 VASCULAR DISORDERS W CC. 131............ PERIPHERAL

0.4698

20.4

17 VASCULAR DISORDERS W/O CC. 132............ ATHEROSCLEROSIS

0.6639

21.8

18.2 W CC. 133............ \1\

0.4502

18.8

15.7 ATHEROSCLEROSIS W/O CC. 134............ HYPERTENSION.... 0.6388

24.7

20.6 135............ CARDIAC

0.7272

23.7

19.8 CONGENITAL & VALVULAR DISORDERS AGE >17 W CC. 136............ \2\ CARDIAC

0.5834

21.0

17.5 CONGENITAL & VALVULAR DISORDERS AGE >17 W/O CC. 137............ \7\ CARDIAC

0.5834

21.0

17.5 CONGENITAL & VALVULAR DISORDERS AGE 0- 17. 138............ CARDIAC

0.6183

20.4

17 ARRHYTHMIA & CONDUCTION DISORDERS W CC. 139............ \2\ CARDIAC

0.5834

21.0

17.5 ARRHYTHMIA & CONDUCTION DISORDERS W/O CC. 140............ \1\ ANGINA

0.4502

18.8

15.7 PECTORIS. 141............ SYNCOPE &

0.4356

18.3

15.3 COLLAPSE W CC. 142............ \1\ SYNCOPE &

0.4502

18.8

15.7 COLLAPSE W/O CC. 143............ \2\ CHEST PAIN.. 0.5834

21.0

17.5 144............ OTHER

0.7364

21.6

18 CIRCULATORY SYSTEM DIAGNOSES W CC. 145............ OTHER

0.4544

18.0

15 CIRCULATORY SYSTEM DIAGNOSES W/O CC. 146............ \7\ RECTAL

1.6862

38.0

31.7 RESECTION W CC. 147............ \7\ RECTAL

1.6862

38.0

31.7 RESECTION W/O CC. 148............ MAJOR SMALL &

1.8800

40.8

34 LARGE BOWEL PROCEDURES W CC. 149............ \7\ MAJOR SMALL

0.7586

24.5

20.4 & LARGE BOWEL PROCEDURES W/O CC. 150............ \4\ PERITONEAL

1.1679

29.6

24.7 ADHESIOLYSIS W CC. 151............ \2\ PERITONEAL

0.5834

21.0

17.5 ADHESIOLYSIS W/ O CC. 152............ \3\ MINOR SMALL

0.7586

24.5

20.4 & LARGE BOWEL PROCEDURES W CC. 153............ \7\ MINOR SMALL

0.7586

24.5

20.4 & LARGE BOWEL PROCEDURES W/O CC. 154............ \5\ STOMACH,

1.6862

38.0

31.7 ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W CC. 155............ \7\ STOMACH,

1.6862

38.0

31.7 ESOPHAGEAL & DUODENAL PROCEDURES AGE >17 W/O CC. 156............ \7\ STOMACH,

1.6862

38.0

31.7 ESOPHAGEAL & DUODENAL PROCEDURES AGE 0-17. 157............ \4\ ANAL &

1.1679

29.6

24.7 STOMAL PROCEDURES W CC. 158............ \7\ ANAL &

1.1679

29.6

24.7 STOMAL PROCEDURES W/O CC. 159............ \7\ HERNIA

0.7586

24.5

20.4 PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W CC. 160............ \7\ HERNIA

0.7586

24.5

20.4 PROCEDURES EXCEPT INGUINAL & FEMORAL AGE >17 W/O CC. 161............ \5\ INGUINAL &

1.6862

38.0

31.7 FEMORAL HERNIA PROCEDURES AGE >17 W CC. 162............ \7\ INGUINAL &

0.7586

24.5

20.4 FEMORAL HERNIA PROCEDURES AGE >17 W/O CC. 163............ \7\ HERNIA

0.7586

24.5

20.4 PROCEDURES AGE 0-17. 164............ \7\ APPENDECTOMY 1.6862

38.0

31.7 W COMPLICATED PRINCIPAL DIAG W CC. 165............ \7\ APPENDECTOMY 1.6862

38.0

31.7 W COMPLICATED PRINCIPAL DIAG W/O CC. 166............ \7\ APPENDECTOMY 1.6862

38.0

31.7 W/O COMPLICATED PRINCIPAL DIAG W CC. 167............ \7\ APPENDECTOMY 1.6862

38.0

31.7 W/O COMPLICATED PRINCIPAL DIAG W/O CC. 168............ \4\ MOUTH

1.1679

29.6

24.7 PROCEDURES W CC. 169............ \7\ MOUTH

0.7586

24.5

20.4 PROCEDURES W/O CC.

[[Page 23648]]

170............ OTHER DIGESTIVE

1.6319

35.9

29.9 SYSTEM O.R. PROCEDURES W CC. 171............ \1\ OTHER

0.4502

18.8

15.7 DIGESTIVE SYSTEM O.R. PROCEDURES W/O CC. 172............ DIGESTIVE

0.8568

21.8

18.2 MALIGNANCY W CC. 173............ \2\ DIGESTIVE

0.5834

21.0

17.5 MALIGNANCY W/O CC. 174............ G.I. HEMORRHAGE

0.6984

22.0

18.3 W CC. 175............ \1\ G.I.

0.4502

18.8

15.7 HEMORRHAGE W/O CC. 176............ COMPLICATED

0.8510

21.5

17.9 PEPTIC ULCER. 177............ \3\

0.7586

24.5

20.4 UNCOMPLICATED PEPTIC ULCER W CC. 178............ \3\

0.7586

24.5

20.4 UNCOMPLICATED PEPTIC ULCER W/ O CC. 179............ INFLAMMATORY

0.9834

24.1

20.1 BOWEL DISEASE. 180............ G.I. OBSTRUCTION 0.9417

23.5

19.6 W CC. 181............ \3\ G.I.

0.7586

24.5

20.4 OBSTRUCTION W/O CC. 182............ ESOPHAGITIS,

0.7753

22.6

18.8 GASTROENT & MISC DIGEST DISORDERS AGE >17 W CC. 183............ ESOPHAGITIS,

0.3959

17.2

14.3 GASTROENT & MISC DIGEST DISORDERS AGE >17 W/O CC. 184............ \7\ ESOPHAGITIS, 0.4502

18.8

15.7 GASTROENT & MISC DIGEST DISORDERS AGE 0- 17. 185............ \3\ DENTAL &

0.7586

24.5

20.4 ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE >17. 186............ \7\ DENTAL &

0.7586

24.5

20.4 ORAL DIS EXCEPT EXTRACTIONS & RESTORATIONS, AGE 0-17. 187............ \7\ DENTAL

0.7586

24.5

20.4 EXTRACTIONS & RESTORATIONS. 188............ OTHER DIGESTIVE

1.0009

24.0

20 SYSTEM DIAGNOSES AGE >17 W CC. 189............ OTHER DIGESTIVE

0.4730

18.2

15.2 SYSTEM DIAGNOSES AGE >17 W/O CC. 190............ \7\ OTHER

0.4502

18.8

15.7 DIGESTIVE SYSTEM DIAGNOSES AGE 0- 17. 191............ \4\ PANCREAS,

1.1679

29.6

24.7 LIVER & SHUNT PROCEDURES W CC. 192............ \7\ PANCREAS,

1.1679

29.6

24.7 LIVER & SHUNT PROCEDURES W/O CC. 193............ \3\ BILIARY

0.7586

24.5

20.4 TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W CC. 194............ \7\ BILIARY

0.7586

24.5

20.4 TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC. 195............ \4\

1.1679

29.6

24.7 CHOLECYSTECTOMY W C.D.E. W CC. 196............ \7\

0.7586

24.5

20.4 CHOLECYSTECTOMY W C.D.E. W/O CC. 197............ \3\

0.7586

24.5

20.4 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W CC. 198............ \7\

0.7586

24.5

20.4 CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE W/O C.D.E. W/O CC. 199............ \7\

1.6862

38.0

31.7 HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR MALIGNANCY. 200............ \5\

1.6862

38.0

31.7 HEPATOBILIARY DIAGNOSTIC PROCEDURE FOR NON-MALIGNANCY. 201............ OTHER

2.0391

36.1

30.1 HEPATOBILIARY OR PANCREAS O.R. PROCEDURES. 202............ CIRRHOSIS &

0.6636

20.5

17.1 ALCOHOLIC HEPATITIS. 203............ MALIGNANCY OF

0.7939

19.5

16.3 HEPATOBILIARY SYSTEM OR PANCREAS. 204............ DISORDERS OF

0.9564

22.9

19.1 PANCREAS EXCEPT MALIGNANCY. 205............ DISORDERS OF

0.6709

20.6

17.2 LIVER EXCEPT MALIG,CIRR,ALC HEPA W CC. 206............ \2\ DISORDERS OF 0.5834

21.0

17.5 LIVER EXCEPT MALIG,CIRR,ALC HEPA W/O CC. 207............ DISORDERS OF THE 0.7600

21.5

17.9 BILIARY TRACT W CC. 208............ \2\ DISORDERS OF 0.5834

21.0

17.5 THE BILIARY TRACT W/O CC. 210............ \5\ HIP & FEMUR

1.6862

38.0

31.7 PROCEDURES EXCEPT MAJOR JOINT AGE >17 W CC. 211............ \4\ HIP & FEMUR

1.1679

29.6

24.7 PROCEDURES EXCEPT MAJOR JOINT AGE >17 W/ O CC. 212............ \7\ HIP & FEMUR

1.6862

38.0

31.7 PROCEDURES EXCEPT MAJOR JOINT AGE 0-17. 213............ AMPUTATION FOR

1.2016

33.9

28.3 MUSCULOSKELETAL SYSTEM & CONN TISSUE DISORDERS. 216............ \4\ BIOPSIES OF

1.1679

29.6

24.7 MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE. 217............ WND DEBRID & SKN 1.2917

38.0

31.7 GRFT EXCEPT HAND,FOR MUSCSKELET & CONN TISS DIS. 218............ \5\ LOWER EXTREM 1.6862

38.0

31.7 & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W CC. 219............ \1\ LOWER EXTREM 0.4502

18.8

15.7 & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE >17 W/O CC. 220............ \7\ LOWER EXTREM 1.6862

38.0

31.7 & HUMER PROC EXCEPT HIP,FOOT,FEMUR AGE 0-17. 223............ \3\ MAJOR

0.7586

24.5

20.4 SHOULDER/ELBOW PROC, OR OTHER UPPER EXTREMITY PROC W CC. 224............ \7\

0.7586

24.5

20.4 SHOULDER,ELBOW OR FOREARM PROC,EXC MAJOR JOINT PROC, W/O CC. 225............ FOOT PROCEDURES. 0.9996

28.9

24.1 226............ SOFT TISSUE

0.9487

30.0

25 PROCEDURES W CC. 227............ \3\ SOFT TISSUE

0.7586

24.5

20.4 PROCEDURES W/O CC. 228............ \4\ MAJOR THUMB

1.1679

29.6

24.7 OR JOINT PROC,OR OTH HAND OR WRIST PROC W CC. 229............ \7\ HAND OR

0.4502

18.8

15.7 WRIST PROC, EXCEPT MAJOR JOINT PROC, W/O CC. 230............ \5\ LOCAL

1.6862

38.0

31.7 EXCISION & REMOVAL OF INT FIX DEVICES OF HIP & FEMUR. 232............ \7\ ARTHROSCOPY. 0.4502

18.8

15.7 233............ OTHER

1.2832

33.9

28.3 MUSCULOSKELET SYS & CONN TISS O.R. PROC W CC. 234............ \7\ OTHER

0.4502

18.8

15.7 MUSCULOSKELET SYS & CONN TISS O.R. PROC W/O CC. 235............ \3\ FRACTURES OF 0.7586

24.5

20.4 FEMUR. 236............ FRACTURES OF HIP 0.6553

25.2

21 & PELVIS. 237............ \1\ SPRAINS,

0.4502

18.8

15.7 STRAINS, & DISLOCATIONS OF HIP, PELVIS & THIGH. 238............ OSTEOMYELITIS... 0.8271

28.2

23.5 239............ PATHOLOGICAL

0.6923

23.6

19.7 FRACTURES & MUSCULOSKELETAL & CONN TISS MALIGNANCY. 240............ CONNECTIVE

0.7320

24.5

20.4 TISSUE DISORDERS W CC.

[[Page 23649]]

241............ \1\ CONNECTIVE

0.4502

18.8

15.7 TISSUE DISORDERS W/O CC. 242............ SEPTIC ARTHRITIS 0.7931

26.6

22.2 243............ MEDICAL BACK

0.6107

23.4

19.5 PROBLEMS. 244............ BONE DISEASES &

0.5280

22.2

18.5 SPECIFIC ARTHROPATHIES W CC. 245............ BONE DISEASES &

0.4651

20.4

17 SPECIFIC ARTHROPATHIES W/ O CC. 246............ \1\ NON-SPECIFIC 0.4502

18.8

15.7 ARTHROPATHIES. 247............ SIGNS & SYMPTOMS 0.5269

21.4

17.8 OF MUSCULOSKELETAL SYSTEM & CONN TISSUE. 248............ TENDONITIS,

0.6627

22.6

18.8 MYOSITIS & BURSITIS. 249............ AFTERCARE,

0.6614

24.7

20.6 MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE. 250............ \2\ FX, SPRN,

0.5834

21.0

17.5 STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W CC. 251............ \1\ FX, SPRN,

0.4502

18.8

15.7 STRN & DISL OF FOREARM, HAND, FOOT AGE >17 W/ O CC. 252............ \7\ FX, SPRN,

0.7586

24.5

20.4 STRN & DISL OF FOREARM, HAND, FOOT AGE 0-17. 253............ FX, SPRN, STRN & 0.6838

26.3

21.9 DISL OF UPARM,LOWLEG EX FOOT AGE >17 W CC. 254............ \1\ FX, SPRN,

0.4502

18.8

15.7 STRN & DISL OF UPARM,LOWLEG EX FOOT AGE >17 W/ O CC. 255............ \7\ FX, SPRN,

0.7586

24.5

20.4 STRN & DISL OF UPARM,LOWLEG EX FOOT AGE 0-17. 256............ OTHER

0.7953

25.3

21.1 MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES. 257............ \7\ TOTAL

0.7586

24.5

20.4 MASTECTOMY FOR MALIGNANCY W CC. 258............ \7\ TOTAL

0.7586

24.5

20.4 MASTECTOMY FOR MALIGNANCY W/O CC. 259............ \2\ SUBTOTAL

0.5834

21.0

17.5 MASTECTOMY FOR MALIGNANCY W CC. 260............ \7\ SUBTOTAL

0.7586

24.5

20.4 MASTECTOMY FOR MALIGNANCY W/O CC. 261............ \7\ BREAST PROC

0.7586

24.5

20.4 FOR NON- MALIGNANCY EXCEPT BIOPSY & LOCAL EXCISION. 262............ \1\ BREAST

0.4502

18.8

15.7 BIOPSY & LOCAL EXCISION FOR NON-MALIGNANCY. 263............ SKIN GRAFT &/OR

1.3245

39.4

32.8 DEBRID FOR SKN ULCER OR CELLULITIS W CC. 264............ SKIN GRAFT &/OR

0.9555

31.9

26.6 DEBRID FOR SKN ULCER OR CELLULITIS W/O CC. 265............ SKIN GRAFT &/OR

1.0426

33.1

27.6 DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W CC. 266............ \3\ SKIN GRAFT &/ 0.7586

24.5

20.4 OR DEBRID EXCEPT FOR SKIN ULCER OR CELLULITIS W/O CC. 267............ \7\ PERIANAL &

0.7586

24.5

20.4 PILONIDAL PROCEDURES. 268............ \5\ SKIN,

1.6862

38.0

31.7 SUBCUTANEOUS TISSUE & BREAST PLASTIC PROCEDURES. 269............ OTHER SKIN,

1.2945

35.9

29.9 SUBCUT TISS & BREAST PROC W CC. 270............ \3\ OTHER SKIN,

0.7586

24.5

20.4 SUBCUT TISS & BREAST PROC W/O CC. 271............ SKIN ULCERS..... 0.8707

27.6

23 272............ MAJOR SKIN

0.7490

22.5

18.8 DISORDERS W CC. 273............ \1\ MAJOR SKIN

0.4502

18.8

15.7 DISORDERS W/O CC. 274............ \3\ MALIGNANT

0.7586

24.5

20.4 BREAST DISORDERS W CC. 275............ \7\ MALIGNANT

0.7586

24.5

20.4 BREAST DISORDERS W/O CC. 276............ \2\ NON-MALIGANT 0.5834

21.0

17.5 BREAST DISORDERS. 277............ CELLULITIS AGE

0.6281

20.9

17.4 >17 W CC. 278............ CELLULITIS AGE

0.4440

17.8

14.8 >17 W/O CC. 279............ \7\ CELLULITIS

0.4502

18.8

15.7 AGE 0-17. 280............ TRAUMA TO THE

0.6728

24.3

20.3 SKIN, SUBCUT TISS & BREAST AGE >17 W CC. 281............ \1\ TRAUMA TO

0.4502

18.8

15.7 THE SKIN, SUBCUT TISS & BREAST AGE >17 W/O CC. 282............ \7\ TRAUMA TO

0.4502

18.8

15.7 THE SKIN, SUBCUT TISS & BREAST AGE 0-17. 283............ MINOR SKIN

0.6968

23.9

19.9 DISORDERS W CC. 284............ \1\ MINOR SKIN

0.4502

18.8

15.7 DISORDERS W/O CC. 285............ AMPUTAT OF LOWER 1.3552

35.6

29.7 LIMB FOR ENDOCRINE,NUTRI T,& METABOL DISORDERS. 286............ \7\ ADRENAL &

1.6862

38.0

31.7 PITUITARY PROCEDURES. 287............ SKIN GRAFTS &

1.1270

33.6

28 WOUND DEBRID FOR ENDOC, NUTRIT & METAB DISORDERS. 288............ \4\ O.R.

1.1679

29.6

24.7 PROCEDURES FOR OBESITY. 289............ \7\ PARATHYROID

1.1679

29.6

24.7 PROCEDURES. 290............ \5\ THYROID

1.6862

38.0

31.7 PROCEDURES. 291............ \7\ THYROGLOSSAL 1.1679

29.6

24.7 PROCEDURES. 292............ OTHER ENDOCRINE, 1.3437

31.7

26.4 NUTRIT & METAB O.R. PROC W CC. 293............ \2\ OTHER

0.5834

21.0

17.5 ENDOCRINE, NUTRIT & METAB O.R. PROC W/O CC. 294............ DIABETES AGE >35 0.7330

24.8

20.7 295............ \3\ DIABETES AGE 0.7586

24.5

20.4 0-35. 296............ NUTRITIONAL &

0.7232

23.1

19.3 MISC METABOLIC DISORDERS AGE >17 W CC. 297............ NUTRITIONAL &

0.5262

18.4

15.3 MISC METABOLIC DISORDERS AGE >17 W/O CC. 298............ \7\ NUTRITIONAL

0.5834

21.0

17.5 & MISC METABOLIC DISORDERS AGE 0- 17. 299............ \4\ INBORN

1.1679

29.6

24.7 ERRORS OF METABOLISM. 300............ ENDOCRINE

0.6413

21.2

17.7 DISORDERS W CC. 301............ \1\ ENDOCRINE

0.4502

18.8

15.7 DISORDERS W/O CC. 302............ \6\ KIDNEY

0.0000

1.0

0.8 TRANSPLANT. 303............ \4\

1.1679

29.6

24.7 KIDNEY,URETER & MAJOR BLADDER PROCEDURES FOR NEOPLASM. 304............ \5\

1.6862

38.0

31.7 KIDNEY,URETER & MAJOR BLADDER PROC FOR NON- NEOPL W CC. 305............ \1\

0.4502

18.8

15.7 KIDNEY,URETER & MAJOR BLADDER PROC FOR NON- NEOPL W/O CC. 306............ \2\

0.5834

21.0

17.5 PROSTATECTOMY W CC. 307............ \7\

0.5834

21.0

17.5 PROSTATECTOMY W/ O CC.

[[Page 23650]]

308............ \4\ MINOR

1.1679

29.6

24.7 BLADDER PROCEDURES W CC. 309............ \7\ MINOR

1.1679

29.6

24.7 BLADDER PROCEDURES W/O CC. 310............ \4\

1.1679

29.6

24.7 TRANSURETHRAL PROCEDURES W CC. 311............ \7\

1.1679

29.6

24.7 TRANSURETHRAL PROCEDURES W/O CC. 312............ \1\ URETHRAL

0.4502

18.8

15.7 PROCEDURES, AGE >17 W CC. 313............ \7\ URETHRAL

0.4502

18.8

15.7 PROCEDURES, AGE >17 W/O CC. 314............ \7\ URETHRAL

0.4502

18.8

15.7 PROCEDURES, AGE 0-17. 315............ OTHER KIDNEY &

1.4005

31.5

26.3 URINARY TRACT O.R. PROCEDURES. 316............ RENAL FAILURE... 0.8208

22.6

18.8 317............ ADMIT FOR RENAL

1.0001

25.5

21.3 DIALYSIS. 318............ KIDNEY & URINARY 0.7648

20.2

16.8 TRACT NEOPLASMS W CC. 319............ \1\ KIDNEY &

0.4502

18.8

15.7 URINARY TRACT NEOPLASMS W/O CC. 320............ KIDNEY & URINARY 0.6185

22.1

18.4 TRACT INFECTIONS AGE >17 W CC. 321............ KIDNEY & URINARY 0.4813

19.0

15.8 TRACT INFECTIONS AGE >17 W/O CC. 322............ \7\ KIDNEY &

0.4502

18.8

15.7 URINARY TRACT INFECTIONS AGE 0-17. 323............ \4\ URINARY

1.1679

29.6

24.7 STONES W CC, &/ OR ESW LITHOTRIPSY. 324............ \7\ URINARY

0.4502

18.8

15.7 STONES W/O CC. 325............ \2\ KIDNEY &

0.5834

21.0

17.5 URINARY TRACT SIGNS & SYMPTOMS AGE >17 W CC. 326............ \1\ KIDNEY &

0.4502

18.8

15.7 URINARY TRACT SIGNS & SYMPTOMS AGE >17 W/O CC. 327............ \7\ KIDNEY &

0.4502

18.8

15.7 URINARY TRACT SIGNS & SYMPTOMS AGE 0- 17. 328............ \1\ URETHRAL

0.4502

18.8

15.7 STRICTURE AGE >17 W CC. 329............ \7\ URETHRAL

0.4502

18.8

15.7 STRICTURE AGE >17 W/O CC. 330............ \7\ URETHRAL

0.4502

18.8

15.7 STRICTURE AGE 0- 17. 331............ OTHER KIDNEY &

0.8033

23.0

19.2 URINARY TRACT DIAGNOSES AGE >17 W CC. 332............ \3\ OTHER KIDNEY 0.7586

24.5

20.4 & URINARY TRACT DIAGNOSES AGE >17 W/O CC. 333............ \7\ OTHER KIDNEY 0.7586

24.5

20.4 & URINARY TRACT DIAGNOSES AGE 0- 17. 334............ \2\ MAJOR MALE

0.5834

21.0

17.5 PELVIC PROCEDURES W CC. 335............ \7\ MAJOR MALE

1.6862

38.0

31.7 PELVIC PROCEDURES W/O CC. 336............ \2\

0.5834

21.0

17.5 TRANSURETHRAL PROSTATECTOMY W CC. 337............ \7\

0.5834

21.0

17.5 TRANSURETHRAL PROSTATECTOMY W/ O CC. 338............ \7\ TESTES

0.5834

21.0

17.5 PROCEDURES, FOR MALIGNANCY. 339............ \4\ TESTES

1.1679

29.6

24.7 PROCEDURES, NON- MALIGNANCY AGE >17. 340............ \7\ TESTES

1.1679

29.6

24.7 PROCEDURES, NON- MALIGNANCY AGE 0-17. 341............ \4\ PENIS

1.1679

29.6

24.7 PROCEDURES. 342............ \7\ CIRCUMCISION 1.1679

29.6

24.7 AGE >17. 343............ \7\ CIRCUMCISION 1.1679

29.6

24.7 AGE 0-17. 344............ \1\ OTHER MALE

0.4502

18.8

15.7 REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY. 345............ \5\ OTHER MALE

1.6862

38.0

31.7 REPRODUCTIVE SYSTEM O.R. PROC EXCEPT FOR MALIGNANCY. 346............ MALIGNANCY, MALE 0.6105

20.6

17.2 REPRODUCTIVE SYSTEM, W CC. 347............ \2\ MALIGNANCY,

0.5834

21.0

17.5 MALE REPRODUCTIVE SYSTEM, W/O CC. 348............ \2\ BENIGN

0.5834

21.0

17.5 PROSTATIC HYPERTROPHY W CC. 349............ \7\ BENIGN

1.1679

29.6

24.7 PROSTATIC HYPERTROPHY W/O CC. 350............ INFLAMMATION OF

0.6562

21.6

18 THE MALE REPRODUCTIVE SYSTEM. 351............ \7\

1.1679

29.6

24.7 STERILIZATION, MALE. 352............ OTHER MALE

0.6360

23.4

19.5 REPRODUCTIVE SYSTEM DIAGNOSES. 353............ \7\ PELVIC

1.1679

29.6

24.7 EVISCERATION, RADICAL HYSTERECTOMY & RADICAL VULVECTOMY. 354............ \7\

1.1679

29.6

24.7 UTERINE,ADNEXA PROC FOR NON- OVARIAN/ADNEXAL MALIG W CC. 355............ \7\

1.1679

29.6

24.7 UTERINE,ADNEXA PROC FOR NON- OVARIAN/ADNEXAL MALIG W/O CC. 356............ \7\ FEMALE

1.1679

29.6

24.7 REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES. 357............ \7\ UTERINE &

1.1679

29.6

24.7 ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY. 358............ \7\ UTERINE &

1.1679

29.6

24.7 ADNEXA PROC FOR NON-MALIGNANCY W CC. 359............ \7\ UTERINE &

1.1679

29.6

24.7 ADNEXA PROC FOR NON-MALIGNANCY W/O CC. 360............ \4\ VAGINA,

1.1679

29.6

24.7 CERVIX & VULVA PROCEDURES. 361............ \7\ LAPAROSCOPY

1.1679

29.6

24.7 & INCISIONAL TUBAL INTERRUPTION. 362............ \7\ ENDOSCOPIC

1.1679

29.6

24.7 TUBAL INTERRUPTION. 363............ \7\ D&C,

1.1679

29.6

24.7 CONIZATION & RADIO-IMPLANT, FOR MALIGNANCY. 364............ \5\ D&C,

1.6862

38.0

31.7 CONIZATION EXCEPT FOR MALIGNANCY. 365............ \5\ OTHER FEMALE 1.6862

38.0

31.7 REPRODUCTIVE SYSTEM O.R. PROCEDURES. 366............ MALIGNANCY,

0.7126

20.3

16.9 FEMALE REPRODUCTIVE SYSTEM W CC. 367............ \7\ MALIGNANCY,

1.1679

29.6

24.7 FEMALE REPRODUCTIVE SYSTEM W/O CC. 368............ INFECTIONS,

0.6455

20.7

17.3 FEMALE REPRODUCTIVE SYSTEM. 369............ \3\ MENSTRUAL &

0.7586

24.5

20.4 OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS. 370............ \7\ CESAREAN

0.7586

24.5

20.4 SECTION W CC. 371............ \7\ CESAREAN

0.5834

21.0

17.5 SECTION W/O CC. 372............ \7\ VAGINAL

1.1679

29.6

24.7 DELIVERY W COMPLICATING DIAGNOSES. 373............ \7\ VAGINAL

1.1679

29.6

24.7 DELIVERY W/O COMPLICATING DIAGNOSES.

[[Page 23651]]

374............ \7\ VAGINAL

1.1679

29.6

24.7 DELIVERY W STERILIZATION &/ OR D&C. 375............ \7\ VAGINAL

1.1679

29.6

24.7 DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C. 376............ \7\ POSTPARTUM & 1.1679

29.6

24.7 POST ABORTION DIAGNOSES W/O O.R. PROCEDURE. 377............ \7\ POSTPARTUM & 1.1679

29.6

24.7 POST ABORTION DIAGNOSES W O.R. PROCEDURE. 378............ \7\ ECTOPIC

0.7586

24.5

20.4 PREGNANCY. 379............ \7\ THREATENED

1.1679

29.6

24.7 ABORTION. 380............ \7\ ABORTION W/O 1.1679

29.6

24.7 D&C. 381............ \7\ ABORTION W

1.1679

29.6

24.7 D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY. 382............ \7\ FALSE LABOR. 1.1679

29.6

24.7 383............ \7\ OTHER

1.1679

29.6

24.7 ANTEPARTUM DIAGNOSES W MEDICAL COMPLICATIONS. 384............ \7\ OTHER

1.1679

29.6

24.7 ANTEPARTUM DIAGNOSES W/O MEDICAL COMPLICATIONS. 385............ \7\ NEONATES,

1.1679

29.6

24.7 DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY. 386............ \7\ EXTREME

1.1679

29.6

24.7 IMMATURITY OR RESPIRATORY DISTRESS SYNDROME, NEONATE. 387............ \7\ PREMATURITY

1.1679

29.6

24.7 W MAJOR PROBLEMS. 388............ \7\ PREMATURITY

1.1679

29.6

24.7 W/O MAJOR PROBLEMS. 389............ \7\ FULL TERM

1.1679

29.6

24.7 NEONATE W MAJOR PROBLEMS. 390............ \7\ NEONATE W

1.1679

29.6

24.7 OTHER SIGNIFICANT PROBLEMS. 391............ \7\ NORMAL

1.1679

29.6

24.7 NEWBORN. 392............ \7\ SPLENECTOMY

0.7586

24.5

20.4 AGE >17. 393............ \7\ SPLENECTOMY

0.7586

24.5

20.4 AGE 0-17. 394............ \5\ OTHER O.R.

1.6862

38.0

31.7 PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS. 395............ RED BLOOD CELL

0.6611

21.8

18.2 DISORDERS AGE >17. 396............ \7\ RED BLOOD

0.5834

21.0

17.5 CELL DISORDERS AGE 0-17. 397............ COAGULATION

0.8665

22.5

18.8 DISORDERS. 398............ RETICULOENDOTHEL 0.8193

23.5

19.6 IAL & IMMUNITY DISORDERS W CC. 399............ \2\

0.5834

21.0

17.5 RETICULOENDOTHE LIAL & IMMUNITY DISORDERS W/O CC. 401............ \5\ LYMPHOMA &

1.6862

38.0

31.7 NON-ACUTE LEUKEMIA W OTHER O.R. PROC W CC. 402............ \7\ LYMPHOMA &

0.5834

21.0

17.5 NON-ACUTE LEUKEMIA W OTHER O.R. PROC W/O CC. 403............ LYMPHOMA & NON-

0.8844

21.3

17.8 ACUTE LEUKEMIA W CC. 404............ \2\ LYMPHOMA &

0.5834

21.0

17.5 NON-ACUTE LEUKEMIA W/O CC. 405............ \7\ ACUTE

0.5834

21.0

17.5 LEUKEMIA W/O MAJOR O.R. PROCEDURE AGE 0- 17. 406............ \4\ MYELOPROLIF

1.1679

29.6

24.7 DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W CC. 407............ \7\ MYELOPROLIF

1.1679

29.6

24.7 DISORD OR POORLY DIFF NEOPL W MAJ O.R.PROC W/O CC. 408............ \4\ MYELOPROLIF

1.1679

29.6

24.7 DISORD OR POORLY DIFF NEOPL W OTHER O.R.PROC. 409............ RADIOTHERAPY.... 0.8567

23.4

19.5 410............ CHEMOTHERAPY W/O 1.1719

26.4

22 ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS. 411............ \7\ HISTORY OF

1.1679

29.6

24.7 MALIGNANCY W/O ENDOSCOPY. 412............ \7\ HISTORY OF

1.1679

29.6

24.7 MALIGNANCY W ENDOSCOPY. 413............ OTHER

0.8990

20.5

17.1 MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W CC. 414............ \7\ OTHER

0.5834

21.0

17.5 MYELOPROLIF DIS OR POORLY DIFF NEOPL DIAG W/O CC. 415............ O.R. PROCEDURE

1.4237

35.5

29.6 FOR INFECTIOUS & PARASITIC DISEASES. 416............ SEPTICEMIA AGE

0.8255

23.4

19.5 >17. 417............ \7\ SEPTICEMIA

0.7586

24.5

20.4 AGE 0-17. 418............ POSTOPERATIVE &

0.8296

24.7

20.6 POST-TRAUMATIC INFECTIONS. 419............ \3\ FEVER OF

0.7586

24.5

20.4 UNKNOWN ORIGIN AGE >17 W CC. 420............ \7\ FEVER OF

0.7586

24.5

20.4 UNKNOWN ORIGIN AGE >17 W/O CC. 421............ VIRAL ILLNESS

0.9474

27.3

22.8 AGE >17. 422............ \7\ VIRAL

0.4502

18.8

15.7 ILLNESS & FEVER OF UNKNOWN ORIGIN AGE 0-17. 423............ OTHER INFECTIOUS 0.9403

21.7

18.1 & PARASITIC DISEASES DIAGNOSES. 424............ \3\ O.R.

0.7586

24.5

20.4 PROCEDURE W PRINCIPAL DIAGNOSES OF MENTAL ILLNESS. 425............ \2\ ACUTE

0.5834

21.0

17.5 ADJUSTMENT REACTION & PSYCHOLOGICAL DYSFUNCTION. 426............ DEPRESSIVE

0.4131

20.7

17.3 NEUROSES. 427............ NEUROSES EXCEPT

0.4713

23.8

19.8 DEPRESSIVE. 428............ \1\ DISORDERS OF 0.4502

18.8

15.7 PERSONALITY & IMPULSE CONTROL. 429............ ORGANIC

0.5831

26.5

22.1 DISTURBANCES & MENTAL RETARDATION. 430............ PSYCHOSES....... 0.4350

24.1

20.1 431............ \1\ CHILDHOOD

0.4502

18.8

15.7 MENTAL DISORDERS. 432............ \2\ OTHER MENTAL 0.5834

21.0

17.5 DISORDER DIAGNOSES. 433............ \2\ ALCOHOL/DRUG 0.5834

21.0

17.5 ABUSE OR DEPENDENCE, LEFT AMA. 439............ SKIN GRAFTS FOR

1.3758

35.6

29.7 INJURIES. 440............ WOUND

1.3261

35.9

29.9 DEBRIDEMENTS FOR INJURIES. 441............ \1\ HAND

0.4502

18.8

15.7 PROCEDURES FOR INJURIES. 442............ OTHER O.R.

1.4028

33.4

27.8 PROCEDURES FOR INJURIES W CC. 443............ \3\ OTHER O.R.

0.7586

24.5

20.4 PROCEDURES FOR INJURIES W/O CC. 444............ TRAUMATIC INJURY 0.7551

25.9

21.6 AGE >17 W CC. 445............ \1\ TRAUMATIC

0.4502

18.8

15.7 INJURY AGE >17 W/O CC. 446............ \7\ TRAUMATIC

0.4502

18.8

15.7 INJURY AGE 0-17.

[[Page 23652]]

447............ \2\ ALLERGIC

0.5834

21.0

17.5 REACTIONS AGE >17. 448............ \7\ ALLERGIC

0.5834

21.0

17.5 REACTIONS AGE 0- 17. 449............ \3\ POISONING &

0.7586

24.5

20.4 TOXIC EFFECTS OF DRUGS AGE >17 W CC. 450............ \7\ POISONING &

0.7586

24.5

20.4 TOXIC EFFECTS OF DRUGS AGE >17 W/O CC. 451............ \7\ POISONING &

0.7586

24.5

20.4 TOXIC EFFECTS OF DRUGS AGE 0- 17. 452............ COMPLICATIONS OF 0.9139

25.2

21 TREATMENT W CC. 453............ COMPLICATIONS OF 0.5449

23.2

19.3 TREATMENT W/O CC. 454............ \3\ OTHER

0.7586

24.5

20.4 INJURY, POISONING & TOXIC EFFECT DIAG W CC. 455............ \7\ OTHER

0.7586

24.5

20.4 INJURY, POISONING & TOXIC EFFECT DIAG W/O CC. 461............ O.R. PROC W

1.2315

34.0

28.3 DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES. 462............ REHABILITATION.. 0.5815

22.4

18.7 463............ SIGNS & SYMPTOMS 0.6234

23.7

19.8 W CC. 464............ SIGNS & SYMPTOMS 0.5565

24.1

20.1 W/O CC. 465............ AFTERCARE W

0.6959

21.8

18.2 HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS. 466............ AFTERCARE W/O

0.6713

21.9

18.3 HISTORY OF MALIGNANCY AS SECONDARY DIAGNOSIS. 467............ \3\ OTHER

0.7586

24.5

20.4 FACTORS INFLUENCING HEALTH STATUS. 468............ EXTENSIVE O.R.

2.1439

40.0

33.3 PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 469............ \6\ PRINCIPAL

0.0000

1.0

0.8 DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS. 470............ \6\ UNGROUPABLE. 0.0000

1.0

0.8 471............ \5\ BILATERAL OR 1.6862

38.0

31.7 MULTIPLE MAJOR JOINT PROCS OF LOWER EXTREMITY. 473............ ACUTE LEUKEMIA W/ 0.8580

20.0

16.7 O MAJOR O.R. PROCEDURE AGE >17. 475............ RESPIRATORY

2.0848

34.5

28.8 SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT. 476............ \4\ PROSTATIC

1.1679

29.6

24.7 O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 477............ NON-EXTENSIVE

1.5867

35.2

29.3 O.R. PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS. 478............ OTHER VASCULAR

1.3338

30.7

25.6 PROCEDURES W CC. 479............ \7\ OTHER

1.1679

29.6

24.7 VASCULAR PROCEDURES W/O CC. 480............ \6\ LIVER

0.0000

1.0

0.8 TRANSPLANT. 481............ \7\ BONE MARROW

1.6862

38.0

31.7 TRANSPLANT. 482............ \3\ TRACHEOSTOMY 0.7586

24.5

20.4 FOR FACE, MOUTH & NECK DIAGNOSES. 484............ \2\ CRANIOTOMY

0.5834

21.0

17.5 FOR MULTIPLE SIGNIFICANT TRAUMA. 485............ \7\ LIMB

0.7586

24.5

20.4 REATTACHMENT, HIP AND FEMUR PROC FOR MULTIPLE SIGNIFICANT TR. 486............ \5\ OTHER O.R.

1.6862

38.0

31.7 PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA. 487............ OTHER MULTIPLE

0.9046

26.0

21.7 SIGNIFICANT TRAUMA. 488............ \5\ HIV W

1.6862

38.0

31.7 EXTENSIVE O.R. PROCEDURE. 489............ HIV W MAJOR

0.8348

21.1

17.6 RELATED CONDITION. 490............ HIV W OR W/O

0.5012

16.4

13.7 OTHER RELATED CONDITION. 491............ \5\ MAJOR JOINT

1.6862

38.0

31.7 & LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITY. 492............ \7\ CHEMOTHERAPY 1.6862

38.0

31.7 W ACUTE LEUKEMIA OR W USE OF HI DOSE CHEMOAGENT. 493............ \4\ LAPAROSCOPIC 1.1679

29.6

24.7 CHOLECYSTECTOMY W/O C.D.E. W CC. 494............ \7\ LAPAROSCOPIC 1.1679

29.6

24.7 CHOLECYSTECTOMY W/O C.D.E. W/O CC. 495............ \6\ LUNG

0.0000

1.0

0.8 TRANSPLANT. 496............ \7\ COMBINED

1.1679

29.6

24.7 ANTERIOR/ POSTERIOR SPINAL FUSION. 497............ \4\ SPINAL

1.1679

29.6

24.7 FUSION W CC. 498............ \7\ SPINAL

1.1679

29.6

24.7 FUSION EXCEPT CERVICAL W/O CC. 499............ \5\ BACK & NECK

1.6862

38.0

31.7 PROCEDURES EXCEPT SPINAL FUSION W CC. 500............ \4\ BACK & NECK

1.1679

29.6

24.7 PROCEDURES EXCEPT SPINAL FUSION W/O CC. 501............ \5\ KNEE

1.6862

38.0

31.7 PROCEDURES W PDX OF INFECTION W CC. 502............ \4\ KNEE

1.1679

29.6

24.7 PROCEDURES W PDX OF INFECTION W/O CC. 503............ \2\ KNEE

0.5834

21.0

17.5 PROCEDURES W/O PDX OF INFECTION. 504............ \7\ EXTENSIVE

1.6862

38.0

31.7 BURNS OF FULL THICKNESS BURNS WITH MECH VENT 96+HRS WITH SKIN GRAFT. 505............ \4\ EXTENSIVE

1.1679

29.6

24.7 BURN OR FULL THICKNESS BURNS WITH MECH VENT 96+ HOURS WITHOUT SKIN GRAFT. 506............ \4\ FULL

1.1679

29.6

24.7 THICKNESS BURN W SKIN GRAFT OR INHAL INJ W CC OR SIG TRAUMA. 507............ \3\ FULL

0.7586

24.5

20.4 THICKNESS BURN W SKIN GRFT OR INHAL INJ W/O CC OR SIG TRAUMA. 508............ FULL THICKNESS

0.8403

29.4

24.5 BURN W/O SKIN GRFT OR INHAL INJ W CC OR SIG TRAUMA. 509............ \1\ FULL

0.4502

18.8

15.7 THICKNESS BURN W/O SKIN GRFT OR INH INJ W/O CC OR SIG TRAUMA. 510............ NON-EXTENSIVE

0.7737

24.6

20.5 BURNS W CC OR SIGNIFICANT TRAUMA. 511............ \1\ NON-

0.4502

18.8

15.7 EXTENSIVE BURNS W/O CC OR SIGNIFICANT TRAUMA. 512............ \6\ SIMULTANEOUS 0.0000

1.0

0.8 PANCREAS/KIDNEY TRANSPLANT. 513............ \6\ PANCREAS

0.0000

1.0

0.8 TRANSPLANT. 515............ \5\ CARDIAC

1.6862

38.0

31.7 DEFIBRILATOR IMPLANT W/O CARDIAC CATH. 517............ \5\ PERCUTANEOUS 1.6862

38.0

31.7 CARDIVASCULAR PROC W NON-DRUG ELUTING STENT W/ O AMI. 518............ \3\ PERCUTANEOUS 0.7586

24.5

20.4 CARDIVASCULAR PROC W/O CORONARY ARTERY STENT OR AMI.

[[Page 23653]]

519............ \5\ CERVICAL

1.6862

38.0

31.7 SPINAL FUSION W CC. 520............ \7\ CERVICAL

1.1679

29.6

24.7 SPINAL FUSION W/ O CC. 521............ ALCOHOL/DRUG

0.4533

19.8

16.5 ABUSE OR DEPENDENCE W CC. 522............ \7\ ALCOHOL/DRUG 0.4502

18.8

15.7 ABUSE OR DEPENDENCE W REHABILITATION THERAPY W/O CC. 523............ \7\ ALCOHOL/DRUG 0.4502

18.8

15.7 ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O CC. 524............ TRANSIENT

0.5069

21.1

17.6 ISCHEMIA. 525............ \7\ OTHER HEART

1.6862

38.0

31.7 ASSIST SYSTEM IMPLANT. 527............ \5\ PERCUTANEOUS 1.6862

38.0

31.7 CARVIOVASCULAR PROC W DRUG- ELUTING STENT W/ O AMI. 528............ \7\ INTRACRANIAL 1.6862

38.0

31.7 VASCULAR PROC W PDX HEMORRHAGE. 529............ \5\ VENTRICULAR

1.6862

38.0

31.7 SHUNT PROCEDURES W CC. 530............ \7\ VENTRICULAR

1.6862

38.0

31.7 SHUNT PROCEDURES W/O CC. 531............ \3\ SPINAL

0.7586

24.5

20.4 PROCEDURES WITH CC. 532............ \8\ SPINAL

0.7586

24.5

20.4 PROCEDURES WITHOUT CC. 533............ \5\ EXTRACRANIAL 1.6862

38.0

31.7 VASCULAR PROCEDURES WITH CC. 534............ \7\ EXTRACRANIAL 1.1679

29.6

24.7 PROCEDURES W/O CC. 535............ \7\ CARDIAC

1.6862

38.0

31.7 DEFIB IMPLANT W CARDIAC CATH W AMI/HF/SHOCK. 536............ \7\ CARDIAC

1.6862

38.0

31.7 DEFIB IMPLANT W CARDIAC CATH W/ O AMI/HF/SHOCK. 537............ LOCAL EXCISION

1.1670

34.6

28.8 AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC. 538............ \7\ LOCAL

1.1679

29.6

24.7 EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC. 539............ \4\ LYMPHOMA AND 1.1679

29.6

24.7 LEUKEMIA WITH MAJOR O.R. PROCEDURE WITH CC. 540............ \7\ LYMPHOMA &

0.5834

21.0

17.5 LEUKEMIA W MAJOR OR PROCEDURE W/O CC. 541............ ECMO OR TRACH W

4.2566

65.6

54.7 MECH VENT 96+ HRS OR PDX EXCEPT FACE, MOUTH & NECK DIAG WITH MAJOR OR. 542............ TRACH W MECH

3.1821

47.9

39.9 VENT 96+ HRS OR PDX EXCEPT FACE, MOUTH & NECK DIAG WITHOUT MAJOR OR. 543............ \5\ CRANIOTOMY W 1.6862

38.0

31.7 IMPLANT OF CHEMO AGENT OR ACUTE COMPLEX CNS PDX. 544............ \5\ MAJOR JOINT

1.6862

38.0

31.7 REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY. 545............ \5\ REVISION OF

1.6862

38.0

31.7 HIP OR KNEE REPLACEMENT. 546............ \7\ SPINAL

1.6862

38.0

31.7 FUSION EXCEPT CERVICAL WITH PRINCIPAL DIAGNOSIS OF CURVATURE OF SPINE OR MALIGNANCY. 547............ \7\ PERCUTANEOUS 1.6862

38.0

31.7 CARDIOVASCULAR PROCEDURE WITH AMI WITH CC. 548............ \7\ PERCUTANEOUS 1.6862

38.0

31.7 CARDIOVASCULAR PROCEDURE WITH AMI WITHOUT CC. 549............ \7\ PERCUTANEOUS 1.6862

38.0

31.7 CARDIOVASCULAR PROCEDURE WITH DRUG-ELUTING STENT WITH AMI WITH CC. 550............ \7\ PERCUTANEOUS 1.6862

38.0

31.7 CARDIOVASCULAR PROCEDURE WITH DRUG-ELUTING STENT WITH AMI WITHOUT CC.

\1\ Proposed relative weights for these proposed LTC-DRGs were determined by assigning these cases to proposed low-volume quintile 1.

\2\ Proposed relative weights for these proposed LTC-DRGs were determined by assigning these cases to proposed low-volume quintile 2.

\3\ Proposed relative weights for these proposed LTC-DRGs were determined by assigning these cases to proposed low-volume quintile quintile 3. \4\ Proposed relative weights for these proposed LTC-DRGs were determined by assigning these cases to proposed low-volume quintile 4.

\5\ Proposed relative weights for these proposed LTC-DRGs were determined by assigning these cases to proposed low-volume quintile quintile 5. \6\ Proposed relative weights for these proposed LTC-DRGs were assigned a value of 0.0000. \7\ Proposed relative weights for these proposed LTC-DRGs were determined by assigning these cases to the appropriate proposed low volume quintile because there are no LTCH cases in the FY 2004 MedPAR file. \8\ Proposed relative weights for these proposed LTC-DRGs were determined after adjusting to account for nonmonotonicity (see step 5 above).

Appendix A--Regulatory Analysis of Impacts

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

I. Background and Summary

We have examined the impacts of this proposed rule as required by Executive Order 12866 (September 1993, Regulatory Planning and Review) and the Regulatory Flexibility Act (RFA) (September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social Security Act, the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4), and Executive Order 13132.

Executive Order 12866 directs agencies to assess all costs and benefits of available regulatory alternatives and, if regulation is necessary, to select regulatory approaches that maximize net benefits (including potential economic, environmental, public health and safety effects, distributive impacts, and equity). A regulatory impact analysis (RIA) must be prepared for major rules with economically significant effects ($100 million or more in any 1 year).

We have determined that this proposed rule is a major rule as defined in 5 U.S.C. 804(2). We estimate that the total impact of these proposed changes for FY 2006 payments compared to FY 2005 payments to be approximately a $2.40 billion increase. This amount does not reflect changes in hospital admissions or case-mix intensity, which would also affect overall payment changes.

The RFA requires agencies to analyze options for regulatory relief of small

[[Page 23654]]

businesses. For purposes of the RFA, small entities include small businesses, nonprofit organizations, and government agencies. Most hospitals and most other providers and suppliers are small entities, either by nonprofit status or by having revenues of $5 million to $25 million in any 1 year. For purposes of the RFA, all hospitals and other providers and suppliers are considered to be small entities. Individuals and States are not included in the definition of a small entity.

In addition, section 1102(b) of the Act requires us to prepare a regulatory impact analysis for any proposed rule that may have a significant impact on the operations of a substantial number of small rural hospitals. This analysis must conform to the provisions of section 603 of the RFA. With the exception of hospitals located in certain New England counties, for purposes of section 1102(b) of the Act, we previously defined a small rural hospital as a hospital with fewer than 100 beds that is located outside of a Metropolitan Statistical Area (MSA) or New England County Metropolitan Area (NECMA). However, under the new labor market definitions, we no longer employ NECMAs to define urban areas in New England. Therefore, we now define a small rural hospital as a hospital with fewer than 100 beds that is located outside of a Metropolitan Statistical Area (MSA). Section 601(g) of the Social Security Amendments of 1983 (Pub. L. 98-21) designated hospitals in certain New England counties as belonging to the adjacent NECMA. Thus, for purposes of the IPPS, we continue to classify these hospitals as urban hospitals.

Section 202 of the Unfunded Mandates Reform Act of 1995 (Pub. L. 104-4) also requires that agencies assess anticipated costs and benefits before issuing any proposed rule (or a final rule that has been preceded by a proposed rule) that may result in an expenditure in any one year by State, local, or tribal governments, in the aggregate, or by the private sector, of $110 million. This proposed rule will not mandate any requirements for State, local, or tribal governments.

Executive Order 13132 establishes certain requirements that an agency must meet when it promulgates a proposed rule (and subsequent final rule) that imposes substantial direct requirement costs on State and local governments, preempts State law, or otherwise has Federalism implications. We have reviewed this proposed rule in light of Executive Order 13132 and have determined that it would not have any negative impact on the rights, roles, and responsibilities of State, local, or tribal governments.

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

The following analysis, in conjunction with the remainder of this document, demonstrates that this proposed rule is consistent with the regulatory philosophy and principles identified in Executive Order 12866, the RFA, and section 1102(b) of the Act. The proposed rule will affect payments to a substantial number of small rural hospitals, as well as other classes of hospitals, and the effects on some hospitals may be significant.

II. Objectives

The primary objective of the IPPS is to create incentives for hospitals to operate efficiently and minimize unnecessary costs while at the same time ensuring that payments are sufficient to adequately compensate hospitals for their legitimate costs. In addition, we share national goals of preserving the Medicare Trust Fund.

We believe the proposed changes in this proposed rule will further each of these goals while maintaining the financial viability of the hospital industry and ensuring access to high quality health care for Medicare beneficiaries. We expect that these proposed changes will ensure that the outcomes of this payment system are reasonable and equitable while avoiding or minimizing unintended adverse consequences.

III. Limitations of Our Analysis

The following quantitative analysis presents the projected effects of our proposed policy changes, as well as statutory changes effective for FY 2006, on various hospital groups. We estimate the effects of individual policy changes by estimating payments per case while holding all other payment policies constant. We use the best data available, but we do not attempt to predict behavioral responses to our policy changes, and we do not make adjustments for future changes in such variables as admissions, lengths of stay, or case-mix. As we have done in the previous proposed rules, we are soliciting comments and information about the anticipated effects of these proposed changes on hospitals and our methodology for estimating them. Any comments that we receive in response to this proposed rule will be addressed in the final rule.

IV. Hospitals Included In and Excluded From the IPPS

The prospective payment systems for hospital inpatient operating and capital-related costs encompass nearly all general short-term, acute care hospitals that participate in the Medicare program. There were 35 Indian Health Service hospitals in our database, which we excluded from the analysis due to the special characteristics of the prospective payment method for these hospitals. Among other short- term, acute care hospitals, only the 46 such hospitals in Maryland remain excluded from the IPPS under the waiver at section 1814(b)(3) of the Act.

As of March 2005, there are 3,693 IPPS hospitals to be included in our analysis. This represents about 63 percent of all Medicare- participating hospitals. The majority of this impact analysis focuses on this set of hospitals. There are also approximately 974 critical access hospitals (CAHs). These small, limited service hospitals are paid on the basis of reasonable costs rather than under the IPPS. There are also 1,138 specialty hospitals and units that are excluded from the IPPS. These specialty hospitals include psychiatric hospitals and units, rehabilitation hospitals and units, long-term care hospitals, children's hospitals, and cancer hospitals. The impacts of our proposed policy changes on these hospitals are discussed below.

V. Impact on Excluded Hospitals and Hospital Units

As of March 2005, there were 1,138 specialty hospitals excluded from the IPPS. Of these 1,138 specialty hospitals, 467 psychiatric hospitals, 80 children's, 11 cancer hospitals, and 21 LTCHs that are paid under the LTCH PPS blend methodology are being paid, in whole or in part, on a reasonable cost basis subject to the rate-of- increase ceiling under Sec. 413.40. The remaining providers--218 IRFs and 361 LTCHs are paid 100 percent of the Federal prospective rate under the IRF PPS and the LTCH PPS, respectively. In addition, there were 1,342 psychiatric units (paid on a blend of the IPF PPS per diem payment and the TEFRA reasonable cost-based payment) and 1,006 rehabilitation units (paid under the IRF PPS) in hospitals otherwise subject to the IPPS. Under Sec. 413.40(a)(2)(i)(A), the rate-of-increase ceiling is not applicable to the 46 specialty hospitals and units in Maryland that are paid in accordance with the waiver at section 1814(b)(3) of the Act.

In the past, hospitals and units excluded from the IPPS have been paid based on their reasonable costs subject to limits as established by the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA). Hospitals that continue to be paid based on their reasonable costs are subject to TEFRA limits for FY 2006. For these hospitals, the proposed update is the percentage increase in the excluded hospital market basket, currently estimated at 3.4 percent.

Inpatient rehabilitation facilities (IRFs) are paid under a prospective payment system (IRF PPS) for cost reporting periods beginning on or after January 1, 2002. For cost reporting periods beginning during FY 2005, the IRF PPS is based on 100 percent of the adjusted Federal IRF prospective payment amount, updated annually. Therefore, these hospitals are not impacted by this proposed rule.

Effective for cost reporting periods beginning on or after October 1, 2002, LTCHs are paid under a LTCH PPS, based on a Federal prospective payment amount that is updated annually. LTCHs will receive a blended payment that consists of the Federal prospective payment rate and a reasonable cost-based payment rate over a 5-year transition period. However, under the LTCH PPS, a LTCH may also elect to be paid at 100 percent of the Federal prospective rate at the beginning of any of its cost reporting periods during the 5-year transition period. For purposes of the update factor, the portion of the LTCH PPS transition blend payment based on reasonable costs for inpatient operating services would be determined by updating the LTCH's TEFRA limit by the estimate of the excluded hospital market basket (or 3.4 percent).

Section 124 of the Medicare, Medicaid, and SCHIP Balanced Budget Refinement Act of 1999 (BBRA) required the development of a per diem prospective payment system (PPS) for payment of inpatient hospital services furnished in psychiatric hospitals and psychiatric units of acute care hospitals and

[[Continued on page 23655]]

From the Federal Register Online via GPO Access [wais.access.gpo.gov] ]

[[pp. 23655-23673]] Medicare Program; Proposed Changes to the Hospital Inpatient Prospective Payment Systems and Fiscal Year 2006 Rates

[[Continued from page 23654]]

[[Page 23655]]

CAHs (inpatient psychiatric facilities (IPFs)). We published a final rule to implement the IPF PPS on November 15, 2004 (69 FR 66922). The final rule established a 3-year transition to the IPF PPS during which some providers will receive a blend of the IPF PPS per diem payment and the TEFRA reasonable cost-based payment. For purposes of determining what the TEFRA payment to the IPF would be, we are proposing that the IPF's TEFRA limit will be updated by the estimate of the excluded hospital market basket (or 3.4 percent).

The impact on excluded hospitals and hospital units of the update in the rate-of-increase limit depends on the cumulative cost increases experienced by each excluded hospital or unit since its applicable base period. For excluded hospitals and units that have maintained their cost increases at a level below the rate-of- increase limits since their base period, the major effect is on the level of incentive payments these hospitals and hospital units receive. Conversely, for excluded hospitals and hospital units with per-case cost increases above the cumulative update in their rate- of-increase limits, the major effect is the amount of excess costs that will not be reimbursed.

We note that, under Sec. 413.40(d)(3), an excluded hospital or unit whose costs exceed 110 percent of its rate-of-increase limit receives its rate-of-increase limit plus 50 percent of the difference between its reasonable costs and 110 percent of the limit, not to exceed 110 percent of its limit. In addition, under the various provisions set forth in Sec. 413.40, certain excluded hospitals and hospital units can obtain payment adjustments for justifiable increases in operating costs that exceed the limit. However, at the same time, by generally limiting payment increases, we continue to provide an incentive for excluded hospitals and hospital units to restrain the growth in their spending for patient services.

VI. Quantitative Impact Analysis of the Policy Changes Under the IPPS for Operating Costs

A. Basis and Methodology of Estimates

In this proposed rule, we are announcing policy changes and payment rate updates for the IPPS for operating costs. Changes to the capital payments are discussed in section VIII. of this Appendix. Based on the overall percentage change in payments per case estimated using our payment simulation model (a 2.5 percent increase), we estimate the total impact of these proposed changes for FY 2006 operating payments compared to FY 2005 operating payments to be approximately a $2.41 billion increase. This amount does not reflect changes in hospital admissions or case-mix intensity, which would also affect overall payment changes.

We have prepared separate impact analyses of the proposed changes to each system. This section deals with proposed changes to the operating prospective payment system. Our payment simulation model relies on the most recent available data to enable us to estimate the impacts on payments per case of certain changes we are proposing in this rule. However, there are other changes we are proposing for which we do not have data available that would allow us to estimate the payment impacts using this model. For those proposed changes, we have attempted to predict the payment impacts of those proposed changes based upon our experience and other more limited data.

The data used in developing the quantitative analyses of changes in payments per case presented below are taken from the FY 2004 MedPAR file and the most current Provider-Specific File that is used for payment purposes. Although the analyses of the changes to the operating PPS do not incorporate cost data, data from the most recently available hospital cost report were used to categorize hospitals. Our analysis has several qualifications. First, we do not make adjustments for behavioral changes that hospitals may adopt in response to the proposed policy changes, and we do not adjust for future changes in such variables as admissions, lengths of stay, or case-mix. Second, due to the interdependent nature of the IPPS payment components, it is very difficult to precisely quantify the impact associated with each proposed change. Third, we draw upon various sources for the data used to categorize hospitals in the tables. In some cases, particularly the number of beds, there is a fair degree of variation in the data from different sources. We have attempted to construct these variables with the best available source overall. However, for individual hospitals, some miscategorizations are possible.

Using cases in the FY 2004 MedPAR file, we simulated payments under the operating IPPS given various combinations of payment parameters. Any short-term, acute care hospitals not paid under the IPPS (Indian Health Service hospitals and hospitals in Maryland) were excluded from the simulations. The impact of payments under the capital IPPS, or the impact of payments for costs other than inpatient operating costs, are not analyzed in this section. Estimated payment impacts of proposed FY 2006 changes to the capital IPPS are discussed in section VIII of this Appendix.

The proposed changes discussed separately below are the following:

The effects of the annual reclassification of diagnoses and procedures and the recalibration of the DRG relative weights required by section 1886(d)(4)(C) of the Act.

The effects of the proposed changes in hospitals' wage index values reflecting wage data from hospitals' cost reporting periods beginning during FY 2002, compared to the FY 2001 wage data.

The effect of the proposed change in the way we use the wage data for hospitals that reclassify as rural under section 401 of the BBRA to compute wage indexes.

The effect of the proposed wage and recalibration budget neutrality factors.

The effect of the remaining labor market area transition for those hospitals that were urban under the old labor market area designations and are now considered rural hospitals.

The effects of geographic reclassifications by the MGCRB that will be effective in FY 2006.

The effects of section 505 of Pub. L. 108-173, which provides for an increase in a hospital's wage index if the hospital qualifies by meeting a threshold percentage of residents of the county where the hospital is located who commute to work at hospitals in counties with higher wage indexes.

The total change in payments based on proposed FY 2006 policies and MMA-imposed changes relative to payments based on FY 2005 policies.

To illustrate the impacts of the proposed FY 2006 changes, our analysis begins with a FY 2006 baseline simulation model using: the proposed update of 3.2 percent; the FY 2005 DRG GROUPER (version 22.0); the CBSA designations for hospitals based on OMB's June 2003 MSA definitions; the FY 2005 wage index; and no MGCRB reclassifications. Outlier payments are set at 5.1 percent of total operating DRG and outlier payments.

Section 1886(b)(3)(B)(vii) of the Act, as added by section 501(b) of Pub. L. 108-173, provides that, for FYs 2005 through 2007, the update factors will be reduced by 0.4 percentage points for any hospital that does not submit quality data. For purposes of the FY 2006 simulations in this proposed impact analysis, we are assuming all hospitals will qualify for the full update.

Each proposed and statutory policy change is then added incrementally to this baseline model, finally arriving at an FY 2006 model incorporating all of the proposed changes. This allows us to isolate the effects of each proposed change.

Our final comparison illustrates the percent change in payments per case from FY 2005 to FY 2006. Three factors not discussed separately have significant impacts here. The first is the update to the standardized amount. In accordance with section 1886(b)(3)(B)(i) of the Act, we have updated standardized amounts for FY 2006 using the most recently forecasted hospital market basket increase for FY 2006 of 3.2 percent. (Hospitals that fail to comply with the quality data submission requirement to receive the full update will receive an update reduced by 0.4 percentage points to 2.8 percent.) Under section 1886(b)(3)(B)(iv) of the Act, the updates to the hospital- specific amounts for sole community hospitals (SCHs) and for Medicare-dependent small rural hospitals (MDHs) are also equal to the market basket increase, or 3.2 percent.

A second significant factor that impacts changes in hospitals' payments per case from FY 2005 to FY 2006 is the change in MGCRB status from one year to the next. That is, hospitals reclassified in FY 2005 that are no longer reclassified in FY 2006 may have a negative payment impact going from FY 2005 to FY 2006; conversely, hospitals not reclassified in FY 2005 that are reclassified in FY 2006 may have a positive impact. In some cases, these impacts can be quite substantial, so if a relatively small number of hospitals in a particular category lose their reclassification status, the percentage change in payments for the category may be below the national mean. However, this effect is alleviated by section 1886(d)(10)(D)(v) of the Act, which provides that reclassifications for purposes of the wage index are for a 3-year period.

A third significant factor is that we currently estimate that actual outlier

[[Page 23656]]

payments during FY 2005 will be 4.4 percent of total DRG payments. When the FY 2005 final rule was published, we projected FY 2005 outlier payments would be 5.1 percent of total DRG plus outlier payments; the average standardized amounts were offset correspondingly. The effects of the lower than expected outlier payments during FY 2005 (as discussed in the Addendum to this proposed rule) are reflected in the analyses below comparing our current estimates of FY 2005 payments per case to estimated FY 2006 payments per case (with outlier payments projected to equal 5.1 percent of total DRG payments).

B. Analysis of Table I

Table I displays the results of our analysis of proposed changes for FY 2006. The table categorizes hospitals by various geographic and special payment consideration groups to illustrate the varying impacts on different types of hospitals. The top row of the table shows the overall impact on the 3,693 hospitals included in the analysis. This number is 204 fewer hospitals than were included in the impact analysis in the FY 2005 final rule (69 FR 49758 ).

The next four rows of Table I contain hospitals categorized according to their geographic location: All urban, which is further divided into large urban and other urban; and rural. There are 2,537 hospitals located in urban areas included in our analysis. Among these, there are 1,399 hospitals located in large urban areas (populations over 1 million), and 1,138 hospitals in other urban areas (populations of 1 million or fewer). In addition, there are 1,156 hospitals in rural areas. The next two groupings are by bed- size categories, shown separately for urban and rural hospitals. The final groupings by geographic location are by census divisions, also shown separately for urban and rural hospitals.

The second part of Table I shows hospital groups based on hospitals' FY 2006 payment classifications, including any reclassifications under section 1886(d)(10) of the Act. For example, the rows labeled urban, large urban, other urban, and rural show that the number of hospitals paid based on these categorizations after consideration of geographic reclassifications are 2,575, 1,410, 1,165, and 1,118, respectively.

The next three groupings examine the impacts of the proposed changes on hospitals grouped by whether or not they have GME residency programs (teaching hospitals that receive an IME adjustment) or receive DSH payments, or some combination of these two adjustments. There are 2,615 nonteaching hospitals in our analysis, 841 teaching hospitals with fewer than 100 residents, and 237 teaching hospitals with 100 or more residents.

In the DSH categories, hospitals are grouped according to their DSH payment status, and whether they are considered urban or rural for DSH purposes. The next category groups hospitals considered urban after geographic reclassification, in terms of whether they receive the IME adjustment, the DSH adjustment, both, or neither.

The next five rows examine the impacts of the proposed changes on rural hospitals by special payment groups (SCHs, rural referral centers (RRCs), and Medicare dependant hospitals (MDHs)), as well as rural hospitals not receiving a special payment designation. There were 134 RRCs, 405 SCHs, 158 MDHs, and 73 hospitals that are both SCH and RRC.

The next two groupings are based on type of ownership and the hospital's Medicare utilization expressed as a percent of total patient days. These data are taken primarily from the FY 2002 Medicare cost report files, if available (otherwise FY 2001 data are used).

The next series of groupings concern the geographic reclassification status of hospitals. The first grouping displays all hospitals that were reclassified by the MGCRB for FY 2006. The next two groupings separate the hospitals in the first group by urban and rural status. The final two rows in Table I contain hospitals located in rural counties but deemed to be urban under section 1886(d)(8)(B) of the Act and hospitals located in urban counties, but deemed to be rural under section 1886(d)(8)(E) of the Act.

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

In Column 2 of Table I, we present the effects of Option 2 for the proposed expansion of the postacute care transfer policy, as discussed in section V.A. of the preamble to this proposed rule. We compared aggregate payments using the FY 2005 DRG relative weights (GROUPER version 22.0) and Option 2 for the proposed expansion of the postacute care transfer policy to aggregate payments using the FY 2005 DRG relative weights (GROUPER version 22.0) and the FY 2005 postacute care transfer policy. The changes we are proposing are estimated to result in a 1.1 percent decrease in payments to hospitals overall. We estimate the total savings at approximately $880 million.

To simulate the impact of this proposed policy, we calculated two sets of transfer-adjusted discharges and case-mix index values for hospitals. The first set was based on the FY 2005 transfer policy rules and the second was based on Option 2 for the proposed expanded transfer policy discussed in the preamble to this proposed rule. Estimated payments were computed for both sets of data and were then compared. The transfer-adjusted discharge fraction is calculated in one of two ways, depending on the transfer payment methodology. Under the transfer payment methodology in place in FY 2005, for all but the three DRGs receiving special payment consideration (DRGs 209, 210, and 211), this adjustment is made by adding 1 to the length of stay and dividing that amount by the geometric mean length of stay for the DRG (with the resulting fraction not to exceed 1.0). For example, a transfer after 3 days from a DRG with a geometric mean length of stay of 6 days would have a transfer-adjusted discharge fraction of 0.667 ((3+1)/6).

For transfers from any one of the three DRGs receiving the alternative payment methodology, the transfer-adjusted discharge fraction is 0.5 (to reflect that these cases receive half the full DRG amount the first day), plus one half of the result of dividing 1 plus the length of stay prior to transfer by the geometric mean length of stay for the DRG. There are 88 DRGs (including 210, 211) that would qualify to receive the special payment consideration. DRG 209 which formerly received the special payment has been split into two new DRGs 544 and 545. Both DRG 544 and DRG 545 are included in the 88 special payment DRGs as they continue to qualify to receive the alternative payment methodology. As with the above adjustment, the result is equal to the lesser of the transfer adjusted discharge fraction or 1.

The transfer-adjusted case-mix index values are calculated by summing the transfer-adjusted DRG weights and dividing by the transfer-adjusted discharges. The transfer-adjusted DRG weights are calculated by multiplying the DRG weight by the lesser of 1 or the transfer-adjusted discharge fraction for the case, divided by the geometric mean length of stay for the DRG. In this way, simulated payments per case can be compared before and after the proposed change to the transfer policy.

This proposed expansion of the policy, which represents a significant change from our prior policy, has a negative 1.1 percent payment impact overall among both urban and rural hospitals. There is only small variation among all of the hospital categories from this negative 1.1 percent impact. The areas that are most dramatically impacted are urban areas, with urban New England experiencing a 1.9 percent decline in payments and the Middle Atlantic experiencing a 1.2 percent decline. Although rural New England hospitals are losing 1.1 percent, most of the other rural regions lose less than 1 percent from this policy change. Urban areas tend to have a greater concentration of postacute care facilities to which to discharge patients than do rural areas and are, therefore, more likely to be impacted by this policy proposal.

D. Impact of the Proposed Changes to the DRG Reclassifications and Recalibration of Relative Weights (Column 3)

In Column 3 of Table I, we present the combined effects of the DRG reclassifications and recalibration, as discussed in section II. of the preamble to this proposed rule. Section 1886(d)(4)(C)(i) of the Act requires us annually to make appropriate classification changes and to recalibrate the DRG weights in order to reflect changes in treatment patterns, technology, and any other factors that may change the relative use of hospital resources.

We compared aggregate payments using the FY 2005 DRG relative weights (GROUPER version 22.0) to aggregate payments using the proposed FY 2006 DRG relative weights (GROUPER version 23.0). We note that, consistent with section 1886(d)(4)(C)(iii) of the Act, we have applied a budget neutrality factor to ensure that the overall payment impact of the DRG changes (combined with the wage index changes) is budget neutral. This proposed budget neutrality factor of 1.002494 is applied to payments in Column 6. Because this is a combined DRG reclassification and recalibration and wage index budget neutrality factor, it is not applied to payments in Column 3.

The major DRG classification changes we are proposing include: reassigning procedure code 35.52 (Repair of atrial septal defect with prosthesis, closed technique) from DRG 108 to DRG 518 (Percutaneous Cardiovascular Procedure Without Coronary Artery Stent or AMI); reassigning procedure code 37.26 (Cardiac electrophysiologic stimulation and recording studies) from DRGs 535 and 536 to DRGs 515 (Cardiac Defibrillator Implant Without Cardiac Catheterization); splitting DRG 209 into two new DRGs based on the presence or absence of the procedure codes for major joint replacement or reattachment of lower extremity and revision of hip or knee replacement, DRG 545 (Revision of Hip or Knee Replacement) and DRG 544 (Major Joint Replacement or Reattachment of Lower Extremity); reassigning procedure code 26.12 (Open biopsy of salivary gland or duct) from DRG 468 to DRG 477 (Non-Extensive O.R. Procedure Unrelated To Principal Diagnosis); reassigning the principal diagnosis codes for curvature of the spine or malignancy from DRGs 497 and 498 to new DRG 546 (Spinal Fusion Except Cervical with PDX of Curvature of the Spine or Malignancy); splitting DRGs 516 and 526 into four new DRGs based on the presence or absence of a CC, DRG 547 (Percutaneous Cardiovascular Procedure With AMI With CC), DRG 548 (Percutaneous Cardiovascular Procedure With AMI Without CC), DRG 549 (Percutaneous Cardiovascular Procedure With Drug- Eluting Stent With AMI With CC), DRG 550 (Percutaneous Cardiovascular Procedure With Drug-Eluting Stent With AMI Without CC); reassigning procedure code 39.65 (Extracorporeal membrane oxygenation [ECMO]) from DRGs 104 and 105 to DRG 541 (ECMO or Tracheostomy with Mechanical Ventilation 96+ Hours or Principal Diagnosis Except Face, Mouth and Neck Diagnoses With Major Operating Room Procedure).

In the aggregate, these proposed changes would result in a 0.1 percent increase in overall payments to hospitals. On average, the impacts of these changes on any particular hospital group are very small, with urban hospitals experiencing a 0.2 percent increase and rural hospitals experiencing a 0.1 percent decrease. The largest impact is a 0.4 percent increase among urban hospitals in New England. This is in part due to the residual effects of the proposed change to the postacute care transfer policy on the relative weights. Including a DRG in the postacute care transfer group reduces the number of cases in the DRG (cases that qualify as transfers are only counted as a fraction of a case) which in turn increases the average charge for the DRG and the weight.

E. Impact of Proposed Wage Index Changes (Column 4)

Section 1886(d)(3)(E) of the Act requires that, beginning October 1, 1993, we annually update the wage data used to calculate the wage index. In accordance with this requirement, the proposed wage index for FY 2006 is based on data submitted for hospital cost reporting periods beginning on or after October 1, 2001 and before October 1, 2002. The impact of the new data on hospital payments is isolated in Column 4 by holding the other payment parameters constant in this simulation. That is, Column 4 shows the percentage changes in payments when going from a model using the FY 2005 wage index, based on FY 2001 wage data, to a model using the FY 2006 pre- reclassification wage index, based on FY 2002 wage data. The FY 2005 wage index baseline incorporated a blended wage index of 50 percent of the MSA wage index and 50 percent of the CBSA wage index in areas where the CBSA wage index was lower than the MSA wage index to reflect the transition policy that was in effect in FY 2005. The wage data collected on the FY 2002 cost report is the same as the FY 2001 wage data that were used to calculate the FY 2005 wage index.

Column 4 shows the impacts of updating the wage data using FY 2002 cost reports. Overall, the new wage data will lead to a 0.4 percent decrease for all hospitals and for hospitals in urban areas. This decrease is due to both fluctuations in the wage data itself and the fact that the transition blended wage index, which benefited areas that were negatively impacted by the labor market

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transition is no longer in effect for FY 2006. Among regions, the largest increase is in the rural New England which is experiencing a 1.0 percent increase. The largest decline from updating the wage data is seen in the urban New England region (a 1.1 percent decrease).

In looking at the wage data itself, the national average hourly wage increased 6.1 percent compared to FY 2005. Therefore, the only manner in which to maintain or exceed the previous year's wage index was to match the national 6.1 increase in average hourly wage. Of the 3,617 hospitals with wage index values in both FYs 2005 and 2006, 1,642, or 45.4 percent, also experienced an average hourly wage increase of 6.1 percent or more.

The following chart compares the shifts in wage index values for hospitals for FY 2006 relative to FY 2005. Among urban hospitals, 58 will experience an increase of between 5 percent and 10 percent and 24 will experience an increase of more than 10 percent. A total of 14 rural hospitals would experience increases greater than 5 percent, but none will experience increases of greater than 10 percent. On the negative side, 56 urban hospitals will experience decreases in their wage index values of at least 5 percent, but less than 10 percent. Fourteen urban hospitals will experience decreases in their wage index values greater than 10 percent.

The following chart shows the projected impact for urban and rural hospitals.

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

For the FY 2006 wage index, we are proposing to leave the wage data for a hospital redesignated as rural under section 1886(d)(8)(E) of the Act in the urban area in which the hospital is geographically located for purposes of calculating the wage index of those areas. We are proposing to move the wage data for these hospitals into the rural wage index only if it increases the wage index in the rural area. In this way, the rural floor is only affected by the wage data for these redesignated hospitals if it would increase the rural wage index and thus reset the rural floor at a higher value. Previously, the wage data for these redesignated hospitals was moved into the rural area wage index calculations regardless of whether it increased or decreased the rural wage index, and this caused the rural floor for several States to be lower than it would have been had the redesignated providers' data not been included.

Column 5 shows the impact of adopting this policy. In aggregate, this policy proposal has no effect on payments to providers. Hospitals in the urban New England region experience an increase in payments of 0.2 percent, which indicates that CBSAs in that region that receive the rural floor are now receiving a higher wage index. Hospitals in West North Central are shown to experience a 0.2 decline. However, when the redesignated data are added to the rural wage index, their rural floor increases and they do not actually experience a loss from this policy. Hospitals reclassified as rural under section 1886(d)(8)(E) of the Act will experience a 0.2 percent increase.

G. Combined Impact of Proposed DRG and Wage Index Changes, Including Budget Neutrality Adjustment (Column 6)

The impact of the DRG reclassifications and recalibration on aggregate payments is required by section 1886(d)(4)(C)(iii) of the Act to be budget neutral. In addition, section 1886(d)(3)(E) of the Act specifies that any updates or adjustments to the wage index are to be budget neutral. As noted in the Addendum to this proposed rule compared simulated aggregate payments using the FY 2005 DRG relative weights and wage index to simulated aggregate payments using the proposed FY 2006 DRG relative weights and blended wage index.

We computed a proposed wage and recalibration budget neutrality factor of 1.002494. The 0.0 percent impact for all hospitals demonstrates that these changes, in combination with the budget neutrality factor, are budget neutral. In Table I, the combined overall impacts of the effects of both the DRG reclassifications and recalibration and the updated wage index are shown in Column 6. The changes in this column are the sum of the proposed changes in Columns 3, 4, and 5, combined with the budget neutrality factor and the wage index floor for urban areas required by section 4410 of Pub. L. 105-33 to be budget neutral. There also may be some variation of plus or minus 0.1 percentage point due to rounding.

Among urban regions, the largest impacts are in the West North Central region and Puerto Rico, with 0.3 and 0.4 percent declines, respectively. The Pacific region experiences the largest increase of 1.1 percent. Among rural regions, the New England region benefits the most with a 1.3 percent increase, while the Mountain region experiences the largest decline (1.2 percent).

H. Impact of Allowing Urban Hospitals That Were Converted to Rural as a Result of the CBSA Designations To Maintain the Wage Index of the MSA Where They Are Located (Column 7)

To help alleviate the decreased payments for urban hospitals that became rural under the new labor market area definitions, for purposes of the wage index, we adopted a policy in FY 2005 to allow them to maintain the wage index assignment of the MSA where they were located for the 3-year period FY 2005, FY 2006, and FY 2007. Column 7 shows the impact of the remaining labor market area transition, for those hospitals that were urban under the old labor market area designations and are now considered rural hospitals. Section 1886(d)(3)(E) of the Act specifies that any updates or adjustments to the wage index are to be budget neutral. Therefore, we applied an adjustment of 0.999529 to ensure that the effects of reclassification are budget neutral as indicated by the zero effect on payments to hospitals overall. The rural hospital row shows a 0.3 percent benefit from this provision as these hold harmless hospitals are now considered geographically rural.

I. Impact of MGCRB Reclassifications (Column 8)

Our impact analysis to this point has assumed hospitals are paid on the basis of their actual geographic location (with the exception of ongoing policies that provide that certain hospitals receive payments on bases other than where they are geographically located, such as hospitals in rural counties that are deemed urban under section 1886(d)(8)(B) of the Act). The changes in Column 8 reflect the per case payment impact of moving from this baseline to a simulation incorporating the MGCRB decisions for FY 2006. These decisions affect hospitals' standardized amount and wage index area assignments.

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By February 28 of each year, the MGCRB makes reclassification determinations that will be effective for the next fiscal year, which begins on October 1. The MGCRB may approve a hospital's reclassification request for the purpose of using another area's wage index value. The proposed FY 2006 wage index values incorporate all of the MGCRB's reclassification decisions for FY 2006. The wage index values also reflect any decisions made by the CMS Administrator through the appeals and review process through February 28, 2005. Additional changes that result from the Administrator's review of MGCRB decisions or a request by a hospital to withdraw its application will be reflected in the final rule for FY 2006.

The overall effect of geographic reclassification is required by section 1886(d)(8)(D) of the Act to be budget neutral. Therefore, we applied an adjustment of 0.992905 to ensure that the effects of reclassification are budget neutral. (See section II.A.4.b. of the Addendum to this proposed rule.)

As a group, rural hospitals benefit from geographic reclassification. We estimate that their payments will rise 2.0 percent in Column 8. Payments to urban hospitals will decline by 0.3 percent. Hospitals in other urban areas will experience an overall decrease in payments of 0.2 percent, while large urban hospitals will lose 0.4 percent. Among urban hospital groups (that is, bed size, census division, and special payment status), payments generally would decline.

A positive impact is evident among all of the rural hospital groups. The smallest increase among the rural census divisions is 0.5 for the Mountain and New England regions. The largest increases are in the rural East South Central region, with an increase of 3.0 percent and in the West South Central region, which would experience an increase of 2.5 percent.

Urban hospitals reclassified for FY 2006 are expected to receive an increase of 2.3 percent, while rural reclassified hospitals are expected to benefit from the MGCRB changes with a 3.7 percent increase in payments. Payments to urban and rural hospitals that did not reclassify are expected to decrease slightly due to the MGCRB changes, decreasing by 0.6 percent for urban hospitals and 0.3 percent for rural hospitals.

J. Impacts of the Proposed Wage Index Adjustment for Out-Migration (Column 9)

Section 1886(d)(13) of the Act, as added by section 505 of Pub. L. 108-173, provides for an increase in the wage index for hospitals located in certain counties that have a relatively high percentage of hospital employees who reside in the county, but work in a different area with a higher wage index. Hospitals located in counties that qualify for the payment adjustment are to receive an increase in the wage index that is equal to a weighted average of the difference between the wage index of the resident county and the higher wage index work area(s), weighted by the overall percentage of workers who are employed in an area with a higher wage index. Using our established criteria, 345 counties and 688 hospitals qualify to receive a commuting adjustment in FY 2006.

Due to the statutory formula to calculate the adjustment and the small number of counties that qualify, the impact on hospitals is minimal, with an overall impact on all hospitals of 0.1 percent.

K. All Changes (Column 10)

Column 10 compares our estimate of payments per case, incorporating all changes reflected in this proposed rule for FY 2006 (including statutory changes), to our estimate of payments per case in FY 2005. This column includes all of the proposed policy changes. Because the reclassifications shown in Column 8 do not reflect FY 2005 reclassifications, the impacts of FY 2006 reclassifications only affect the impacts from FY 2005 to FY 2006 if the reclassification impacts for any group of hospitals are different in FY 2006 compared to FY 2005.

Column 10 reflects all FY 2006 changes relative to FY 2005, shown in Columns 2 through 9 and those not applied until the final rates are calculated. The average increase for all hospitals is approximately 2.5 percent. This increase includes the effects of the proposed 3.2 percent market basket update. It also reflects the 0.7 percentage point difference between the projected outlier payments in FY 2005 (5.1 percent of total DRG payments) and the current estimate of the percentage of actual outlier payments in FY 2005 (4.4 percent), as described in the introduction to this Appendix and the Addendum to this proposed rule. As a result, payments are projected to be 0.7 percentage point lower in FY 2005 than originally estimated, resulting in a 0.7 percentage point greater increase for FY 2006 than would otherwise occur. In addition, the impact of section 505 adjustments accounted for a 0.1 percent increase. Payment decreases of 1.5 percent are primarily attributable to the impact of expanding the postacute care transfer policy (-1.1 percent). Indirect medical education formula changes for teaching hospitals under section 502 of Pub. L. 108-173, changes in payments due to the difference between the FY 2005 and FY 2006 wage index values assigned to providers reclassified under section 508 of Pub. L. 108-173, and changes in the incremental increase in payments from section 505 of Pub. L. 108-173 out migration adjustments account for the remaining -0.4 percent.

Section 213 of Pub. L. 106-554 provides that all SCHs may receive payment on the basis of their costs per case during their cost reporting period that began during 1996. For FY 2006, eligible SCHs receive 100 percent of their 1996 hospital-specific rate. In addition, in this proposed rule we are proposing to revise the budget neutrality adjustment applied to the hospital-specific rates to reflect only the payment changes resulting from DRG recalibration. Previously, we had also adjusted the hospital- specific rates to reflect payment changes based on area wage levels. The impact of this provision is modeled in Column 10 as well. In addition, section 402 of Pub. L. 108-173 increases the DSH adjustment for hospitals that serve a disproportionate share of low- income Medicare and Medicaid patients, which include rural hospitals and urban hospitals with fewer than 100 beds, SCHs, rural referral centers, and rural hospitals with less than 500 beds. The increase in DSH payments became effective for discharges occurring on or after April 1, 2004. As provided in the new Medicare law, the cap on DSH payment adjustments increased from 5.25 percent to 12 percent for urban hospitals with fewer than 100 beds, SCHs, and rural hospitals with less than 500 beds. There is no cap on rural referral centers, large urban hospitals over 100 beds, or rural hospitals over 500 beds.

There might also be interactive effects among the various factors comprising the payment system that we are not able to isolate. For these reasons, the values in Column 10 may not equal the sum of the changes described above.

The overall change in payments per case for hospitals in FY 2006 would increase by 2.5 percent. Hospitals in urban areas would experience a 2.5 percent increase in payments per case compared to FY 2005. Hospitals in rural areas, meanwhile, would experience a 2.6 percent payment increase. Hospitals in large urban areas would experience a 2.4 percent increase in payments and hospitals in other urban areas would experience a 2.7 percent increase in payments.

Among urban census divisions, the largest payment increase would be 4.0 percent in the Pacific region. Hospitals in the urban East South Central and West South Central regions would experience the next largest overall increases of 3.0 percent and 3.1 percent, respectively. The smallest urban increase would occur in the New England region, with an increase of 1.0 percent.

Among rural regions in Column 10, no hospital category will experience overall payment decreases. The Pacific and Middle Atlantic regions will benefit the most, with 3.3 and 3.2 percent increases, respectively. The smallest increase will occur in the West South Central region, with 2.2 percent increases in payments.

Among special categories of rural hospitals in Column 10, those hospitals receiving payment under the hospital-specific methodology (SCHs, MDHs, and SCH/RRCs) would experience payment increases of 2.8 percent, 2.4 percent, and 2.7 percent, respectively. This outcome is primarily related to the fact that, for hospitals receiving payments under the hospital-specific methodology, there were several increases to payments made in relation to implementation of the Pub. L. 108-173.

Urban hospitals reclassified for FY 2006 are anticipated to receive an increase of 3.0 percent, while rural reclassified hospitals are expected to benefit from reclassification with a 2.8 percent increase in payments. Those hospitals located in rural counties, but deemed to be urban under section 1886(d)(8)(B) of the Act, are expected to receive an increase in payments of 1.4 percent.

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Table II presents the projected impact of the proposed changes for FY 2006 for urban and rural hospitals and for the different categories of hospitals shown in Table I. It compares the estimated payments per case for FY 2005 with the average estimated per case payments for FY 2006, as calculated under our models. Thus, this table presents, in terms of the average dollar amounts paid per discharge, the combined effects of the changes presented in Table I. The percentage changes shown in the last column of Table II equal the percentage changes in average payments from Column 10 of Table I.

VII. Impact of Other Proposed Policy Changes

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

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

In section II.D. of the preamble of this proposed rule, we discuss the proposed changes in the LTC-DRG relative weights for FY 2006 based on the proposed version 23.0 of the CMS GROUPER (including the

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proposed changes in the classifications, relative weights and geometric mean length of stay for each LTC-DRG). Based on LTCH cases in the FY 2004 MedPAR file, we estimate that the proposed changes would result in an aggregate decrease in LTCH payments of approximately 4.7 percent. When we compared the version 22 (FY 2005) LTC-DRG relative weights to the proposed version 23 (FY 2006) LTC- DRG relative weights, we found that approximately 72 percent of the LTC-DRGs had higher relative weights under version 22 in comparison to the proposed version 23. We also found that the version 22 LTC- DRG relative weights were, on average, approximately 16 percent higher than the proposed version 23 LTC-DRG relative weights.

In addition, based on an analysis of the most recent available LTCH claims data from the FY 2004 MedPAR file, we continue to observe that the proposed average LTC-DRG relative weight decreases due to an increase of relatively lower charge cases being assigned to LTC-DRGs with higher relative weights in the prior year. Contributing to this increase in these relatively lower charge cases being assigned to LTC-DRGs with higher relative weights in the prior year are improvements in coding practices, which are typically found when moving from a reasonable cost-based payment system to a PPS. The impact of including cases with relatively lower charges into LTC-DRGs that had a relatively higher relative weight in the version 22.0 (FY 2005) GROUPER is a decrease in the average relative weight for those LTC-DRGs in the proposed GROUPER version 23.0. We also found that there is over a 15 percent increase in the average LTCH charge across all LTC-DRGs from FY 2003 to FY 2004. For some LTC- DRGs in which the average charge within the LTC-DRG increase is less than 15 percent, the relative weights for those LTC-DRGs will decrease because the average charge for each of those LTC-DRGs is being divided by a larger number (that is, the average charge across all LTC-DRGs). For the reasons discussed above, we believe that the proposed changes in the LTC-DRG relative weights, which include a number of proposed LTC-DRGs with lower proposed relative weights, would result in approximately a 4.6 percent decrease in aggregate LTCH PPS payments.

B. Impact of Proposed New Technology Add-On Payments

We are no longer required to ensure that any add-on payments for new technology under section 1886(d)(5)(K) of the Act are budget neutral (see section II.E. of the preamble to this proposed rule). However, we are still providing an estimate of the payment increases here, as they will have a significant impact on total payments made in FY 2006. New technology add-on payments are limited to the lesser of 50 percent of the costs of the technology, or 50 percent of the costs in excess of the DRG payment for the case. Because it is difficult to predict the actual new technology add-on payment for each case, we are estimating the increase in payment for FY 2006 as if every claim with these add-on payments will receive the maximum add-on payment. As discussed in section II.E. of the preamble of this proposed rule, we are not proposing to approve any of the new technology applications that were filed for FY 2006. However, we are proposing to continue to make add-on payments in FY 2006 for an FY 2005 new technology: KinetraTMimplants. We estimate this approval would increase overall payments by $12.8 million. The increase in payments for this new technology is not reflected in the tables.

C. Impact of Requirements for Hospital Reporting of Quality Data for Annual Hospital Payment Update

In section V.B. of the preamble to this proposed rule, we discuss our implementation of section 1886(b)(3)(B)(vii) of the Act, as added by section 501(b) of Pub. L. 108-173, which revised the mechanism used to update the standardized amount of payment for inpatient hospital operating costs. Specifically, section 1886(b)(3)(B)(vii) of the Act provides for a reduction of 0.4 percentage points to the update percentage increase (also known as the market basket update) for each of FYs 2005 through 2007 for any subsection (d) hospital that does not submit data on a set of 10 quality indicators established by the Secretary as of November 1, 2003. The statute also provides that any reduction will apply only to the year involved, and will not be taken into account in computing the applicable percentage increase for a subsequent fiscal year. We are unable to precisely estimate the effect of this provision because, while receiving the full update for those years is conditional upon the submission of quality data by a hospital, the submitted data must also be validated, as described in section V.B. above. The final date for submission of quality data for purposes of receiving the full adjustment in FY 2006 is May 15, 2005. Preliminary results indicate that over 98 percent of IPPS hospitals have submitted quality data. The QIOs are still in the process of validating that data and certifying those hospitals eligible to receive the full update for FY 2006. We have continued our efforts to ensure that QIOs provide assistance to all hospitals that wish to submit data. In the preamble to this proposed rule, we are proposing additional validation criteria to ensure that the quality data being sent to CMS are accurate. Our validation process requires participating hospitals to submit five charts per quarter. We reimburse each hospital for the cost of sending charts to the Clinical Data Abstraction Center at the rate of 12 cents per page for copying and approximately $4.00 per chart for postage. Based on our experience, the average size of a chart is 140 pages. Therefore, we estimate our expenditures for chart collection at $380,000 per quarter. Because we provide reimbursement to hospitals for the costs of chart submission, we believe that this requirement represents a minimal burden to participating hospitals. Based on test applications of these validation criteria to quality data that have been submitted thus far, we currently estimate that approximately 5 percent of hospitals will fail the edits and receive the reduced market basket update to the standardized amount. Based on this reduced payment to some hospitals, we estimate savings to the Medicare program of approximately $20 million for FY 2006.

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

In section V.E. of the preamble to this proposed rule, we discussed our proposed FY 2006 implementation of section 1886(d)(12) of the Act, as added by section 406 of Pub. L. 108-173, which provides for a payment adjustment to account for the higher costs per discharge of low-volume hospitals under the IPPS. For FY 2006, we are proposing to continue to apply the low-volume adjustment criteria that we specified in the FY 2005 IPPS final rule (69 FR 49099). Currently, our fiscal intermediaries have identified 10 providers that are eligible for the low-volume adjustment. We estimate that the impact of these providers receiving the additional 25 percent payment increase to be approximately $1.5 million.

E. Impact of Proposed Policies on Payment for Indirect Costs of Graduate Medical Education

1. IME Adjustment for TEFRA Hospitals Converting to IPPS Hospitals

In section V.F.2. of the preamble of this proposed rule, we discuss our proposal to incorporate into regulations our existing policy regarding the IME adjustment for TEFRA hospitals converting to IPPS hospitals. We establish an FTE resident cap for TEFRA hospitals converting to an IPPS hospital for IME payment purposes as if the hospital had been an IPPS hospital during the base year used to compute the hospital's direct GME FTE resident cap. We are only aware of four hospitals where this issue has arisen. The proposed addition to the regulations clarifies the established policy for computing an IME FTE resident cap for these hospitals. Because this is a proposal to clarify existing policy and codify it in regulations, there is no financial impact for FY 2006.

2. Section 1886(d)(8)(E) Teaching Hospitals That Withdraw Rural Reclasssification

In section V.F.3. of the preamble to this proposed rule, we present our proposal to adjust the IME FTE resident caps of hospitals that rescind their section 1886(d)(8)(E) rural reclassifications so that they do not continue to receive the increase in the FTE resident cap that is applied for rural teaching hositals. The purpose of this policy is to prevent urban hospitals from reclassifying to rural areas under section 1886(d)(8)(E) of the Act for a short period of time, solely as a means of receiving a permanent increase to their IME FTE caps. The impact of this policy is that section 1886(d)(8)(E) hospitals may receive decreased IME payments if they return to urban status. This impact cannot be quantified because we are unable to determine the number of hospitals that would otherwise game the system in the absence of this proposal and we are not aware of any teaching hospitals that became rural under the provision of section 1886(d)(8)(E) of the Act that have subsequently reverted to urban status.

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

In section V.H. of the preamble of this proposed rule, we discuss the impact of our implementation of the new labor market areas on multicampus hospital systems. Under our current policy, a multicampus hospital with campuses located in the same labor market area receives a single wage index. However, if the campuses are located in more than one labor market area, payment for each discharge is determined using the wage index value for the labor market area in which the campus of the hospital is located. In addition, current provisions provide that, in the case of a merger of hospitals, if the merged facilities operate as a single institution, the institution must submit a single cost report, which necessitates a single provider identification number. This provision also does not differentiate between merged facilities in a single wage index area or in multiple wage index areas. As a result, the wage index data for the merged facility is reported for the entire entity on a single cost report.

The current criteria for a hospital being reclassified to another wage area by the MGCRB do not address the circumstances under which a single campus of a multicampus hospital may seek reclassification.

Specifically, we are proposing that for reclassification applications submitted for FY 2006 (that is, applications received by September 1, 2004), we would allow a campus or campuses of a multicampus hospital system to seek geographic reclassification on the basis of the average hourly wage data submitted for the entire hospital system. For reclassification applications that would take effect for FY 2007 (that is, applications received by September 1, 2005) and thereafter, a campus of a multihospital system could not use the wage data of the entire hospital system, but rather, would have the opportunity to separate out campus-specific wage data for purposes of seeking reclassification for such campus. We estimate that this proposal will apply to fewer than 12 multicampus hospital systems nationwide and, therefore, will not lead to additional program expenditures because hospital geographic reclassifications are budget neutral under section 1886(d)(8)(D) of the Act.

G. Impact of Proposed Policy on Payment for Direct Costs of Graduate Medical Education

1. GME Initial Residency--Match for Second Year

In section V.I.2. of the preamble to this proposed rule, we discuss our proposed changes related to the initial residency period for residents that match into an advanced residency program, but fail to match into a clinical base year of training. We are proposing that, in instances where a hospital can document that, prior to commencement of any residency training, a resident matched into an advanced program that begins in the second residency year, that resident's initial residency period will be determined based on the period of board eligibility for the advanced program, without regard to the fact that the resident had not matched for a clinical base year training program. For purposes of this proposed rule, we have estimated the impact of this proposed rule change for FY 2006, using assumptions about the national average per resident amount, the number of affected residents, and the national average Medicare utilization rate. We estimate that this provision will affect approximately 600 residents. Using a national average per resident amount of $92,000, and an average Medicare utilization rate of 35 percent, we estimate that, for FY 2006, the impact of treating those residents as a full FTE rather than .50 FTE, Medicare payments for direct GME will increase by approximately $9.7 million.

2. New Teaching Hospitals' Participation in Medicare GME Affiliated Groups

In section V.I.3. of the preamble to this proposed rule, we discuss our proposed changes related to new teaching hospitals' participation in Medicare GME affiliated groups. Under current regulations, a new teaching hospital located in an urban area that establishes an FTE resident cap under Sec. 413.79(e) may not participate in a Medicare GME affiliated group. We are proposing to revise the regulations to allow a new teaching hospital located in an urban area to participate in a Medicare GME affiliated group, but only if any adjustments made by the Medicare GME affiliation agreement result in an increase to the new teaching hospital's adjusted resident FTE resident caps for purposes of IME and direct GME payment. There is no estimated increase in program payments related to this proposed change because any additional residents that would be counted at the new teaching hospitals as a result of this change could have been counted prior to the affiliation for Medicare GME payment purposes at the hospital that is losing slots under the affiliation agreement.

H. Impact of Policy on Rural Community Hospital Demonstration Program

In section V.K. of the preamble to this proposed rule, we discuss our implementation of section 410A of Pub.L. 108-173 that required the Secretary to establish a demonstration that will modify reimbursement for inpatient services for up to 15 small rural hospitals. Section 410A(c)(2) requires that ``in conducting the demonstration program under this section, the Secretary shall ensure that the aggregate payments made by the Secretary do not exceed the amount which the Secretary would have paid if the demonstration program under this section was not implemented.'' As discussed in section V.K. of the preamble to this proposed rule, we are satisfying this requirement by adjusting national IPPS rates by a factor that is sufficient to account for the added costs of this demonstration. We estimate that the average additional annual payment for FY 2006 that will be made to each participating hospital under the demonstration will be approximately $977,410. We based this estimate on the recent historical experience of the difference between inpatient cost and payment for hospitals that have applied for the demonstration. For 13 participating hospitals, the total annual impact of the demonstration program is estimated to be $12,706,334. We describe the budget neutrality adjustment required for this purpose in the Addendum to this proposed rule.

I. Impact of Proposed Policy on CAH Relocation Provisions

In section VII.B.3. of the preamble to this proposed rule, we discuss the proposed change to the necessary provider provision as it applies to CAHs. As required by statute, no additional CAHs will be certified as a necessary provider on or after January 1, 2006. We are proposing to revise the regulations to allow some flexibility for those CAHs previously designated as necessary providers that embarked on a replacement facility project before the sunset provision was enacted on December 8, 2003, but find that they cannot be operational in the replacement facility by January 1, 2006. We are proposing that, when a CAH is determined to have relocated, it may continue to operate under its existing necessary provider designation that exempts CAHs from the distance from another provider requirement only if certain conditions are met. The proposed clarification to the sunset of the necessary provider provision is intended to allow CAHs to complete construction projects that were initiated prior to the enactment of Pub. L. 108- 173. The Health Resources Services Administration (HRSA) estimates that this proposal will apply to fewer than six CAHs nationwide. The average cost of construction of a new 25 bed CAH is approximately $25 million. Given a depreciation schedule based on a 25 useful life and Medicare utilization of approximately 50 percent, the additional capital costs for six CAHs would be $3 million. However, the actual cost to the program would be further reduced since those 6 CAH are currently being reimbursed for their existing capital costs and also the increased operating costs that are associated with operating an aged facility. Accordingly, the budgetary impact for the proposed change on the affected CAHs is estimated at between $1 million and $2 million. Expressed on a per-facility basis, the budgetary impact of this proposed change is estimated at between $167,000 and $333,000 per CAH.

VIII. Impact of Proposed Changes in the Capital PPS

A. General Considerations

Fiscal year (FY) 2001 was the last year of the 10-year transition period established to phase in the PPS for hospital capital-related costs. During the transition period, hospitals were paid under one of two payment methodologies: fully prospective or hold harmless. Under the fully prospective methodology, hospitals were paid a blend of the capital Federal rate and their hospital- specific rate (see Sec. 412.340). Under the hold-harmless methodology, unless a hospital elected payment based on 100 percent of the capital Federal rate, hospitals were paid 85 percent of reasonable costs for old capital costs (100 percent for SCHs) plus an amount

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for new capital costs based on a proportion of the capital Federal rate (see Sec. 412.344). As we state in section VI. of the preamble of this proposed rule, with the 10-year transition period ending with hospital cost reporting periods beginning on or after October 1, 2001 (FY 2002), beginning in FY 2002 capital prospective payment system payments for most hospitals are based solely on the capital Federal rate. Therefore, we no longer include information on obligated capital costs or projections of old capital costs and new capital costs, which were factors needed to calculate payments during the transition period, for our impact analysis.

In accordance with Sec. 412.312, the basic methodology for determining a capital PPS payment is:

(Standard Federal Rate) x (DRG weight) x (Geographic Adjustment Factor (GAF)) x (Large Urban Add-on, if applicable) x (COLA adjustment for hospitals located in Alaska and Hawaii) x (1 +3 Disproportionate Share (DSH) Adjustment Factor + Indirect Medical Education (IME) Adjustment Factor, if applicable).

In addition, hospitals may also receive outlier payments for those cases that qualify under the threshold established for each fiscal year.

The data used in developing the impact analysis presented below are taken from the December 2004 update of the FY 2004 MedPAR file and the December 2004 update of the Provider Specific File that is used for payment purposes. Although the analyses of the changes to the capital prospective payment system do not incorporate cost data, we used the December 2004 update of the most recently available hospital cost report data (FY 2003) to categorize hospitals. Our analysis has several qualifications. First, we do not make adjustments for behavioral changes that hospitals may adopt in response to policy changes. Second, due to the interdependent nature of the IPPS, it is very difficult to precisely quantify the impact associated with each change. Third, we draw upon various sources for the data used to categorize hospitals in the tables. In some cases (for instance, the number of beds), there is a fair degree of variation in the data from different sources. We have attempted to construct these variables with the best available sources overall. However, for individual hospitals, some miscategorizations are possible.

Using cases from the December 2004 update of the FY 2004 MedPAR file, we simulated payments under the capital PPS for FY 2005 and FY 2006 for a comparison of total payments per case. Any short-term, acute care hospitals not paid under the general IPPS (Indian Health Service hospitals and hospitals in Maryland) are excluded from the simulations.

As we explain in section III.A.4. of the Addendum of this proposed rule, payments are no longer made under the regular exceptions provision under Sec. Sec. 412.348(b) through (e). Therefore, we no longer use the actuarial capital cost model (described in Appendix B of the August 1, 2001 proposed rule (66 FR 40099)). We modeled payments for each hospital by multiplying the capital Federal rate by the GAF and the hospital's case-mix. We then added estimated payments for indirect medical education, disproportionate share, large urban add-on, and outliers, if applicable. For purposes of this impact analysis, the model includes the following assumptions:

We estimate that the Medicare case-mix index would increase by 1.0 percent in both FYs 2005 and 2006.

We estimate that the Medicare discharges will be 13.5 million in FY 2005 and 13.3 million in FY 2006 for a 1.5 percent decrease from FY 2005 to FY 2006.

The capital Federal rate was updated beginning in FY 1996 by an analytical framework that considers changes in the prices associated with capital-related costs and adjustments to account for forecast error, changes in the case-mix index, allowable changes in intensity, and other factors. The proposed FY 2006 update is 0.7 percent (see section III.A.1.a. of the Addendum to this proposed rule).

In addition to the proposed FY 2006 update factor, the proposed FY 2006 capital Federal rate was calculated based on a proposed GAF/DRG budget neutrality factor of 1.0019, a proposed outlier adjustment factor of 0.9497, and a proposed (special) exceptions adjustment factor of 0.9997.

2. Results

In the past, in this impact section we presented the redistributive effects that were expected to occur between ``hold- harmless'' hospitals and ``fully prospective'' hospitals and a cross-sectional summary of hospital groupings by the capital PPS transition period payment methodology. We are no longer including this information because all hospitals (except new hospitals under Sec. 412.324(b) and under Sec. 412.304(c)(2)) will be paid 100 percent of the capital Federal rate in FY 2006.

We used the actuarial model described above to estimate the potential impact of our changes for FY 2006 on total capital payments per case, using a universe of 3,693 hospitals. As described above, the individual hospital payment parameters are taken from the best available data, including the December 2004 update of the FY 2004 MedPAR file, the December 2004 update to the Provider-Specific File, and the most recent cost report data from the December 2004 update of HCRIS. In Table III, we present a comparison of total payments per case for FY 2005 compared to FY 2006 based on the proposed FY 2006 payment policies. Column 2 shows estimates of payments per case under our model for FY 2005. Column 3 shows estimates of payments per case under our model for FY 2006. Column 4 shows the total percentage change in payments from FY 2005 to FY 2006. The change represented in Column 4 includes the 0.7 percent update to the capital Federal rate, a 1.0 percent increase in case- mix, changes in the adjustments to the capital Federal rate (for example, the effect of the new hospital wage index on the GAF), and reclassifications by the MGCRB, as well as changes in special exception payments. The comparisons are provided by: (1) Geographic location; (2) region; and (3) payment classification.

The simulation results show that, on average, capital payments per case can be expected to increase 1.7 percent in FY 2006. In addition to the 0.7 percent increase due to the capital market basket update, this projected increase in capital payments per case is largely attributable to an estimated increase in outlier payments in FY 2006. Our comparison by geographic location shows that urban hospitals are expected to experience a 1.8 percent increase in IPPS capital payments per case, while rural hospitals are only expected to experience a 1.2 percent increase in capital payments per case. This difference is mostly due to a projection that urban hospitals would experience a larger increase in estimated outlier payments from FY 2005 to FY 2006 compared to rural hospitals.

All regions are estimated to receive an increase in total capital payments per case from FY 2005 to FY 2006. Changes by region vary from a minimum increase of 0.1 percent (Middle Atlantic rural region) to a maximum increase of 3.3 percent (Pacific urban region). The relatively small increase in projected capital payments per discharge for hospitals located in the Middle Atlantic rural region is largely attributable to the proposed changes in the GAF values (that is, the proposed GAFs for most of these hospitals for FY 2006 are lower than the weighted average of the GAFs for FY 2005) . The relatively large increase in capital payments per discharge for hospitals located in the Pacific urban region is largely due to the proposed changes in the GAF values (that is, the proposed GAFs for most of these hospitals for FY 2006 are higher than the average of the GAFs for FY 2005) and a larger than average increase in estimated outlier payments for FY 2006.

Hospitals located in Puerto Rico are expected to experience an increase in total capital payments per case of 1.0 percent. This slightly lower than average increase in payment per case for hospitals located in Puerto Rico is largely due to the proposed changes in the proposed GAF values (that is, the proposed GAFs for most of these hospitals for FY 2006 are higher than the average of the GAFs for FY 2005).

By type of ownership, government hospitals are projected to have the largest rate of increase of total payment changes (2.0 percent). Similarly, payments to voluntary and proprietary hospitals are expected to increase 1.6 percent and 1.8 percent, respectively. As noted above, this slightly larger projected increase in capital payments per case for government hospitals is mostly due to the larger than average increase in projected outlier payments for FY 2006 and a smaller than average decrease in the proposed GAF values.

Section 1886(d)(10) of the Act established the MGCRB. Previously, hospitals could apply for reclassification for purposes of the standardized amount, wage index, or both. Section 401(c) of Pub. L. 108-173 equalized the standardized amounts under the operating IPPS. Therefore, beginning in FY 2005, there is no longer reclassification for the purposes of the standardized amounts; hospitals may apply for reclassification for purposes of the wage index in FY 2006. Reclassification for wage index purposes also

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affects the GAF because that factor is constructed from the hospital wage index.

To present the effects of the hospitals being reclassified for FY 2006 compared to the effects of reclassification for FY 2005, we show the average payment percentage increase for hospitals reclassified in each fiscal year and in total. The reclassified groups are compared to all other nonreclassified hospitals. These categories are further identified by urban and rural designation.

Hospitals reclassified for FY 2006 as a whole are projected to experience a 2.0 percent increase in payments. Payments to nonreclassified hospitals in FY 2006 are expected to increase 1.7 percent. Hospitals reclassified during both FY 2005 and FY 2006 are projected to experience an increase in payments of 1.3 percent. Hospitals reclassified during FY 2006 only are projected to receive an increase in payments of 3.2 percent. This relatively large increase is primarily due to the proposed changes in the GAF values (that is, the proposed GAFs for most of these hospitals for FY 2006 are higher than the average of the GAFs for FY 2005).

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

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

I. Background

Section 1886(e)(4)(A) of the Act requires that the Secretary, taking into consideration the recommendations of the Medicare Payment Advisory Commission (MedPAC), recommend update factors for inpatient hospital services for each fiscal year that take into account the amounts necessary for the efficient and effective delivery of medically appropriate and necessary care of high quality. Under section 1886(e)(5) of the Act, we are required to publish update factors recommended by the Secretary in the proposed and final rule. Accordingly, this Appendix provides the recommendations of appropriate update factors for the IPPS standardized amount, the hospital-specific rates for SCHs and MDHs, and the rate-of-increase limits and Federal prospective payment amounts for hospitals and hospitals units excluded from the IPPS. We also discuss our update framework and respond to MedPAC's recommendations concerning the update factors.

II. Secretary's Recommendations

Section 1886(b)(3)(B)(i)(XIX) of the Act sets the FY 2006 percentage increase in the operating cost standardized amount equal to the rate-of-increase in the hospital market basket for IPPS hospitals in all areas subject to the hospital submitting quality information under rules established by the Secretary under section 1886(b)(3)(B)(vii) of the Act. For hospitals that do not provide these data, the update is equal to the market

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basket percentage increase less 0.4 percentage points. Based on the Office of the Actuary's fourth quarter 2004 forecast of the FY 2006 market basket increase, we are proposing an update to the standardized amount of 3.2 percent (that is, the market basket rate- of-increase) for hospitals in all areas, provided the hospital submits quality data in accordance with our rules.

Section 1886(b)(3)(B)(iv) of the Act sets the FY 2006 percentage increase in the hospital-specific rates applicable to SCHs and MDHs equal to the rate set forth in section 1886(b)(3)(B)(i) of the Act (that is, the same update factor as for all other hospitals subject to the IPPS, or the rate-of-increase in the market basket). Therefore, the proposed update to the hospital-specific rate applicable to SCHs and MDHs is also 3.2 percent.

Section 1886(b)(3)(B)(ii) of the Act sets the FY 2006 percentage increase in the rate-of-increase limits for various hospitals and hospital units excluded from the IPPS, that is, certain psychiatric hospitals and units (now referred to as inpatient psychiatric facilities (IPFs)), certain LTCHs, cancer hospitals, and children's hospitals, equal to the market basket percentage increase. In the past, hospitals and hospital units excluded from the IPPS have been paid based on their reasonable costs subject to TEFRA limits. However, some of these categories of excluded hospitals and units are currently, or soon will be, paid under their own prospective payment systems. Currently, children's and cancer hospitals and RNHCIs are the remaining three types of hospitals still reimbursed fully under reasonable costs. Those psychiatric hospitals and units of hospitals not yet paid under a PPS are still reimbursed fully on a reasonable cost basis subject to TEFRA limits. In addition, those LTCHs and IPFs paid under a blend methodology have the TEFRA portion of that payment subject to the TEFRA limits. Hospitals and units that receive any reasonable cost-based payments will have those payments determined subject to the TEFRA limits for FY 2006.

As we discuss in section IV. of the preamble and in section IV. of the Addendum to this proposed rule, we are proposing to use the estimated FY 2006 IPPS operating market basket percentage increase (3.2 percent) to update the target limits for children's hospitals, cancer hospitals, and religious nonmedical institutions.

As described in greater detail below, under their respective PPSs, LTCHs and IPFs are in a transition period during which some LTCHs and IPFs are paid a blend of reasonable cost-based payments (subject to the TEFRA limits) and a Federal prospective payment amount. Under the respective transition period methodologies for the LTCH PPS and IPF PPS, which are described below, payment is based, in part, on a decreasing percentage of the reasonable cost-based payment amount. As we discuss in section IV. of the preamble of this proposed rule, we are proposing to rebase the market basket used to determine the reasonable cost-based payment amount for LTCHs and IPFs. We are proposing that the portion of payments to LTCHs and IPFs that are reasonable cost-based will be determined using the FY 2002-based excluded hospital market basket (currently estimated at 3.4 percent).

Effective for cost reporting periods beginning FY 2003, LTCHs are paid under the LTCH PPS, which was implemented with a 5-year transition period. (Refer to the August 30, 2002 final rule (67 FR 55954).) A LTCH may elect to be paid on 100 percent of the Federal prospective rate at the start of any of its cost reporting periods during the 5-year transition period. For purposes of the update factor for inpatient operating services for FY 2006, the portion of the LTCH PPS transition blend payment that is based on reasonable costs would be determined by updating the LTCH's TEFRA limit by the current estimate of the FY 2002-based excluded hospital market basket (or 3.4 percent).

Effective for cost reporting periods beginning on or after January 1, 2005, IPFs are paid under the IPF PPS under which they receive payment based on a Federal per diem rate that is based on the sum of the average routine operating, ancillary, and capital costs for each patient day of psychiatric care in an IPF, adjusted for budget neutrality. During a transition period between January 1, 2005 and January 1, 2008, some IPFs are paid based on a blend of the reasonable cost-based payments, subject to the TEFRA limit, and the Federal per diem base rate. For cost reporting periods beginning on or after January 1, 2008, IPFs will be paid based on 100 percent of the Federal per diem rate. For purposes of the update factor for FY 2006, the portion of the IPF PPS transitional blend payment based on reasonable costs would be determined by updating the IPF's TEFRA limit by the current estimate of the FY 2002-based excluded hospital market basket (or 3.4 percent).

IRFs are paid under the IRF PPS for cost reporting periods beginning on or after January 1, 2002. For cost reporting periods beginning during FY 2004, and thereafter, the Federal prospective payments to IRFs are based on 100 percent of the adjusted Federal IRF prospective payment amount, updated annually. (Refer to the July 30, 2004 final rule (69 FR 45721).)

III. Update Framework

Consistent with the current law, for FY 2006, for IPPS hospitals, we are recommending an update of 3.2 percent, which reflects the CMS Office of the Actuary's most recent (fourth quarter) 2004 forecast of the FY 2006 market basket increase. In previous years, in making a recommendation, we included an update framework that analyzed hospital productivity, scientific and technological advances, practice pattern changes, changes in case mix, the effects of reclassification on recalibration and forecast error correction. Although we have used this framework in past years, we are no longer including this analysis in our recommendation for the update. We are not discussing the framework because the productivity measure cannot be adequately computed for FY 2006 because of the anticipated effects on admissions due to the expected increases in enrollment in Medicare Advantage plans. The increased enrollment in Medicare Advantage plans has the effect of causing admissions to decline. However, we do not have information on how hospital employment will be affected for our methodology. Thus, in the absence of data to predict the effect of a decline in hospital admissions on hospital employment, we cannot appropriately reflect productivity in our framework. As a result, based on the discussion above, we believe it is appropriate to recommend an update of 3.2 percent, based on the Office of the Actuary's fourth quarter 2004 forecast of the FY 2006 market basket percentage increase.

We note that, although we are not using the framework for our recommendation to update the operating standardized amounts due to the reasons above, we continue to use the framework to calculate the capital standardized amounts as discussed in section III.A.1.a. of the Addendum to this proposed rule. This is due to the fact that the framework for the capital standardized amounts is calculated without a productivity factor and, therefore, the reasons discussed above do not apply to the update framework of the capital standardized amounts.

We also note that section 1886(e)(3) of the Act directs the Secretary to report to Congress an initial estimate of the recommendation of an appropriate payment inflation update for inpatient hospital services for the upcoming fiscal year. Earlier this year, the Secretary reported to Congress that the initial estimate of the recommendation of an update factor was 3.3 percent, which was the market basket update for the IPPS standardized amount in the President's FY 2006 budget. The difference between the Secretary's initial estimate and the update we are recommending in this proposed rule (3.2 percent) is due to the availability and use of more recent data for the market basket than were available at the time the Secretary's initial estimate was developed. In addition, the Secretary's initial estimate was based on the FY 1997-based hospital market basket, while the proposed update in this proposed rule (the current update recommendation) is based on the proposed FY 2002-based hospital market basket.

Aside from making a recommendation for IPPS hospitals, in accordance with section 1886(e)(4)(A) of the Act, it is necessary to make a recommendation of the update factor for all other types of hospitals. Consistent with current law, for FY 2006, for SCHs and MDHs, we are recommending an update of 3.2 percent, which reflects the CMS Office of the Actuary's most recent (fourth quarter) 2004 forecast of the FY 2006 market basket percentage increase.

Consistent with our proposal in section IV. of the preamble of this proposed rule, for FY 2006, for cancer hospitals, religious nonmedical health care institutions, and children's hospitals, we are recommending an update of 3.2 percent to the target limits. Consistent with our proposal in the February 3, 2005 LTCH PPS proposed rule (70 FR 5735), we are recommending an update factor of 3.1 percent for rate year (RY) 2006. For LTCHs that currently may be paid during a transition period a blend of reasonable cost-based payments (subject to the TEFRA limits) and Federal prospective payment amounts,

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we are recommending an update factor of 3.4 percent for the portion of the payment that is based on reasonable costs, subject to the TEFRA limits, consistent with our proposal in section IV. of the preamble of this proposed rule. For the Federal portion of this same blended payment amount, we are recommending an update of 3.1 percent. Because the IPF PPS was effective for cost reporting periods beginning on or after January 1, 2005, and the base rates are effective until July 1, 2006, we are recommending an update of zero for IPFs (69 FR 66922). Finally, for the IRF PPS, we have not published a proposed rule proposing an update for FY 2006. As a result, we are recommending an update of 3.1 percent to IRF PPS for FY 2006, the same update used for FY 2005.

IV. MedPAC Recommendation for Assessing Payment Adequacy and Updating Payments in Traditional Medicare

In the past, MedPAC has suggested specific adjustments to its update recommendation for each of the factors discussed under section III. of this Appendix. In its March 2005 Report to Congress, MedPAC assessed the adequacy of current payments and costs and the relationship between payments and an appropriate cost base, utilizing an established methodology used by the Commission in the past several years. MedPAC stressed that the issue at hand was whether payments were too high or too low, and not how they became either too high or too low.

In the first portion of MedPAC's analysis on the assessment of payment adequacy, the Commission reviewed the relationship between costs and payments. MedPAC's indicator of the relationship between payments and costs is the overall Medicare margin. The overall Medicare margin is calculated as the difference between payments and costs divided by payments. Based on the latest cost report data available, MedPAC estimated an inpatient hospital Medicare operating margin for FY 2003 of 1.3 percent (down from 5.9 percent and 9.8 percent for FY 2002 and FY 2001, respectively).

MedPAC also projected margins for FY 2005, making certain assumptions about changes in payments and costs. On the payment side, MedPAC applied the annual payment updates (as specified by law for FYs 2001 through 2005), and then modeled the effects of other policy changes that have affected the level of payments. On the cost side, MedPAC estimated the increases in cost per unit of output over the same time period at the rate of inflation as measured by the applicable market basket index generated by CMS.

In addition to considering the relationship between estimated payments and costs, MedPAC also considered the following three factors to assess whether current payments are adequate:

Changes in access to or quality of care;

Changes in the volume of services or number of providers; and

Change in providers' access to capital.

MedPAC's recommendation was to increase payments under the IPPS by the projected increase in the hospital market basket index, less 0.4 percent, for FY 2006. MedPAC noted that the indicators of payment adequacy present a mixed picture. MedPAC was concerned about the trend of falling hospital margins, which may result in hospitals having a limited financial cushion for dealing with pressures that may arise in the coming year. On the other hand, MedPAC stated that the current cost trend was unsustainable and may have been driven by a lack of cost containment. Therefore, MedPAC concluded that an update of the hospital market basket index minus 0.4 percent is appropriate.

Response: As described above, we are recommending a full market basket update for FY 2006 consistent with current law. We believe this will appropriately balance incentives for hospitals to operate efficiently with the need to provide sufficient payments to maintain access to quality care for Medicare beneficiaries.

In addition, because the operating and capital prospective payment systems remain separate, we are proposing to continue to use separate updates for operating and capital payments. The proposed update to the capital payment rate is discussed in section III. of the Addendum to this proposed rule.

[FR Doc. 05-8507 Filed 4-25-05; 4:12 pm]

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